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HomeMy WebLinkAboutORDINANCES-1989-048-O-89f' 1 ri`?r_€ ilil;o,•_I-HI t=:. L 1 Y.Q i ;a:,., -,.."S a!1✓ ! 1t`y CQ. f,iC:i A r-;rtrof- r a%.0�f= _ t� 1 �.; i _,q• -?'.a, .rh=_..',� rr-❑1Ji did T_n r`==i+der-t= ,_-r 1 ong ;!_�rt':3 care C1 l -' ti _ • ?iifj _ iii-lif'` u; y t;;C. !"'Z'";' i`'1iinC__ y '�;:? 1-=� rf 1'C ;_,n rti r,,=�'i ;_�-f '(_e—a.;r t1Tj,_nt g theMen' al Heal th Be=tar-may an the !�cii 1711_ =�� _�rl =P, `-t'�i rt�' :�' T' i \ 'ram T h J 1 •r '' ^' C .=: G_ 2 t 11 G r `! y r'i a 1 . i e e=ir '_ _ mpro' _ qU a 2 _� t r: r1 ne r esiI fan+=s i � t `. c'-.11=C• ±S l+�S,� term S3 +_� =1 i 1 =1 = s a =an.i, 1�t^:rfi�: r_ �N i_:1 _y-OLMIiC i s a rho �`!-art�fip!? I`eAi h r nar'T fnsnt a r !"I F n t + H ea i t' and ci hen C-om,frti ==i on !:ar. `ie] 3 in c_,, t .terresident r' a� ar rr e���ir-e t� �.��-:r_ that �_._h a_h��`!_-- t� f13c"ilnT_Biit=_ it i..:iheat Practicable mental, physic -al and p _. c ti isi_,t_-1 _ i !;�u:i !Htr°=i !_`t''_y i;r T T Ls tiE, i f,t G !� C­IFIFY OF r�:f=l�l:j�:��•s, Coij-f:: �O �r.T , 1LLI,'iC-1'��; E CTli�i`� 1e That Sections -1=et-1 tt3ri tEgF3 '-1=i-`j %�j ti;EP �7vanston Long Term Care Ord i nance o't the !-1 %`. l::1_ !•-.i r y Cet E`!.-zrl5toR ct'= a1rfp►'3,jaarm ['t=r =,h ,, ..=,tT<_. 1 d'_' f C,1 i ,_:.a5 e -- :D__ 1 GENERAL S' ROV I S 1' iiIS {- NLt a 15 -1 -1 , SHORT TITL" This Chapter c_.hai 1 be ::r,-ev:tn and ma`. - be rit•ed as the IIEv,=tnstori Long Term Care Ordinance." .:, -- _ i =+"- 1 ' ;'`� ir'r-'; i'j;= q :.'r'_.L:-Sr';f'3 ; 1 UI`� Ems` =his Ord inanC_ and the PCI iCv 0`ne __ _ ;,T C'!r.i a'GCrtg not s to estab l i sii eta n d a r d s y r=_Q 1 ati ons , and _.-i + eF I 5t L-+_, r_y{_+•.lr- f3_;,? Trp'f_f,T1fI1=1 1a �! o-f care =tnd=L'p-,sr-vi=J+,n b --r,C`!i ded to resi ents of tn`d long term Care _Fa,Ci L 1 !-1, •�t�;+ i _ ac de Fi feed 4n tnLc e�.ii-i .r r,%�;`"a he cT.jf?,�_�.r '�'_•3 =:-II i. ;, a. r" 7 -%r'-. i .an! -I cr Z _Cr:. a ed of i ne=C t3 ='r =i n =_-� 1= ice C,e =.Cif;er-eu and ram'_ an ?. s ' _=n=e -a operate f r ' _ C% =-Eat s ach "aci i=.j;.al l j if1�'t== the r=5±��ori'CS 1n,ji'•1i,3L;•al rlsC'e �t+Jr _-,r+3:-.-_:_(�EenT_ and.. i ,gin t` Es a._ = y _ ,3nner- • +-'_ en`!1 O{lfi*rni '•d1-ii'_n r!-ir: _Ci ! i_ i ! i prOtsCt she ri g; = of ri sids!'iT= Mevel rip a written ph-'--. p r-ro,_;i i_j o.1 J ♦1:H Y'.J rc. n �$ i'_: er=i)f tS?e` .y i', •a._'-;?s- •ra `:j y _.;emonstrata'good management. B-15-1-3: ADOPTION OF STATE RULES AND City adopts s by reference T "Minimum _ _ _. d=- ides.-aned The - �_^ __ _nu --'i=:�r"�.'i .mot- Rules Regulations for Classification any ! is =n"sure of Long Term Care Facilities," as _'romu1_e=_d by the Illinois Departmentof public Health, pursuant `o the "Nursing i Home Care r • tat=. c !_h. 111 _ 2,paragraphs 41 1-1 ii at cc_ _ 1?87 as may from time to time be amended. Violation of .an'-_ of c_.eiit Rules andRegulations shall be considered a d`i of ai i _n of the • Provisions of _i41s Chapter, provided 1._T_ p [ (A) Any reference it said Rules a f d Regulations to "Department" .Dera _m_rF _R_!1 roe- to the Evanston Health Department; A n - reference n said s Rules a 1 �,j Regulations o ' I 1 5 - a ' shall 1 refer to the Public Health Director of the Evanston Health Department; and _. Any reference In said ^;{_!1e= and h:egui-•-i-•-= to "Fire _:;_=-r . shall refer to the Fire Chief ci the Evanston Fire One (1) copy of said Minimum Standards, r'.;1!les .and Regulations shall be kept In the 1' __ of the City vl=r:•. ar'.!d the Evanston Public Public Library and available for p{_Rhiic use, inspection, and examination for a period of at least fifteen .15) ,-;.ays prior to the effective date h•_ r e o'r' . At least .+_i n e & i ? copy of said Rules and Regulations shall be available for public inspection in We office of the Director, 8-15-1-0 CONSTRUCTION OF CHAPTER. (A) This Chapter shall be liberally construed and applied to promote its purposes and policies. i_'j Nothing in this Chapter small be construed as authorizing the medical supervision, regulation or control of the All remedial care or treatment of residents in •any facility conducted for those who rel`? Upon treatment by prayer '=+'f spiritual means, in accordance with the creed or tenets of any well -recognized church or religious domination. (C) The provisions of this Chapter are severable, invalidity 0+ a.n`;` provision herein shrill not invalidate the remaining provisions. _--15-1-5: ADMINISTRATION: The City Manager or his/her- designee shall administer this Chapter and may, with the review of the City Council, promulgate regulations to carry out its enforcement. <.-15-1-6; DEFINITIONS: ABUSE Any physical or mental injury inflicted on a re=_ident other than by accidental means; or aii'•i sexual assault inflicted on a resident, in a facility or while engaged in an activity sponsored by the facility. There is = presumption that abuse has occurred whenever ;there has been some harmful or offensive contact with a resident which has injured or threatens to injure or harm the resident. Physical contact with .a resident for the purpose of retaliation, even in response to a physical attack or 'verbal abuse, is never_ justifiable and does constitute .abuse. ACCESS The right to: A. Enter any facility; B. I._:i,!T1Tunlcat._ privatelyand +',i_-_i-out restriction with any resident who consents to the communication; I Seek consent to communicate z ♦:`_! __l r without restriction with any resident; D. Inspect clinical and other records of a resident with the express written consent of the resident; and E. Observe all areas of the facility except the living area of any resident who protests the observation... ACTIVITIES OF Include but are not limited to the +oliowing^ DAILY LIVING walking, bathing, shaving, brushing teeth, (ADL) combing hair, dressing, eating, getting in and out of bed, doing g laundry, y, cleaning rooms, managing money, shopping, using public transportation, writing letters, using the telephone, arranging and keeping appointment=_•, taking medication, using leisure time, and ;.using vehicles or wheelchairs. ACTIVITY A specific planned program of varied_r_•_tp and i-`t'iO}-r'tAM individual activities geared to the individual resident's needs and available for a reasonabie number of hours s each day. The program is designed for personal enjoyment and to encourage self -care, to maximize residents' personal enjoyment, to develop interpersonal =_•=;ils, and to enhance residents' development. The program also includes activities to integrate the residents into the recreational and leisure time activities outside the facility. ADEQUATE Enough in either quantity or qual i t'.i , as determined by a reasonable person familiar with the professional standards of the subject under review, to'meet the needs of the residents of the facility under the particular set of 40 circumstances in existence at the time or review. ADMINISTRATIVE A notice to a facility issued by the WARNING Department, which indicates that a situation, condition, or practice in the facility violates this Chapter, or State `standards, and isnot a Type A, B, or }C Violation, as defined in This Chapter. ADMINISTATOR A person who is charged with the general full-time administration and supervision Of a .a s i i s } "`Home facility and i licensed under the "Nursing Administrators Licensing Act," ill. Rev. tat., Ch. ill, par. 601 et seq. i1?E77, as now or hereafter amended. ADVANCED A document allowing a resident to give DIRECTIVE directions about future medical care and to designate who should make those decisions in the event of the resident_ decision -making incapacity. Two types exist: a treatment directive` known in Illinois as a Living Will; and a proxy directive known in Illinois as a Durable Power of Attorney for Health Caren • AD`•f!_l1.,ACY The act or process of representing the interests of an individual or group so that: rights to which the individual or group are entitled are recognized; legally mandated services are obtained; barriers are removed from obtaining these mandated services; and conditions are improved for the individual or group. . HLIVOCATE An individual or representative 0i a community organization or agency who is assisting residents in asserting se_ rights or in obtaining full enjoyment of their rights. Advocates may not charge for their services, nor may there be a commercial purpose. AFFILIATE A. With respect to p_-- � a partnership, each partner- thereof; • D. With respect to = corporation, each officer, director, and stockholder thereof; C. With respect to a natural person, any person related in the first aegree of kinship to that person; each partnership and each partner thereof which that person or an- affiliate of that person is a partner; and each corporation in which that Gerson or any affiliate of that person is an officer, director or stockholder. APPLICANT Any person making application for a license. CARE PLAN See individual care plan. CARE REVIEW An interdisciplinary team responsible for COMMITTEE assessing the needs of a resident, and developing and evaluating the individual care plan. CERTIFIED A person who is eighteen p g n v,13) '.ears or older NURSE'S AIDE who has completed an approved Basic Nursing SCNA? Assistant Program and has passed the proficiency examination, as established by the Illinois Department of Public Health. is A person who holds a clinical social work: SOCIAL WORKER license under the Cl i n i cal Social Work: Practice Act, Ill. Rev. Stat., Ch. ill, par. 6351 et seq. (1989). COGNITIVE A syndrome of physical and neurological . IMPAIRMENT disorders, which may include a diagnosis of Alzheimer s Disease or a related disorder and is manifested in one or more of the following symptoms not attributable to drug intoxication or intolerance or depression: gradual memory loss, decline in ability to perform routine tasks, including ADLs; impaired judgment; disorientation; sleep dysfunction; personality or behavioral changes; diminished learning capacity; loss of control; and loss of language gage skill, characterized by progressive decline; may be diagnosed by a physician as irreversible. COMMUNITY An individual who is selected by the REPRESENTATIVE resident council to serve as a voting member of the council, but is not a resident of a facility. This Gerson may represent a community organization, advocacy group or - religious organization, and may be family or - friends of residents or be a volunteer �nteer at the facility. The person shall not be on staff • of the facility, or have any financial interest in the operation of the facility-. He/she shall not be a member of the board of the facility. DAY Calendar- day, unless specified in this Chapter as working day. DEPARTMENT The Evanston Health Department. -4- DISABILITY which: ( D i 1 ) A. .s attributable to a ? ental or physical impairment or combination of mental and physical impairments; B, Is manifested before such person attains ape twenty-two (22) • C. is likely to continue indefinitely,' D. Result_ in substantial functional limitations in three 3) or more of the following areas of major life artivi y: 1, Self -care, 2. Receptive and expressive languageg 3. Learning, 4. Mobility, 5. Self -direction, 6. Capacity for independent living, or -io Economic sufficiency; and E. Reflects the rper_.on's needs for a 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. DIRECT CARE All staff of a facility other than admi ni s- • STAFF trative, dietary, food service, janitorial and housekeeping staff. DIRECTOR The Public Health Director of the Evanston Health Department. DISABLED PERSON A person eighteen (18) years r-s of age or older who a) because of mental deterioration or physical incapacity is not filly able to manage his person or estate, or b) is mentally -ill or developmentally disabled and who because of his mental illness or - developmental disability ' is not fully able to manage his person or estate, or W because W gambling, idleness, debauchery, y, or excessive use of intoxicants or drugs, so spends or wastes his estate as to expose himself or his family to want or suffering. ill. Rev. v_i't_at, , Ch. 110-1. 2, Section i la-.:... .l'?B7 DISCHARGE !he full release of any resident froma. facility. EMERGENCY A situation, physical condition or one or more practices, methods or operations which present imminent danger of serious physical or mental harm to resident(s) of a faci l i tY. •FACILITY H private home, institution, building, residence or any other place or oar"'_ thereof, whether operated for profit or not, or .a county home for the infirm and chronically . ` 1 coo,'EL a a I Ora ann L Vo '� a Act- as :ow or nereafter ameccec, ^ or my � county pursuant to "An act in reintion to homes for the ageo^ approven D'^i|' 21. M4. as now or hereafter amendec, 0 or any simi1ar institution c'ersted oy a politics:''; suodivzsion of Me State, Orion provioeH, through its ownership or managamenr, perEonal care, shaitered care or nursing for tnras `W or more persons not related to the comer or Molicant by blood or marriage. it inc!UQes facilities ±01led nursing and in�ermedi�t� care taciiities, as rhoEe terns are oefina_�i in Titie xVIil and Title Z1A ur tme Feoersl Eocial Security ACV, as �uv Cr nereaire,' amendeo." It also inc1uoes instinutzons ano a:v other place cpsrazzng a Kcmmunit� Living Faczizty as oefineo in the `�cm`nuniry Living Facility uhcenszng Act'"' and a -Community Residential AlLernavivs" as dsfineo in the ^Lommur.zcy �esi�enc�a� A1ternatzves Licensing Act" does not iccluoe the fol1cwiog: A. A nome, institution or cc!`er piac� operated by the federal goyernment, agency thereof or oy the State.- S. A Mospikal' sanitarium or other institution woose prinaipal buHinesn or activity is the diagnosis, cars, anu treatment of human illness r/o'ougr Ure - ~ maintenance and lzperaticn as on organzce�:!, facility therefore which iH requiceo to 1icensed under the ''Hospital Licensing Act" as now or hereafter amended, ' Except to the extent the instizuticn operated a "Facility" as defined herein; or ''Facility C. A for Child Care" as de§zneo the "Child Care Act of 1960" as now ar hereafter amended.,.-.) FIRE CHIEF The Fire Chief of the EvanEton 7irs Department. SCALS Long range outcomes that are generally expected to be achieveo by a reyio2nr wzcoin one to five years and that are stated in measurable terms so tnat ��`eir stinznoeno l=n be determined. 6�J H. i__':DIAN ri person appoinreo as a guardian oi tRe oe/Aen o,' guardian of the estate, cr bcth, of a resio�nt under the "Prooate Act of iTT5' ` as now cr hereafter amended, 1ll. Rev. Mnt., Ch. 110-1/2, par. 1-206 (1587/. l. 111.Rev.Etat., Cn, 64" Paragrapms bss1-0169 QTG/t �. I11.Rev.Stat., Ch. 34, Paragraphs 3561-W71 (!+8i) 3. 411 U.3.0. Sections 1003-iWs /&6T` 4. lll.Rev.�tat., Ch. ill-k/2 Paragraphs 0161-4iK (1437) 5. 111.Rev.Stat., Ch. 91-1/2 Paragrapns 62i- bin �i%7) 6. ��. M.Rev.Stat., Ch. ii1-1/2 Paragraphs 4161-4103 0987� 7. I11.Rev.6tat., Ch. 11i-1/2 Paragraphs 14i-M (176Y'' 6. lll.Rev.Stat., Ch. 23, Paragraphs 221i-2200 k1987) HABILITATION The process of educatiQn and training, througi.n. which the staff of a facility assists residents in acquiring and maintaining those life skills which enable them to cope more effectively with activities of daisy living and demands of living in the community. Habilitation seeks to raise the levels of residents' physical, mental, and social functioning. INDEPENDENT A person who can do all activities of daily LIVING living without assistance and who can care for • STATUS his/her own health needs without .any nursing _ RESIDENT care,management�_ Ipe or'! determined .at , r supervision �'� admission and in .a semi-ann+_ial review by a (ilulti-disciplinary team. INDEPENDENT H separate floor or section of a facility that LIVING UNIT is staffed separately from ether portions of the facility and which is occupied solely by those residents who meet the requirements of independent living, as defined in this Chapter. IMMEDIATE the spouse, an adult child, a parent, an adult FAMILY brother or sister or an adult grandchild of '= person. INDIVIDUAL A written plan of care for each individual CARE PLAN resident cased on a comprehensive interdisciplinary assessment of the resident's total needs. The plan identifies goals, objectives, and activities based on the assessment, and provides the basis for evaluation of resident outcomes, as directed in Section 8--15-3-:0) ;_I of this Chapter. it may also be referred to as the care plan, pion of '__re, resident care plan, treatment plan, or - rehabilitation plan. LICENSEE The individual or entity licensed by the • Department to operate the facility. LIFE SAFETY instruction in basic first aid proc_d!!resi TRAINING cardiopulmonary resuscitation, Tire safety, artificial respiration, emergency evacuation procedures, water safety, and any other training relevant to maintenance of a safe environment and reduction of the risk: of harmful or life -threatening situations. LONG-TERM See "Facility'' _ARE FACILITY r'1(-Y In this Chapter, an auxiliary term used to express permission or opportunity. MAINTENANCE Food, shelter, and laundry services provided for residents. MEDICAL Written chronological transcript of information RECORD regarding a resident, obtained from a resident, guardian or representative and staff servicing the resident. 'IEN T A.L A primary or secondary diagnosis of mental ILLNESS disorder (as defined in the Diagnostic c and isEdition), Manual of Mental Disorders, d Edition) , and not a primr_'-+.r'`a diagnosis of Cognitive impairment or a related disorder. May include a disability evidenced by behavioral problems which are not associated with a diagnosis of Cognitive impairment or a related disorder. Title iVj Subtitle {, Nursing Home Reform, Part _ p Medicaid NEGLECT A failure of a facility to provide au e ua+_ e medical or personal care or maintenance in a facility or while engaged in an activity sponsored by the facility, which failure results or may result in physical or mental injury a resident or in the deterioration of a resident's physical or mental condition. There is a presumption t^at neglect has occurred whenever a facility fails to provide a treatment or service to a resident which • is necessary to maintain or improve his/her health or safety, !finless such treatment or service is prohibited by an advanced directive; and the failure to provide that treatment or service results or may result in a lack of expected improvements or a noticeable deterioration of his/her physical or emotional condition. NURSE A registered nurse or a licensed practical nurse, as defined in "The Illinois Nursing Act," !!!- Rev. Stat. , Ch. ill, par. 0402 (1` 87), as now or hereafter amended. OBJECTIVE A statement of a result to be achieved or a point to be reached in the implementation of a goal in the Individual Care Plan. OMBUDSMAN A person who represents a legally -designated obmudsman program, as defined in the "Older Americans Act" , 42 U.S.C., section 300 et seq. • (19M, as amended, and who has ` h e authority to; ai have immediate access to the facility; have -immediate access to any resident, subject to the resident's right to deny or revoke consent to the personal visit at any time; and have access to examine a • resident's record, with the permission of the resident or guardian, consistent with state rules and regulations regarding confidentiality; b] receive, investigate, and attempt to resolve complaints filed by or on behalf of residents of facilities relating to action, inaction or decisions of providers of long term care services which may adversely affect the rights, welfare, safety or health of such residents; W visit, tali.: with, and matte personal, social, and legal services available to residents; di inform residents of their rights and entitlements under local, state, and federal laws; e: assist residents in asserting their rights by means of personal advocacy or in groups, such as resident councils and floor meetings; f i consult with the facility staff and administrator in order to negotiate or offer solutions to issues discovered in the course of carrying out the ombudsman program; and g) refer to, and consult with, appropriate -a- local, state, and federal agencies regarding the conditions of facilities. OWNER The individual, partnershi o . cor post i on a association, or other person who owns a . _-=i l i ty. In the event a facility is operated by s person who leases a physical plant owned by another person, "owner" mean_ 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 of this Chapter imposed on an owner. PER'"ONAL 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 his person, whether or not a guardian has been appointed for such individual. PH`rSICIAN A person licensed by the Department of Professional Regulation to practice Medicine or - Osteopathy. PROTECTION The continuing responsibility of a f ac i l i t - to take all necessary actions- to insure residents a r e free from physical harm, intimidations humiliation, and exploitation of any kind. PSYCHIATRIST A physician who has had at least three years or formal training or primary experience in the diagnosis and treatment of mental illness. • PSYCHOLOGIST A person registered pursuant to Section =_of the .S Psychologist Registration Act, Ill. Rev. cat., Ch. 111, par. 5=0 (1987). QUALIFIED MENTAL A certified, registered or licensed mental RETARDATION retardation professional who provides services PROFESSIONAL under this Chapter. A QMRP must meet one of iQMRPI the following criteria, and, in addition, must have a minimum of one year of supervised specialized training in direct care V persons who are developmentally disabled, which training is approved by the Li rector 'of the Mental 1 Health :Board. 1. A physician licensed by the Department of Professional Regulation to practice Medicine or Osteopathy. 2. A psychologist registered Pursuant to Section of the Psychologist Registration Act, !I!. Rev. `;tat., Ch. 111, par. 5303 (1987) a A clinical social worker or social worker licensed under the Clinical Social Work Practice Act, Ill. Rev. Stat. , Ch. 111, par. 6351 =- seq. (1989), who has a master's degree in social work or counseling from an accredited school; • 4. A registered nurse licensed pursuant to Section 2 of the Illinois Nursing Act,. Ill . Rev. Stat. , Ch. 111, par. =402 198 ) g 5. An occupational therapist registered pursuant i • to Section _ of the Occupational Therapy Practice Act, (= •_ } I ± 1 . 1'ti e `� - `� % ._i'C . g '•1 ii . !I!, par. 3703 '. 1 9 8 / 1 or 6. An individual who holds a master's degree or higher in psychology, sociology or•co+!nselinq and who is certified or registered by the Commission for Rehabilitation Counselor Certification, the National Board of Certified Counselors or .a national or state certification board or commission which certifies- practitioners on the basis of education and training, work experience, and examination. REASONABLE HOUR �R Any time bet � . between the hours of _fight O'clock <.E;�i���;' A.M. and eight o'clock: (8:0 ,) P.M. daily. RECREATIONAL AND Elements of a resident's daily life in which LEISURE ACTIVITY participation may be planned, requested or self -initiated to meet the resident's need to find personal enjoyment. RECURRENT Two or more violations within a facility, which VIOLATION are similar in nature and, in the opinion of the Department, demonstrate an ongoing pattern, or practice which indicates a deficiency in the facility's operation. REHABILITATION Actions directed toward the alleviation of a disability or toward increasing a person s level of physical, mental, social or economic functioning. REPEAT VIOLATION A violation which has been cited during a previous inspection of the facility and which has not been corrected pursuant to an approved plan of correction or order of abatement, as indicated by a subsequent inspection. • RESIDENT A person residing in a facility and receiving personal care from the staff of a facility. RESIDENT A formal organization composed at and ADVISOR`r operated by residents and established by the COUNCIL facility to be a forum for residents to; 1) express their views, opinions, and concerns; 2) obtain and disseminate information regarding their facility and long term care issues, in general, 3) present complaints on behalf of one or several residents to the following: a) the facility administrator; b) the legally -designated ombudsman; c) the Evanston Health Department, or d) other organizations responsible for investigating such complaint=_, 4) identify problems and make suggestions for - timely resolutions of those problems; and • 5) review policies and procedures for implementing residents' rights and making recommendations for changes. - 10- RESIDENT'S A person other than the owner or an agent Or REPRESENTATIVE employee Of a facility designated in writing by a resident to be his/her representative, or the resident's guardian. RESTRAINT The direct restriction of movement of the ii,?bs, head or body of a resident through the use of mechanical means, personal physical force, or The use of drugs. SECLUSION Sequestering a resident in a room by which there • is no means of exit except with staff assistance. SELF- The ability to follow directions and PRESERVATION recognize impending danger or emergency situations and to react by avoiding or leaving the unsafe area. SHALL in this Chapter, an auxiliary term used to express obligation or imperative requirement. SHELTERED CARE Maintenance and personal care. SHELTERED A structured vocational program designed to WORKSHOP enhance residents' productivity, and which may provide them remuneration. SOCIAL HISTORY A written assessment which is part of the ASSESSMENT resident's medical record and includes the following: personal and family history in as much detail as possible, history of mental health treatment and intervention for the previous five (5) years, history of alcohol or substance abuse for the previous five (5) years, legal status, financial status, level of education or training, work: history, mental status, and communication skills. • 'SOCIAL WORKER An individual who holds a -social work: license under the Clinical Social Work Practice Act, Ill. Rev. Stat., Ch. 111, par. 6351 et seq. (i?8?) and who has a master's degree in social work: or counseling from an accredited school. STAFF An organized orientation and continuing_ DEVELOPMENT education program, for employees which AND TRAINING includes, but is not limited to, orientation, skill development and supervision, and in-service training. STATE ACT Nursing Home Care Act, Ill. Rev. Stat., Ch. 111-1/2, paragraphs 4151-101 et seq. (1?E+7) as now or hereafter amended. STATE STANDARDS Minimum Standards, Rules and Regulations for Classification and Licensure of Skilled Nursing Facilities, Intermediate Care Facilities, Intermediate Care Facilities for the Developmentally Disabled, Sheltered Care Facilities, and Residential Rehabilitation Facilities promulgated under the State Act. STOCKHOLDER Any person who, directly or indirectly, beneficially owns, holds or has the power to vote, at least five percent (J/) of any class of • securities issued by a corporation. SUPERVISION Guidance and protection of residents in the OF RESIDENTS activities of daily living, including but not limited to the following: -11- H fissuring that residents observe their medication schedule; B. Assuring that residents participate in activities of their choice that are carried out on an hourly, daily or weekly y basis; C. Assuring that residents keep appointments; • D. Monitoring residents' general whereabouts, even though they may travel or move abort the community; and E. Maintaining a safe environment and reducing risk: of life -threatening situations. TITLE =VI I I Title XVIII of the Federal Social. 'Security Act as now or hereafter amended, 4= U.S.C.,sec, 1=y5 (1988). TITLE XIx Title XIX of the Federal 'Social Security r-ity Act as now or hereafter amended, 42 U.S.C., sec. 139 (1988). TRANSFER A change in status of a resident's living arrangements from a facility to a hospital or another facility for temporary care. j A transfer is not a discharge within the meaning of this Chapter. TYPE `A' A violation of this Chapter or o+ the VIOLATION State Standards which creates a condition or - occurrence relating to the ,operation and maintenance of a facility presenting a substantial probability that death or serious mental or - physical harm to a resident will result therefrom. • TYPE ''S' A violation of this Chapter or of the VIOLATION State Standards which creates a condition or occurrence relating to the operation and maintenance of a facility directly threatening to the health, safety or welfare o+ a resident. TYPE '+C' A violation of this Chapter or of The State VIOLATION Standards which creates a condition or occurrence relating to the operation and maintenance of a facility indirectly threatening to the health, safety or welfare of a resident. VOCATIONAL An organized program in which a resident TRAINING acquires the skills necessary to ee perform a PROGRAM specific job. WORK ACTIVITY A transitional, time -limited structured program which is provided for the purpose of developing and maintaining residents' capabilities. 5-1=-2s LICENSING REQUIREMENTS: 8-15-2-1: LICENSE REQUIRED: No person or entity may establish, operate, maintain, or advertise a facility within the City without 11btainineg a :sale municipal license therefor which license remains unrevoked and unexpired. is(A) No public official or employee may place any person in or - recommend that any person be placed in any facility which is being operated without a valid license. if the Department is denied access to -. Private r-,_me_ institution, building., residence or .any other plate which it reasonably believes is required to be licensed as a facility under this Chapter, it shall request intervention of local, County or State law enforcement agencies to seek an appropriate court order or warrant to allow the Department to enter and inspect the facility and to examine or interview the residents and staff of such private home, institution, building, residence or place. Any person or entity preventing the Department from carrying out its duties under this `.Section shall be in violation of this Chapter and shall be subject to • penalties hereunder-. S-15-2-2: LICENSE PROCEDURE`: Each applicant shall submit a completed application form and the required additional information prior to issuance of a license. No application shall be considered complete until 1 all required information is submitted. The procedure for obtaining a valid municipal license shall be as f of 1 ows. (A) Application to operate a facility shall be made to the Department an forms furnished by the Department. if the application is for renewal of a license, it shall be submitted at least one hundred twenty (120) days, but not more that one hundred fifty (150) days, prior to license expiration. The .applicant shall be !ender oath. Pursuant to section 3-103 of the State Act, the submission of false or misleading information shall be a Class A misdemeanor in addition to a violation of this Chapter. The Department shall refer suspected violations to the State's Attorney or the Attorney General for investigation. Ail applications 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 board of directors, officers, stockholders, 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 and the name of the beneficial owner (s) . of the premises and facility; 3. The name of the person (s) or entity ender whose management or supervision the facility will be operated 4. The number and type of residents for whom maintenance, personal care or nursing is to be provided; and C. A statement attesting to the good moral character of the applicant and employees. (B) All applications shall be accompanied by the following: 1. A statement of ownership, which shall be public information, available through the Department, and whirh shall set forth the following: a. The name, address, telephone number, occupation or - business activity, business address, and business telephone number of the person who owns the facility .and every person who owns and operates the building in which the facility is located. b. If the owner(a) . of the premises is a partnership, or corporation, the name and mailing address of the registered :agent, e`,tery partner, director, officer, and stockholder-, -13- C. he address of all other facilities, if any, in which the applicant holds or mas held a i i fancial interest within the past five (5) years; 2. Such information relating to the number, experience, and ! a n1 +� f the facility, i ', ._h Department '!- i r -•� _+'9' the e employees �! 1 1 �1 P t? �_-, (� a ;' f' 'Y '• ,_;'-. the may deem necessary; -. Any ;management agreements for the operation of the facility; ; • 4. A financial statement audited by an independent , certified public accountant, utilizing generally accepted Principle::; W accounting, setting forth the financial condition of the applicant for the most recently completed fiscal year, if any, or initial fiscal period, and a copy of the applicant's mfo .1_ recently filed federal income tax return, or a federal annual information return form 990 if a not -for -profit organization; `•_+. 14 i the case of new construction or the conversion of existing structures, preliminary plans and specifications for the proposed facility; 6. A list of other programs, services, institutions, facilities and activities operated by the applicant; 7. The current .annual operating budget for the first Year wit!l a statement of the Rinds that have been or are projected to be committed to the operation of the facility and the sources of those funds; - 8% Certified copies of any Medicare and/or Medicaid certifications; 9. Other information necessary to determine the applicant's identity and qualifications to operate a facility in accordance with this Chapter, as required by the Department; • 1° An agreement to update all information in the application and its attachments within ten (10) days of any change thereto; and 11. An annual license fee of Three hundred dollar 1$300.00), plus thirty r i 30�+;_0) per licensed bad. to be? refunded ;.,1 � .hir dollars :�•_ p - - - should The application be denied. (0) in addition, initial applicants shall provide: 1. A permit, as required by the "Illinois health Facilities Planning Act," iil. Rev. St.at. , Ch. 111-1. 2, paragraphs ll__ t seq . (1987) . 2. A certificate from the 11Ppartment of Housing and Property Services stating that the building or structure to be used as a facility complies with the requirements of the Evanston Building Code and the t'1stn5tu'n Zoning Ordinance; 3. Current and any previous experience with long term care facilities; 4. H specific written plan for developing and securing expertise in the management of facilities, programs, and services. Applicant must. sdemonstr ate current ability to provide programming and services appropriate for the population to be served, to monitor individual functioning, and to assist individual residents to make appropriate changes consistent with individual needs; and app, i - a i -.. fee of two _nousan`-' (0 ) After receipt and review of the appropriate to appl i eat i on, and before a license is issued: 1. The Director shall ,_ai.?se an inspection to be made of the appii{__int s facility any premises b the Department, by the Fire Department, and by toe Department of Housing ._-.'-.nd 'p-oper't Services. • 2. The Director of the Department of Housing andKrOp-rM e' Servics shall determine whether the building or stri_ic is it occupied by the facility complies with the applicable provisions of the State Standards and the Evanston '-CiT'`.='' Code; any -a The Fire Chief shall determine whether the building and premises meet the minimum applicable life safety standards established by the State Standards and he Evanston City Code. B-15.>_-_ a LICENSE ISSUANCE: The Director shall issue a license if it is found: tip; That the applicant is responsible and suitable to operate or to direct or participate in the operation of a facility ter'•.,• virtue of sufficient financial resources, appropriate business or professional experience, a record of compliance with lawful orders of the Department and the provisions of this Chapter, and absence of revocation of a license to operate a facility within or without the State during the previous five ,,:'_ ) years; has submitted a completed application and the required additional information; and currently is able to provide programming and services appropriate for the population to be served, to monitor individual functioning, and to assist residents in marling appropriate changes consistent with their individual needs. (B) That the facility is under the supervision of a licensed administrator; and [! : j That the facility is in substantial compliance with this Chapter. 8-ic._ -4aCONTENTS,LICENSE: it_e1-se gr� rt _i �i _ _ _ � . a Ti=i^:1 ! > ii- Any license granted s _ _ • the Director shall state the maximum bed capacity for which it i granted, the rate the 'license was issued, and the expiration date. !jlich licenses shall be issued for a period of one year. However, the Director may issue licenses or renewals for periods of less than one year in order to distribute the expiration dates of such licenses throughout the calendar year, and fees for �r such licenses shall be prorated on the basis of the portion of a year for which they are issued. Each license shall be issued sni for -_ t-s e facility and persons named in the application and shali be transferable or assignable. 8-15-2-5 o PROBATIONARY LICENSES ON INITIAL APPLICATIONS. For all initial license applicants, the Department shall issue _. probationary license except where the � issuance of _ conditional license is warranted, as determined by the Director. , probationary license shall be valid for one hundred twenty (120) days unless sooner revoked pursuant to _ect:. n - 1v-.>_ _ below. Within thirty (30) days prior to the termination of a pr=eb.ationar"y license- the Department stall fully and completely inspect the facility and, if he facility sheets the applicable requirements for licenl+re, a-ati issue a license under Section B-15-2-3 above. If the Department finds that the facility does not meet the requirements for licensure, but has shade substantial progress toward meeting those - i `_ — requirements, probationary license renewed once for period not to exceed one hundred twenty MO) days from the "pira ion date of the initial probationary license. 5-15-2-6a ISSUANCE, RENEWAL NOT A WAIVER: The issuance or renewal of a license after a )Notice of Violation has been sent shall not constitute a waiver by the Department of its right to rely on the violations as the basis for subsequent license revocation or other enforcement action arising out of the Notice of Violation and 'statement of Violations. . 8-15-2-7 ; TRANSFER OF OWNERSHIP: Whenever ownership of a facility is to be transferred from the license named in the license to a new owner who is applying for a license: (A) The transferee must obtain a new license. The transferee shall notify the Department in writing of the transfer and apply for a new license at least thirty (0) days prior to final transfer. (B) The transferor shall notify the Department in writing at least thirty {0) dams prior to final transfer. The transferor shall remain responsible for the operation of the facility until such time as a license is issued to the transferee. (C) The license granted to the transferee shall be subject to any plan of correction imposed by the Department or submitted by the previous owner and approved by the Department; any court orders; and any conditions contained in a conditional license issued to the previous owner. The Director may issue a conditional license to an applicant in lieu of a probationary license if the facility ;need a. conditional license at the time the applicant purchased the facility and the vi of ati.ons resulting in the issuance of a conditional license have not been corrected. Q) The transferor and transferee shall remain jointly and severally liable for all penalties, except monetary fines, lopassessed against the facility which are imposed +or violations occurring prior to transfer of ownership. The transferor shall remain liable for all monetary penalties imposed on the facility prior to transfer of ownership. 8-15-2-8= DENIAL OF APPLICATION; REASONS: An application for a license may be denied for any of the following reasons (Ai Failure to meet any of the applicable provisions of this Chapter; (B ) Conviction or imposition of supervision, probation, or conditional discharge of the applicant, or if the applicant ia a firm, partnership or association, of any of its members, or if a corporation, the conviction or imposition of supervision, probation or conditional discharge of the corporation or any of its officers or stockholders, or of the person designated to manage or supervise the facility, of a felony or of two M or more misdemeanors involving moral turpitude during the previous five (_) `!ears as _.!'powr! by a certified cope of the record of the court, , or other satisfactory evidence that the moral character of the applicant, administrator or direct care staff of the facility is not reputable; (C) Personnel insufficient in number or unqualified by training or experience to care properly for the proposed number and 410 type of residents; (L) Insufficient financial or other resources to operate the facility in accordance with this Chapter; -16- Revocation of a facility license during ng the p,,,i dick five (_) years, if sucM prior license was issued to the individual applicant, a controlling owner or controlling combination of owners of the applicant or any affiliate o- thle applicant; provided, however, that the denial � i:: _y R R � �_1-_ I- 1 f n application for a license pursuant to till= erect R-• � Section 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 standards set forth in • this Chapter; or (F) That the facility is not under the direct supervision of a licensed administrator. 8-15-2-9: NOTICE OF DENIAL: iJ e denial Upon ri n i of any '`+ application for a license under this Section, the Department shall notify the applicant in writing. Notice of denial shall include a statement of the reasons for denial and notice of the opportunity for a hearing under Section B-15-6. B"-15--2-10: DENIAL CONTESTED: if the applicant desires to contest the denial of a license, it shall notify the Department in writing of its request for a hearing within Ten (10) da;'s after receipt of notice of denial. The Department shall ha_i conduct the hearing pursuant to Section B-15-6. 8-15-2-1 1 : REVOCATION OR NONRENEWAL OF LICENSE, REASONS: T I e Department, after notice to the licensee, may revoke or refuse to renew a license in any case in which the Department fines any of the following: (A) h substantial failure of the facility to comply with this Chapter, including, but not limited to, repeat and recurrent violations; (B) Conviction or imposition of supervision, probation, or - conditional discharge of the licensee, administrator- or- • direct care staff of a felony or of two () or more misdemeanors involving moral turpitude during the previous five (5) years as shown by a certified copy of the record of the court, or other satisfactory evidence that the moral character of the licensee, administrator, or direct care staff of the facility is not reputable; (C) Personnel insufficient in number or unqualified by training or experience to care properly for the number and type of residents served by the facility; (D) Financial or other resources insufficient to operate the facility in accordance with standards set forth in this Chapter-; or (E) Lack of a .licensed administrator. 3-15-2-12: NOTICE OF REVOCATION OR NONRENEWAL: Notice under this Section shall include a statement of the reasons for :r nonrenewal or revocation; the provision, statute or rule ale violated; and notice of the opportunity f ppc nit; for a nearir:.:� 7!1'•:oer- Section B- l 5-6 . - B- . 5-2-1.= : REVOCATION OR NONRENEWAL CONTESTED: if o facility desires to contest the revocation or nonrenewal e nr ene al of a license, rise, the facility shall, within ten sip%) days after receipt of - ceip_ notice of revocation or nonrenewal, notify the Department in writing of its request for a clearing under :Section B-15-6. Upon receipt of IM the request, the Department shall send notice to the facility and hold a hearing as provided under Section S-1 -6. 8-15-2-14: DATE OF REVOCATION OR NONRENEWAL: The effective -17- _.:_.... of revocation or nonrenewal of a licensen:_ we Department shall be either of the following-. Unless otherwise se ordered '^..;fi the circuit court, Pve'".+__t+_ion effective on the date set by the Department in he notice of revocation or upon final action after hearing under Section B--15-6, whichever is later; () Unless otherwise ordered by the circuit court, nohrenrewal is effective on the date of expiration of any existing license or upon final action after hearing under Section _--15-61 • whichever is later; however, a license shall not be deemed to have expired if the Department fails to respond in a timely manner to a request for renewal under this Chapter or -tor a hearing to contest nonrenewal. The Department may extend the effective date of license revocation or expiration on any case in order to permit orderly removal and relocation of resident_. 8-1 _- - 1 5: INSPECTIONS: The Department shall have thee right to visit and inspect at any time The premises and records of any facility and to evaluate the facility residents and oersonne {. for the purpose of determining whether the applicant or licensee is in compliance with this ;Chapter. All records must be readily available for inspection and copying. The Department may also inspect any/ former facility which once hold a lic ense to inspire that the facility is not again operating without a license. 8-15-2-16 CRIMINAL LAW POWERS: Notwithstanding any other provision of this Chapter, the City'= law enforcement agencies shAl l have gill and open access to any facili-ty pursuant to Article 1:8 0f the"Code of Criminal Proc edure," Ili. Rev. Stat. , Ch. 36, Article 108 (19B7) , in the exercise of their investigatory and prosecutorial powers in the enforcement of the criminal laws of this 'estate and may at any time request lest the assistance of County or State law enforcement agencies. • 8-15-3: FACILITY REQUIREMENTS: --15-3-1: RESIDENT'S RIGHTS: Every resident of any facility as defined in this Chapter shall be guaranteed the rights enumerated 'below: (A) No resident shall be deprived of any rights, benefits or privileges guaranteed by law, the Constitution of the State of Illinois or the Constitution of the United States solK on the account of being a resident in any facility as defined in this Chapter. ;any resident who believes that his/her rights are being or have been violated may file grievance, pursuant to Section B-15- 2(P) or section --15-4-6 of this Chapter. (B) No resident shall be presumed disabled except as determined by a court pursuant i= to Section !!(a-2) of the l l l i not Probate Act, Ill. Rev. Stat. , 1'h. 110-1/2. ( {_) Each resident shall be provided with adequate, appropriate! ,and humane care and services in he least restrictive setting, pursuant to an individual care_ plan .and shall be permitted to participate in the development of this plan to the extent that his/her condition permits. (D) Each resident shall be permitted private and uncensored communications with persons of the resident's choice, through the mail, in person or on the telephone, including but not limited to visits with and access to advocates and ombudsmen. The facility shall establish visiting hours, as defined in this Chapter. The administrator shall insure that functional telephones are reasonably accessible. ;any -Is- restrictions of this right, in order to protect the,resinent or others from harm, harassment, or intimidation, shall be ordered by the resident's physician, shall be in writing, and shall state the reason for and time limits of the . restriction and shall be placed in the resident's individual care plan and medical record. No or - der shall be valid for more thin thirty (30) days, However, resident correspondence to and from the Governor, members oi the General Assembly, Attorney General, Judges, State'_, Attorney, the Department, the Evanston Commission on Aging, . the Evanston Mental Health Board, the l l 1 i not s Department o f Public Health, or licensed attorneys at law h _.� _� 1. l be promptly delivered or mailed without examination or restriction. (E) No resident shall be subjected to physical, sexual, verbal or psychological abuse or neglect ect 1 _•. - e r g� from staff, other residents or visitors. o An employee or agent of the facility, an advocate, ombudsman or a representative from any regulatory agency has reasonable cause to believe that resident with wom they have direct contact has been subjected to abuse or neglect shall immediately report the matter to the facility administrator and to the Department. 2. The administrator, when 'becoming aware of the abuse or - neglect of a resident, or when receiving a report of suspected abuse or neglect shall immediately report the matter to the resident's representative and to the Department. _. Any person may report suspected abuse or neglect to the Department. (F) Each resident shall be permitted to refuse generally accepted care and treatment, including but not limited to medications, 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 medical record. if such services are refused, , the resident shall be informed in a. nonthreatening manner of alternatives available and risks associated with the refusal and alternatives. The refusal shall be documented in the resident's medical record. The facility's social worker shall be informed of the refusal and shall discuss the refusal with the resident. The social worker shall document the outcome of the discussion and inform the direct care staff. (G) No resident shall be subject to restraints through the use of mechanical means, personal physical force, or the use of drugs, sinless there is a written order from a licensed physician. The order shall be based on the physician s personal knowledge of the resident and clinical judgment of The resident's condition and shall state that the use is justified to prevent the resident from causing harm to him; herself or others and is the least restrictive alternative available. Restraints shall not be used merely for the convenience of staff or for punishment. The facility shall establish procedures for regulating the use of restraints in compliance with the provisions of this Chapter. (:H) Each resident shall have the right to privacy for communications, when receiving care and treatment, and when 411 in one's individual room. in rooms with more than one (1) occupant, the facility shall provide sufficient functional privacy screens to afford separation of each resident's individual living area. The right to privacy includes freedom from engaging in or having sexual activity carried -19- out in one's room without express -consent of each resident. . Residents shall have access to their- rooms at all times. . Except in an emergency, no one may enter a resident's room without first knocking, identifying him/herself and obtaining permission to enter. (i) Each resident shall be permitted the use of personal funds as he/she chooses, unless otherwise ordered by a court -appointed guardian. The facility shall establish • policies and procedures forhandling residents' funds, !nds, as specified in Section S-15-3- 2 VA) of this Chapter. Quarterly written reports shall be provided to each resident or representative to account for those funds which the resident or representative has authorized the facility to manage. (' ) Each resident shall be provided safe, adequate storage for personal property, clothing, items of value and personal funds kept in The lnoividual:c room, consisting of at least one (1) piece of furniture with a locking device controlled by the resident. (K) Each resident shall be given the opportunity to wear his/her own clothing, and use his/her personal property. Clothing shall be labeled with the resident's name and shall be of proper tit, in good repair, and clean, whether furnished by the resident or the facility. (L ) Each resident may refuse to work for the facility. When the resident agrees in writing to work for he facility in other than an approved work. Therapy program specified in the individual care plan, the facility shall pay at least minimum wage as established by State or Federal legislation and shall maintain payroll transactions available for inspection by the Department. (M) Each resident shall have access to inspect and copy all records kept by the facility pertaining to all services of the facility which the resident has received. (N) H resident may present complaints on behal+ of self or others to the resident ,advisory council, the facility administrator, the legally -designated ombudsman program, the Department, State or Federal governmental agencies or other persons without threat of discharge or reprisal in any manner whatsoever. 0) Each resident shall be permitted the frpe exercise of religion. Upon a resident's request, an administrator shai 1 make arrangements for a resident's attendance at a religious service of the resident's choice. if transportation cannot be arranged by The resident and if the resident so requests, the facility shall incur any reasonable costs for the resident's attendance at such service. No religious beliefs, practices or attendance at religious services may be imposed upon any resident. (P) Married residents shall be permitted to reside in the same room, unless it is deemed medically inadvisable by the attending physician and so documented in the residents'' records. (Q) No resident shall be subjected to research or unusual, • hazardous or experimental treatment without express written and informed consent. All research or unusual, hazardous or experimental treatment involving human subjects must be approved by the facility's Medical Director and. institutional Review Committee, as prescribed under Rules -20- 12 i-,. a !Q l = i a t 1 0 health. rrior _ mar tics' r!_1on 1n such research: wr ttcn t- - consent shall be obt dined f'r om each resident or his her at it-dl minnd 5t`l al 1 be pl aced i n the M-ocl `ljef'T ;'?ea Record. cry) H resident =_•hall be permitted to retain the services ci' h i sr her own personal physician, regardless of whetner one resident !utilizes the facility's medical staTf , at his/ er o!•4n expense, or u:+hether the resident is under an i ndl - i d is 1 or group plan of health insurance, or under- any public ar- private assistance program providing such cover age. t :'ery resident shall be permitted to obtain -From his/her *own physician or the physician attached to the facility complete and current information concerning hisi'her- medical diagnosis, treatment and prognosis in terms and !=ngua=pe th= resident can reasonably be expected to under -stand. Every resident shall be permitted to participate in the planning of his/her total care and medical treatment to the e:c!­ent that his/her condition permits. ( The i aci l i t'i shal 1 make avai !able one i ;.i 1 --i =ngt:i mi r r' �r cn each resident floor for use by res l deents. k:Ti Staff shall not use residents' rooms for personal pur-p=oSes. =,!JI ! he adrrii ni 5trator shall insure that rest dents may have on vate visits at any reasonable hour and that space is. available for such visits. All persons entering a fa=_-ility shall promptly notify appropriate facility personnel of their presence and shall upon request, prodLICe identification. The facility shaii establish policies and procedures regarding the role of visitors and documentation of visits by non-f aci 1 i ty personnel, and shall conspi CUO ! l y post them for review by visitors and residents. I1; addition: 1. The facility shall retain the responsibility for monitoring and supervising of residents while they are engaged in facility -sponsored activities with visitors and .iolunteers, except as prohibited by the resident s rii_h�_ to privacy. The adml n i stra.tor of a f aci 1 i t`-�' may refuse rse a`res= _� Any person if the presence of that person in the faci ; r.- Wc=!!id bje injurious to the health or safety of any resident, Wou1 d threaten the security of any resident's property, or i7, she purpose of the visit is commercial. Hn,; person refused access may, within ten (10) days of the denial of a--ce_s, request a hearing under Section S-15-6. In that hearing, the burden of proof shall be on the +aci l i ty. This section shall not limit the power of the Llepar-t;ment or other public agency otherwise permitted or required by law to enter and inspect a faci i i ty. i'Y ) The facility shall prepare a document i temi 74 n �g A-!! belongings of the resident. This document shall be (kept in the residents medical record and sh-all be updated que.rterly and upon the acquisition of any new items. (!i The transfer of a resident from one room to another within the facility shall occur in accordance with facility procedures. Residents shall be given notice of the proposed transfer stating the reasons for the trans+er. The resident • has the right to be present end to participate in the packing and moving of belongings. '=l. i TRE11 I - T 1 r :-1�-.•T--': FACILITY F:_ ►� E � T =, h fo 1 o�<ei !g are reQ!iirements for all facilities: _1_._ (H? I c, protect the resident's fun+.~,,s, the facility: 1 = Shai 1 , or his/her explaining and listing charged and resident or statement; at the time .of admission on provide _anh .r_si;den : representative with a written statement the resident's rights regarding personal the services for which the resident will obtain a signed acknowledgment from cam each representative that he/she has received funds. be -r h e •2. May accept funds from a resident for safekeeping and management, if it receives written authorization from he resident or his/her guardian or representative; such authorization shall be witnessed by a person 'wo has no pecuniary interest in the facility or its operations and who is not connected in any 'ray to the facility or the administrator; 3. Shall maintain and allow each resident access to a written record of all financial arrangements and transactions involving the individual resident's funds; 4. Shall provide each resident or his representative with •a written itemized statement, at least quarterlY, Of all financial transactions involving the resident's Binds; 5. Shall purchase a surety bond to guarantee the security of the resident's finds; r, Shall keep any fends received from a resident for safekeeping in an account separate from the facilitY'_ 7. Shall deposit any funds received from •a resident in excess of one hundred dollars ($100.00) in an interest -bearing account insured by agencies of, or corporations chartered by, the State or federal government is the account shall be in a -corm which clearly indicates that . the facility has only a fiduciary interest in the + nds and any interest from the account shall accrue to the resident. The facility may keep up to one hundred dollars (r.10 j. 0+_i) of a resident's money in a noninterest-bearing account or patty cash fund, to be readily available for the resident's current expenditures. G. 'shall return to the resident, upon written request, all or part of the resident's funds given .the facility for safekeeping, including the interest .accrued from deposits; 9e Shall ay any monthly allowance to whichresident isp- _ entitled in that resident's personal account or give it to the resident, unless the facility has a written authorization from the. resident, the resident s guardian or representative, to handle it differently; 10a Shall establish written policies governing operation of the petty cash program, and shall print such policies in _ne residents handbook; shall post hours of the petty cash program outside the office from which it is conducted and designate at least one (1 ) staff member to be available during all hours of the program's operation; 11. Unless ess otherwise provided by State law, upon the death of a resident, shall provide the executor or administrator oil of the resident's estate with a complete accounting of all the resident's personal property, including any *+Ends of the resident being held by the facility; 12. If an adult resident is incapable of managing his/her funds ,,ds and ,^soes not have _. representative Or guardian, -Me facility shall notify 'i' h e office of theState Guardian :o f the Guardianship an'dAdvocacy Commission; and 13. I": the facility is solo, shall ,pr ovi "d e the _'uyer - wi th a written verification by a certified public accountant of all residents monies and properties being transferred and obtain n a signed receipt from the new owner. (B) Before a person is admitted to a facility, .and upon emp i ration of the period of previous contract, or when the source payment - the resident's s e changes from • _�J�lr�_ �"!' p_.,m_n'� for - r-=_�i nt �-�ar-•_ han,��_, - - private to public funds or from public to private Tl:nC.s, written contract shall be executed between a facility and the following in cider of priority: (1) the person; 2)guardian; or (•_) the resident's representative. An adult person shall be presumed to have the cap a ci t• •.. to contract for admission to .a facility unless he/she has been adjudicated a "disabled person" within the meaning of section! 11a-2 of the "Probate Act of 197," M. Rev. St._t, 3 Ch. 110-1/2, as now or hereafter- amended, or !_roles_ a petition for such adjudication is pending in a circuit c='!`r't of Illinois. If there is no guardian, resident's representative, or - member of the persons immediate family available, able or - willing to execute the contract required by this Section and a physician determines that the 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 court order has been entered allowing residential placement of the person, that person may be admitted to a facility before the execution of _=t contract required by this Section; provided that a petition for guardianship is filed within fifteen (15) days of the person ' s admission to a facility, and provided further that such a contract is executed within ten (10) days of the disposition of the petition. • No person shall be admitted to a facility i -!: he/she :objects, orally or in writing, to Such admission. The following requirements shall apply to all written contracts between a resident and a facility' 1. The contract shall be written in clear and unambiguous language and shall be printed in not less than twelve ?. ! ) point type. y. The contract shall include and specify: a. The parties and the term of the contract; b. The services to be provided under the contract and the charges for the services_; C. The services that may be provided to supplement the contract and the charges for the services; d. The sources liable for payments due under the contract; e. The amount of deposits paid; f. The rights, duties, and obligations of the • resident, except that t;-!+_ specification Je �f ar esi d;=nt be furnished may furnished on separate document which complies. with The requirements of Section B-1 — --2(H); g. The name of the resident's representative, if any. agreement between the resident and the resident's representative, which agreement authorizes the resident's representative to inspect.and :_:_p, the resident's records and authorizes the resident's representative to execute the contract on behalf of the resident required by this Section; h . A provision that if the resident is compelled by a change in physical or mental health to leave the • facility, the contract and all obligations thereunder may be cancelled at the resident's request without advance notice. it shall .also provide that in , ail other situations, -, resident may terminate the co('f=t,'_act and all obligations under it with seven (i ) days'' notice. All charges shall be prorated as of the date on which the contract terminates; and, F l o, if a n y payments have been made in advance, the excess shall be promptly refunded to the resident. This provision i_.+ n-,tisi_n shall � apply to life -care contracts, through which a facility agrees to provide maintenance and care for a resident throughout the remainder of his/her :lire, nor to continuing -care contracts, through which .a facility agrees to supplement all available farms of financial support in providing maintenance and care for a resident throughout the remainder of his/her life; i. A provision that the facility shall give thirty ( 0) dayso prior written notice of any contractual modification to the resident or residents guardian and to any residents representative. Said modification shall be clearly and fully described; and .7. An authorization for the facility to obtain or - provide information -.from or to any health facility, hospital, or physician regarding the resident a care or - treatment. • 7.In addition to all other contract specifications contained in this Section, contracts shall also specify: a. Whether the facility accepts medicaid clients; b . Whether the facility requires res a deposit prior o t ._ the establishment of Medicaid eligibility; C. In the event that a deposit is required, the procedure to be followed for the return of such deposit to the resident or the appropriate family member or of the person; d. That all deposits made to a facility by __ resident or on behalf of a resident shall be returned by the facility within thirt•., (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 illinci_ Department of Public Aid; and E. That, pursuant to section 2-202(f: ) of the State Act, it shall be .a business offense for a facility knowingly and intentionally Moth to retain a resident's deposit and accept Medicaidpayments � ` p_., m,=nts on behalf r �f the {r= resident. • 4. A cop; of the contract shall be given to the resident and his/her representative, if any, guardian, if any, c :r- any other person who executed the contract. A copy of The contract for a resident who is supported b.., nonpublic funds other than the resident's own funds shall be made ?a avai _ G 1 e -24- to the perEon providing the funds for the resinent'-E- uppor _. The original or _. copy of the _on7-ra=_r shall be maintained in the facility and be mad`' available tff-= n request to a ese t ac es of th Dep r ment and the, , it ._ c -._!fir-__._.l _ _ _ _ Illinois Department of Public Aid ``_. Contract terms are binding upon the facility ,end do no-- pc become void if ownership or administration changes. (%) Each facility shall establish a resident advisory council as defined in this Chapter. • 1. The Administrator shall appoint a staff person, - preferably r i- :r Activities o Social Services, c es, `o act as from H_-_i i � e=' r i•_ � r _ - Resi dent Council Liaison. The Liaison _hall be responsible for-. a. Establishing =! schedule of council meetings, to b held monthly, not conflicting with other regularly scheduled activities for that time period; b. Securing a room which can acc^ltir?3c?date at leas_ one-fourth (1 /4) of the facility's average census, which room is equipped with sound amplification devices for the hearing -impaired and which is fully accessible to the physically -impaired; and c. :assisting the council officers in preparing and disseminating the agenda/order of business prior- to each meeting, gathering informational items to share with residents during the meeting, assisting in recording and distributing the minutes, and preparing other reports as deemed :-necessary by the council. d. Consulting with the Community Representative(s) when working with the council officers to plan their meetings. The Liaison may also consult with the legally -designated ombudsman regarding meeting preparation. At no time shall the Liaison conduct the • meetings or be a member of the council. 2. There shall be at least one (1) representative from each floor of the facility, but not less than fife (_=) residents elected to serve as members of the council. By-laws of the council shall specify the method(s) to be used to elect the council, such as general elections for the entire facility or floor- elections for the residents of each floor. in facilities of fifty (50) beds or fewer, the entire resident population may be considered the resident advisory council. a. In addition to elected resident members, there shall be community representatives. in: facilities of less than one hundred (1 i ji j) beds a _here shall be one (1 ) community representative. In facilities of one hundred (1==x6) or more beds, there shall be two (2) community representatives. Officers of the council may consult with the ombudsman for assistance in selecting community representatives. The community representative may have the following responsibilities: 1) Represents the residents of the facility in community -based settings, meetings, and conferences; _) ;`lots as liaison of the community to the facility; Provides assistance as needed to the officers of the • council in preparing the by-laws, agenda, and order of business of the council meetings and may assist in facilitating the discussion at meeting_; and 4) Attends training and orientation offered by the -ti c � .1 ,r.-de _n.ii"=�-�i!r���s,.�r3i�-.af1_1...7. _r _...., ��:-� =:.._j s:j _-.---� i residents' rights; b ), definitions of nursing ng homes and in -mg terct; c=•ar e in general; and ci listening skills and group dynamics. b . There shall be at least a President, Vi ce--- President, and Secretary serving as officers of the council. Ozt'icers shall be responsible fOor Creating • the bylaws of the council and insuring -t�-,at Fhey are approved by the full council. 0 t- + i ca-rs sTIC?{ seek. assistance f rom the 1 i ai son and the s]mb� !'•dsmaan in preparing the bylaws. Other of+ices may be establi.=-hed in the council' bylaws. 3. Council bylaws shall establish terms of of f i r-e far council members and officers. 4. fleet i n g s of the r e s i dent advi scary cour:ci l s, ;a1 . b,G open to 2.1 1 rest dents of the f a ci 1 i ty. A portion of each :? aeti ng shall be reserved for input from residents woo- are not elected members of the council. and voting on actions may, be limited to the elected members of the council, unless otherwise specified in the Council.'s bylaws. 5. Minutes are to be kept of all meeting_. Copies small be available for all residents and given to the facility administrator. A copy of the minutes shall al so be given to the ombudsman upon request. J.D) A facility shall immediately notify the resident's next Of kin, the guardian, if any, the resident's representative, and the resident's physician of the resident's death or when the resident's death appears to be imminent. (E) A facility shall admit only that number of residents for • which it is licensed. (F) 1. Facilities shall comply with the requirements set forth in Fart 4 of the Nursing Home Care Act, 111 . Rev. ' tat. , Cht. 111-1/22, par. 415 -401 - 4153-4L•= (1987) with regard to discharge or transfer of residents, except that the term Department shall mean the Department of Health of the City of Evanston within the context of this Chapter-. �n. A resident shall be discharged upon his/her request no later than seven (7) days after notice to the facility, and assistance shall be offered in developing a plan for a. new living arrangement. 71. Within ten (1()i days of discharge, all valuables, and personal property shall be returned to the resident. 4. A record of the date of discharge and the reason far discharge shall be made. The disposition of funds and valuables held for safekeeping, and the farwardinQ address of the resident and the representative shall also be made in the resident's record. 5. No resident shall be discharged ogle ,_a the exercise of any legal rights) _arising under this Chapter, t+ce laws of the United States, the State of Illinois, and other • ordinances of the City of Evanston. N. Hospitalization is not a discharge within the meaning at this Chapter-. All discharge procedures mU!_.t be followed if a resident is not to return to the facility. A facility shall not involuntarily transfer or discharge a resident except or medical reason-; for the resident's safety or for the safety 04 other residents, the facility staff or facility visitors; or for late payment or nonpayment of the resident's stay, except as prohibited by Titles XVII and ;SIX 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 forty-five (45) days after submission of a bill, the facility may send a notice to the resident and • responsible party requesting payment within thirty (30 ) days. If payment is not received within such thirty (30) days, the facility may thereupon institute transr er or discharge proceedings by sending a notice of transfer or. discharge to the resident and responsible party b registered or certified mail. The notice shall state, in addition to the requirements of section 3-403 of the State Act and Section 8-15-=-:• 0) (2) of this Chapter-, that this 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 does not apply to those residents whose care is provided under the Illinois Public Hid Code, Ill. Rev. Stat. , Ch. 111-1y2, per. 415. -401 (1?87) . Involuntary transfer shah be governed by the following procedure: 1. involuntary transfer or discharge of a resident from a facility shall be preceded by the discussion required gender Section 5-15- -2 0)7 below and by a minimum written notice of twenty-one (21) mays. The twenty-one (21) day requirement shall not apply in any of the following instancesa a. When an emergency transfer or discharge is mandated by the residents health care needs and is in accord • with the written orders and medical justification of the attending physician; or b. When the transfer or discharge is mandated by the physical safety of other residents as documented in the clinical record. 2. The notice shall contain all of the following: a./ The stated reason for the proposed transfer or discharge; b. The effective date of the proposed transfer or discharge; C. A statement in not less than twelve (12) point type, which reads; "You have a right to appeal the facility's decision to transfer or discharge you. If you thine: you should not have to leave this facility, you may file a request for _a hearing with the Evanston Health Department within ten (10) days after receiving this notice. if you request =. hearing, it will be held not later then ten (10) days after -roar- request, and you generally will not be transferred or discharged prior to the expiration of thirty (0) 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 Evanston Health Department at the telephone number listed below"; d. A hearing request form, together with a postage -27-- fir add -'s sed envelope to the Department; and E. The name, address and telephone number of the person charged with the responsibility of supervising the transfer or discharge. _ ... 3. y request for •a nearing made under Section 8- 1 5_ - (G )� 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 twenty-one ( days as described under paragraphs ai and {b) of Section B-15-3-2(G) i above develops in the interim. • 4= A copy of the notice required by Section B-15-3-2CG1.� shall be placed in the resident's clinical record and a copy shall be transmitted to the Department, the resident, the resident's representative, and if the resident's care is paid for In whole or in part through Title XIX, to the Illinois Department of Public Aid. 5. When the basis for an involuntary transfer or discharge is the result of an action or inaction y the Illinois Department of Public ;=sit with respect to = recipient of Title h I F: and a hearing request is filed with the Department of Public Aid, the twenty-one 21) day written notice period shall not begin until a final decision in The ,Matter is rendered by the Department of Public Aid or a court of competent jurisdiction and notice of that final decision is received by the resident and the facility. 6. When nonpayment .is the basis for involuntary transfer or discharge, the resident shall have the right to redeem up to the dace that the discharge or transfer is to be made and then shall have the right to remain in the facility. '. The planned involuntary transfer or discharge shall be discussed with the resident, the resident's representative, guardian, and person or agency responsible for the resident's placement, maintenance and care in the facility. • The explanation and discussion of the reasons tor - involuntary transfer or discharge shall include the f aci 1 i t, administrator- or other appropriate facility representative as the administrator - s designee. The content of this discussion and explanations shall be summarized in writing .and shall include the names of the individuals involved in the discussions and made a part or the resident's clinical record. • S. The facility's social worker shall otter the resident counseling services before the transfer or discharge of the resident and shall document the offering of such services in the resident's medical record. 9. A resident, subject to involuntary transfer or discharge from a facility, or the resident's guardian shall have the opportunity to file a request for a hearing with the Department within ten (10 ) days following receipt of the written notice of the involuntary transfer or discharge by the facility. 10. When the basis for involuntary transfer or discharge is other than action by the Illinois Department of Public Aid -28- with respect to the rifle nl;. Meoi a d recipient, _tit_ Department hall hold c? hearing at the resident s t.ac3 i -i r not later than ten (10) days after a hearing request is. riled and render a decision .within fourteen (14) days after the filing or the hearing request. The nearing shall cre conducted as prescribed under Section B-15-6. In determining whether a transfer or discharge is autho3riced, the burden of proof in this hearing rests on the person requesting the transfer or discharge. i 1. , if the Department determines that a transfer fer- or • discharge is authorized under :erection B-s 5- -L 0) , the resident shall not be required to leave the facility be, -ore the thirty-fourth day following receipt of the notice required under Section S-15-=-2(6)2 or the tenth, day following receipt of the Department's decision, whichever is later, unless a condition which would have allowed transfer or discharge in less than twenty-one (21) days as described under- paragraphs a. and o. of Section B-15-=-2(G) i develops in the interim. 12. An owner of a facility licensed under this Act shall give ninety (90) days, notice prior to voluntarily l';f -losing .a facility or closing any parr of a facility if closing such part will require the transfer or discharge of more than ten perc ent cent (10) of the residents. Such notice shall be given to the Department, to any resident who must be transferred or discharged, to the resident's representative, and, if practicable, to a member of the resident's family. Notice shall, state the proposed date of closing and the reason for closing. The facility shall offer to assist the resident in securing an alternative placement, and shall .advise the resident on available alternatives. ?There 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. The facility shall comply with all applicable laws and regulations until the data 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 Sr-15-4-12. (H) Each facility shall distribute a handbook: printed in not less than twelve (12) point type to be given to each resident and his resident representative, and/or- family. Residents shall be given a copy of the handbook at the time of admission to a facility or as soon thereafter as the condition of the resident permits, but in no event later than forty-eight (48 ) hours after admission. Said handbook shall be updated annually. The handbook shall i ncl uden 1. H list of all rights and responsibilities enumerared .above in Sections e-15-3-1 and 9-15-=-2, and those additional rights listed in the State Act, sections _`n;;_ii through 6 y, ?. A statement of services offered by the facility and any charges for which the resident is responsible; . H current guide to all required red costs for residence in the facility; - 4. A summary of the policies and procedures of the facility for implementing the rights and responsibilities enumerated above in Sections 8-15- -1 and 5-15-=-2. The policies shall include the procedures for the investigation and resolution • of resident complaints as set forth in Section 5--15-4-6= 5. The address and phone number of each of the following agencies and a brief description of services provided by each agency: _.., Evanston Health _ Department b„ Evanston Commission on Aging - Nursing Home Ombudsman C. Evanston Mental Health Board d. Cook County Legal Assistance Foundation, Inc. e, Adult and Child Guidance Center, St. Francis. • Hospital f . Evanston Hospital Crisis intervention and Referral Service g Family Counseling Service of Evanston 3{_'d 3k ki_ vat l ey h. Local Social Security Office i. i l l i not s Department of Public Health 3. Illinois Department of Public Ai k:. Illinois Department of Mental Health 1. Protection and Advocacy, Inc. b, The procedures for the discharge of .a. resident from a. facility, including information On transferring public assistance, social Security, Supplemental Security inc-me QSJ ? , or other payments; 7. A Summary of the policies and procedures regarding the petty cash program; 8. A summary of the policies and procedures regarding • advanced directives, including blank: copies of directives, as found in the Illinois Living Will Act, !!i. Rev. Stat. Ch. 110-1i2, paragraphs 701-710 (1987); the Illinois Durable Power of Attorney Act, Ill. Rev. St at , , i h . i 1 � �-1 i 2 paragraphs 801-1 to 804-12 (1987); and additional 'directive_ approved by the Evanston Commission can Aging; and .. A summary of the smoking rules of the facility. if a resident is unable to read the handbook, it shall be read to the resident in a language the resident understand_, including sign language. In the case of a minor or person, having a guardian or representative, both the resident and the parent, guardian or representative shall be given a copy of the handbook. For blind residents who read braille, one i 1 i copy of the handbook: shall be translated into braille .and made available to them. (I) The facility shall insure 'Chest its staff is familiar with and observes the above rights and responsibilities enumerated in Section 8-15-3-1 and 8-1 5-?-2. (j) Every facility shall conspicuously post in the lobby the following: 1. its current license; 2. y description, provided by the Department, Of complaint . procedures established under Section B-15-4-6 and the name, address and telephone number of a person authorized by the Department to receive complaints; 3. A copy of every order pertaining to the facility issued by the Department or .a court; and •"{•. `'S list of the material available for public _?=•ec_ii; under Section -1 5-="..:(K) . _,. Name, address, and telephone number of the Nursing i-i_m Ombudsman Program. (K) i facility shall retain the following for Public inspection.' 1. H complete copy of every Report of Findings, Facility Response, Statement of Violations, and Plan of Correction W the facility received from the Department including • operation under previous ownership during the preceding five (5) year 2. A copy of every order pertaining to the facility issued by the Department or a court during t fe preceding five (_ ) 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; A. E copy of The statement of ownership required by Section B - 1 5-i-i (E) I , 5. A record of personnel employed or retained by the facility who are licenser, certified or registered by the Illinois Department of Professional Regulation; 6. H copy of the resident handbook; and %. Minutes of resident council meetings for the past two _') years. (L) the following shall apple to the employment of all certified nurse's aides: 1. No person shall act as a certified nurse's aide in .a • facility, nor- shall any person under any other title, not licensed, certified or registered to render medical care by the Illinois Department of Professional Regulation or - Illinois Department of Public Health, assist with the personal or medical care of residents in a facility] unless such person meets the following requirements: a. Be at least eighteen (13) years of age, of temperate habits and good moral character, honest, reliable and trustworthy; b. Be able to communicate clearly in English or a language understood by a substantial percentage of the facility's residents; c . Provide evidence of employment or occupation, if any, and residence for- two (2) years prior to his/her present employments d. Have completed at least eight (8) years o= grade school or provide proof" of equivalent knowledge; S. Have successfully completed the Basic Nursing ng Assistant Program and passed the Certified Nurse's Aide pryoficiens=`, exam within 45 days of employment in a facility. Equivalency for the Basic Nursing Assistant Program ,may be established by one of the following' • 1) Documentation of successful completion of a training course approved by another state as evidenced by'a diploma or certificate and approved by the Illinois Department of Public Health. The applicant must document that the course is equivalent to, or exceeds, the -requirements of the State Act. 2) Documentation of auccessful completion of a nursing arts course in an accredited nurse - training program as evidenced by a diploma, certificate or other written verification from the school. f. Be familiar with and demonstrate genjeral skills related to resident care. 2. Application forms which are utilized for the employment of certified nurse's aides shall include an inquiry related to any prior felony conviction record. 3. Certified nurse's aides shall perform their duties under the supervision of a nurse. 4. It is unlawful for any facility to employ any person in the capacity of certified nurse's aide or under any other title not licensed or certified by the State to assist in the care of residents in such facility unless such person has complied with this Section. 5. Proof of compliance by each employee with the requirements set out in this Section shall be maintained for each such employee by each facility in the individual personnel folder of the employee. 6. Each facility shall certify to the Department on a form provided by the Department the name and residence address of each employee, and that each employee subject to this Section meets all the requirements of this Section. 7. Any facility which is operated under Section 8-15-1-4(B) shall be exempt from the requirements of this Section. - (M) 1. The facility shall have a quality assurance program which addresses all departments, services and categories of staff who have an impact on resident care. The program shall be developed, implemented, systematically monitored, and evaluated in accordance with the residents' individual care plans and the desired outcomes of this Chapter. The findings, conclusions, recommendations, actions taken, and results of actions taken shall be documented and reported to the Administrator through channels established by the facility. The Administrator is responsible for appointing a person to coordinate with all departments and services to implement the components of the quality assurance program. 2. The quality assurance program shall consist of the following components: a. A written quality assurance plan which includes: (1) The facility's philosophy statement; (2) The goals and objectives of the facility in relation to quality assurance; and (3) A statement which describes the scope of quality assurance` including its integration and coordination among all facility departments, and that states which staff position is responsible for the quality assurance program within each department or service. (4) Criteria, indicators, and evaluation mechanisms to assure the quality and appropriateness of care for: ;,a) Nursing service3 (b) Medical care (c ) Social Services 4dt Psychological rehabi l i to t i'=,ef haoi l i t - -i =e care (a) Activities program is f• Medication (g) Dietetic services. (h ) Oral health care (i) Housekeeping, laundry and environmental service (5) Facility -wide monitoring and evaluation of: (a) Resident satisfaction (b) Admission and discharge criteria (W Infection control (d) interdisciplinary planning and care {,_} Interagency communication and linkage (+) Emergency care and hospitalization (g) Use of restraints b. An audit system to sample at least annually a representative number of all residents` records. C. A method developed within the program to initiate is action when opportunities for improvement are identified in the course of systematic quality assurance monitoring and evaluation. d. A method developed to insure that actions taken result in measureabl e improvement in the quality ' of resident care. 3. The quality assurance program's objectivesi accp_, organization, and effectiveness shall be examined at. least annually and revised as necessary. VN) The following continuing education programs shall be required. 1. Every facility administrator- shall complete annually a six ib? hour training program, which shall provide information and skill development on aging, cognitive impairment, mental illness, or developmental ;disabilities! and which shall be approved by the Director. . Documentation of course attendance stall be maintained in the administrator's personnel tile. •'. Each facility in which twenty percent (20%) or more of its residents are mentally -ill shall provide or arrange for a formal, structured in-service training program for all nurse's aides to include information and _kill development for the care and management of persons with mental. illness. Such training program shall be approved by the Evanston Mental Health Board. his program shall be a minimum 0-f twelve (12) hours in length, stall be provided quarterly to each current employee, and shall provide for sequential learning. Any newly employed certified nurse's aide `.rill !ir•+urs of orientation information covering the special needs of he mentally -ill. Documentation of _l± _=nd_Src e in the orientation program and/or the in-service _raining program shall be maintained in each employee's personnel file. 3. { Facility which twenty percent i— % Or more Of its residents have +a developmental disability shall re_1d_ti_ or arrange for 3 formal, structured in-service training program for all nurse's aides to include information and skill development for the care and management of persons • with developmental disabilities, including habilitation training according to Federal Health Care Financing Administration Standards. Such = training program shall b approved by the Evanston Mental Health Board. This program shall be a minimum of twelve e i._? hours in length, shall b provided quarterly to each current employee, and shall provide for sequential learning. Any newly -employed certified nurse's aide shall receive, j within iourteen S1 f days of employment, six (6) hours of orientation information covering the special needs of residents with developmental disabilities. Documentation of attendance in h orientation programand/or in-service training program shall be maintained in each employee =_ personnel file. 4. Each facility in which twenty percent (_ ' ) or more o-f its residents are mentally -ill shall arrange for all nurse_ and clinical social workers to complete at least one continuing education course each year. :such course shall provide information and skill development for the _are and management of persons with mental illness. Documentation of attendance in such course shall be maintained in each e mpioy:ee _ personnel file. 5. Each facility in which twenty percent (0%) or more of its residents have a developmental disability shall arrange for all nurses and clinical social workers to complete at least one continuing education course each year. Such course shall provide information and skill development for fitthe care and management of persons with developmental disabilities. Documentation of attendance in such course shall be maintained in each employee's personnel file, 6. Each facility in which twenty percent (20%) or more of its residents have a cognitive impairment shall provide or arrange for a formal, structured i n-eervi ce training program i or all certified nurse's aides regarding the treatment, care and management of persons with cognitive impairments. The training program shell be approved by the Evanston Commission on Aging. The program shall be a minimum of three . = i hours in length quarterly; shall be provided to each current certified nurse's aide, and shall provide sequential learning. Within fourteen ice}! days Of employment, each newly -employed certified nurse's aide shall receive, in addition to orientations three (3) hours o-f training rjegarding the special needs of residents with cognitive impairment (s) . Documentation of the training program shall be maintained in each employee's personnel Ole. 7. Each facility in which _went`, percent (20%) or more 0+ its residents have a cognitive impairment shall arrange for all nurses and clinical social workers to complete at least one continuing education course each year. the course shall pWa'•>ide for information and skill development regarding the • treatment, care, and managements of persons with cognitive 's.) impairment. Documentationof attendance in he course shall be maintained in each employee's personnel file. .t I 1. For all legallycomp+=tent residents, the facility small inform the resident, by way of a form provided by the Department, of the right to r'!ame a resident's representative to ,act on his/her behalf through a. !r _ bi = power oi attorney 4 - in the event that ne/she-can no longer decisions as to his/her -=r medical is financial needs- h-,_ facility shall also provide assistance to all residents as may be necessary or .==it-}p:. opriate to naming I . esi___ _ s � - repr senta_i�`1e. Documen ii... _a iok 6 the �i k of a ! ==iN6 a representative or ecl ti' to name a representative shall be made part of the re=j.den s medical record. 2. For all alleged disabled persons (residents), as defined in the illinlls Probate Act. i1!. Rev. St•_r. p • Chapter 1 0-.t t: ._, Section !.la-_y_ the facilitysnail file -Or cause to be filed a petition for appointment o a legal guardian with a court Of competent jurisdiction ti+=n within sixty (60) days of admission to the facility. 3. For current residents who have not d-_i gnat=d a resident'_ representative and .are alleged disabled personsi as defined in the Illinois Probate Act, M. Rt_'+i. Sta_:. 9 Chapter 1 fSection the facility shall file or - cause to be filed a petition for appointment of a legal guardian with a court of competent jurisdiction 'within si.`:?=y (ire_)) days of the determination of the alleged disability. 3. To the greatest extent feasible, the facility shall encourage involvement of the representative in the care and treatment of the resident. (P ) The facility shall establish a resident grievance procedure which provides the process by which a resident may raise an issue, concern, problem, or file a complaint and obtain a resolution. This grievance procedure shall be included in the residents' handbook. At a minimum, this procedure shall. i. Identify staff responsible for receiving resident grievances; 2. Require staff to write the grievance as presented, on a • term developed bythe facility and give the grievant a copy of the form; 3. Allow groups of residents such as the resident council to file a grievance on behalf of a resident or a group of residents; 4. Identify staff responsible for investigating grievances; 5. Provide documentation on to the grievant of the outcome of the investigation and any actions which result; and 6. Provide written information to residents concerning :ether resources for grievance resolution, including b it not limited to: a. Evanston Health Department b . Commission an Aging - Nursing 't3ome Ombudsman +_ . Cook County Legal Assistance Foundation d. Protection and Advocacy, inc. . Evaluate all complaints monthly to assess the need for change in procedures, staff or programming to serve We residents. • (iQ) he facilit`! shall: 1. Develop and implement written -interagency linkage agreements with community ,agencies and nospital's that are -_5._ '•_!=�'d''_ r p_i din _S. _^ _�`���' ;!_�; it-t_ -�- r, ri in-Form-ation To ai.an r?+ ecti,'e1 Tr:r- rt,-e-nT=•; a summary of any resi d=fiT. ' S i i tdi `l i dt_!al c ire plait, social hi stcr{, and medic al record lwitn the resident _ written consent, t0 any agency or h0=..pital whi ii _h -ssu ,� s�_ - mt_s an i responsibility -For the resident's care .and supervi si .fin; Communicate with the resident T rac t c E_. e. r'. � 1p i bl = -r- td ._rte hospital staff every three (? ) days vjh i l o the resident- is i rt • the hospital. free date content Of c, r� P da__ and rite o_.ttTt!!ni cation=- sh_sl l be documented in the resident's medical record at the facility; and programming t etGe•. a14. Coordinate f- _ and agency. (R) The mobility of each resident shall be as=essed at admission and reviewed as needed by an occupational therapist and documented in the individual care plan. To meet the mobility needs of the residents, the f aci I i tv si-tal 1 1 . Have su$f i ci e n t and gUa1 i + i ed Staf + t0 mteet ? he lTt+ b 1 _ 1 t'' needs Of residents in accordance with ri?eir ifidl''idua1 -a a plans; - 2. Have or obtain services and equipment to maintain or - increase mobility of residents; Instruct residents, staff, family member=., and voi unteers in the safe use of mobility devices and procedures.; 4. Have and maintain all needed equipment in proper- worF::ing ..condition; 5. Insure that the facility's building and outdoor recreational facilities meet the federal standards of • accessibility for handicapped persons; b. Insure that residents have transportation that enables them to have access to needed programs and service_; and 7. Assist residents in being up and out of bed as Much as possible and repositioning residents whether- in beaI Or Out as their conditions require. 5-15-=-_. MINIP•iUM STANDARDS; The following standards shall be deemed to be the minimum standards to be met for licensing pursuant- to th-s Chapter (A) i'aursing; The following personnel requirements shall apply. 1 . Skilled Nursing Facilities and intermiedi ate _.are i-aci1itles; a. There shall be a fFul .-time Di-eci- ;r 0+ "lur :sec licensed as a real stet ed j"jt -Se in the S �.�. ..F. •�t__:ie: 1 he time of the Director of Nurses may not be included in _he nursing time required +o meet the 5ta- - 'q - f-re_1 dent ; a,_i o requirements in the State Standards. b. In facilities of one hundred (10!_Di ;weds or more, • there shall be a full-time Assistant Director Cof Nurses, who shall be licensed as a registered nurse in the State and who shall be on duty between the hours Of seven o'clock: A.M. and seven ❑`clOC?:: <.;- 0? for five (5) days within any weer-: and shall e on dLt*,/o on those days upon which the Director of Nurses is not resident _ dietary card and indicated prominently n, the resident's meal service card. b. Residents continuously rejecting most of '_heir. od shall be brought to the attention of the physician. c. Residents who require assistance with eating shall be given help promptly on receipt of a tray. Patients who are unable to teed themselves shall be fed with attention to safety, comfort and dignity. There shall • be ample time allowed for unhurried meal service. 2. Personnel Requirements: a. Dietary Consultation: All facilities shall have consultation from a dietary consultant who is eligible for registration by the American Dietetic Association; or has a baccalaureate degree with major studies in food and nutrition, dietetics, or food service management, has one year of supervisory experience in 1 the dietetic service of a health care institution, and participates annually in continuing dietetic education. he dietary consultant shall: (1) Schedule most consultation visits during weekday work hours for food service personnel. (2) Provide the service for a duration of four- (4) or more continuous hours per visit. (3) Give the following minimum hours of consultation per month: 1-29 beds As determined by Administrator, Consulting Dietitian and Department 0-49 beds 8 hours per month 50-99 beds 12 hours per month 100-149 bads 16 hours per month 150-199 beds 20 hours per month 200-249 beds 24 hours per month 250-299 beds 28 hours per month 300 and over 32 hours per month I.Tne director of Food service shall be a qualified dietician; or be eligible for registration by the American Dietetic Association as a dietary technician, including an Associate of Arts Degree as a dietary technicians with emphasis in food service management or nutritional care; or one trained and experienced in food service supervision and management in a military service program substantially equivalent in content to the programs above. Correspondence courses shall not be acceptable in lieu of classroom instruction. The Department may waive the requirements of this subsection upon a determination by the Departmentl together with the facility's administrator and consulting dietician, that the food service supervisor or cook manager of such facility is qualified by training, experience, and performance to fulfil! the responsibilities of e + 1 ` ct_ - p the d r-__ r of rood service. ) Social Services: All facilities shall provide e the _ntollr+wlii+ social services: ^ 1. Referral to appropriate agencies where there are . indicators that financial, psychiatric, rehabilitative, legal or social service help will be needed that the facility cannot provide. 2. Assistance with the resident's adjustment to the facility and availability of continuing social services to residents of the facility including the availability of contact with i ami i member_ to keep them involved, on duty. This ,person email assist Me Director ^.' Nurses and shall perform the duties of the Director o—; Nurses when the Director of Nurses is not in the facility. The Assistant. Director, o-f itia_trses t!lcty provide direct patient care, and his or her time may be included in the nursing time required to meet the staff -resident ratio requirements in the State Standards. c . in addition to the Director of Nurses and the Assistant Director of Nurses, ;'where required, there • shall be at least one Illinois licensed practical al nurse in 'charge of each eight (S) hour sift, regardless ='f the size of the facility. This person s duties shall be to provide de professional supervision vi _ion and instruction to the nonprofessional staff. d. There shall be coverage on days off for all licensed staff by Illinois registered nurses or Illinois licensed practical nurses, on all shifts seven (%) days a week. e . Each facility shall employ at least one full s time nurse who has completed a course in restorative nursing approved by the Department. This nurse shall provide in-service training in restorative nursing techniques to all other nursing personnel. The restorative nurse _hall be a person other than The Director of Nurses. 2. sheltered Care Facilities: In facilities of one hundred (100) licensed beds or more, there shall be _. registered nurse licensed in the State or a practical nurse licensed in the State on duty for each eight (8) hour shift witri coverage on days off. In the event all three ._) shifts are covered by a practical nurse licensed in the State, the facility shall have as a consultant an Illinois licensed registered nurse at least sixteen (16) hours a month. In those instances in which a sheltered care facility has .a • skilled or intermediate infirmary, the nurse covering the infirmary may also cover the sheltered care areas. 3. All medications administered to a resident in any facility shall be administered b; a physician, registered _tered nurse or practical nurse licensed in the State. :any licensed practical nurse responsible for the administration of medications shall complete a pharmacology course approved by the Department prior to employment, or within six (6) months of employment. Documentation which demonstrates compliance with this Section shall be contained in each employee's personnel file. All self -Medication administration training programs shall be conducted :by .a person licensed to administer medications in the State. 4. When a resident's condition dictates, the physician tit=•!y give permission in writing for the resident to administer medication himself/herself except when such resident requires skilled care. r, in all facilities there shall be additional personnel to meet the total needs of the residents. VB) Dietary Service: 1. Resident Care Procedures: • a. There shall be reasonable adjustment to the food likes, habits, customs, condition and appetite of u residents. Special attention shall be given individual reside: � to the preparation and service of food to residents with problems such as inability to cut food, to _hew, and to swallow. Such problems shall be charted on -the- t, taif arc rasiaents in discharge planning and its implementation. 4. Assistance in providing in-service training to iactlity staff directed toward understanding emotional problems and - social problems of residents and assistance in solving these problems. 5. Assistance to staff and residents in using c;_.+rmuni-"r'y resources. 6. Service- of a _o?-,al worker according to the following ratio of residents to hours ot service: -99 residents 100-199 ,residents 200--299 residents 00 or more residents i min. /Yeci aent.' we k mire. i re'=ident;"weW: 6 min./resident/week i min./resident/week: .i!-!e amount of social work _if.!_ 5n_.1_ not be less thanthe ratio required for the number of residents in the facility at that time. (D) Mental Health Services: All facilities with residents who are mentally -ill or developmentally disabled shall meet the following staff requirements; 1. A psychiatrist licensed to practice in Illinois shall be finder formal contract by the facility to i provide services determined by the Care Review Committee. 2. Each facility shall have one clinical social wi<eker. Facilities with mentally -ill or developmentally disabled residents shall provide time of a additional clinical social work at the rate of twenty-five (25) minutes per resident per weed_:. (E) Activity Program: • • -.; 1. All facilities shall have an activity program directed by a full-time staff member who shall be qualified to direct an activity program. Qualification shall be established by one of the following: a. Status as an occupational therapist registered with the occupational Therapy Association; or b . A bachelor's degree in recreation therapy; or- c . Evidence of S!_lccessf t_tl . comp l etl on of a forty-two -two (42) hour course certified by the Illinois Ac=7.''=it`! Professionals Associations. Activity directors who do not meet the degree requirements above must ccm P l et e the course within six (6) months after hiring. 2. Records of activity programming and resident participation shall be maintained and shall include program goals, individual resident goals related to the _are plan, attendance records and progress notes. 3. The plan for acti'll•C`,-.' programming Shell incorporate community resources and Shill include group activities to promote learning about interpersonal behavior and individual .activities for residents unable or unwilling to participate in group activities. Physical Therapy: Each facility shall make available to its residents the Services of a registered physical therapist currently licensed by the 'Marta who -.hall implement physicians' orders in the facility. _39- • C: • ( t_ ) Occupational Therapy/Recreational Therapy: apy: All facilities _hall provide the services of an occupational therapist who is registered by the American Occupational Therapy raps Association or =S therapeutic recreation specialist who shall. 1. Complete an evaluation of each resident within thirty (30) days of the admission or re -admission to the facility. . The evaluation shall include an assessment of communication skills, mobility, physical strength and coordination, and self -care status, and shall include recommendations for care and treatment needed to maintain or restore maximum functioning in the above areas. The evaluation Mail be utilized by the Care Review Committee in the review WF resident care required in. Section _i--1 j (H) _. L. Conduct at mast two () ire -service programs Per Year which are designed to arise star- in carrying cut restorative procedures. -- ?"review annually each residents planned and --'t-td'._i_ted activity program with the activi'r_=, director- to plan activities which are supportive of restorative t_=.,r-e need_. (H) Procedures: All facilities shall follow the procedures listed below: 1. Admission Records: A medical history and interim psychosocial history of each resident shall be compiled within seventy-two (7 ) hours of admission to _. facility and filed with each resident's medical record. • :ter- persons with mental illness, the record shall include psychosocial information for the previous three (=) years. A mental status assessment shall be completed within seyJen (:' ' days of admission and filed with the residents medical record. A complete psychosocial assessment shall be completed within thirty (t ) days of admission and tiled with the resident's medical record. 2. Medical Record: H resident's medical record should include medical and social history;, diagnosis, allergies, individual care plan, treatment, restrictions to activities of daily 'living, results of tests and notes on resident's response to care and treatment. In addition, the record should include the flame, address, and telephone fie rtur-ber of the residents physician and the name, address, and telephone numbers of any other person or agency, Wither- than the facility, which provides direct service to the resident. 3. individual Care Plan: The facility shall develop an individual care plan for each resident. There shall be established in each facility a written procedure for reviewing each resident's care plan, for evaluating each resident's short and long-term needs, .and for reviewing the are and Cer`?ices provided based on this evaluation. This procedure shall be the responsibility of a Care Review Committee. a.Composition of Care Review Committee: The composition of the Care Review Committee shall Vary based on the needs of each resident being reviewed; provided that each Care Review Committee shall consist of at least one supervisory nurse, nur -e ' s aide, social worker or clinical social worker, and activity worker who are familiar with the resident being reviewed. For residents with developmental disabilities, the Carr_, Review Committee shall include a Qualified Mental Retardation Professional. For residents with. mental illness, the Care Review Committee shall include .=+ -4 j_. psychiatrist, clinical social wcrkar, and ower ments]. health -professionals. Other_ persons, including representatives from physical therapy, occupational therapy, recreational therapy, dietary, pre.=,rlm='-• ' _ housekeeping, and the resident's physician shall also be included where appropriate. The resident, when able, ew? shall be encouraged to participate in the Care = Review Committee, or shall be consulted by a stiff member for the resident's input into the care plan. The Director may designate additional personnel to be included on the Care Review! Committee based on the needs of the • individual resident being reviewed. b. Function of the Committee: The Committee =i-l.=l.l evaluate each es , e }" s immediate and long-term needs and shall prepare __ rare plan for each individual resident for services to restore and maintain !T;---q__{ i mu;T! functioning. his evaluation shall include_ an assessment of the resident's physical and mental status, the resident's behavior patterns, and the resident's environmental milieu s! + as to identify he current o safety ty problems s _ � the i 'dent r potential sa r �1_ 1e 'r'='�._ . including an evaluation of the resident's self-preservation activities, and the need for precautions to be taken by the facility too protect he resident, including additional supervision of residents. Each Care plan shall contain the following. (1 ) Assessment of strengths and needs of the r:esi dent l including the identification of physical, mental, emotional, and behavioral problems of the resident. () Measurable goals and objectives for the resioen+_ and services (cloth in -hoarse and community -based), to be provided on a twenty-four (24) hour- basis, including type, frequency, and duration. The Care plan =_.n._ll specify which personnel will be assigned to address t!Y problems of the resident, their qualifications to do • so, and what Community services, if any, will be utilized to supplement services provided by the facility. Community Services include, but are not limited to, recreational and leisure activity pr"^gr-ms5 sheltered workshops, vocational training programs, and other word:: activity programs. ( identification of safety precautions to be carried out on a twenty-toy+r (24) hour- oasis, whether in the facility or in activities sponsored by the 'i aci l i ty, by staff, including supervision of residents, and those actions necessary to provide safety for residents Yn,_, are unable to perform self-preservation activities. Pprecautions..tea ss a C.� carried oI!•r v the resident Ti'��_ m•_:{ also b_ rr_ o"," _ - and/or visitors to protect the resident or other residents from potentially dangerous behavior of the resident. (4) Review of drug therapy. () Identification of one professional staff Person -- be responsible for coordinating y the implementation the care plans on each shift.. c. Frequency of Review: The initial _valuations of all n(•'_w residents shall be done within thirty (30) da';-r= of admission. Each resident shall be evaluated at least • every ninety (:0) days except residents requiring _killed nursing cars', who shall be evaluated W: intervals not greater than thirty l:-_ot days for the 'First simty (60) days and at intervals of not greater than ninety (90) days thereafter. A written =_!::7•!ST•l.y:"'•:i of the review shall be entered into the record. a! d appropriate adjustments in the resident's '"are plan hall be instituted. he written r_\li ew shall note any -41 - note any problems identified in reacming established goals. Reviews snail L_k_ place more frequently 1Y there is any change in the resident's needs or K there is any change in the treatment Or services to be rotr; 'i fjiad v d. implementation: Each facility is responsible =ible Or implementing the care plan and for providing tFii-••. services to the resident in accordance with the plan.. • -t Physician's Orders_ All treatme{it_. and procedures shall be administered as ordered b -' physician. However, if a n+_!r-=e, pharmacist or other health professional believes t -!- physician's order is not suited to an individual ; __ide eT he/she must _all the physician to apprise him%fier of the problem and obtain a modified ed order or a confirmation of 1-.hk_ original order. . In any case where orders are not followeQ there shall be documentation in they resident's record indicating the reason That the order was not followed and that the physician was notified. M Advanced d Directives: es: !-=`-h facility jna.11 . 1. Include information regarding a resident's right to '-t• i theresident's handbook k e'.eC�li=2 3n �?�'!'anCe� directive f? -_I"1_ r eq i red i n Section 8-15-=-20) and include - reproductions Of blank: Directives +ound in the Illinois Living Will Act, 11.1.. Rev. :tat., Ch. 110-1/2, paragraphs /'_ 1- 10 (1987)- he 111iofeiC Power of ts!}'iori_ey Act, M. Rev. S aZ". , Ch. 1 _ .Li`2, paragraphs 60--1 to _ (i'. 'f )q and thosi prui-+>:ered by the Evanston Commission on Aging. ,he handbook shall also state that execution of , or refusal to execute, an advanced directive will not affect in any 6'd_.y the resident's stay in, or the services of, the facility. 2. Provide residents, at least annually during the individual care plan conference, or within thin;- ON days • of admission, information concerning advanced directives, provided the resident does not have a legally appointed guardian or has not executed any form of an advanced ed directive. 3. Request est the agent, t_ % resident who has executed durable power of attorney, to participate with that resident, in the individual care plan conference and gin•,f future decision -making regarding the care of that resident. 4. Establish procedures which specify the assistance available to residents seeking c'td`:'ci[-ced directives. his assistance shall include but is nro't, limited to a. providing residents with the name, address, telephone number of the legally -designated o,l-bud'saTlal'j program and Cook County Legal Assistance Foundation; b. _._silting residents in contacting the ombudsman or an attorneys if _o requested, for the purposes o..t. executing advanced directive; C. designating a member o-f t";7ee :_ioe_ia1 Services Department to contact the above named resources and family if so requested by the resident. With consent of the resident, the family and/or representative shall be informed when a resident executes an advanced • directive. _. Establish procedures for the regular review a provisions of advanced directives with r=si dent sa If -a resident with such •a document chooses to change, modify or —42--- cancel the directive, in shall _- properly document_..__ in _n resident's medical record and individual care plan. 6. Maintainadvanced e+"'ir directives in _ readily retrievable place for the duration of a resident's stay. The medical record for a resident with an advanced directive shall have a special marking on he outside of the record .'drd indicating the existence 1f such a document. The resident's identification wristband or other identification worn by the resident shall also be marked to indicate the existence of an advanced directive. Direct -are staff shall be informed • of residents who have an advanced directive. I. Provide, upon transfer to a nospitai or discharge :+_ another facility, the transfer information face sheet which contains notice of or a copy of the advanced directive for the resident. S. Inform all physicians responsible for a resident's care of the existence of an advanced directive. in the event a physician chooses net to comply with the resident's choice of an advanced directive, the facility _hall seek the services of another physician who will comply. if the physician is a private physician, the facility shall assist the resident in obtaining the services of another physician. 9. Provide training and in -services for all direct car staff regarding advanced directives: their legality, .al-:d their effect on Treatment, care decisions, and emer genc-i care provisions. implementation and evaluation of the training and in -services shall be d+_rumenTed and shall i include the names of staff receiving training. W ? Restraints: 1. The 'facility shall develop policies and procedures for the use of restraints. These shall include: • a. Procedures for informing a resident that restraints have been ordered and what to expect during their use; b. Definitions of the types of restraints, including but not limited to. physical restraints, mechanical restraints. Posey belts and vests, the use of drugs including tranquilizers, soft restraints ,chile in gteri chai rs and safety devices and their possible side effects; c. Conditions which warrant a physician's orders for restraint, when lesser restrictive alternatives natives have been unsuccessful in ameliorating the problem; d. Procedures for monitoring and attending to residents while in restraint, including but not limited W repositioning the resident at least once every two hours, or more often, as his/her condition warrants, providing regular meals, and toi l eti ng z e. Procedures r t i H record 1 observations -r_r maintaining record � r of residents while in a restraint; f . Supervision of staff responsible or monitoring _. resident's condition while in •a restraint; and g. Methods to reduce or eliminate the use of • restraints. 2. Documentation shall include who is responsible for monitoring the condition of the residdent g .the time of out each observation, any action _a.._}.]. including nt_-_._- ... l: limited to, repositioning, _along vital _.i tgns providing meals, T of c.9-' i ng and release from restraint. 3. Copies of all restraint t oroars shall be reviewed by the Director Nursing -,r his/her designee of a i' i it�S ±. _Lor of d� _ ng ?� 1S �. n_r >�e� -_i-f 1 _ I.t�_r". l basis. He/she shall inquire iS-;to the reasons for orders of restraints, evaluate the care provided during restraint, and assess the measures being taken to reduce or eliminate the use of restraint. Documentation of This review shall become part of the • quality assurance program of the facility,, _'i._ he facility shall provide in-service training to all direct care staff regarding We use of restraints. It _hall be part of the orientation for all direct care staff and shall be provided quarterly for = minimum of two (2) hours in length. The training shall include information and skill development concerning the facility's policies and procedures, the provisions of this Chapter, State Rules and Regulations, and methods h:Jr's to reduce or eliminate restraint use, and shall provide for sequential learning. Documentation of attendance shall be rec orued in each employee's personnel file. (K) Staff identification: Each facility which has over twenty (20) residents shall develop Jp and implement policies and proce ores which insure that . 1. All current employees will possess and wear- an identification badge which has s their name an^ title printed in easy -to -read block: print; f. Each new employee, upon being hired, shall be issued an identification badge and receive instructions regarding The wearing of the badge; and 410 S. Upon dismissal or resignation of an employee, the facility shall require the return of the badge. (L) Smoking Restrictions: To insure smoking is limited and allowed with proper supervision, the facility shal i g 1. Designate one i 1 i area, per f 1 oor , preferably an area in which there is no ongoing food service, where smoking i permitted by residents and visitors. Smoking shall be prohibited in all other areas, exceptthose established for personl use b staff, , such as offices; or those personal use areas of residents in sheltered care facilities or independent living units as established by faciiitY policy in accordance with restrictions established by the Fire Department. All efforts shall be made to place nonsmoking residents together as roommates, and to .'lace smoking residents together. If a smoker- and non-smoker share a. room, the rights of the non-smoker shall prevail; 2. Equip each 'smoking area with a properly functioning and maintained air cleaner system appropriate to the size of the room to reduce airborne pollutants produced by :smoking; 3. Assess each resident 4 J smokes, as to his/her ability to comply with smoking rules, for the desire tq reduce or • quit smoking, and the need for health reasons to quit smoking. This assessment shall take place at each individual care plan review conference and shall be documented in the carp plan; -44- smoking area. That person shall be present at all times when smokers are in he area and shall monitor the smoking behavior of those residents; 5. Establish policies and procedures es for the use 04 ;.!{oki!'{g areas, including rules to be given residents regarding the use of smoking material's and the hours of operation for it he smoking areas. Such rules shall also be part of the resident's handbook; •6. Prohibit staff from smoking while providing direct_ __re to residents, conducting group activities, or whi i _. in resident care areas, such as bedrooms, examining rooms or - the nurse's station; and C7 • 7. Offer "Smoking Cessation" programs as part of the Activities Program. (M) Provide functional life --saving emergency equipment, including a cardiac board, ventilator assistance bag, and suction equipment (�Provide each resident with a functional bedside cabinet J_ _h a drawer. This requirement shall not affect the requirement to provide drawers in dressers for each resident () Application forms which are utilized for the employment o+' all direct _are staff shall include an inquiry related to .any prior felony conviction record. B-11-3-4: ADDITIONAL NAL STANDARDS: he following _.t.an and Kali apply in addition to State Standards for all f ci liti:= v hereafter constructed, , for existing structures which are hereafter converted to use as facilities, and for all additions to existing facilities: (A) Provide all corridors with six (c) tempered fresh air changes per hour at a rate of two Q) cubic feet per minute per square foot ii Provide all laundry, storage and counting rooms with four (4) changes of fresh air and exhaust per hour at the rate of one and one-half (1-1 /2) cubic feet par- minute per square 'hoot, unless said rooms are `rented directly outside by proper operable windows (C) Provide twenty-+ive (25) square feeT of outside space Per beds (D) provide a maximum total of one hundred (100) beds for a c..j-;elter-ed care facility, and a maximum total of one hundred fifty ({5 i) beds for any combination of skilled, intermediate, or sheltered care facility. No f aci l i'' whether new or existing, shall be constructed, converted, altered, created, or expanded to house more then one hundred fifty f _0) resident beds in a single free-standing struct<<re= (r) i='rovide that residents living Spaces ;.li.•all meet the following st.andards i' __ square feet of floor area 1 0 -i"�,,r, hundred twenty-five .���. - .- - - _ p bed a provided. _ +=r- b•_ shall l be These two hundred twenty-five - +�:a•• feet � c :•e r!r_! {;ne no less than t`�.:_�1 square f_�•_ +�; living =paC�- shall i - one hundred twenty (120) square feet of bed space per single bedroom, one hundred (100) square feet of bed space per multiple bedroom, a{".'-d seventy-five (75) fact of recreational .and dining space .per residents -45- functional closet or wardrobe with a floor area of no less than four (4) square re feet. This area is in addition to the above requirements. If^ J Provide c one ( i -i bathroom equipped d with = �_ -=�=t A f-t,: .. _: r m �-- rye_ ' h least _n_ _i.l: _r each bedroom oom except that one flitch bathroom directly accessible from each of two (2) rooms may serve !_,.-:_h, provided there are not more than four (4) r-=='i'==`nts is-f _.._ provided i 2 rooms. :. addition, c' there shall .1-r'�' one toilet or t Ito .� r_.�m . n d =i n q 1_ � _ - each twenty 1201 resident accessible from the corridor. • r results ; ff,a4r f ) toilets ass !r more, �+`e�:� are `r :_ Where this e_.1_i1 i _h .�• 'i _ _ r be placed in two (`) separate bathrooms, one .for each sex. Each room shall contain a 'sink:. Each resident's privacy shall be preserved. Provide vi: e e ;1/ bathtub or shower er +r.r each =i.. _1 resident beds on each floor with direct acces..., thereto T%-•om he resident's room or from the common hallway. (H) Provide sufficient elevators, maintained in a Sa ' operating condition at a ratio of one elevator for each .ili_i residents and _--staff in a facility. l 1 1 Assure that windows on the second floor and above, accessible to residents have limited openings of no more than 12 inches (one foot). r ;_i-0 ENFORCEMENT: n addition _ion powers and s -:. i_ E I "'i i; ;- i 1_ D the F f' ll o - �, t. responsibilities provided for elsewhere in this Chapter, the Department is responsible for the following' 8-- 1 r-`'-1 e DEPARTMENT iENT TO ENFORCE: The Department shall enforce this Chapter, including the applicable Provisions Of the State Standards. The Department shall utilize the license classifications of facilities according to the levels of service which are established by the Illinois Department of Public Health and shall issue licenses according to these . classifications. B- 1 5-4 -2. COOPERATE WITH OTHER AGENCIES: he Department shall cooperate with departments of State government- including the Department of Public Health, the Department rent of Public Aid! and the Department of Mental Health and Development !i=a_'ii l i ti es, and the departments of the City of Evanston in monitoring facilities, with the goal of assuring necessary, equitable, and consistent supervision of facilities without unnecessary duplication of survey, evaluation and consultation services or of complaint investigations. 8-15 -u-=: INSPECTIONS: The Department, whenever it deems necessary but not less than annually, shall inspect ='ver'--.: facility to determine compliance with applicable l i cen} ur.e requirements and standards. The annual inspection shall occur within one hundred twenty .120! days prior to license renewal. The department may periodically conduct .an inspection at a facility for the sole purpose of consultation. n. An i nsp ction, other than an inspection 04 financial records or for the sole purpose of consultation, shall be conducted without prior notice o the facility., 8--15-4-3la. . INSPECTION CRITERIA: In determining whether to make more than the required number of unannounced inspections of a facility, the Department may consider- one or more of the following: previous inspection reports; prior plans of oil cor re} tion; the facility's historyof compliance with standard, rules, or regulations under this Chapter; the facility's record ctf violations; corrections; penalties, or other enforcement actions; the number and severity of complaints received about the facility; any allegations of resident abuse or neglect; -46- that deficiencies exist. i_i- J--4-W ; 2 . REPORTOF FINDING& The Department shall submit - _. copy of the Repot{ of Findings to the licensee. Except for "A" violations, iof- Report snail ;e governed in part by Section 8..._1- __ l r-!t-7 te;e -�,i _�. �!t- !_ T!i!�;n-j_= %r-; :� i _.i!Qi%i7 =: _ _ _ . S-7 1 ; = n ;' !] •_ .. 3 n i_ i !1 C ! . -! _ - _ i _ _ = rs _ _ _ _ _ shall be provided 1n writing to the Department within e__n { i i i days of receipt of the copy of the report. The Director shall then determine whether thr� report's � findings �d gs -'omst i t ute .ti _ n f� � f'• n _ s t ,1 - - � - r• violations ; t,i`. ;if which r t facility must b given • violation- ter- i i _ne _,-.arli_n _:!e -_-.c1 _�s t-ri+_..:_ L_., _''��':i notice in accordance with Section i_-:-1J'_-1 0) -=nd 8-15 -4-3 . VIOLATIONS (_-_iONS CRITERIA: ._{';_ Determination -=Y'er i "ii!_n of a -Ji___"I_io � L based upon n rs the t_ severity r ?findings .r outlined 5 i...r shallL.-_ O =t�+� t- n -_ �.1T the -• We Report of Findings, he danger posed to resident health or safety, the comments ._r d documentation, `f -!_vi der+ b - ! and any, ':' a provided _ the facility is response sse a Department's .•..e'er t`..I_ s_!. Findings, 2 ni i = � !- !� theReport . n _ � j the diligence and efforts to correct deficiencies, corrections of the repl::rtcf;+'i deficiencies, and r eci_.a,9_ =Ind recurrent .iol._.r"}_:ns. The Department shall maintain all Reports r^ Findings, facility response_, if any, Statements o Vi :i_._.1_na, and Plans o Correction for at least five l.-:r years in a manner accessible to %},`t,:= public in accordance with the 1 _ i 1 not _ Fr _ecr=m of information Act, 11i. Rev. Star., , e. 116. paragraphs =phs .:01 =t seq. (1987). ._ 1 -i]r-_ ': �'J UNANNOUNCED INSPECTIONS: An�•f!1• ,i.' of --City charged +with inspecting facilities who directly or indirectly gives prior notice of an inspection other than an inspection of financial records or for consultation, to a facility or to ,f-I employee oye= or agent of a facilityis inviolation Of this •'_..-.aPmer and is guilty t a Class h misdemeanor pursuant to !_ t:_, i-; 3-212 a, of the State Act. B-15-4-4, REPORTS REQUIRED: To the extent necessary to carry out this Chapter, the Department -hall require periodic reports and shall have access to and may reproduce or photocopy • any bock:, records or other documents maintained by the facility. The Departmentshall not divulge or disclose the contents of a record lender this Section in violation of Section 8-15-4-17 or as otherwise prohibited by this Chapter-. B-1 -4 RIGHT � {r ENTRY; Any holder of _. license or applicant for a license shall be sjp•-m'i-d to h='t'=_ given ,en consent -- any authorized officer, employee, or agent of the Department to enter and inspect the facility in accordance with this Chapter. Refusal to permit such entry or inspection shall constitute grounds for immediate denial, nonrenewal , 0- revocation of a license. 3..-15-4-6a COMPLAINT PROCEDURES: ° The Department snail investigate all complaints thoroughly and Promptly. Such investigation shall be carried out according to the following procedures: A person who believes that this Chapter may have been violated may request an investigation. he request ^a•:.: be submi!!b tt-.sd i-- t_sr+ Department ! writing, i'.r �'e epMi_!te or i=: '•_ tted -- -!3 -' - _far _!.._n t 1 r. .r _ - ! _ � �!�'.' - !er=ona1 visit. An oral complaint shall be reduced =!::_r writing by .he Department. (Li) The substance of the complaint shall be Git^.'`;;1d!;d in writing to the licensee, ,owner or administrator no earlier than at the commencement of the on -site inspe_tion of the facility - which takes place pursuant to ''r_he complaint. t_ t a not disclose s c 1 o _. e the name r .. the +:;�� The Department =�:._.1:i n_ �.. t-:_ .m-_ i" !>_ complainant unless the complainant consents in writing -- the disclosure of the investigation results, in a judicial -47 _._ oroceeding, or unless aisclosure is essential to tmc--, investigation, in i'?r3i!ch case the complainant shall be given she opportunity to withdraw the complaint before disclosure. Upon the request of the r-� :-mpl •ai nan"_ the Department may permit the complainant or a representative of the complainant to .accompany the person making the on -site inspection of the facility. -"_''1 Upon receipt of a complaint, the department shall ond_'.ot an investigation to determine !whether this Chapter or State Standards have been or are being violated. The Department nt shall begin investigation of all complaints. of abuse 0r nieglect which indicate that a resident's life, health, or - safety 1' in imminent danger withintwenty-four (24) hours. oT receipt pt of the complaint. � a. =m_ t 1 begin s_F.�r:= eo ��, ��-: shall o �in investigation of all tuner complaints alleging =.'use and neglect within seven (7) days of receipt 04 the complaint. investigation of all other complaints shall begin with11' thirty (0) days of receipt of the complaint. ;-ill complaints shall be classified ` as 'valid or invalid. For c;r1',i complaint classified as valid in the Report of Findings, the Department shall determine it any r%1P -. provision of this Chapter has been or is being violated. if the Department determines that a violation has occurred, a Notice o Violation and a Statement of Violations shall be issued. (E) in all cases, the Department shall inform the complainant of the results of its investigation. Within fifteen (15) days of the issuance of a Statement of Violations, the Department shall mail to the complainant a cop`; of the Report of Findings and the Statement of Violations. The complainant -1=-e';- request the Department to send a r-,-p of such reports to another person subject to the provisions of The Illinois Freedom of information Act, M. Rev. St._.t. , Ch. 116, paragraph 207 (1987). The Department's reports may include comments or documentation provided by either- the complainant or the licensee pertaining to the complaint. The name of the complainant or resident shall not be disclosed in any notice to the facility. The Notice of Violation shall 411 Include a cop; of the Statement of Violations; the correction order, if any; the warning notice, if a.n'•.?; and ._. copy of any other actions taken by the Department a specified in Section 9'-15- 5-1. (F) A Statement of Violations and any actions taken by the Department concerning a complaint shall be available for public inspection, subject to the provisions of the Illinois Freedom of Information Act, 111. Rev. Stat. , Ch. 116, paragraph 207 (1967) , but the name of the complainant or resident shall not be disclosed wit ut his/her consent. j_) u complainant who is dissatisfied with the determination n investigation by the Department may request a hearing under Section 5-15-6. The facility shall be given notice of any such hearing and may participate in the hearing as a party. If a facility requests a hearing under Section 5-15-6 which concerns _? matter covered by a valid complaint, the complainant shall be given notice, and may participate in the hearing as a party. A request for a nearing by a complainant shall he submitted in writing to the Department ent within thirty (30) days after the mailing of the Department's findings as described in Section b-15-4-6 e' ) . Upon receipt of the request, the Department shall conduct a hearing in accordance with Section 8--15-6. (H) A licensee, discharge, ge, resident, _ employee or or files a the report its agents or employees, shall not transfer, evict, harass, dismiss, or retaliate against =. resident's representative or an agent who makes a report under Section .ems-15 _ -1 _ complaint under Section 8-1 -4-6 ;:=!j because of or compla'inO. - _18.__. 1 Any person, institution or -agency participating in g000 faith in he making of a ?report, Or in, the investigation e of such a report shall not be deemed to have violated any. ori'vi l eed communication and shall have immunity 4r om any liability, civil or criminal or any other proceedingsl =i vi l or criminal, as a consequence e of making such r _port , The good faith of any persons sons required to report, Or permitted to report, cases of suspected resident abuse Or neglect under this Chapter shall bje presumed. • B- 1 =:-4- r : DEPARTMENTAL DISCHARGE OR TRANSFER OF Rt-= I y EN I . The Department may transfer or discharge any resident from an'';i facility when any of the following conditions exist: (A) Such facility is 'operating without -a tic ,ense3 '.,i,_;j The Department has suspended, revoked or refused to renew the license of the facility, as provided under Sections 1` l (C) The facility has requested the aid of the Department in the transTer or discharge of the resident, and the Department finds that the resident consents to transfer or discharge; (D) the facility is closing or intends to close and adequate arrangements for relocation of theresidents have not been Made at least thirty (30) days prier to clQs.urea or (E) The Department determines that an emergency exists which requires immediate transfer or di=_ci-targe of the r__.ident. in deciding to transfer or discharge a resident from -. facility, the Department shall consider the likelihood of serious harm which ch may result if the resident remains in the facility. Residents small be involved in planning t: transfer or discharge and shall choose among the available alternative placements, except that if an emergency makes prior resident involvement impossible, the Department may • make a .temporary placement until a final placement can be arranged. Residents may choose their final alternative placement and _hall be given assistance in transferring to _.rich place. No resident may be forced to remain in a temporary or permanent placement. Where 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 snail be .allowed three (3) visits to potential alternative placements, prier- to removal, except where medically contraindicated or where the need for immediate transfer or discharge requires reduction in the number of visits. -4-8, DEPARTMENTAL TRANSFER OR DISCHARGE, SAFETY PROCEDURES: Where the Department so transfers or discharges residents, it shall arrange for the preparation of the resident transfer or discharge plans to assure safe and orderly removal and to protect residents` health, safety, welfare, and rights. in nonemer gencies and, there possible, in emergencies, the Department shall design and implement such plans in advance transfer or discharge. .. ,� _ r DEPARTMENTAL -� ' TRANSFER OR DISCHARGE, NOTICE ;��-�=�-�--, li�r'hi-�:i.,_��T�,L i,. t-._r�r�: _�:_ �st✓i=: E, i•; i��'E REQUIREMENTS: Where the Department transfers or discharges r-jesidents, the Department shall (A) Provide written notice to the facility prior to the transfer or discharge. The notice shall state the basis for the Order of transfer or discharge and shall inform the ?a'.ci l i t;! of its right to an informal conference prior. to transfer of discharge under this Section and its right to -? subsequent hearing under 'erection B-15-4-11 below. If a facility -49- desires to conteEt nonemergency transfer or diacnarge prior to transfer or -discharge, it shall within four (4) working days after receipt of the notice send a written request for an informal conference to the Department. The Department shall within four (4) working days from the receipt of the request hold such conference. Following this conferenze, the Department may affirm, modify or overrule its previous decision. Except in an emergency, transfer or discharge may 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 a decision renoered.; and (B) Provide written notice to any resident to be removed and to the resident's guardian, representative' or family. The notice shall state the reason for which transfer or discharge is ordered and shall inform the resident of the resident's right to challenge the transfer or discharge under Section 8-15-4-11 below. The Department shall hold an informal conference with the resident and the resident's guardian, representative, or family prior to transfer or discharge, at which the resident and guardian, the representative, or family may present any objections to the proposed transfer, discharge plan or alternative placement. Following this conference, the Department may affirm, modify or overrule its previous decision. Except in an emergency, transfer or discharge may not begin until after a conference has been held and a decision rendered. 8-15-4-10: DEPARTMENTAL TRANSFER OR DISCHARGE, EMERGENCY REMOVAL: In any transfer or discharge conducted under Section 8-15-4-7(E), the Department shall notify the facility and any resident to be removed that an emergency has been found to exist and removal has been ordered and shall involve the residents in removal planning, if possible. Following emergency removal, the Department shall provide written notice to the facility, to the resident, and to the resident's guardian, 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 Section 8-15-4-11. 8-15-4-11; TRANSFER OR DISCHARGE, HEARING REUUESTED: Within ten (10) days following transfer or discharge, the facility or any resident transferred or discharged may send a written request for a hearing under Section 8-15-6 to challenge the transfer or discharge. The hearing shall commence within tnirty (30) days of receipt of the request. Where a challenge is by a resident, the hearing shall be held at a location convenient to the resident. No resident transferred or discharged may be hald liable for the charge for care which would have been made had he/she remained in the facility. The Department shall assist the resident in returning to the facility, if assistance is requested. 8-15-4-12: RELOCATION TEAMS: 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. 8-15-4-13: MONITORS AND RECEIVERS: The Department may place a monitor in a facility or may petition the circuit court for appointment of a receiver for a facility or both, when any of the following conditions exist: (A) The facility is operating without a license; (B) The Department has suspended, revoked, or refused to renew the existing license of the facility; (C) The facility is closing or has informed the Department that -50- .'_'•, f _r i _ 1 I s p r- i n r- t' t- i'lji p ip, r!_.� Grto a.-?"}t_ l-; L_ra. _sv_n=rRllr} _.r! f::_r_ _r rtor ~_, +_rle: �r- ii- % P iiGr! r e. f doitinp=. t ��.. - ) n _ra.r __m n _ _ -er: : __ _n rprrjQ„'t !ter- ,==Llrr=1? _ Z _!1 z; i i._ir!E n he { ; i •j' o (-. c. a "J p ,-!ice a_ r,'i_ i !� ? E %r" io ri _ Ue?.ar-}sncrt n) _n.e ovule ;q L T li ! n_ r_�or __ _ _ ._ m=_:nl __r f _ r `j_`vrr!: .r`j_Inc'�rSt _.�=*,�_1a 'r _tt�1A; !�!.,�r-S% cT14•, !"ron�t_n �c ict !_n I CON i'•.1 1 y !r I i-: T i ! i i-i ! ' iz : +'- resident, ? 'pSl�=nfi _ !ri �3.�n rt r_'=1�_n= _ r-�nr--=='f=�._i = - =r g �_. _. _ alr ,t ri_S_i dent c r1 e::t +�"�• ,'.lid �i�.!__ Tn•_. ^n ty+iir f�f=f; ''i _.._=% o —f _ ! ! e rftS tii>_! z_4 v e r 1 4: i != d •e r 1 t 1 +-_• n 7_ _! "r r7i a !_ i ;- !_ # I 1 (_ _ - t ! r !_ ,r' lCoot: County for an t_'+.'-ci+=r placinn _-1_-+-15y i r" !_!S`'dS}'St-1 l !jr Y'. C-0LIr'- aQ.p!oi n.r+ilant !or ar e'-_-ei `f er s a.1 f1e i n aC!_'_r-!=._ t i}; c t , sections _ Jt_3_ i_nrOUgh • •-'1!c-4-Ieb, t-'!�BL.IC '_s'1 L:L_OSSUR� 1'1'`�1-!'P;fy!f=! { �f Cli l !'t•� i•.�_ i='t:�11P.!� lnrormat ion i= SL!•bject to d1_--.+ 1o=Sur e i=:^. tf"Oe pub I I f-!' Dep-ar-tm e nt a iii% Information ubmittrd tinder .�'E' _. -�ri -ro ff?=. t i on -r. n c r n in q Z _.,'!;-!er"'a T1!=;' or oersonne1 11cen=ea, r e g J a t = r e or !=ertl ed b t!"t! 1111nai= DOepa.rtment of ProteS51onal i^:egLt1ation .=:r!+d k!o!-!th1':' cflarges tor an`{ individual private residenta (hi Records or license inspection=, Report_ of IFindimg=, Facl l i t`d Responses, Sit atemen t= of Vi of ati on , F.:ECI le5•t' • i or Hear ingsi, and Pans of C=+r_rSrtionsub _Jet__ T_+ _r•_�' _r _• =_Zon +o'r the Illinois r'reedom oi• intc!r ati fir! �r_t n i 1 L = �`v �C-=•=n g Ch l 16 , p,�r agr ":ph 1 I. _i ! :! ( _! Cost and reimbursement reports c.Lttbimi !_ =ed '-ectlon ts-15-t-itrr?t a report's o� a!tdit_. of •r_t_llIi_1=_ _.!!+] it A- Public recorO-S concerning costs i n __.r-r_!� ^ %� _l_ received Lrk-, %and r-imbUrsement '_•y' -r acilit1!-5, =_;nd Cop3 aints riled against a tacility a ;d +=osr!plair,= m ti,e5t t apnrt=. ie ca t t�:at a comp I ai nt or = ,f -:p _ �.i flt i r! 1 � a =ion r- •_ r- ._ , , _ p ,- inve =ti Qatl on report sf Iai l not be di=c1o=Ad T'o oet- on other than the c t?pl--_:tin_--'_nr or comp!i=1nc?nt s be --ore it is disclosed to a r==ilittf resident's name --;hall not be discicsec =.-CEnQ'r• !!n,ier- :=,e ?_i'=n t�i-15-4~-6 is C % abo •rp the 'Del3artment Shall disclose inrormaticn Llr!der !i _-'C:=J in accordance t,.i41tl provi=.ion= for inspe= ion ;and !_i_!p%/ing Jr .!!0!__r' .-+! � b♦r A l no S =_eulc t1'r ! -)•` T%'f n:51 --�.. r-•ecords re•� {ir_d t�?_ Ii i i t=r_ .} ��. _r !_: _ ,._-- F"1fl'�`�e'd`pr-a +'ie d? i--0 !=.11 no' Ca r-P=i r-i cte b:_' n'*! rJ:r f_`•`:=1 ±f1 l` ii#_ t_ liL1n!��_ rre�dc!m of Int•orMatii_!n E c:t -i•_+-= -1 : )1'�FIL�'s� i IFrL-I i , _+ r: + ?r;;Lti; �'-!- -- - - respert the cco, n+ i+denti-a11ty of a re=ie_'nt - re!=!ord a nd i! div!!1 ge or dl_rio'se the contents O a record 1'I a manner ?.)1-!1Ln, identifies the resident, except upon - resi;j emt. . d=atn IZO .e r mIatJve or guardlan; or under- jLid icial prC!Lpc..l1n9 =aCtlri{! Stall not [E' +=on_trls.=d 7=o �.1mJ the r'�QIS!_ ':T d. ':'- i!�i�'tl!_ ro in=rJe(_t or copy his/her own r ecc-r-!3a on-; idy_n!tiaJ r#=r ic a a!v3 •Ek personal for iinanc lal iniortrl-ation 1'r'enLit`s'ina a re-_i dent- shall not be available for Public inspection in a manner Which identifies a resident. S-L5-4-18: DIRECTORY OF FACILLIES: Each year, the Department shall prepare pr pr=re a directory of facilities in Evanston n to be made available to the public. The information in the directory z! be forwarded to the Illinois Department of Public Health for • -rr l ,-si;_T� annual statewide recto y. The I! �oartment may i t_ � in an nn•- _directory. r ep _ charge a fee for the directory. The directory shall contain, at a minimum, the following information - (A) The dame and adre=•s of the facility; T.b! The n!!mLear and type of licensed beds" (C) he name of the cooperating hospital, it any; l.l!' The name of the administrator; (E) The facility telephone number; and (F) Membership in provider associations and accreditation organizations, if any. 8-15-4-I . ANNUAL REPORTS ON EACH !'ACIR_l!.*. REQUIRED: TheiDepar'r tent shall make at least_ one report an 1 each facility in Evanston annually. All conditions and practices not 1n compliance with .applicable standards within t_ie last year shall be specifically stated. if a violation is corrected or is subject to an approved plan of correction, he same shall be specified in the annual report. The Department shall forward said report to the Illinois Department of Public Health and shall send a cope to any person upon receiving a written rt=pf_!•e=t=. The Department may charge a reasonable Tee to cover copying costs. • 8-15_4-20: DEPARTMENT NOT O PRESCRIBE TREATMENT: The Department shall not prescribe the course of Mani =a. treatment provided to any individual resident b the resident's physician an in ._,. facility. l 5---4 1 ; WEATHER AND OTHER HAZARDOUS CONDITIONS: ! i`! - Department shall develop and implement a system of educating facilities and their personnel as to weather emergencies or other hazardous circumstances which may endanger resident health or safety and promulgate any precautions to prevent or minimize I such danger. The Department may assist any f ac i l i t experiencing difficulty in dealing with such emergencies. The_ Department may provide for announcement to the pt!bli= of the dangers posed to facility residents by existing or potential weather or hazardous circumstances. f --•l5-VIOLATIONS, ADMINISTRATIVE i` E WARNINGS, AND PENALTIES; IES; B-15-1 (`H). NOTICE OF VIOLATION .'=NfD =Tr±ENENT OF VIOLATIONS; �J if aFtar receiving tna reporr Epecifies in Eection 0-1t-4-3 UK, the Director or his/her designee(si determine(s) that a facility is in violation of this Cbapterr, he/she shall within tMirty 130) working days of the date of the Report of Findings servea- written Notice of Violation and a Statement of Violations upon the licensee. The Notice of Violation shall inform the licensee of any action the Department may take under this Chapter, including the requirement of a facility plan of correction under Section 8-15-5-3; placement of the facility on a list prepareo under Section 8-15-5-4; assessment of a penalty under Section 8-15-5-5; issuance of a conditional license under Section 8-15-5-11: or license non -renewal or revocation under Section 8-15-2-11. The Director or his/her designee shall also inform the licensee of its right to a hearing, under Section 8-15-6. The Statement of Violations shall be prepared in writing and shall specify the nature of the violation and the provision or rule alleged to have been violated. If a Facility desires to contest any Department action under this Section, it shall send a written request for such a hearing, pursuant to Section 8-15-6, within ten (10) days of receipt of the Notice of Violation and Statement of Violations. 8-15-5-100 ADMINISTRATIVE WARNINGS: 1. Each Administrative Warning shall be in writing and shall include the following information: a. A description of the nature of the violaticn; b. A citation of the specific statutory provision of this Chapter which the Department believes has been violated; and _ . C. A statement that the facility shall be responsible for correcting the situation, condition, or practice. 2. Each Administrative Warning shall be sent to the facility and the licensee or served personally at the facility within ten (10) days after the Director or his/her designee determines that issuance of an Administrative Warning is warranted. 3. The facility is not required to submit a plan of correction in response to an Administrative Warning. 4. Any facility issued an Administrative Warning under this Chapter shall not be entitled to a hearing, 5. If the Department finds, during the next on -site inspection which occurs more than 90 days after 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, and shall issue a Notice of Violation and Statement of Violations, charging the facility with at least a Type "C" Violation. The facility must then submit a written plan of correction within ten (10) days of receipt of the Notice of Violation and Statement of Violations. 8-15-5-2: SEPARATE OFFENSE FOR EACH DAY OF VIOLATION: For Type "A" violations, each day of violation from the date of discovery constitutes a separate violation for purposes of assessing penalties under Section 8-15-5-5. For Type "B" and Type "C" violations, each day the violation exists after the date upon which a Notice of Violation and Statement of Violations is served under Section 8-15-5-10) shall constitute a separate violation for purposes of assessing penalties under Section 8-15-5-5(1)(A). No penalty or fine shall be assessed for a condition for which the facility has received a variance or waiver of a standard from the Department. 6--'1=- . ABATEMENT PROCEDURES: ES: Any violation shall be abated cz di :ems to the followingschedule. e. A) The situation, condition, or practice +consti ut_iny a Type "A" violation shall be abated or eliminated immediately upon [_n the order of The apartment unless _. fixed period not exceeding fifteen (15) days, as determined by the Department and specified in the Notice of `:violation and order of abatement, is allowed for correction. • (B) At the time of issuance of ? notice of airpe "_" or Type violation, The Department shall request a plan of correction, which is object to the Department's approval. The facility shall have ten (1 i ) days after receipt of he Notice,of Violation and the Statement of Violations in r:'nich to e prepare and submit a plan of correction. The Department may -.'tend this period up to third' (30) days if correction involves substantial capital improvements. The plan shall include a fixed time period not in excess of ninety (90) days within which violations are to be corrected. ed. the Department rejects a plan of correction, it shall _end notice of the rejection .and reason for the rejection to the facility. Except as provided in section e-'15-5- (i) (E) for Type 1 B" violations, the facility shall have ten (10) (jays. ,after receipt of the notice of rejection in which to submit a modified plan. if the modified plan is not submitted or if the modified plan is rejected, the facility shall follow a plan of correction imposed by the Department. (C) if the `:violation has been corrected prior to submission and approval of a plan of correction, the facility may submit a report of correction in place of a plan of correction. Such report shall be signed by the administrator- under oath. (D) Upon a licensee's petition, the Department shall determine whether to grant a licensee's request for an extended correction time. Such petition shall be served on the • department prior to expiration of the correction time originally approved. The burden of proof is on the petitioning facility to =_•now good cause for not being agile to comply with the original approved correction time. (E) if a facility desires to contest any Department action under this Section, it shall send a written request for a hearing under `_iection B-15-6 within ten (10) days of receipt of notice of the contested action. The hearing shall be held as provided under Section 5-15-6. Wherever possible, all actions of the Department under this Section arising out of a. Notice of Violation and Statement of Violations shall bie contested and determined at a single hearing. issues decided after nearing may not be reheard at subsequent hearings under- this Section. -15-5-4: LIST OF VIOLATORS PREPARED: site Department shall prepare on a quarterly basis a list containing the names and addresses of .all facilities against which the Department during the previous quarter has: (A) Sent a notice under Section B-15-5-7 regarding penalty assessment under Sections 5-15-5-=e i ' (A) through (E); (B) Sent a notice of license revocation under Section i_._1 _ea-2-:1 1 q (C) Sent a notice refusing renewal of a license under Section i8-15-2-11 (Di issued a conditional license for violations described under Section's E-15-5-'1 (A) , 8-15-5-3 and B-155-11; (E) Placed a monitor under Section B-15-4-13; and -54-- action(F) initiated an tM MPOint a receiver under Sect!"' 8-15-4-134 In addition to the name and address W the facility, the - i _T hall include the name and =4ddKesd of the person or licensee against whom the action has been initiated, a summary of the facts which warranted the initiation of each action, We type of action initiated, the date of the initiation of the action, the amount of the penalty assessed or _.(_?light to be asse•_sesl - i l- any, and the disposition of the action, if completed. The list shall be available without charge to any member .of the public upon oral or written request. 8-•- 15-5-5 a PENALTIES AND �N D tJ RESTITUTION; The licensee of y facility which is 1n violation of this !_3t=tptie�r mc+.'}% be subject to the e 1 tF e levied Department _nd the restitution n_ penalties i.-- l�_ d h-; the provisions as specified in this Section. 8-15-5-5 (1) PENALT i E W (A) Unless a greater penalty is allowed under Section 8- 1 5-5--_+ L i : (D) , _± licensee who commits c-! Type "A" violation is automatically issued a conditional license for a Period of six (6) !months .and assessed a penalty computed at a rat_ of five dollars ($-5.00) per resident in the facility plus twenty cents ($.20) per resident for each day of the violation, commencing on the date the violation is discovered and ending on the date the violation is corrected, or a penalty of not lees than seventy-five hundred dollars (iy% 00.'•_0) , whichever is :greater. the facility shrill also comply with an order of abatement issued under Section i_-15- 3 any ,=:r tm a t•--1 m: if_._.etd 'plan of t_.nd r ',_ i- n � _ �;r and rl;, i�'=P-:r�_+-< .p correction. !Bi A licenCee who commits a Type n'B" violation is subject to a penalty computed at a rate of three dollars {:; T— 00 ) per resident in the facility plus fifteen cents Q.15i per resident for each day of the violation, commencing on the date a Notice of Violation and Stafiement of Violations is 411 served under Section B-15-5-1 and ending on the date the violation is corrected, or a penalty of not less than one thousand dollars ($1000.00) , whichever is greater= Such penalty, if assessed, shall commence on the date of service of the Notice of Violation and Statement of Violations and may be suspended for violations that continue after such date upon submission of an approved plan of correction in accordance with Section 8-15-5- . The final penalty computation may be reduced or waived in accordance with Section 5-15-5-5. Failure to correct such violation within the period approved by the Department and under a plan � -f correction shall result in a penalty and conditional lii__n_e as provided under 'erection B-15-5-5i 1 'J L E? . W A licensee who fails to correct a Type "C" violation within the time period od approved under a plan of correction or any lawful extension granted by the Director or timely to submit .a plan of correction pursuant {ant to Section B- { =:-_' may be subject to a penalty computed at a rate 4 one dollar fifty cents 01.50) per resident in the facility plus -en cent Q. 10) per resilient for each day of the violation, or penalty of not less than five hundred dollars s 500.00) , whichever is greater, commencing on the date the Notice of Violation and the Statement of Violations is served under Section 3-15-5-1 and ending on the date the violation is corrected. If an original plan of correction is approved • and carried out, no penalty shall be assessed. (D) A licensee who commits ' Type "A" violation winic h continues beyond the time specified in Section 5-15-5-30? shall be cited with a repeat violation, shall have its license revoked, and shall be assessed a penalty three (5) times the Menalty computed per resident par day unoer Eectio!­.! 8..._155-5(;-+)or ='- fine of twenty-two thousand, five hundred dollars 022,500.00), a whichever i- greater. (E) A licensee who fails to satisfactorily comply with an approved Milan of correction for a Type "B" violation shall be cited with a repeat f?P_'•ti violation and shall be automatically issued a conditional license for a period od of not less than six (6) months together with _t Department -imposed plan of correction. A penalty shall be assessed in accordance with _: Section B-15-5_ (i ) () . This penalty shall be computed for • all days of the vi olation, including the duration of the first plan of correction compliance time. A licensee who fails satisfactorily to correct or address =. repeat or recurrent Type +epee violation is subject to •= conditional. i:cfial license. In determining whether to issue such a l i ect=nse , the Director shall consider the factors set forth in Section B - 1 5- 5-8 1. l_ :e . (F) For the purpose of computing a penalty under Sections 5- 511.! (A) through (E) the numberof residents :ter day hail be based on the average number of residents in the facility during thirty e_ _0 a days preceding he discovery of the violation. 15 -5 (2 ) RES T I T U I ClM e:E-i1 Violation of r.eslhe±'1t's !^:lgl'"lts and Facility Requirements: Upon being issued ?ed an Administrative Warning or ,a Statement of violations for a Tapia "A," "B", or "C" Violation, which �' :.:e t- c t provision •-i e c i' e, s }_'.S •- 1 t.. _ l - B - y _ ._ vt__.y_e� that a f Sections _ _ r 1•:+-_a" been violated with regard to a particular resident, the facility may be ordered, with the approval of the resident, to compensate each identified resident one hundred fifty dollars ($150,00) , to be placed in an interest -bearing account in the resident's name. i B i Property Damage or Loss; Upon being issued red an Administrative • Warning or a Statement of Violations for a Type "A", "B" , or 11t " Violation,which states that a resident right of property protection, as defined in section has been violated, the facility may be ordered, with the approval of the resident, to compensate the resident (s) for the a ct� tal cost of the damage or loss, or one hundred fifty doll•ars 0150.00), whichever is greater, to be placed in an interest -bearing 'account in the resident's naive. l requested by the resident, the facility shall assist the resident in replacing the item. (C) Privacy Rights; '-upon being issued an Administrative Warning :_t Statement f Violations fo Type . A `'B� _t_ e;!_:e r a o r- �� ;r_ , �, Violation, which states that a resident's privacy rights. as defined in section B-15-=-1 have been violated, the facility may be ,ordered, With the .approval of the resident-, to reimburse each identified resident five hundred dollar 0500.00) , to be placed in an interest -bearing account in the resident's name. (D) Neglect: Upon being issued an Administrative Warning or a. Statement of Violations for a. Type "A", "Bu - or :et-• . Violation, which .state_ that a resident was neglected, the facility shall be ordered, with the approval of the resident, to compensate each identified resident one thousand dollars ($ 1 , i 00. hill , to be placed in an interest -bearing account in the resident s name. • (E) Psychological Abuse: Upon being issued an Administrative Warning or a Statement of violations for a. large "A", 1 B" , or "C" Violation, which states that. ,_. resident was psychologically abused, the facility shall be ordered, with the approval of the resident, to compensate each identified resident twelve hundred dollars to be pjacad i!---, an interest -bearing account in the resident's name. (F) Physical Abuse: Upon being issued .an Administrative Warning Statement a �atement of Violations f e=+ a Typ"A", "B - or- Violation, which stated that a resident was physically abused, the facility shall be Ordered, with the approval of the resident, to compensate each identified resident two thousand dollars ($ !_)i}._l,!:0) to t_!e placed i , _ _ , _ r, _ a � h an i interest -bearing account in the resident's name, • - l��J •Sexual7Abuse:��pon being i s=Ll=d an Administrative Warning or a Statement of Violations for a Type '`A", "j " or_ 401 Violation, which states that a resident was sexually abused, the facility shall be ordered, with t'-..= approval of the resident, to compensate each identified resident four thousand dollars ($4,000.00) , to be placed in ar, interest -bearing account in the resident'_ name. ( ) Monetary amounts recovered by residents under this Section and any interest accrued shall be exempt -for purposes o-f determining initial or continuing eligibility medical assistance under the Illinois Public Aid Code, Z11, Rev. � f:? .tat , , L i'! i_, . 9 par. 1-1 et seq. '. 1 9 %J t '1 as now ,, e.r or h e r._ 2 ._ f t e r- amended , and shall neither be taken into consideration nor" ! r reqi red to be applied toward the payment or partial payment of the cost of medical care or services available under the Illinois Public Hid Code. (1) All restitution paid to the resident(_) shall be paid within ten (10) days of receipt of a Statement of Violation and .a Notice of Restitution. Verification that restitution has- been paid by the facility shall be provided to the Department within ten (10) days of the payment. 8-15-5-6: PENALTY DETERMINING FACTORS: In determining whether a penalty is to be imposed for a violation, the Director shall consider the following factors: is (A) The gravity of the violation, including the probability ?_h,=et 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 applicable statutes or rregulations were violated; (8) The reasonable diligence exercised and efforts made by the licensee to correct violations; (C) Any repeat or recurrent violations committed by the licensee; and (D) Any possible financial benefit to the facility old gain as a result of committing or continuing the violation. _ t i_i-1 J-'J—r : ASSESSMENT OF PENALTY: the Director may directly .assess penalties provided de Section - - F- p d d for !+n��_r _e.__ion �-1C-:o-_p(1? of v'.^.i Chapter. if it is determined that - penalty should be assessed for a particular violation or for failure to _- it. ._a notice shall be sent to the facility, The notice =hal l peci f'• the amount of the penalty assessed,the violation, the Chapter : Provision, _•loin, or state standard alleged to have been violated, and the right to a hearing under Section `i-15-6 of this Chapter. if the violation is a repeat or recurrent violation, the notice shall specify the amount additional r assessment per a/ r sp�-- m-'3_.nt of atb+,l •_1 final ?s='='_s P es+ day -;-:_'- the violation. • - -- -. FOR r`•;L T .j Y+1•``E'��ii'!EI`! 1 . PLANS r=!�.=.: CORRECTION: imposition of penalties for Types f1A", and 1 C" violations -shall conform to the following: (A) In the case of a T _p= "A" violation, a penalty shall be, the penalty; or '.C. Revoke the license of The facility. 8--15-5-11: CONDITIONAL LICENSES: In addition to the issuance of •a conditional license pursuant to Sections S-15-2-51 8--15-2- 0), and 8-15- 5 (i) of this Chapter, he Director may issue a conditional license to any facility if he%she finds that Type "B" or Type "C" violation exists in such facility. The issuance of a conditional license shall supersede any license previously held by the facility. (A) Prior to issuance if a conditional licence, the Department shall develop a written plan of correction to he imposed upon the facility. The Department shall specify the violations which prevent full 'licensure and shall establish! a schedule for correction of deficiencies. issuance of a. full license shall be conditional on the timely correction of the deficiencies in accordance with the plan of correction or on the completion of the mandatory time periods established in this Chapter for automatic issuance of conditional licenses. (B) Written notice of the decision to issue .a conditional license shall be sent to the licensee together with: (1) the specification of all violations of this Chapter which prevent full licensure and which form the basis for the Department's decision to issue a conditional license; and (2) the Department -imposed plan of correction. The notice shall inform the applicant or licensee of the right to a hearing under Section 5-15-6 to contest the issuance of the conditional license. (C) if the licensee desires to contest the basis for issuance of a conditional license or the terms of the plan of • correction, the licensee shall send a written request for hearing to the Department within ten (10) days after- receipt by the licensee of the Departmentos notice and decision to issue a conditional license. The Department shall hold a hearing in accordance with Section S-15--6. (D) Except as otherwise provided in this Chapter, a conditional license shall be issued for a period specified by the Department, but in no event for a period exceeding one `1) year. The Department shall 1 periodically inspect any facility operating under a conditional license. i.f the Department finds substantial failure by the facility to correct the violations which formed the basis for the Department's decision to issue a conditional license; the conditional license may be revoked, as provided under :_section B-15--2-11. (E) The Director may issue a conditional license to an applicant in lieu of a probationary license, if the facility held a conditional license at the time he applicant purchased he facility, and the violations resulting in the issuance oi a. conditional license have not been corrected. 3-15-5-12: INTERFERENCE WITH ENFORCEMENT; No person =hall . (A) Intentionally fail to correct or interfere with the correction of a Type "A" or Type "B" violation within the • time specified on the Notice of Violation or approved plan of correction under this Chapter- as the maximum period give'') for correction, unless an extension is granted by the Department and the corrections are made before the expiration of extension; -59- r!ri •�j l;� ;-+!•-_ =r7 1.._t Zre _ i? r • •= :.1.= �J a ?-! :_` _! ? !'I_ j l r-r i _ e,-i _ r '..t e 1 _ i '� %y -i_ _ i t _. f ! +._ _ ("1 r !_ . ill=E (ti irl^'1 �._,�.Ti [•% ij" _ fi._ .a +_? i 3 isn inori_cmpr-1� 'i_ i c 1'h.ti�,1'f_er- n n pr. 1-.t-Gr GrG r3 .1 9_-1 • et:i pence Oer 'Ca1n1no t_:-? r.%4 it i:=- Ti+_ 1':;ri1 �. E -J r ❑ 1 S _ r 1 1r? i n -a L - a - • =! 1 rl _ _ _, '`! -' � _ _. o !" T r ,_ Cr, t .a c 1 i-1 ?Z' +=�r �;C-O``'..c1'..!f' 1}l.}.^r-m,_;#_:.15'! _= ar?` L.1.r !fir �3=aT: 0T _� S i � r � i r! i 'r y atj r t� T r j'1 r 1 r': _, _ � ri -4 _ -1 {` ?,_a- rerp i?t Ori z,2:i :1 t- � i - 1� m. _. _ _ _ t _ _ P an •y� } a. - - i �! !-1 L O 1'! ri S et � C. ?' l n _ = n -_ l _ ?...: e:arl rt a_ ill+-Jrm%+=i+-4 t? i.f_ t7 1ed ?,r e : F !_ ?"• o?, s.-4 i i t u l I v T a 1 1 .' r r- a t u _ _ _ o 4- _ n - cq ? 1 i-tTnrill a 1 ?'l cryr- ri linen or -operate a ta,_iS1r bylrnoFut S1--en . e 1"l_lr=i_1an= -_o section _ =12, :of the `._f a=!= ".ct '_ec- on con stst??tes a bUSiness 'Oft-=n=_ un--,- _4!'; 'f' i- f- �J ?_i e . :a o fi e 'S t r`. t e _ :..:1 r !_ i•%;; 0 � i f! ��:_ r � � 1 !_'I ror.fner r _n _ __ r ri r _ i ilTi_ti ,��'t �; 17 i-1 !�' �j1 rPc for o't .a (?'.y' E??_.o e!'t p!� !?101�. 1'�r1= _,r 1 ctyon. 7, .i .._�. _�__'-..1•r_ I i1._�s-a �l i_,� ?';=1;_:^'f':`=_. n.� ��r r�i-at 1'_!rI _r ,'?._i_r Cry:- a Ta_1S i_;lr in jl=:SaL1Jn J7 T:t1= is 'ter 1= oroIar o+� a o!i1=1S1'_ '.'C.a.riaa- inim cal to the public v4el are. he Direc"i-or, in 'I 'a name of the Cit;- y of Evanston through he o-f — -o the 1_r!roor ati on Counsel of the i....it._j, may! in aooiLSort _+_ other rc�rrfedies herein provided, bring action f'c'r an iF-I un+=_ion to enjoin the '*llti_!re operation or maintenance of arienjoin sac=^ farilit�. �•ti r-'RI 4-tS)t�r': i.7 e Any o =`r sort --r.f = c i 1 i •;~ ; ill •a hears nay pur-c.i lant to '=a=+_t1C!t'1= i :Ji i.{r- _4 -._15-7,-_ t+_1 contest ? deci: s1 on rendered in ffla,?' have S :Ch decd. �1 on revs ewe d 1 r? accordance !t'j1 {_r 1 =, ect-1 ion �_.. (H A regi1e=_•t for a nearing shall be inade in ;+,riling ,o t-lam _+ir 'C+or ari+3 =•hai 1 inc1Lid e the cC,rr er"t CCial I Sf -ad !_.Ir ' of the gri e-va.nt. ( i I ne City Manager sf-al1 !de=i a Person r_C1 nearing officer to conduct a nearing to revi=cad the Le -vision, fitter notice ?o'? isearirt'g under { hi= ='=r hearing officer sh.al? not t ommunicate, direct-1 Or 1n'direCt I, 'y , in conneoti+on !Kith an y i;s;ue 1't t._c t in %hct•�-' case or he.=tr ing with an,/ per -son or Dartc%':r=f !!oon! noticze .and fonr:ort-unit; for aSi ?=arl_ies tul p!_rTl_lp=,?_1-I._,r;cIT'"er 9 i he Ceasing o+'t'1_er inav have' the .a1Q and a.dvi,_p o-t- one or - more person,---,!- asai st antc not related to e'_'i = -•r -F i = ten i. :. C. oC1 '.�a Ar1or i-!'i inG Ike rS nq ri-,e Y{t r_+f�tor.- r1.3t11 aend notice to ne C?=tr1P.^_ To the �r 1�'J-ant-_q?!_=.fi r1--? the hear-ino. The native sha11 speci`7v rha ChEit F_- t 111e af-I0 . place of the hearing an the decision being te!!_' n?,tl re :-+o .i.. is a. - y I '7e sc r e a, eC_ _et -- he qr v_n ha n • o =�; �-fir• for th ,try t;,e req�?.est +or riearing o`� ter tltled vials ; r-Urn recei p lf_ r = qs_ , or stl i be r... •_ r _on a! VF'' tJl The hearing tlal i commence no 1 ii=ter ±_flan th r - ;' !. _;:i i. _ -tat j._. after the receipt by the Director oi a request for hearing and shall end no l.rr=r than ninety (=€_?) days after 1.h commencement unless justice requires otherwise. CEl The hearing officer may compel by subpoena or subpoena duce'a tecum the attendance and testimony of witnesses and the production of books and papers, and administer oaths to witnesses. iri The hearing officer shall permit the grievant to appear in person .and to be represented by counsel at the hearing at • which time the applicant or licensee shall be afforded an opportunityto present all relevant matter in =. Sr. port of his position. in the event of the inability of either the applicant, licensee or The Department to testimony procure the attendance of witnesses �� give o- p r_uce boo-.=._. and papers, either he applicant, licensee or the Department may take the deposition of witnesses in accordance with the provisions of the laws of this State. All testimony taken at =. hearing shall be recorded and all such testimony and other- evidence introduced at the hearing shall be _. part W The record of the hearing. (G) The hearing officer shall not be bound by common law or statutory rifles of evidence, or by technical or formal rules of procedure, out shall conduct hearings in the manner best_ calculated to result in substantial justice. (H) All subpoenas issued by the hearing officer may be served as provided for in civil l actions. The Fees of witnesses for attendance and travel shall be the same .at the f`✓e=. for witnesses before the circuit court and shall be paid by the party at whose request the subpoena is issued. if such subpoena is issued at the request of the Department or by a person proceeding in forma pauperi s, the witness fees shall be Raid by the Department as an administrative expense. (1) In case of refusal of ? witness to attend or testify or to. produce books or paper_ concerning any matter upon which he might be lawfully examined, the Circuit Court 04 Cook County , wherein the hearing is held, upon application of any Party to the proceeding, may compel obedience by a proceeding +or - contempt as in cases of a like refusal to obey a similar order of the court. '.G1 The Department at its expense, shall record the tee.?_1,7ony and preserve a record of all proceedings under this Section. The notice of hearing, the complaint and all other documents in the nature of pleadings and written Notion__ filed in the proceedings, the transcript of testimony, and the findings and decision shall be the record of the proceedings. The Department _hall furnish a transcript of such record to any person Interested in such record upon payment as determined by the Department. =-1 -6-2, HEARING OFFICER TO MAKE FINDINGS: An impartial hearing officer appointed by the City Manager _hail make findings of •r act in such hearing and shall make a recommendation for a. decision to the City Manager. The City Manager shall render his/her decision within thirty ( _:il) days after termination of the hearing, unless additional time, not to exceed ninety, 0 :jars=, is required by him/her for a proper disposition tion of the matter. If a hearing has been conducted, the City Manager shall review the record and findings. lit fact before rendering a decision. All decisions rendered by the City •Manager shall be binding upon the Department, the facility, or the persons involved in The hearing, as appropriate to eacri case. B-15-6- a DEPOSIT OF COSTS REQUIRED: The Department shall not be required to, certify any record or file any :answer- or assessed from the date cn Hrich the violation i:�-- discovered. The facility shall comply with a plan W` -- rf der o abatement issued d b��/ the Department correction ._. order t a_ f n __ _ _ .e _r _. _.. rft pursuant Section S_ _ (B) if a plan of correction is approved ved and carried out for ._! •.pe "B" violation with respect to a violation t?.1_t continues after the date of notice of violation, the penalty provided under `.section 1-15- '-5 (i) snail be suspenow for the time period specified in the approved plan of correction. In The case of fa Type "B" violation, .a penalty - shall be assessed on the date of service of the Notice of Violation and statement of Violations, but the Director may reduce the amount or waive such payment for any of the following reasons; 1. The facility submits a true report of correction within ten f 10 j days; 2. The facility submits a plan of correction within ten (10) nJ':1ys and subsequently submits .a true report f correction i ion within teen + 15) daysthereafter; _ r_ i �ith�n fifteen - _ � 3. The facility submits a plan of correction within ten (I0) days which provides s for .a correction time t!lat is less than or equal to thirty (30) days, and the Department approves such plan; or 4. The facility submits a plan of correction for violations involving substantial capital improvements which provides for correction within the initial ninety (30) day limit ender Section 8-15-5 l;! (C) For Type "B" Violations, the Director shall consider he following factors in determining whether- to uphold, reduce or waive penalties or to issue a conditional license: W The extent to which the violation has caused Adkd+`+X harm to a resident; 2. The extent to which the facility has made a diligent effort to correct the violation; 3. The extent to which the facility has engaged in repeat or recurrent violations; and 4. Whether or not the facility violation record reveals a substantial failure to comply with this Chapter. 8-15-5--?: ASSESSMENT CONTESTED: Subject to Section 8-15-6, a facility may contest an asaessment of a penalty by _ending a written request for nearing within ten (10) drays of receipt of notice of assessment. Upon receipt of the request by the -Department, a hearing shall commence as provided under Section 8-1 5-6 , 8-15-5-10: PAYMENT OF PENALTIES: All penalties shall be paid to. the Department within ten (10) days of receipt of notice of assessment or, if the penalty is contested finder Section 8-15-5-9 above, within ten (10) days of receipt of the final decision, unless the decision is appealed and the order- is stayed by the court order under Section 8-15-8Q) a r penalty assessed under this Chapter shall be collected by the Department. If the person or facility against whom a penalty has been assessed does not comply with a written demand for •- '.30 r ment within thirty ) days, the Director shall issue an p-'l order to do any of the following: (A) Add the amount of the penalty to the facility's lic ena•in tee. if the licensee refuses to make 'rile payment ? the . p -- : time of application +or- renewal of its license, the license shall not be renewed; (B) Bring an action in circuit court to recover the _+[n!_unt of .._ .;.. _, _ r•• :mot .� ._ Na .� r : ; :..� :_ -_ - r, - _ _t r+. e c r•3 - - _ t.,) Li, :_:'._��.Ct`nf i:r;y Vic,_ i-.-_ r?::;✓_'•.F -�71_i!!_,-i'�"!N _f;%(iel_!1 _._':1!. r1 C:-=_): __ tJi 'i__. _'7= ___ .. .lr =Llr'.-i ..I _!i:r� Gq11 t _� C.�.� ftl� i?'.C-.;.i' ' I afTI0 .;it ,a+ f.!f_:neT.�ry _C.,en-a `� 1fripas.ea ;-c;' .:7 _,_, !,n!,e;.- '•-1-tA t'er '7-'-=rf^lf a'� ='= CT ={'� ,� 7'i=' !=1n1S q _ -a i w. Q(n •rne nar -_ a y..^,e C:.Iain"=if Y"!e f.1a E2 SU_t !_I�+ne=!.1:• L._ ._;e._ i 1 `!_ llrrtt;n+�= -;-'J{ '-!1_!Ill==r=1 o-r' rr!e =C_iOn persons S!_C1= n;-r?r_e!�'y,n,,� in ? _t !7la CclLf '-1 4!1"Ci! _ i= ciD r!�•1_� _ F- _ L ( l T C _� L! ; - -r = s .a ,{, l !- _ T S] e Y" = +.ry ! i 1 = + to C C ' ".i '1' j ! e s e t e e' s . • - i L, - r,J!" I'? S �: A S 1 ! E F: R � ' _ E L' i f' ?1 _ � ° i � i, r' n. > i = > n r.'e !_! � t - h; e _ .S r;C' _ rfTixni=-=[".s_3''!e t=`Y ! Ce+7i:s'e_:, - - -!s is ;3 �t _•epa {. �r� r+mot �p l," _e ;!ems;--nqs :_^r:+�L!cT-! _ �.. 5 p' iQ'U E _ ST, E J H 4'_:Ci�.i 111c. 41 =eeK e11 TrC!Zl r_n nr Ci r r jT -.!e '{-r,l 1 =�.!] i A. specific it 1eC!;i l•fir �1'Cua,,=1 =!fl e:' i =r_ '•!t!? = amp li-ar,Ce a. Qrc_ti+C:tL 1Rmo0er1b1I1t--,/ al an eIx. %r e m e r;'1•_.d_•hl�t= For tf!a+_!r"r7on Of a YaCllit Mn1l=tl 15 of lndr;r+en+_rt'r 1i''v1rtg L?fi1Lq -as Hde+1+d ne1r! ;Ih1s i_:jt. n`:=S q �__!'tefft _ 'i_n: _ those provisions lions wr!Ltl d inT'ri nQe !_1Qo+n the ' ndepenCent t i',i nQ C+'?' residents wl-lo are �l.LQib'.! rC r _--1,Je in c!1! ii-ideQendent li dinQ. unit. ': ?-i T _L'_ l i l t tiJ 1 •� L� e -: - 1 n+ r =1 1 e' e i! %-1 '!. i � U Q m l r I n w r J _} t l +a } J1rect-or the Toll!ewaing- i.a For section 8-1.5-7i i1. d_.._.il_d ex, ' planation o-F !'"easons why compliance with the provisions oT thisl1- . __ lNoL ll d create a practical i mpossi b i l i t Y, or an e:;trem:e • hardship and a plan +or al te-rn.ati "•, e me tin --d a+-.r-r',1 }'j•ace< r:I' C`,i i(an to incLire tt a cafnoara.r! bl-_ ar icher- gi_!aIi1_"C? :' t service 1s provided to residents; or yz For- t liC-=.i' d e:;-p'-tnaticn n he o r aviSion= f'C'tr which a t:wa.i`,er is s'Ging r-eq,weated an: rj r'- le ,a = , -n e lj,& `f the !td a i "der S r! Q L! .L d be !7 r '=ante d i•f'� iiQnn rem el pt Git such reQue Stq a.n --:kd .,Lnl=r`-i='�=i dJ_ l be condUCt d by the Di. eCt':'-r cr- hi-3:'1!er aesi+yn„=!- within tInir - j' !.S'_-'1 da`iS of fine reCeiPi_ !-_-,..�r the re_L!es "o ste p{-r ,C_rj! i!re = ii.+? tie as rid a� t? r!+sri-e {3Y tn�' Crin#=rer! e =n_.1_ 0- n! =a •a.7 _!{= f' =! C l l l 'C \' 1 fl a p W. C1 i i C p l c! C {=i, The rCn eren= ' S�-fa: l �e ,-r!pr! -C to !i-, i p �_. _ o iE1!e Tacilit`.!=.1y_e-'1 present wri+_1_'n an {� r� +_ ! r .(.. <e c , , , it '? '1" the _ request- f a S �._ - _ o l•3 `ti '_ r _ testimony �n __:p_Lrt t s! = r qu �r _ =�'le con+erenc-e. �� f!f!� na_r='Cn '-,i=tlinr :,? pnrr:J ! ne !,.al`;e r_C�'-+__! i r -' _ - _:Inaii I_le �ife!'"!T.!i-_-[c%+j'Co speak at the ronterence, ! :1 nLEteS et file cant=rence shE?,I Lne taL —f-tom T , The Director or hu s/ tier designee nee {3i'!o c :pnQUr-i— zC 1 'try conference =_••i:al? pr-eDrr-E' tiis�i tp= Li!? .'"FrCfr,Crsaf"t+LtiCaCis T h e _f i T i. _ i j) !-i �� S r _ h o - - in i r, a.i r! G- : t "_ h e- i o n e r = s r 'Al .-_-+,l . zF i.._ i r.i e.`J ]a =a nee l� i-: a 'i_ a r ' L., _fit! datar`nin4 nwha-, h e r- _r gr_an'_ _. :•.c'!i &r %ra its r----'r ...n ia1 J=r -f ha -i o11i_i v41 nQe _ K-Gat of !_nG n-`-'i=.L •_-I-G'i'v r.,. Si �nI-.t i • �s . 1 i S t� -i I ! C... i r 'I °_ "�' : ._ I dent � _. r _ _. t' r �; c' t -aI [__ ina T.ac, 14. s_y s ni s4 cir j' f'T =o:;I p I I+ a. n s__ !rii _!.'{i _ i•". ice!-e%_ d h '.'-aci1i•I-y' _-attaff.-. st tQ _^:nJl rl_!iasksi or Standard(S) In quest:.cn., c. a _,-. tan t to sWnIs_T' a practical I1-10 �JS_. '! :i! i 'C isr .+, F, aXT c.;Sc .r s r _ ..T5 I C: Off 1 "'� l t, i t i .. _ _ S h I h"' =.. - n ' IsJ _ j fQ d under 31.ppeal a �,. r�r-i- ; c +4r:ict'? •an _,_car}ti5'=(1=-f' a -v i Ca wi 1 1 be imp 1 c`mentad; and a. The G i ant to '?Ihi - t the independent-ll't''lna =T_i'i=UE :_, residents is infringed !_!pin, Inc' !•jai_-var sna.11 Da gran#='"! for a perloo not :to tl'e '_ �!_lr•aton o-; the annual l icens re period. H =c+rJY cj e-a--.m _real 1 lD _n r i i a wi e_n the 'Eep-z_;.rr!T-a_nt anc _.. a s :aQia -Q`,- h:3!:D _ _ 1 t�;E EST r ��' Ii A"i I �i'.! f r:_L i- . i- ; wiiich has Qaan granted raliof from a proviSicn of tii a CI'm a0. _r ii?• .`j r eqL!,=5 _ T_ a c o n t i nLiat i on o t _uch rat i a+ i n a l at _ar- �o t(zh Li:iractor when the annual license renevial application I "ilad. Ti-,a Di rector shal 1 Qrant such r el i of i f t'ha f aci 1 i _ h.a`_ !ti!T!it'_F'd an adequate Snr��ing that the 1aT!e 3 cinditi_:n,a-;''.M.T at �he time :of 1 i can e renewal as a;<i =.ted when the, -ell i =t ,,.!._a_. gina11 r!r�.Il"�adWithout said raq!_!a•_.t 5 _a_!c i _i ia'f- t a r m i nat-a5 at the end of the 11 c enSUr= = aaY t --1 -c= r=DMI lISTRA'ITIVE F�E!1IEW-. The -Fol lowing Pro­_dul­ to, the ra`./i a- ^f administrativa daciSion_. Hi F i n a i adimin1straI:ive decziSions Sha11 ba subl..-?c_j 1!71=1a.1 r aalv e`, C1 U S i Vfa1=+/ a s 0r0-Vi ded f1;1fd n tSe Am1 n1_.t F. t1 ve f', e`•!4 e,�d r!cti 111- Rev. St.ti.t Ch 11s.fi r_+.r: Ik-1 as i:`_"sw or hereaitar amended, F?,` ce--i:t that an`-i Oet'itiDn T<Qr Judicial r_w _f lieQ.=rtmant .acti o-n Ltnd ar- t_j-ji ; C!!a0 =er=,:a,11 =� ti-i1=d t1ithl in ..'f teen s... j'1 s�•='1� a "`'=r r�rc'T �i_ ^ n+_ __= r?'?' +;-sue. n_dteri.term aaIT,4 nia -_{_i V�ra e r ._ i r n` %i a T_ f? e ._Z• i '"� a =. c e :t o % I n `_ .i_ I iJJ !_ ci _1_ J. n_._ h m n 73a - Y 1J d _ 1 _ __ n n•= r i strat: v o i ,' Act y i r ?_ may S •(' >.r+ R + s,_t ant ii a f"t .a i.- a n �_ = i i i i or 'Co! 1 t h a c ontIn!,i nn_ _,rcr->_!a1 0t n,..1 !-1, ;,-1 r- a r i- _i n 1 _ - J - �- r +- x sc f ! s C s_ _. T_ I t_7'r f�": . a. jl i_ 1.•s 11-1 i'! '! - Ali._{+_ia t_ _at tnere, i = _- SI!CE-:_anti al �r _`17 ._, [!1 i 1 _, r f-I [ _.! rs .._'.. -. SeeKi nc r ?�ii aw !•'di l I QSre 3 i j _n t 71a mie-1-i sit_ -!`_'; wi l l =U'7 r 1 ar stay i= i>_: granted, .any t =r the 1 r : _ p ._' �''" _•e �t P � Sii i ,r a ._ � 1 _ , _ ! _: _ - tacility w i 1 11 maat the r'a'?'•_!ir--Men_S of tIhi= Cl:=p_ei i+.in Z_ _'i_-av is; granted, t- hs C__i!!rt- im %', imoocSa =uch =cin Id =i n"s a!! the _ra.,'i ,g of thestay _ m_., b e r!e c a ssa.r: to -+'-�-f.u=t"d • Lhe liveshealth, -_a _t and welt:_= see- o r==iCj=;St' =nd -n a-s_— !r-a compliance the * =.i=i 1 i t, vii th thf= r=QUirar!ant=.._• of this Chapter, including an ordiar ;- •�n i-c� - s e t S _- _-4i:ran_fer or diSc a J s1 re^'dham_ e [ _ _i;r oL!sJ!-�8 -155-4-1r)- or_ -r!nr a p P am, li n t m a r, t o�+ _sit -e- a �s a_r i!nder '._ie i_i on5 A_-1=-4-I•=� �_;Sr J�.s�in '-3-1J-'.}__15. (L/ Actions brought under Lhis Lhapter shall be set forth for trial at the earliest possible date and shall take precedence un the court calendar over all other cases except maLters to which equal or superior precedence is specifically granted by law. 8-15-V: RBiEU1ES CUMULAllVE; !he remedies provided in this Chapter are cumulative and shall not be construed as restricting any party from seeking any remedy, provisional or otherwise, provided by law for the benefit of the party or from obtaining additional relief based upon the same facts. SEC|IUN 2: The provisions of this Chapter are severable. invalidity of any provision herein Mail not invalidate the remaining pruvisions. SECTION 3: All u/dinaMes or parts of ordinances in conflict MenewitA are hereby repea1ed. SECTION 4: This ordinance shall be in hull force and effect ninety days From and after its passage, approval, and publication in the manner provided by law, with exception of section 8-1b-/, which shall be in full force and ef/ecL from and after its passage, approval, and publication in the manner provided by law. Introduc22 1989. Adopted: 1989. �-...... .... ... ..... ... ----- ~ Mayor � City Clerk App ----t_/'^/-'--'\------------ \ Corporation Counsel -64-