HomeMy WebLinkAboutORDINANCES-1985-079-O-85Revised 7/18/85
79-0-85
AN ORDINANCE.
Amending the Long Term Care Act,
Title 8, Chapter 15 of the City Code of the
City of Evanston, 1979, as.amended
BE' IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF
• EVANSTON, COOK COUNTY, ILLINOIS:
SECTION 1:. That Section 8-15-1-6 the Long Term Care
Act,. Title 8, Chapter 15 of the City Code,
of the, City of. Evanston, 1979, as amended,, is hereby
further amended by the�additi.on of the following new
terms and definitions:
8-15-1-6: DEFINITIONS
DEVELOPMENTAL DISABILITY: A severe chronic disability of
a person which:
• (A) is attributable to a mental or physical impairment or
combination of, mental and physical impairments;
(B) is manifested before such person.attains age
twenty-two;
(C) is likely to continue indefinitely;
(D) results in substantial functional limitations in
three or more of the following areas of major life
activity:
1. self care
• 2. receptive and expressive language
3. learning
4. mobility
5. self -direction
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6. capacity for independent living., and
7. economic sufficiency; and
(E) reflects the person's need 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.
LICENSEE: The Individual. or entity licensed by the.
Department to operate- the. facility.
MENTAL. IMPAIRMENT`: A disability evidenced by
discharge from psychiatric care (inpatient
hospital care,. partial hospitalization, outpatient, and
day hospital care, iacl.uding care for alcohol anal/or drug:
abuse) within three (3) years:,. and/or;
A disability attributable to the residual effects of a.
mental disorder or emotional disturbance that causes some.
functional Impairment and.that alone or in connection
with social.,: legal or economic constraints, requires the
provision of specialized services over an extended period
of time directed toward the Individual's social,
personal, physical and/oreconomic habilitation or,
rehabilitation,. and/or;
A disability evidenced by behavioral problems as
determined by the facility's consulting physician and the
Care Review Committee.
QUALIFIED MENTAL RETARDATION PROFESSIONAL: A person
who is:
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(A) An educator with a bachelor's degree in education
from an accredited program and with either
specialized training in working with mentally retarded or
one (1) year of experience in working with the mentally
retarded..
(B-) A. physical therapist or occupational therapist with
either specialized trainingin working with the
mentally retarded or one-(1) year of experience in -
working with the mentally retarded,.,
(C) A..physician licensed by the State of Illinois to
practice medicine: or. osteopathy with either
specialized training, in working;: with the mentally
retarded or, one (1) year of experience -in working with
the, mentally retarded.
(D) A psychologist registered with the: State of Illinois
• Department of'Regi.stration and Education in.
accordance with the-",Psychol,ogist's Licensing Act"' and
either spe.cial.ized training in working with the mentally
retarded or one (1) year of experience in working with
the mentally retarded.
(E) A registered nurse with a. valid current Illinois
registration to practice as a registered professional
nurse with either specialized training in working with
the mentally retarded or one (1) year of experience in
working with the mentally retarded.
(F) A speech pathologist or audiologist with either
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specialized
training
in
working with
the mentally
retarded or one
(1) year
of
experience in
working with
the mentally retarded.
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(G) A.registered.social worker with a. bachelor's. degree
in social. work from an accredited program, or a
bachelor's degree- in a field other than social work and
at least three (3) years social work experience under the
supervision of a- qualified social. worker, and with
• either specialized training in working with the mentally
retarded. or one (1), year of experience in working with -
the mentally retarded..
(3). A therapeutic recreation. s;peaiali.st who i.s a graduate
of anaccredited,program.and eligible for
registration in the National Therapeutic Recreation
Society, and with, either specialized, training, in working
with the mentally retarded or one: (1) year of experience
in working with the. -mentally retarded.,
SECTION 2: That the remaining sections of the Long
Term Care Act, Title 8, Chapter 15 of the
• City Code -of- the City of Evanston, 1979, as amended,, are
hereby further amended as follows:
LTCENSE:.REQUIRED: No person or entity may
establish, operate, maintain, offer or
advertise a facility within the city unless and until he
obtains a valid Municipal. license therefor provided
herein, which license remains unrevoked and unexpired._
(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.
• (B) If the Department is denied access to a private home,
institution, building, residence or any other place
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which it reasonably believes is required to belicensed
as a facility under this Chapter, it shall request.
intervention of local, county or State -law enforcement
agenci.es.to-seek-an appropriate court order or warrant ta.
examine or interview the residents of such.private home,
institution,, bui.lding,, 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 --such penalties related
thereato..
8-15-2-2.:
be. as follows:
LICENSE PROCEDURES': The -procedure -for
obtaining; a valid municipal license shall
(A).� Applicat.ion to: operatea fa.cil.ity shall be made to
the Department on forms furnished by the Department..
The.applicant shall. be under 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 w violation of this -Chapter.. The Department
shall, refer. suspected. violations to the Sta.te's Attorney
or the Attorney General for investigation. The
application 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 officers 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;
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3'. Thei name of. the person or persons under whose
management or supervision -the facility will be
operated.;
4. The number, and- type: of: residents for whom
maintenance., personalcare or nursing is to be.
provided'; and
5..- Such information, relating to- the. number,.
experience,- and training of the: employees of the
facili.ty-,. any management agreements' for -the operation.
of the facility, and: the moral character of the
appl-tcant and employees as the. Department may deem
necessary.
(R) Each -initial. application shall be accompanied by the.
following.:
1. A financial. statement setting forth the
financial condition of: the applicant;
2. A permit as required: by the *'Illinois°Health.
racilit.ies Planning Act"';1
3. A certificate from the Department of Housing and
Property Services stating that the building or
structure to be used' as a long term care facility
complies with the requirements of the Evanston
Building Code and the Evanston Zoning Ordinance.2
4. In the case of new construction or the
conversion of existing structures, preliminary
plans and specifications for the proposed facility;
(Ord. 72-0-80) and
Revised 7/18/85
S. Other information necessary to determine the
Identity and__qualifications of an applicant to.
operate a facility in accordance with this Chapter
shall be included in the application as required by
the: Department .
6.. A& initial. non-refundable appli.ca-tion fee of
five hundred dollars ($500.00), plus an annual
license fee- of, .two hundred, twenty dollars. (S-220.00) ,.
plus: twenty-two: da.11ars:, ($22. 00 ) per licensed, bed: to,
be, refunded should the, application. be denied.. (Ord.
1'7-0-82.)
(C) After the- application is approved, the applicant
shall advis-e: the,Department every six (6) months of
any changes, in the: information originally provided in -the
application. (Ord.. 72-0-80)
• (D) Renewal License Applications: At least one hundred
twenty (120) days, but not more than one hundred
f.ift.y (1.50) days prior, to the license expiration, the
1.1c:ense.e. shall. submit an: application for renewal, of the
license on forms provided by the Department. The annual
license renewal fee shall be submitted with the renewal
license. application and shall. be.non-refundable. The
annual license renewal fee shall be two hundred twenty
dollars ($220.00) plus twenty-two dollars ($22.00) per
licensed bed for all facilities issued a license after
the effective date of this Chapter. (Ord. 17-9-82)
(E) Before the license can be issued or renewed, the
• applicant shall provide to the Department the
following:
1. A statement of ownership which shall be public
information, available through the Department,
and shall set forth the following:
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(a) Thename., address, telephone number,
occupation or business activity, business-
address and` business telephone number of the
person. who owns the facility and/or every person
who owns the building in which -the -facility is
located,if other than the owner of the
applicant facility and,.if the owner 1s.a
partnership or corporation, the- name and mailing
address of every partner and: stockholder of the.
owner-.
(b) The -address of all other facilities, if
any, in which the applicant holds: a.
f inancia-1 interest..
(c) An agreement to update. all information in.
the.sta.tement of ownership every six-(6)
months.
2. An atste.sted:financial statement in accordance
with requirements stet forth in the State- Act.,
3. Other information necessary to determine the
identity and qualifications of an applicant or
licensee to operate a facility in accordance with
this Chapter as required by the Department.
(F) Inspection Required: After receipt and review of the
appropriate application, the Director shall cause an
inspection to be made of the applicant's facility by the
Department, by the Fire Department and by the Department
• of Housing and Property Services.
1. The Director of the Department of Housing and
Property Services shall determine that the
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building or structure occupied by the long term care
facility complies -with the applicable provisions of
the State Standards and the Evanston City Code.
2. The Fire Chief shall determine that the building
• and premises meet the minimum applicable life
safety standards established by the State Standards
and. the Evanston City Code.
8=15-2:=8 DENIAL OF' APPLICATION; REASONS': An,
a:pplication.for license may be denied for
any of the following reasons:
(A) Failure= to meet- any of the applicable provisions of
this, Chapter
(B) Conviction of the.applicant, or if the applicant is a
firm,, partnership or association, of any of its
0 members, or if a corporation, the conviction of the
corporation or any of i..ts.officers or stockholders, or of
the. person designated, to manage or. supervise the,
f'ac111ty,., of" a felony,,. or of two (2) or more misdemeanors
involving moral turpitude, during the previous five (5)
years as shown by a certified copy of the record of the
court of conviction, or other satisfactory evidence that
the moral character of the applicant, or administrator,
or manager, or supervisor of the facility is not
reputable;
(C) Personnel insufficient in number or unqualified by
training or experience to properly care for the
• proposed number and type of residents;
(D) Insufficient financial or other resources to operate
the facility in accordance with this Chapter; or
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(E) Revocation of a facility license during the previous
five (5) years,. if such prior license was issued to
the.!indi.vidual applicant, a controlling owner or
controlling combination of owners of the applicant; or
any affiliate of the individual applicant or controlling
owner of the applicant. and such individual applicant..
controlling controlling owner of the applicant or affiliate of the
applicant was a. controlling owner of the prior license;
provided,. however,,. that the denial. of anapplication. for
& li_cens.e pursuant to. this 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.
thi.s.. Chapter; or
(F) That the facility is, not under the direct supervision,
of a full-time administrator,. as defined by
regulation, who is licensed, if required., under the
Nursing Home Administrators Licensing Act.
8-15-2-11.: REVOCATION OR NON -RENEWAL OF'LICENSZ;.
REASONS: The Department, after notice
to the applicant or licensee, may revoke or refuse to
renew a license in any case in which the Department finds
any of the following:
(A) a substantial failure of the facility to comply with
this Chapter;
(B) conviction of the.licensee, or of the person
designated to manage or supervise the facility, of a
felony, or of two (2) or more misdemeanors involving
moral turpitude, during the previous five (5) years as
shown by a certified copy of the record of the court of
conviction, or other satisfactory evidence that the moral
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character of the licensee, administrator,. manager or
supervisor of the facility is not reputable;
(.C`) personnel Insufficient in number or unqualified by
training.or experience -to properly care, for the
number and: type of residents served by the fac:ility;.
('D)-financial or other resources insufficient to operate
the facility in. accordance- with: standards set. forth
In this; Chapter;.:
(E), the fac.ili.ty is: not under the direct supervision of a
full-time administrator.', as defined: by, regulation,
who- is licensed, if. required, under the -Nursing Home
Administrators Li.censing-.Act.
8-15-2-12': NOTICE OFREVOCATION OR NON -RENEWAL:
Notice -under this Section shall include
a clear and. concise statement of the violations on which
the nonrenewal or revocation is based, the provision,
statute or rule violated and notice -of the opportunity
for.- a hearing under Section 8-15-6..
I:f' a facility desires to contest the nonrenewal or
revocation of a license, the facility shall, within.ten
(10) days after receipt of notice, notify the Department
in writing of its request for a hearing under Section
8-15-6. Upon receipt of the request the Department shall
send notice to the facility and hold a hearing as
provided under Section 8-15-6.
The effective date of nonrenewal or revocation of a
license by the Department shall be any of the following:
1. Until otherwise ordered by the circuit court,
revocation is effective on the date set by the
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Department in the notice of revocation, or upon final
action after hearing under Section 8-15-6, whichever
is later;
2. Until otherwise ordered by the circuit court,
• non -renewal is effective on the date of
expiration of any existing license, or upon final
action after hearing under Section 8-15-6, whichever
is later; however, a license shall not be deemed to
have expired if the Department fails to timely
respond to a timely request for renewal under this
Chapter or for a hearing to contest non -renewal;
3. The Department may extend.the effective date of
license revocation or expiration in any case in
order to permit orderly removal and relocation of
residents.
8-15-2-13: INSPECTIONS: The Department shall have the
right at any time to visit and inspect the
• premises and records of any facility and.to.evaluate the
facility residents and personnel for the purpose of
determining whether the applicant or licensee is in
compliance with this Chapter. The Department may survey
any former facility which once held a license to ensure
that the facility is not again operating without a
license.
Notwithstanding any other provisions of this Chapter, the
City's law enforcement agencies shall have full and open
access to any facility pursuant to Article 108 of the
Code of Criminal Procedure of 1963 in the exercise of
their investigatory and prosecutorial powers in the
enforcement of the criminal laws of this State, and may
• at any time request the assistance of county or State law
enforcement agencies.
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8-15-3 FACILI.TY REQUIREMENTS :.
8-15-3-1 RESIDENT RIGHTS The following resident
rights shall apply, to all faci.l.ities.:
• (A) No resident shall be ddeprived. of any rights., benefits.
or privileges guaranteed by law, the Constitut.ioa.of
the State of Illinois or the,Constitutioa of the United
States, solely on: account of his:, status, as, a resident of:
the facility.
(B) A. resident. shall be permitted.to manage his own.
financial affair's unless he or his guardian or if the,
resident is a minor, his parent, authorizes the
administrator -of the facility in writingto manage such.
resident's financial.afffairs, under Section 8-15-3-2.
(C.) A resident and a resident's family shall be advised
• of the right to name a resident representative and of
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the functions of said . represen.tative .
(D)° A resident. shall be permitted to retain and use or
wear his personal property in his immediate living
quarters, unless deemed medically inappropriate by a
physician and.so documented in the resident's clinical
record.. If clothing is provided to the resident by the
facility, it shall be of a proper fit.
(E) Each room containing -more than one resident shall
contain sufficient functional privacy screens so as
to afford privacy to each resident therein.
(F) The facility shall provide adequate storage space for
the personal property of the resident.
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1. The -facility shall provide each resident with a
functional bedside cabinet with a. drawer. This
requirement shall not affect the requirement to
provide drawers in dressers for each resident.
• 2.. In one of the, pieces of. furniture- required there -
shall be a. space capable, of being secured by- a
Locking device which is. to. be controlled by the
resident provided., however, that where- in the: opinion:
of the.- a:t.tending physician such secured: space., would.
be contrary to.the: health.or welf are of the resident,
such requirement may be abrogated during such period
of time when there exists, a: danger to the- health: or
welfare of sucha: resident. In. such. instances,. the:
facility, shall provide alternate means of
safeguarding small items of value and° shall mak-e
available daily access,to. such valuables.
• 3. The facility shall develop written procedures.
for, investigating complaints concerning. theft of
residents' pr=operty and shall". promptly investigate
all such, complaints.. If thefacility is unsuccessful
in locating resident property which is of value to
the, resident, the -facility shall promptly make a
report to the police. All complaints concerning:
thefts and actions: taken in response shall be listed
and the list available for inspection by the
Department.
(G) The facility shall make available one full-length
mirror on each resident floor for use by residents.
(H) A resident shall be permitted to retain the services
of his own personal physician at his own expense, or
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under an individual or group plan of health insurance., or
under any public or private assistance program providing,
such coverage. However, the facility is not liable for
the negligence of any such personal physician.._ Every
resident shall be permitted to obtain from his own.
physiciaa.or the physician -attached to the -facility
complete and current, information. concerning. his_ medi-cal
diagnosis,, treatment and prognosis. tn.terms and language
the resident can reasonably be expected to: understand-.
Every: resident shall be: permitted to participate: in the
planning of his: total care and medical treatment to the
extent that his condition permits. No resident shall be
subjected to, experimental research.or treatment without
first obtaining his, informed, written -consent. The
conduct of any experimental' res.e.arch or treatment shall
be authorized and monitored by an institutional review
committee appointed by the administrator of the facility
where such research and treatment is conducted. The
membership, operating procedures and review criteria for
Institutional review committees. shall be prescribed under
rules- and-, regulations of the_ Il.linoi.s. Department of
Public H:eal.th.
(I) Every resident shall be permitted to refuse medical
treatment and'to be informed of and know the
consequences of such action, 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 clinical
record. When a resident refuses medical treatment, the
facility shall immediately notify the facility's social
worker and the resident's family or resident's
representative. The resident's refusal shall free the
facility from the obligation to provide the treatment.
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(J) Every'r.esA dent, resident's guardian., or parent If the
resident is- a. minor shall be permitted: to inspect and
copy all his clinical and other records concerning his
care and mainteaaace-kept by the -facility or by his
physician. The facility may charge a reasonable fee for
duplicatioa of a record..
(K), A resident shall be�permitted respect and: privacy is
his: medical and person -care program. Every
res:i:dent' % case dis.cuss-ion, consultation,, examination and -
treatment shall be! confidential and shall be conducted
discreetly, and those persons not directly involved. in
the res.i.deat's: care must have his permission to be
present.
(L) The needs and individual lifestyles of resi.den.ts
shall. be considered a. priority. Routines and.
schedules should.be, individualized and based on an
assessment.ofeach res-ident, providing structure or
Independence as appropriate. Notations,on the need for.
structure and appropriate types, ot' freedom from. routines
shall.be,noted in the resident care plans
(M) Facilities shall allow residents•access to their
rooms at all times.
(N) The facility shall develop and follow procedures for
any transfer of a resident from one room to another
within the facility. Such procedures shall list reasons
for a transfer, provide for notice to resident prior to
the transfer, and provide notice and opportunity to the
resident of his or her right to be present and to
participate in packing belongings.
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(0) Neither. restraints nor confinements shall be employed
for the purpose of punishment or for the, convenience
of any facility personnel. No restraints or confinements
shall be employed except as. ordered by & physician in the -
resident's clinical record.
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(P) Anowner.. licensee-, administrator,, employee or agent.
of a- facility shall not abuse or neglect a, resident.
I.t, Is., the duty of any fa.c.il.i.ty employee, or agent who
becomes, aware, of su.ch. abus°e: or aegl.ect to, report: it as.-
provided- in Section 8:-15-3.-1(Z).
(Q) Every resident, shall be, permitted unimpeded,. private,
and uncensored communication of his cho.i.ce by mail,
public telephone'or visitation.
1. The, administrator shall ensure that
correspondence is conveniently received and
• mailed, and. that telephones are reasonably accessible.
Z. The admintst.ra.tor shall ensure that residents
may -have private visits at. any reasonable hour,
unless -such visits are not medically advisable for the
resident as documented in the resident's clinical record
by the resident's physician.
3. The administrator shall ensure that space for
visits is available, and that facility personnel
knock, except in an emergency, before entering any
resident's room.
• 4. Unimpeded, private and uncensored communication
by mail, public telephone and visitation may be
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reasonably restricted by a. physician only in order to
protect the -resident or others from harm, harassment
or intimidation, provided.that the reason for any
suchrestriction is' placed° in the resid'ent's clinical
record by the physician and that notice of such
• restriction shall be given to all residents upon
admission. However,_ all letters, addressed by a,
resident to the Governor,, members o.f the�Gene.ral
Assembly,. Attorney General, judges,.. S.tate's
Attorneys,, the: Department, the Illinois Department- of
Public Health, the Evanston. Commiss.1on on. Aging-, the
Mental Health.Board, or licensed attorneys at law
shall be forwarded at. once to the persons to whom:
they are: addressed without examination by facility
personnel. Letters. in reply from the.officia:ls and
attorneys. ment.ionad a.b-ove=shall be delivered to the
recipient without examination by facility personne-1.
• S. The -administrator shall. ensure that. married
resi.deats. residing in the same facility be
allowed to reside. in- the same- room within, the
facility unless there Is,,, no room available in the -
facility or i-t- is deemed: medically inadvisable by the
.resident's attend.ing.physician and so documented in.
the resident's medical records.
(R) A resident shall be permitted.the free exercise of
religion. Upon a resident's request, and if
necessary at his expense, the administrator shall make
arrangements for a resident's attendance at religious
services of the resident's choice. However, no religious
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beliefs or
practices, or
attendance at religious
services,
may be imposed
upon any resident.
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(S.) Residents shall be allowed access to advocates, as
follows..
1. Any employee or agent of a public agency, any
representativemof a- community legal. services
• program: or any other member of the genera-1 public=
shall be,permitted access at reasonable hours -to any
Individual. resident of any facility,, but only if
there is:neither a. commercial purpose nor effect to,
such-, access:_ and; If the pur.pos'e. is to do any of the:
f o l l ow:ing.:.
(a), Visat',. talk- with and make personal,. social
and legal. services available- to all,
residents;
- (b) Inform residents. of their rights and
entitlements and their corresponding
• obligations. under Federal, State and local
laws., by means. of educational materials and -
discussions irr groups with individual. residents;
(c) Assist residents in asserting their legal
rights regarding claims for public
assistance, medical assistance and social
security benefits, as well as in all other
matters in which residents are aggrieved.
Assistance may include counseling and
litigation; or
(d) Engage in other methods of asserting,
• advising and representing residents so as
to extend to them full enjoyment of their rights.
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2. All persons. entering a facility under, this
Section shall promptly notify appropriate
facility personnel of their presence. They
shall,, upon request,. produce identification to
establish,their identity. No such person.shall
• enter, the -immediate living area of any resident
without. first identifying; himself and then
receiving permission from the residentto.
enter... The rights of other residents, present in
the, room.. shall be- respected. A resident may
terminate at any time. a. visit by a person having.
access, to the resident's living area under this
Section.
3.- This Section shall not limit the power of the
Department or other public agency -otherwise,
permitted or -required by law to enter and inspect a
facility.
4. Notwithstanding Section 8-15-3-1(S) above, the
administrator of a facility, may re -fuse accesT to
the facility to any person if the- presence of that
person in the facility would be injurious to the
health and, safety of a resident or would threaten the
security of the property of a residentor the
facility, or if the person seeks. access to the
facility for commercial purposes. Any person refused
access to the facility may within ten (10) days
request a hearing under Section 8-15-6. 'In that
proceeding, the burden of proof as to the right of
the facility to refuse access under this Section
• shall be on the facility.
(T) A resident may be discharged from a facility after he
gives the administrator, a physician or.a nurse of
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the facility -written notice of his desire to be
discharged. If a guardian has been appointed for a
resident or if the resident is. a minor, the resident
shall be discharged upon written consent of his guardian
or if the resident is a minor, his parent unlessthere is
• a court order to the contrary. In such cases., upon.the-
resi.dent's discharge,, the facility is.relieved from any,
respons.ibi.lity for the resident's care, safety or
well-being..
(U) A.resident.shall be permitted to present grievances:
on behalf of himself or others to the administrator,,
the Department,. the Long Term Care Facility Advisory
Board, the re.sidents:' advisory council, governmental.
agencies or.other persons without threat of discharge or
reprisal in any form or manner whats.oever. The
a-dministrator shall provide all residents or their
representatives with the name, address: and telephone
• numbers of the appropriate City and State governmental
offices where complaints may be -lodged.
(V) A resident may refuse to perform labor for. a facility.
(W) When any facility permits residents to work within
the facility and obtains agreement from the resident
to work in other than an approved work therapy program,
the facility shall:
1. Pay the minimum wage as may from time to time be
established by State or Federal legislation.
• 2. Record and maintain payroll records of such
transaction available for inspection by the
Department.
-21-
Revised 7/18/85
•
L�
•
(X.). A. licensee: or its: agents- or employees shall not
transfer, discharge,, evict,. harass, dismiss, or
retaliate against a resident, a resident's representative
or an employee; or agent who makes a report under Section
8-15-3-1(P), or files a complaint under Section
8-15-4-6(A) because of the -report or complaint..
(Y) Any pe.rson,. institution oragency participating in
good' faith- in: the making of a. report, or in the
investigation of such a report shall not be deemed,to
have vio.lated.any privileged communication and -shall have
immunity from any liability, civil or criminal, or any
other proceedings, civil or, criminal as a consequence of
making such.report.' The good faith of' any persons:
requir.ed,to report, or permitted to report,_ cases of
suspected resident abuse or' neglect. under this. Chapter
shall be presumed.
(Z). A facility employee or agent, an advocate,, or a
,representative from any regulatory agency who has
reasonable=cause to believe that a resident with whom
they have directcontact has been subjected to abuse or
neglect shall immediately report the matter to the
facility administrator and to the Department. The
administrator, when becoming aware of. 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.
8-15-3-2
facilities:
FACILITY REQUIREMENTS : In addition, the
following are requirements for all
-22-
Revised 8/6/85
(A) To protect the residents' funds, the facility:
1. Shall at the time of admission provide each
resident, or his representative, with a written
statement explaining the resident's rights regarding
personal.funds and listing the services for which the
resident will be charged, and obtain a signed
acknowledgment from each resident or his
representative that he has received the statement;
2. May accept funds from a resident for safekeeping
and management, if it receives written
authorization from the resident or his guardian; such
authorization to be attested to by a witness who has
no pecuniary interest in the facility or its
operations, and who is not connected in any way to
facility personnel or the administrator in any manner
whatsoever;
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 funds;
5. Shall purchase a surety bond to guarantee the
security of residents' funds;
6. Shall keep any funds received from a resident
for safekeeping in an account separate from the
facility's funds;
-23-
•
•
Revised 8/6/85
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. The account shall be in a'form which
clearly indicates that the facility has only a
fiduciary interest in the funds and any interest from
the account shall accrue to the resident. The
facility may keep up to one hundred dollars ($100.00)
of a resident's money in a non -interest bearing
account or petty cash fund, to be readily available
for the resident's current expenditures;
8. Shall return to the resident, upon written
request, all or any part of the resident's funds
given the facility for safekeeping, including the
interest accrued from deposits;
9. Shall place any monthly allowance to which a
resident is entitled in that resident's personal
account or give it to the resident, unless the
facility has written authorization from the resident
or the resident's guardian, or if the resident is a
minor, his parent, to handle it differently;
10. Unless otherwise provided by State law, upon the
death of a resident, shall provide the executor
or administrator of the resident's estate with a
complete accounting of all the resident's personal-
property,,including any funds of the resident being
held by the faclity.
11. If an adult resident is incapable of managing
his funds and does not have a representative or
guardian, the facility shall notify the office of the
State Guardian of the Guardianship and Advocacy
Commission; and - cl�_
Revised.7/18/85
12. If the facility is sold, shall, provide the buyer
with a.written verification by --a public
accountant of all residents' monies and properties
being transferred., and obtain a. signed receipt from.
the new -owner.
(B). Before a person is admitted to -a- facility, or at. the
expiration of the period of previous contract, or
when: the source of payment for the resident's care-
changes from private- to public- funds: or from public to
private funds, a written contract shall be executed
between a. licensee and the following in order of
pri.ori.ty: (1) the- person:,, or if the, per:s.on is:a minor,.
his: parent or guardian.; or (2) the- person' & guardian,, if
any, or agent, if any, as defined in Section lla-23 of
the *Probate Act of 1,9750, as now or hereafter amended;
or (3) a member of the person's: immediate family.
. An adult person shall. be..presumed to have: the capacity to
contract for admission to- a long term care facility
unless he: has been.adjudicate.d a "'dis.abled: person within
the meaning of: S-ec-tion ll.a-2 of' the 'Probate -Act of
19750, as now or hereafter amended, or unless a. petition
for such an adjudication is pending in a circuit court of
Illinois.
If there is no guardian, agent or member of the person's
immediate family available, able or willing to execute
the contract required by this Section and a physician
determines that a 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
order has been entered
allowing residential
placement of
the person, that person may be admitted to a facility
before the execution of a contract required by this
-25-
Revised 7/18/85
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 adult shall be admitted to a, facility if he objects,,
orally -or in writing,. to such admission,, except as
otherwise provided 1n Chapters III and. IV of the "Mental
Health and Developmental Disabllitie.s•Code',, as. amended,
or. Section lla:-14.1 of the 'Probate -Act of 1975", as
amended.
Lf a person, has not executed a contract as: required° by
this -Section, then such a contractshall be executed on
or before July l,. 1981, or within ten (10), days: after the
disposition ofa petition for guardianship or
modification.of guardianship that wa.s filed prior to July
. 1, 1.981. whichever is later.
A resident shall. not be discharged or, transferred at the
expira.t.ion:of the term of a contract, except:- as provided.
in Section 8-15-3-2 (F). 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 12-point type. The general form of the
contract shall be prescribed by the Department.
• 2. The contract shall include and specify:
(a) The term of the contract;
-26-
Revised 7/18/85
(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) They amount of deposit paid;
(f) The rights, duties and obligations of the
resident, except that -the specification of
a resident's rights. may be furnished on a
separate- document which complies with the
requirements of Section.8-15-3-2(G);
• (g) The,name of the resident's representative,,
if any. The resident shall provide the
faci.li.ty with: a. copy of the wr,i ten. agreement
b.etween.the resident and. the resident's,
representaive which authorizes the- resident's
representative to inspect and copy 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 under it may be cancelled at the
resident's request without advance notice. It
shall also provide that in all other situations,
a resident may terminate the contract and all
-27-
Revised 7/18/85
obligations under it with seven (7) days.
notice. All -charges shall be prorated a-s of -the
date on.which the contract terminates, and,if
any payments.have been made in advance, the
excess shall be,refunded to the resident. This
• provis,ion.shall not apply to life -care contracts
through which a facility agrees to provide
maintenance. and carefor, a resident throughout
the remainder of his. life nor to continuing -care
contracts:: through which, a. facility agrees to
supplement all available forms, of financial
support in providing maintenance and care for a
res-i.dent. throughout the remainder -of his Life..
(i) A.provision.that tha facility shall give
thirty (30) days prior written notice of
any contract modification to the resident or
resident's_ guardian and to any resident's
. representative. Said modification shall be
clearly and fully described.
n
LJ
3- In addition to all other contract specifications
containedin this Section, admission -contracts
shall also specify:
(a) whether the facility accepts Medicaid
clients;
(b) whether the facility requires a deposit of
the resident or his family prior to the
establishment of Medicaideligibility;
(c) in the event that a deposit is required, a
clear and concise statement of the
-28-
Revised 7/18/85
•
•
•
procedure to be followed for the return of such
deposit to the resident or the appropriate -
family member or guardian of the person;
(d) that all deposits made to a facility by a
resident, or on behalf of a resident,. shall
be returned by the facility within thirty (30)
days. of the: establishment of Medicaid
eligibility, unless: such deposits must be drawn
upon or encumbered in accordance with Medicaid
e--l.i.gibi.lity requirements established by the
Illinois- Department. of Public. Aid.
(a) pursuant to Section 2-202(K) of the State
Act, it shall be, a business offense for a -
facility, to knowingly and intentionally both
retain a: resident's deposit and accept Medicaid.
payments on behalf of the resident.
4. At the time of the resident's admission to the
facility, a copy of the contract shall. be given.
to the -resident, his guardian, if any, and any other
person.who executed the contract. A copy of the
contract for a resident who is supported by nonpublic
funds other than the resident's own funds shall be
made available to the person providing the funds for
the resident's support. The -original or a copy of
the contract shall be. maintained in the facility and
be made available upon request to representatives of
the Department and the Illinois Department of Public
Aid.
S. Contract terms are binding and do not become
void if ownership or administration changes.
-29-
Revised 7/18/85
(C) Each facility shall.es-tabli.sh a. residents' advisory
council. The -administrator shall designate a member
of the -facility staff tocoordinate the establishment of
the council. After consultation with the -council, the
administrator shall designate a member of the facility
• staff to provide ongoinq.assi.stance to the council.
1. The composition of resident's -advisory councils.
shall adhere to State Standards for resident
members In.addition, resident advisory councils in
faci.litie.s, that have more than seventy -five -percent
intermediate or skilled care residents shall. have at
least two (2') nonres.ident members. Nonresident
members shall not. have a. f inancial interest in the
facility.. If resident members are unsuccessful in
finding acceptable nonresident members, the resident
council shall inform the Director. The Director -
shall notify the Evanston Commission on Aging or the.
0 Evanston Mental Health Board who shall offer
a.ss.i.stance to the -resident council in finding
acceptable nonresident members. The Director may
grant an exception to the requirements for
nonresident members only with the approval of the
Evanston Commission on Aging. Such exception shall,
be valid for a period not to exceed one year.
(D) A facility shall immediately notify the resident's
next of kin, representative and 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.
-30-
Revised 7/18/85
(F) A facility shall not involuntarily transfer or
discharge a. resident except for medical reasons; for
the resident's safety or for the safety of other
residents; or for nonpayment of the resident's: stay,
•
except
as prohibited by
Titles
XVIII and XIX of the
Federal
Social Security
Act.
Involuntary transfer shall
be -governed by the following procedure:
1.. Involuntary transfer or discharge of a, resident
from a.faci.lit.y shall be preceded by the
discussion required under Sect1oa.8-15-3-2(F)7 below,
and by a minimum written notice of twenty-one. (21)
days. The twenty-one (21) day requirement shall. not
apply in any of the -following instances:
(a). When an emergency transfer or discharge is
mandated by the resident's health care
needs and is in accord with the written orders and
• medical justification of the attending physician;
(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. be on a form prescribed by the
Department and 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;
-31-
Revised.7/18/85
(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 think you should not have
•
to
leave this
facility,
you may
file a request
for
a hearing
with the
Evanston
Health
Department within ten (10.) daysl after receiving —
this notice. If you request a hearing, it will
be; held: not later than ten (10) days after your
request., and you generally will not be
transferred or discharged:,prior to the
expiration of thirty (30) days following receipt
of the original notice of the transfer or
discha,rg-e-.. 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 paid, preaddressed 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. A request for a hearing made under Section
8-15-3-2(F)9 shall stay a transfer pending
a hearing or appeal of the decision, unless a
condition which would have allowed transfer or
idischarge in less than twenty-one (21) days as
described under paragraphs a. and b. of Section
8-15-3-2(F)l above develops in the interim.
-31-
Revised 7/18/85
4. A copy of. the notice. required by Section
8-15-3-2(F)2._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 inwhole or part through Title: XIX, to the
Illinois Department of Public Aid.
S. When: the. basis. f,or an involuntary transfer or
dis.cha-rge: isthe: result of. an action or inaction
by -the -Illinois Department of Public Aid with respect
to a, recipient of Title X.IX 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 receivedby the residentand the facility.
6. Whe.n, nonpayment is the basis for involuntary
transfer or discharge,. the resident shall have
the right to redeem up to the date that the discharge
or transfer is to be made and then shall have the
rightto remain in the facility.
7. The planned involuntary transfer or discharge
shall be discussed with the resident, the
resident's representative and person or agency
responsible for the resident's placement, maintenance
and care in the facility. The explanation and
discussion of the reasons for involuntary transfer or
• discharge shall include the facility administrator or
other appropriate facility representative as the
administrator's designee. The content of the
discussion and explanation shall be summarized in
-33-
Revised 7/18/85
writing and shall include the names of the
individuals..involved in the discussions and made a.
part of the resident's clinical record.
• 8'.. The facility's social worker shall offer the
resident counseling services. before the transfer
or discharge of the resident..
9.. X resident subject to involuntary transfer or:
discharge from a facility, the° re-s.i.dent' s:
guardian.or if the -resident is a: minor,. his parent,
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. The Department, when the basis for involuntary
transfer or discharge is other than action by
• the Illinois Department of Public Aid with respect to
the Title XIX Medicaid recipient, shall hold a
hearing -at the resident's facility not later than ten
(10) days�af ter a hearing request i.s filed, and,
render a decision within fourteen (14) days after the
filing of the hearing request.. The hearing shall be
conducted as prescribed under. Section 8-15-6. In
determining whether a transfer or discharge is
authorized, the burden of proof in this hearing rests
on the person requesting the transfer or discharge.
11. If the Department determines that a transfer or
discharge is authorized under Section
• 8-15-3-2(F), the resident shall not be required to
leave the facility before the 34th day following
receipt of the notice required under Secion
8-15-3-2(F)2 or the tenth day follwing receipt of the
-34-
Revised.7/18/85
Department's decision, whi.chever 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 b. of Section
• 8-15-3-2(F)1 develops in the interim.
12., Any, owner of a facility licensed under this. Act
shall give ninety (90.) days- notice prior to
voluntarily closing a facility or clos-ing any part of
a. facility if. closing such.part- will require the
transfer or discharge of more than ten percent (1.0%)
of the residents. Such notice shall be given to•the
Department,, to any re.siden.t 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 toassist the resident in securing an
• alternative placement, and shall advise the resident,
on available alternatives. Where 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 applicabl-e laws and regulations
until the date 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 8-15-4-12.
(G) Each facility shall distribute a handbook printed in
not less than twelve (12) point type 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
-35-
Revised 7/18/85
later than forty-eight (48) hours after admission. Said
handbook shall be updated annually. The Handbook shall
include a written summary of all the rights enumerated in
Section 8'-15-3.
is 1. A list of all rights and responsibilities
enumerated above in Sections 8-15-3-1 and
8-15-3-2, and those additionalrights listed in. the•
State,Act, Sections 3-601. through 3-607..
2. A statement of services of.f.ered by the- facility.
3, A. currentguide to all required, costs for.
residence: in the. facility.
4.. Pol.i.ci.es, and procedures ofthe facility for
implementing the rights and.responsibi.l.ities
enumerated above in Sections.8-15-3-1and 8-15-3-2.
• The policies shall include the procedures for the
•
investigation and resolution of resident complaints
as. set forth in Section 8-15-4-6.
5. The address and phone number of each of the
following agencies and a brief description of
services provided by each agency:
(a) Evanton Health Department.
(b) Illinois Department of Public Health.
(c) Illinois Department of Public Aid.
(d) Illinois Department of Mental Health.
-36-
Revised 7/18/85
(e) Evanston Mental. Health Board.
(f) Cook County Legal Assistance -Foundation,
Inc.
•
(q) Local Social. Security Office.
•
(h) Evanston: Commission on Aging.
UY Evanst.on Hospital: Crisis. Intervention and
Referral Service-,.
(J) Family Couns.elIng Service of Evanston and
Skokie Valley.
6. The procedure for leaving a facility, including
Information on -transferring Public Assistance,
Social. Security, SSI or other payments.
If a resident is unable to read such copy it shall be
rea& to -the -resident in.a language the resident
understands:. In. the case of a minor or -person -having
a guardian, both the resident and the parent or
guardian shall be fully informed of the content of
the handbook.
(H) The facility shall ensure that its staff is familiar
with and observes the above rights and
responsibilities enumerated in Sections 8-15-3-1 and
8-15-3-2.
•
(I) Every
facility
shall conspicuously post
for display
in an
area of
its offices accessible to
residents,
employees and visitors the following:
- 37-
Revised 7/18/85
1. Its: current license;
2.. A description,. provided by the Department, of
complaint procedures established under Section
• 8-15-4-6 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 thet Deprtment or a court; and-
4. A list of the -material available for public
inspection under Section 8-15-3-2(J).
(J)' A facility shall retain the following for public
inspection:.
1., A complete copy of every inspection report of
the facility received from the Department during
the past five (5) years;
2. A copy of every, order pertaining to the, facility
issued by the Department or a court during the
past five (5) 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;
4. A copy of the statement of ownership required by
• Section 8-15-2-2(E)l.
5. A record of personnel employed or retained by
the facility who are licensed, certified or
-38-
Revised. 7/18/85
registered by -the Department of Registration and
Education; _
6. A complete copy of the most recent inspection
• report of the facility, received from the -
Department;
7. A copy of the resident handbook; and
8.. Minutes of resident council, meetings. for the -
past two (2) years.
(K)- The foll.owing shall apply to the employment of all.
nurse aides and nurse assistants:
1. No-person,except a volunteer who receives no
compensation from a facility and is not included
for the purpose.of meeting any staffing requirements
• set.forth by, the Department, shall act as. a nurse's
aide, orderly or nurse technician in a facility, nor
shall, any -person under. any other title:, not licensed,
certified or registered to render medi.cal care by the
Department of. Registration and Education, assist with
the personal or medical care of residents in a
facility, unless such person meets the following
requirements:
(a) Be at least sixteen (16) years of age, of
temperate habits and good moral character,
honest, reliable and trustworthy;
• (b) Be able to speak and understand the English
language or a language understood by a
substantial percentage of the facility's
residents;
-39-
Revised 7/18/85
(c) Provide evidence. of employment or
occupation, if any, and residence for two
(2) yearn prior to. his present employment;.
(d) Have completed at least eight (8) years of
grade. school or provide proof of, equivalent
knowledge;
(e). Successfully complete a: current course of
training for nurse's aides, orderlies and,
nurse technicians, or an equivalent course of
training approved by the Department of Public
Health within one hundred eighty (180) days,of
the effective date of the. -State Act or within
sixty (60) days. of initial employment in the
capa-cityof a nurse.'s aide, orderly, or nurse
technician at any facility, whichever is later.
However., no person who on the effective date of
• the State Act has been continuously employed at
the same facility for one year or who has been
employed at more than one facility for. two (2)
yearn a.s; a nurse's aide, orderly or. technician
shall be required to complete such a course of
training'; and
(f) Be familiar with and have general skills
related to resident care.
2. Application forms which are utilized for the
employment of nurse aides and assistants shall
include an inquiry related to any prior felony
• conviction record.
3. Persons subject to this Section shall perform
their duties under the supervision of a nurse.
-40-
Revised 7/18/85
4. It is unlawful for any facility to employ any
person in the capacity of nurse-'s aide, orderly
or nurse technician, or -under any other title, not
licensed by the State of Illinois 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.. E`ach fac.il.ity 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.
(L) There shall be a --quality assurance program conducted
by facility staff that is designed to enhance care
provided by the facility through the ongoing objective
identification of problems in the: delivery of care and
the correction of these problems. The program shall be
implemented and monitored by an interdisciplinary team
that includes administration, nursing staff, medical
staff, social work staff and other disciplines as
necessary. The program shall be reappraised annually by
• the facility to evaluate its effectiveness and to be
changed as necessary. The program shall include at a
minimum:
-41-
Revised 7/18/85
•
P�
1. identification of important, problems in the:
delivery of care to residents. Problems. may -be
identified through review of committee minutes,
resident care plans, medical records,, incident
reports, utilization review findings- and through
Interviews, and observationsof residents and staff...
2. objective -assessment of the cause and scope -of
such problems, through use of written criteria
or., s.tanda.rds that relate to- essential or crit..ical
aspects- of resident care°, including resident goals,
processes: of care -, and therapeutic -interventions.
3. implementation of a mechanism to eliminate the
problem or to reduce the degree of problem,.
which may include training.programs, revised policies
or procedures, staffing changes, equipment or
facility change, or adjustment in admission practices.
4. consistent and routine -monitoring of activities
to assure that corrective acti.on Is.adequate.
By July 1, 1986 a written plan shall be developed for
compliance with this. Section. By January 1, 1987, all
facilities shall comply with the requirements of this
section by fully implementing said quality assurance
program.
(M): The following continuing education programs
shall be required:
1. Every facility administrator shall complete
annually a six (6) hour training program which
-42-
Revised 7/18/85
shall provide information and skill development on
aging, mental impairment, or developmental
disabilities, and shall be approved by the Director.
Documentation of course attendance shall he
• maintained in the administrator's personnel file.
2. Each facility in which 20% or more of its
residents have a mental impairment shall provide
or arrange for a formal, structured in-service
training program for all nurse aides and nurse
assistants, to include information and skill
development for the care and management of persons
with mental impairments. Such a training program
shall be approved by the Evanston Mental Health
Board. This program shall be a minimum of % 3xq�;twelve
(:2�) hours in length, shall be provided quarterly to
each current employee, and shall provide for
sequential learning. Any newly employed nurse aide
• or nurse assistant shall receive, within fourteen
(14) days of employment, six (6) hours of orientation
information covering the special needs of the
mentally impaired. Documentation of attendance in
the orientation program and/or the in-service
training program shall be maintained in each
employee's personnel file.
3. Each facility in which 20% or more of its
residents have a developmental disability shall
provide or arrange for a formal, structured
in-service training program for all nurse aides and .
nurse assistants, to include information and skill
development for the care and management of persons
with developmental disabilities, including
G° habilitation training according to Federal Health
Care Financing Administration standards. Such a
11�
4 -43-
Revised 7/18/85
In
training program shall be approved by the Evanston
Mental Health Board. This program shall be a minimum
of hours in length, shall be provided
quarterly to each current employee, and shall provide
for sequential learning. Any newly employed nurse
aide or nurse
assistant shall receive,
within
fourteen (14)
days of employment, six
(6) hours of
orientation information covering the special needs of
residents with developmental disabilities.
Documentation of attendance in the orientation
program and/or the in-service training program shall
be maintained in each employee's personnel file.
4. Each facility in which 20% or more of its
residents have a mental impairment shall arrange
for all nurses and clinical social workers to
complete at least one (1) continuing education course
each year. Such course shall provide information and
skill development for the care and management of
persons with mental impairments, and shall receive
prior approval from the Director of the Mental Health
Board. Documentation of attendance in such course
shall be maintained in each employee's personnel file.
5. Each facility in which 20% or more of its
residents have a developmental disability shall
arrange for all nurses and clinical social workers to
complete at least one (1) continuing education course
each year. Such course shall provide information and
skill development for the care and management of
persons with developmental disabilities, and shall
receive prior approval from the Director of the
Mental Health Board. Documentation of attendance in
such course shall be maintained in each employee's
personnel file.
-44-
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Revised, 7/18/85
8--15-3-3 MINIMUM STANDARDS: The following standards
shall be deemed to be the minimum.standards-
to be met for licensing. pursuant to this Chapter:
• (A) Nursing:. The following personnel requirements shall
apply:
1... Skilled Nursing Facilities and Intermediate Care
Facilities.:
(a) There- shall. be a full-time Director of
Nurses licensed as a registered nurse in
the, State of Illinois... The time of the Director of
Nurses may not be included in the nursing time
required to meet the st.aff.-res-ident ratio
requirements in the State Standards..
(b) In facilities of one hundred (100) beds or
• more, there shall. be a full-time Assistant
Director of Nurses, who shall be licensed as a
registered nurse -in the. State of Illinois and
who shall be on duty between the hours of seven
o'clock (7:00) A.M. and seven o'clock (7:00)
P.M. for five (5) days within any week and shall
be on duty oa those days upon which the Director
of Nurses is not on duty. This person shall
assist the Director of Nurses and shall perform
the duties of the Director of Nurses when the
Director of Nurses is not in the facility. The
Assistant Director of Nurses may 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.
-45-
Revised 8/6/85
(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 nurse in charge of each eight
•
(8) hour
shift,.
regardless of the size of
the
facility.
This
person's duties shall be
to
provide professional supervision 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 (7) days a week.
(e) Within six (6) months of the effective date
of this; ordinance and continually thereafter,
each facility shall employ at least one 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 nursel shall be a person other
than the Director of Nursing.
2. Sheltered Care Facilities:; In facilities of one
hundred (100) licensed beds or more, there shall
be a registered nurse licensed in the State of
Illinois or a practical nurse licensed in the State
of Illinois on duty for each eight (8) hour shift
with coverage on days off. In the event all three
(3) shifts are covered by a practical nurse licensed
in the State of Illinois, 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
-46-
Revised 7/18/85
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 by a
physician, registered nurse or practical nurse
licensed in the State of Illinois. Any licensed
CJ
•
practical nurse responsible for the administration of
medications shall complete a pharmacology course
approved' by the Department prior to employment,
within.six ( 6 ) months- of employment -or within six ( 6 )
months of the effective date of this Chapter,
whichever is later. Documentation which indicates
compliancel with this Section shall be contained in
each employee' s- personnel file. All self -medication,
administration tra:ini.ng programs shall be conducted
by° a person licensed to administer medications, in the
State of Illinois.
4. When a. resident's condition dictates, the
physician may give permission in writing. for the
resident to administer medication himself exceptwhen.
such resident requires skilled care.
5. In all facilities there shall be additional
ancillary personnel to meet the total needs. of
the residents.
(B) Dietary Service:
1. Resident Care Procedures:
(a) There shall be reasonable adjustment to the
food likes, habits, customs, condition and
-47-
Revised 7/18/85
•
appetite of individual residents. Special,
attention shall be given to the preparation and
service of food to residents with problems such
as inability to cut food, to chew, to swallow.
(b) Residents continuously rejecting most of
their food 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
feed themselves shall be fed with attention to
safety and comfort. 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 has'qualifications for eligibility 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 the dietetic service
of a health care institution, and participates
annually in continuing dietetic education. The
dietary consultant shall:
(1) Schedule most consultation visits
• during active, week day work hours for
food and service administration personnel.
-48-
Revised 7/18/85
E
•
•
(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
30-49 beds-
8
hours:
per
month
50-99 beds
12
hours
per
month
100.-149 beds:
16
hours
per
month
150-199' beds:
20
hours
per
month
2-00-24.9 beds
24
hours
per
month
250-299 beds.
28
hours
per
month
300 and over
32.hours
per
month
(b) The Director of Food Service shall be a
qualified diet.iclan.; a graduate of a
dietetic technician or d.ie..t.etic assistant
training program approved by the American
..Dietetic Association; a graduate of a State
approved course -that provides ninety (90) or
more hours, of. classroom_ instruction in food
servic.e supervision and has had experience as a
supervisor in a health care institution (which
included consultation from a dietician); 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
-49-
r. C
Revised 7/18/85-
determination by the Department, 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 fulfill
the responsibilitiesoof the Director of Food
Service.
(C) Social Services.: All.faci.lities shall provide the
followting:social services:.
1. Referral. to appropriate agencies where there are
indi.cato.rs that financial, psychiatric,
rehabilitative, legal or social service help will.be
needed that the- long term care facility cannot
provide.
2. Assistance with the resident adjustment to the
• long term care facility and availability of
continuing social services to residents of the
factl,it.y including the availability of contact with.
family members to keep them,iavolved.
3. Assistance to staff and residents in discharge
planning and its implementation.
4. Assistance in providing in-service training to
long term care facility 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
community resources.
-in-
Revised 7/18/85
•
CJ
•
6. A11 facilities shall engage the services - of a
clinical social worker accord-ing,to the
following ratio of residents to hours of service
0-99-residents.
100-199 residents
2.0.0-2.99 residents
4 mind resident/week.
5 min./resident/week
6 min./resident/week.
300, or more residents. 7 min./resident/week
At ao time- shall the- amount of s.oci.al work time, be
less- than the. -ratio required for the -number of
residents in the.facility at that time.
A clinical social so-rker. shall, have a master's degree
in social work:, six (6) months supervised clinical
experience,, and. current certification by the State of.
Illinois. The. degree requirements. herein provided
may bewaived by written application to the
Department and. Mental Health Board, upon a clear
showing that the applicant has achieved an equivalent
degree in. counseling., psychology or community mental.
health. and. clinical, experience. These requirements,
shall bewaived for those social workers who have
been employed at a long term care facility in
Evanston for at least six (6) months prior to the
effective date of this Chapter.
(D) Mental Health Services: All facilities with
residents who are mentally impaired or
developmentally disabled shall meet the following
staff requirements.
1. A psychiatrist licensed to practice in Illinois
shall be under formal contract by the facility
-51-
Revised 7/18/85
to provide -services determined by the Care Review,
Committee.
2. Additional clinical social work -hours -shall be
• provided to residents _defined' above at the rate
of twenty-five ( 25 ) minutes per resident per, week.
(E) Activity -Program: Al.l.facilities shall have an
activity program directed: by a full-time staff member
whoa shall. be qualifiedto: direct an activity, program.
Qualification, shall. be- established, by one of the
following:
1. status as an occupational therapist registered
with the Occupational Therapy Association; or
2. a: bachelor's degree in recreation therapy; or,
• 3. evidence of successful completion of a forty-two
hour course certified by the Illinois
Professd-onals.' Association...
All Activity Directors must meet one of these
qualifications within one year of adoption of this
Ordinance. Activity Directors hired after the adoption
of this Ordinance who do not meet the degree requirements
above must complete the course within six (6) months
after hiring.
Records of activity programming and resident
participation shall be maintained and shall include
• program goals, individual resident goals related to the
care plan, attendance records and progress notes.
-52-
Revised 7/18/85
They plan for activity programming shall incorporate
community resources and shall include group activities to
promote learning about interpersonal behavior and
Individual activities for residents unable or unwilling
• to participate in group activities..
(f') Physical Therapy: Each facility shall make available
to, its: residents the services. of a registered
physical therapist currently licensed: by the State. of
L111nois:who shall,_ under physicians,' orders, spend such
time within the�facilit.y- as such orders may require..
(G) Occupational. Therapy/Recreationa.l Therapy: All
facilities, shall provide the services of an
occupational therapist who is registered by the. American
Occupational Therapy Association or a therapeutic
recreation specialist who shall:
• 1. Complete an evaluatioa.of each resident within
thirty (30) days: of admission or readmission to
the, facility. The eva-luati.on 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 shall
be utilized by the Care Review Committee in the
review of resident care required in Section
8-15-3-3(H)2.
2. Conduct at least two (2) in-service programs per
• year which are designed to assist staff in
carrying out restorative procedures.
-53-
Revised.7/18/85
3.. Annually review each resident's planned and
conducted activity program -with the activity -
director to plan activities which are supportive of
restorative care needs.
•
(H). Procedures: All. facilities shall follow the
procedures- listed below:
1.. Admission Records: A. medical, history and,
interim, psycho-socia.l history of each resident
shall be -compiled -within -seventy-two (72) hours of
admission to a long,term,care facility and.filed with
each, resident's chart. For persons who have a. mental,
impairment, thet record shall include psychosocial
information.for the previous three years. A mental
status assessment shall be completed within seven (7).
days of admission and also filed with the chart. A
complete psychosocial assessment shall be completed
within thirty (30) days of admission -and also. filed with
the -chart.
2. Review. of. Resident Care: There shall be
established in each facility a. written procedure
for evaluating each resident's short and long term
needs and for reviewing the care and services
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, nurse aide, social worker and
-54-
Revised 7/18/85
•
•
•
activity worker who are familiar, with the
resident being reviewed. For: residents with
developmental disabilities, the- Care Review
Committee shall include a qualified mental
retardation professional with experience or
training, in developing habilitation plans
according to Federal Health -Care Finance
Administration standards. For residents with
mental impairments,. the Care Review Committee
shall inc-lud'e a psychiatrist, clinical social -
worker, or other mental health professional as
approved'by the Director. Other persons,
including representatives from physical therapy,
occupational therapy, recreational therapy,
dietary, pharma.cy,, housekeeping, and the
resident's physician shall also be -included
where appropriate. The resident,. when able,
shall be encouraged to participate in the Care
Review Committee, or shall be consulted by a
staff 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
shall evaluate each resident's immediate
and long term needs and shall prepare a Care
Plan for each individual resident for services
to restore and maintain maximum functioning.
This evaluation shall include an assessment of
the resident's physical and mental status, the
resident's behavior patterns and the resident's
environmental milieu so as to identify the
current or potential safety problems of the
-55-
Revised 7/19/35
resident., and the. need.f.or precautions to be
taken by the�_facility to protect the resident..
Each -Care -Plan shall contain the following:
• (1) Assessment. of strengths and needs: of
the resident, including the
identification of physical, mental,
emotional and behavioral problems of the
resident..
(2) Development of a treatment plan,
including measurable goals and
o.bject.ives for the resident and services
(both in-house and community based) to be
provided on a twenty-four (24) hour basis,.
including type, frequency and duration.
The treatment plan shall specify which
personnel will be assigned to,address the
• 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.
(3) Identification of safety precautions
to be carried out on a twenty-four
(24) hour basis by staff, the resident
and/or visitors to protect the resident or
other residents from potentially dangerous
behavior of the resident.
• (4) Review of drug therapy.
(5) Identification of one professional
staff person to be responsible for
-56-
revised 8/29/85
coordinating the implementation of the Care
Plan on each shift.
(c) Frequency of Review: Each 'resident shall
be evaluated at least every ninety (90) days
except residents requiring skilled nursing care,
• who shall be evaluated at.intervals not greater
than thirty (30) days for the first sixty (60)
days and at intervals of not greater than ninety
(90) days- thereafter. The initial evaluation of
all new residents shall be done within thirty (30)
days of admission. A written summary of the review
shall be entered into the record and appropriate
adjustments in the resident's Care Plan shall be
instituted. The written review shall note any
changes in the resident's needs and/or treatment
plan and shall note any problems identified in
reaching established goals. Reviews shall take
place more frequently if there is any change in
•
the
resident's needs or if
there is any change in
.the
treatment or services
to be provided.
(d) Implementation: Each facility is
responsible for implementing the Care Plan
and for providing the services to the resident in
accordance with the Plan.
3. Physician Orders: Physicians' orders shall be
followed. However, if a nurse, pharmacist or
other health professional believes that such order is
not suited to an individual resident,he/she must
call the physician to apprise him of the problem and
obtain a modified order or a confirmation of the
original order. In any case where orders are not fol-
io lowed there shall be documentation in the resident's
record indicating the reason that the order was not
followed and that the physician was notified.
-57-
Revised 7/18/85_
8-15-4-3: INSPECTIONS; REPORTS OF FINDINGS: The
Department, whenever it deems necessary -
but not less- than annually, shall_ inspect, survey and.
evaluate every facility to determine compliance with
• applicable licensure requirements and standards. The.
annual inspection should occur within one hundred twenty
(120) days prior to license renewal_ The Department may
periodically visit a.facility for the purpose of
consultation. An inspection,_ survey, or evaluation,.
other than -an inspection of financial records, shall be
conducted without. prior notice to the facility. A visit
for the sole purpose of consultation may be announced.
An employee of a: State or unitof local government agency
charged withinspecting, surveying, and evaluating
facilities who.directly or indirectly gives prior notice
of an inspection, survey or evaluation,. other than an
inspection of financial records,, to a facility or to an
employee of a facility in violation of this Chapter and
• is guilty of a Class A misdemeanor pursuant to Section
3-212(a) of the State Act. In determining whether to
make more than the required number of unannounced
inspections, surveys and evaluations of a facility, the
Department may consider one or more of the following:
previous inspection reports; the facility's history of
compliance with standards, rules and regulations under
this Chapter or the State Act; the facility's record of
violations, corrections, penalties or other enforcement
actions; the number and severity of complaints received
about the facility; any allegations of resident abuse or
neglect; weather conditions; health emergencies; other
reasonable belief that deficiencies exist. Upon
• completion of each inspection, survey and evaluation, the
appropriate Department personnel who conducted the .
inspection, survey or evaluation shall submit a copy of
their report to the licensee upon exiting the facility,
-58-
Revised 7/18/85
and.sha.11. subm.i:t the actual, report to the: Director..
Except for "'A:" violations whichshall be -governed in part
by Section 8-15-5-3(A), any documentation or comments of
the licensee shall be provided in writing to the
• Department within ten (10) days of receipt of the copy of
the report.. The Director shall then determine whether
the report's findings. constitute a violation or
violations of which the fac.il.ity must be given notice..
Such determination shall. be -based upon.the severity of
the,find.inge, the danger posed to resident health and:
safety,. the comments and documentation provided by the
facility,. if any, the diligence and. efforts to. correct
deficiencies, correction of the reported deficiencies,
the frequency and duration of similar findings in
previous reports and the facility's general inspection
history., Violations shall be determined under this.
Section and notice of violation, if any, served pursuant
• to Section 8-15-5-1 no la -ter than thirty (30) days after
completionof each inspection, survey and evaluation
report. Any required plan of correction shall be
requested, in. said. notice of violation.. The Department
shall maintain all inspection, survey and evaluation
reports for at least five (5) years in a manner
accessible to the public in compliance with the Freedom
of Information Act.
8-15-4-4: The Department shall require periodic
reports and shall have access to and may
reproduce or photocopy any books, records and other
documents maintained by the facility to -the extent
necessary to carry out this Chapter. The Department
• shall not divulge or disclose the contents of a record
under this Section in violation of Section 8-15-4-17 or
as otherwise prohibited by this Chapter.
_Sa_
Revised 7/18/85
8-15-4:-6:. COMPLAINT PROCEDURES.: The Department,shall
investigate all complaints thoroughly and
promptly. Such investigation shall be carried out
according to the following; procedures: _
(A) A person who believes_ that this. Chapter may have been
violated may request an investigation. The request
may be -submitted to theiDepartment in writing, by
telephone,. or by personal visit. An oral complaint shall
be reduc.ed.to writing.by the Department.
(B) The substance of the complaintshallbe provided in
writing.to the licensee, owner or administrator no
earlier than at the commencement of the on -site
inspection of the=facility which takes place pursuantto
the complaint.
(C) The Department shall notdisclose the name of the
• complainant unless the complainant consents in
writing to the disclosure. or the investigation results. in.
a judicial proceeding, or unless -disclosure is essential
to the-investigat.ion, in which case the complainant shall
be given the -opportunity to withdraw the complaint before
disclosure. Upon the request of the complainant, the
Department may permit the complainant or a representative
of the complainant to accompany the person making the
on -site inspection of the facility.
(D) Upon receipt of a complaint, the Department shall
determine whether this Chapter or the State Act or
State Standards has been or is being violated. The
• Department shall investigate all complaints alleging
abuse or neglect within seven (7) days after the receipt
of the complaint except that complaints of abuse or
neglect which indicate that a resident's life or safety
Revised 7/18/85
is- in.imminent.danger shall be investigated within.
twenty-four (24) hours after receipt of the complaint.
All other complaints shall be investigated within thirty
(30) days after the receipt of the complaint. -All
•
complaints -shall
be classified
as "valid" or
"invalid".
For any complaint
classified as
"valid"', the
Department
must determine within thirty (30.) working days if any
rule or provision of this Chapter has been.or is being
violated'.
(E ). In. all cases:-,.. the., Department shall inform the
complainantof itsfindings within ten (10) days of
the -determination unless otherwise indicated by the -
complainant,, and the complainant may direct the -
Department to send a copy of such findings to another
person. The Department's findings may include comments
or documentation provided by either the complainant or
the licensee pertaining to the complaint. The Department
• shall also notify the facility of such findings within
•
ten (lA) days of the determination,. but the name of the
complainant or residents, shall not be disclosed- in this
notice to the. facility.. The;' notice of such. findings
shall include a copy of the written determination; the
correction order, if any; the warning notice, if any; the
Inspection report; or the licensure form on which the
violation is listed.
(F) A written determination, correction order or warning
notice concerning a complaint shall be available for
public inspection, but the name of the complainant or
resident shall not be disclosed without his consent.
(G) A complainant who is dissatisfied with the
determination or investigation by the Department may
11fa
Revised 7/18/85
request a hearing under Section 8-15-6.. Lf a facility
requests.a hearing under. Section 8-15-6 which concerns a
matter covered by a- complaint, the complainant shall be,
given notice and may participate in the hearing as. an
• party. A request for a hearing by either a complainant
or &.facility shall be submitted in writing to the
Department within thirty (3.0)- days -after the- mailing of.
the. Department' s.. f indings, as described in Section
8-15-4-6 (E.) . Upon- receipt of the request the, Department
shall conduct &, he.arinq as provided. under S'ecton 8-15-6.
8-15-4-1.6: PUBLIC:DISCLOSURE INEORMATIOU: The
following; information is subject to
disclosure to thelpublic-from the -Department:
(A)- Info.rmat.ioa submitted under Sections 8-1.5-2-2.(E)1 and
8-15-2-2(E)2, except information concerning. the
remuneration of personnel licensed, registered or
• certified by the Department of Registration and Education
and monthly charge.s for an. Individual private resident;
(B) Records_ of license inspections, surveys and
evaluations of facilities, and other reports of
inspections, surveys and evaluations of resident care;
(C) Cost and reimbursement reports submitted by a
facility under Section 8-15-2-2(E)2, reports of
audits of facilities and other public records concerning
costs incurred by, revenue received by, and reimbursement
of facilities; and
is (D) Complaints filed against a facility and complaint
investigation reports, except that a complaint or
complaint investigation report shall not be
-62-
Revised 7/18/85
•
disclosed -to a person other than the complainantor
complainant's representative before -it is disclosed to a
facility. A complainant or resident's name shall not be
disclosed.except under Section 8-15-4-6(C) above.
The Department shall disclose information under this
Section in. accordance with provisions for, inspection and:
copying of public records required by the Freedom of
Information Act. However,: the= disclosure, of information
described in Section 8`-15-4-16(A) shall not be restricted
by any provision of the, Freedom of Information Act.
&-15-4-21.: WEATHER AND OTHER HAZARDOUS CONDITIONS:
The Department shall develop and implement
a system of. educating facilities and their personnel as
to weather eme.rgenci.es• or other hazardous circumstances
which may endanger resident health or safety and
designating any precautions to prevent or minimize; such
• danger. The Department may assist any facility
experiencing difficulty in dealing with such
emergencies. The. Department may provide for announcement
to the public of the dangers posed to facility residents
by existing or potential weather or hazardous
circumstances.
8-15-5-1: NOTICE OF VIOLATION: If after receiving
the report specified in Section 8-15-4-3
the Director or his/her designeedetermines that a
facility is in violation of this Chapter, he/she shall
within thirty (30) days of the report of findings serve a
notice of violation upon the licensee. Each notice of
• violation shall be prepared in writing and shall specify
the nature of the violation and the Chapter provision or
rule alleged to have been violated. The notice shall
-63-
Revised 7/18/85
inform the licensee of any action the Department may take
under the Chapter, including the requirement of a
facility plan of correction under Section 8-15-5-3,
placement of the facility on a list prepared under
• Section 8-15-5-4; assessment of a penalty under Section
8-15-5-5; 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- rights to a hearing under Section
8-15-6.
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 is served
under Section 8-15-5-1shall constitute a separate
violation for purposes of assessing penalties. under
Se.ct.ion 8-15-5-5.. No penalty or fine may be. assessed for
a condition for which the facility has received a
variance or waiver of a standard from the Department.
8-15-5-3: ABATEMENT PROCEDURES: Any violation shall
be abated according to the following
schedule:
(A) The situation, condition or practice constituting a
Type "A" violation shall be abated or eliminated
immediately upon order of the Department unless a fixed
• period of time, not exceeding fifteen (15) days, as
determined by the Department and specified in the notice
of violation and order of abatement is required for
correction.
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Revised 7/18/85
(B_) At thetime of: issuance: of- a. notice of. Type "B" or
Type -*CO' violation, the Department shall request a
plan of correction which is subject to the Department's
approval. The facility shall have ten (10) days after
• receipt of notice of violation in which to prepare and
submit a- plan of correction. The Department may extend
this period, up to thirty (30) days where correction
Involves substantial capital improvement. The plan shall.
include a fixed time period not in excess of ninety (90)
days within. which violations- are to be corrected. If the
Department rejects a plan of correction, it shall send
notice of the rejection and the reason for the rejection
to the facility. Except as provided in Section
8=15-5-5(EJ for Type "B violations, the facility shall
have ten. (1.0) days after receipt of the notice of
rejection in which to submit a modified plan. If thei
modified plan is not timely submitted, or if the modified.
• plan is reject.ed�, the facility shall follow an approved
plan of correc.ion 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 show good cause for not
being able to comply with the original correction time
approved.
_6S_
Revised 7/18/85
(E) If a facility desires. to contest. any Department
action under this.. -Section, it shall send a written
request for a hearing, under Section 8-15-6 within ten
(10) days of receipt of notice of the contested action.
• The hearing,shall be held°as provided under Section
8-15-6. Wherever possible, all actions of the Department
under this Section arising out of a violation shall be
contested and determined at a single hearing. Issues
decided after hearing may not be, reheard. at subsequent
hearings,hearings$ under, this Sec.ton,..
8-15-5-4.: LIST OF` VIOLATORS'PREPARED: The 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 8-15-5-7 regarding a
penalty assessment under Sections 8-15-5-5 (A)
through (E);.
(B) sent a n.o.t ae of 11cense revocation under Section
8-15-2-11;
(C) sent a notice refusing renewal of a license under
8-15-2-11;
(D) issued a conditional license for violations described
under Sections 8-15-5-1, 8-15-5-3 and 8-15-5-11;
(E) placed a monitor under Section 8-15-4-13;
(F) initiated an action to appoint a receiver;
Revised 7/18/85
(G) recommended to the Director of the Department, of
Public Aid, or the Secretary of the United States -
Department of Health and Human Services, the
decertification for violations in relation to patient
• care -of a facility pursuant to -Titles, XVIII and XIX of
th&Eederal Social Security Act..
In: addition to the name- and address of the facility, the
list shall include the: name and address of the person or
licensee., against whom�the action has been initiated, a-
self-explanatory summary of the facts. which warranted the
initiation of each action, the type of action initiated,
the datee of the initiation of the action, the amount of
the penalty assessed or sought to be assessed, if any,
and the disposition of the action, If completed.
The list shall be available to any member, of the public
upon oral or written request without charge.
•
8-15-5-5: PENALTIES: The licensee ofa facility
which is in.violation of this Chapter may
be subject.to the penalties levied by the,Department as
specified in this Section.
(A) Unless..a greater penalty is allowed under Section
8-15-5-5(D), a licensee who commits. a Type "A"
violation is automatically issued a conditional license
for a period of six (6) months and assessed a penalty
computed at a rate of five ($5.00) dollars per resident
in the facility plus twenty (200) cents 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 less than
five thousand ($5,000) dollars, whichever is greater.
The facility shall also comply with any order of
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Revised 7/18/85
abatement issued under Section 8-15-5-3(A), and any
Department imposed plan of correction.
(B) A licensee who commits a Type- "B" violation is
• subject to a penalty computed at a rate of three
($1.00) dollars per resident in the facility, plus
fifteen (150) cents per resident for each day of the
violation_,, commencingon the -date a: notice of. the
violation is: served under Section 8-15-5-1 and ending on
the: date the, violation is corrected, or. a penalty -of not
less than five -hundred ($500) dollars, whichever is
greater- Suchpenalty shall be assessed on the date of
notice of the violation and shall be suspended for
violations that continue after such date upon submission
of an approved: plan of correctionin accordance with
Section.8-15-5-3. The final penalty computation may be
reduced*or waived in accordance with S'ection.8-15-5-8.
• Failure to correct such violation within the time period
approved by the Department under a- plan of correction
shall result in a penalty and conditional license as
provided under Section 8.-1.5-5:-5(R).
(C) A licensee who fails to correct a Type "C" violation
within the time period approved under a plan of
correction or any lawful extension granted by the
Director or to timely submit a.plan of correction
pursuant to Section 8-15-5-3 may be subject to a penalty
computed at a rate of one dollar, fifty cents ($1.50) per
resident in the facility, plus ten (100) cents per
resident for each day of the violation, commencing on the
date the notice of violation is served under Section
• 8-15-5-1 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.
W�"
Revised 7/18/85
(D.) A.licensee who,c.ommits.a Type "A" violation which
continues beyond the time specified in Section
8-15-5-3(A) shall be cited with a repeat violation, shall
have its license revoked and shall be assessed. a penalty -
three .(3) times the penalty computed per resident per day
under Section
(Z.). A- licensee who failsto satisfactorily comply with an
approved: planof correction for a Type OW' violation
shall be cited with a repeat violation and: shallbe
automatically issued- &.conditional license for a period
of not less than six (6) months together with a
Department -imposed -plan o-f correction. A penalty shall
be assessed: in accordance with S-ection 8'-15-5-5.(B). This,
penalty shall be computed for all days of the, violation,
including the duration of the first. plan of correction
compliance time. A licensee who, fails to satisfactorily
• correct or address a recurring Type "'B violation or
pervasive pattern of the same or similar violations is
subject to a conditional. license In determining whether
to issue such a license, the Director shall consider the
factors set forth in Section 8-15-5-8(C).
(F) For the purpose of computing a penalty under Sections
8-15-5-5(A) through (D), the number of residents per
day shall be basedon the average number of residents in
the facility during the thirty (30) days preceding the
discovery of the violation.
(G) When the Department finds that a provision of
Sections 8-15-3-1 and 8-15-3-2 has been violated with
• regard to a particular resident, the Department shall
issue an order requiring the facility to reimburse the
resident for injuries incurred, or one hundred ($100)
dollars, whichever is greater.
Revised 7/1.8/85
•
•
•
(H) For purposes of_ assessing penalties under this
Section, a repeat --violation shall be a viola.tion —
whichhas been cited during one inspection of the
facility and which was not corrected pursuant to an
approved plan of correction or order of abatement; a
recurring violation shall mean a new citation of the
same rule, when it demonstrates a failure -.of the licensee
to substantially address the issue or problem in the
facility.
8-15-5-8: DATE OF PENALTY ASSESSMENT; PLANS OF
CORRECTION: Imposition of penalties for
Types. "A"',: "B,% and *V violations,- sha-11 conform to the
following:
(A) I.n: the- case. of a Type "A" violation., a penalty may be
assessed from the date on which the violation is
discovered. The.facilit.y shall comply with a plan of
correction or order of abatement issued by the Department
pursuant to Section 8-15-5-3(A).
(B) If a plan of correction is approved and carried- out
for a Type "B" violation, with respect to a violation
that continues after the date of notice: of violation, the
penalty provided.under. Section 8-15-5-5 shall be
suspended for the time period specified in the approved
plan of correction. In the case of a Type "B" violation,
a -penalty shall be assessed on the date of notice of the
violation, 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 (10) days;
-70-
Revised 7/18/85
2. The facility submits a plan of correction within
ten (10) days and subsequently submits a true --
report of correction within fifteen.(15) days
thereafter;
•
3. The -facility submits a plan of correction within-
ten.(10) days=which provides for a correction
time that is less than or equal to thirty (30) days
and the. Department approves such plan
4'. The facility submits a plan of correction for -
violations involving: substantial capital
improvements which provides for correction within the
initial ninety (90) day limit under Section
8-15-5-3(B).
(C) For Type 4B" violations, the Director shall consider
the following factors in determining whether to
uphold, reduce or waive penalties or to issue a
conditional license:
1.. The extent to which the violation has caused
actual harm to a resident;
2. The extent to which the facility has made a
diligent effort to correct the violation, to
prevent its recurrence and to address the problem(s)
existing in any of the facility service delivery
systems which manifests itself in the occurrence of
the same or similar violations;
• 3. Whether or not the facility has a record of
and/or is currently evidencing a pattern of
the same or similar violations; and
-71-
Revised.7/19/95
4. Whether or not the facility violat.ion,record
reveals. a failure to substantially comply with
this Chapter.
• (D) In the: case of a "C" violation, a penalty may be.
assessed on and from the,date, of notice of
violation. The facility shall submit a plan of
correction in accordance with Section R-15-5-3.
8-15-5-11: CONDITIONAL LICENSES: In addition to the
right to assess penalties under this
Chapter, the Director may issue a. conditional license to
any facility if the Director finds that a. Type., *1% Type-
*Bm, or Type "-C" violation exists in such facility. The
issuance of a conditional license shall revoke any
license held by the facility.
• (A) Prior to the issuance of a conditional license, the
Department shall develop a written plan of
correction to be imposed -upon the facility. The,
Department shall specify the violations.which prevent
full licensure and shall establish a. time schedule For
correction of the deficiencies. Retention of the license
shall be conditional onthe 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
-72-
Revised 7/18/85
•
plan of correction. The notice shall inform the
applicant or licensee of its right to a hearing under
Section 8-15-6 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 & written
request for hearing to the Department within ten (10)
days, after receipt. by the licensee of the Department's
notice anddecision to issue a. conditional license. The
Department shall. hold the hearing as'provided under
Section 8-15-6.
(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 more
than one. (1) year. The. Department shall periodically
• inspect any facility operating under a conditional
license.. If the Department finds substantial -failure by
the -facility to timely correct the violations which
prevented full licensure and formed the basis for the
Department's decision to issuea conditional license in
accordance with the required plan of correction, the
conditional license may be revoked a-s provided under
Section 8-15-2-11.
8-15-5-12: INTERFERENCE WITH ENFORCEMENT: No person
shall:
(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 given for correction, unless an extension is
-73-
Revised 7/18/85
granted by the Department and the corrections are made
before expiration of extension;
(B) Intentionally prevent, interfere with, or attempt to
• impede in any way any duly authorized investigation
and enforcement of this Chapter;.
(C) Intentionally prevent or attempt to prevent any -
examination of'aay relevant books or records..
pertinent to investigations and enforcement of this
Chapter;
(D) Intentionally prevent or interfere with the
preservation of evidence pertaining to any violation
of this Chapter;
(E) Intentiona.l.l.y retaliate or discriminate against any
resident or employee for contacting or providing
• information to:any City or State official, or for
initiating-, participating in or testifying in an action
for any -remedy authorized under this. Chapter;
(F) Willfully file any false, incomplete or intentionally
misleading information required to be filed under
this Chapter or willfully fail or refuse to file any
required information; or
(G) Open or operate a facility without a license.
Pursuant to Secton 3-318 of the State Act, a violation of
this section is a business offense. The State's Attorney
• of the county in which the facility is located, or the
Attorney General, shall be notified by the Director of
any suspected violations of this Section.
-74-
Revised 7/18/85
HEARING PROCEDURES: Any pers.on..requesting
a hearing pursuant to Sections 8-15-2-10,
8-15-2-11, 8-15-3-2(F), 8'-15-4-11, 8-15-5-1, 8-15-5-30
8-15-5-9, or 8-15-6, to contest a decision rendered in a,
•
particular
case
may have
such decision reviewed in
accordance
with
Section
8-15-6..
8-15-7:. WAIVERS
81-15-7-1: RELIEF REQUESTED: A facility may seek
relief from the provisions of this Chapter
when a specific or peculiar situation exists. which makes,
compliance a practical impossibility or extreme,
hardship. Afa:cility requesting relief shall submit to
the:.Director in writing a detailed explanation of why
compliance with the provisions of this Chapter would
create a practical impossibility or extreme hardship, and
• a plan for an alternative method of service provision to
ensure that a comparable or higher quality of service is.
provided to residents. Upon.receipt of such request, a
hearing shall, be: conducted a.s provided_ in Section
8-15-6- In determining whether to grant a waiver, the
Hearing Officer shall consider the effect of the waiver
upon the health and safety of residents, the quality of
resident care at the facility, the facility's history of
compliance with this.Chapter, the facility's attempts to
comply with the particular rule or standard in question,
the extent to which a practical impossibility or extreme
hardship exists in complying with the provision under
appeal, and the extent to which an acceptable alternative
method of service provision will be implemented. The
• waiver shall be granted for a period not to exceed the
duration of the annual licensure period. A copy of each
waiver application and each waiver granted or renewed
shall be on file with the Department and available for
public inspection.
-.4
•
•
U
Revised 8/6/85
SECTION 3: This ordinance, by its terms, is severable
if any court of competent jurisdiction
should determine any paragraph, subparagraph or clause
unconstitutional or invalid. Such declaration should be
determined to be excised and the remainder of this
ordinance shall be in full force and. effect.
SECTION 4:. All ordinances or parts of ordinances in
conflict herewith are hereby replealed.
SECTION 5: This ordinance shall be in full force and
effect from and after its passage, approval
and publication in.the-manner provided by law.
Introduced:
Adopted:
ATTEST:
r
City Clerk
pproved as to form:
J
Corporation Counsel
I , 1985
1985
Adopted:
�ayor
SL•-2