HomeMy WebLinkAboutORDINANCES-1980-072-O-809/19/80
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AN.ORDINANCE
Amending Title 8, Chapter 15 of
the Evanston City Code, 1979 Relating
to Long Term Care Facilities
WHEREAS, the City of Evanston as a Home Rule unit may
exercise any power and perform any function pertaining to its
government and affairs; and
WHEREAS, effective local licensing, regulation and
enforcement of minimum standards of nursing care at facilities
located within Evanston is a matter directly relating to the
affairs of the City of Evanston.
NOW, THEREFORE BF.IT ORDAINED BY THE CITY COUNCIL OF THE
CITY OF EVANSTON, COOK COUNTY, ILLINOIS:
SECTION 1: That Title 8, Chapter 15 of the Evanston City
Code, 1979, be and hereby is amended to read as follows:
8-15-1 GENERAL PROVISIONS AND DEFINITIONS:
8-15-1-1 SHORT TITLE. This Chapter shall be known and may
be cited as the "Evanston Long Term Care
Ordinance."
8-15-1-2 PURPOSE, DECLARATION OF POLICY. It is the
purpose of this Chapter and the policy of the
City of Evanston to establish standards for the licensing
and regulation of all 'facilities, as defined herein, within
• the City of Evanston and to require compliance with at least
the minimum requirements of the Nursing Home Care Reform Act
of 1979, including the rules and regulations promulgated
thereunder.
3-15-1-3 ADOPTION OF STATE RULES AND REGULATIONS. The
City adopts by reference the P.Iinimum Standards,
Rules and Regulations for Classification and Licensure of
Long Term Care Facilities as promulgated by the Illinois
Department of Public Health pursuant to the Nursing Home
Care Reform Act of 1979, in effect iMarch 1, 1980, and as may
from time to time thereunder be amended. Violation of any
of said Rules and Regulations shall be considered a
violation of the provisions of this Chapter, provided that:
A. Any reference in said Rules and Regulations to
"Department" shall refer to the Evanston -North Shore
Health Department.
B. Any reference in said Rules and Regulations to
"Director" shall refer to the Public Health Director of
the Evanston -North Shore Health Department.
C. Any reference in said Rules and Regulations to "Fire
Chief" shall refer to the Fire Chief of the Evanston
Fire Department.
Three (3) copies of said Minimum Standards, Rules and
Regulations shall be kept in the office of the City Clerk
• and available for public use, inspection and examination
for a period of at least fifteen (1S) days prior to the
effective date hereof. At least one (1) copy of said Rules
and Regulations shall be available for public inspection in
8-15-1 the office of the Director.
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8-15-1-4 CONSTRUCTION OF CHAPTER.
A. This Chapter shall be liberally construed and
applied to promote its purposes and policies.
• B. Nothing in this Chapter shall be construed as
authorizing the medical supervision, regulation,
or control of the remedial care or treatment of
residents in any facility conducted for those who
rely upon treatment by prayer or spiritual means
in accordance with the creed or tenets of any well
recognized church or religious denomination. A
license is required and all remaining rules and
regulations and minimum standards shall apply.
8-15-1-5 ADMINISTRATION. The City Manager, or his
designee, shall administer this Chapter and
may, with the review of the City Council, promulgate
regulations to carry out its enforcement.
8-15-1-6 DEFINITIONS.
ABUSE Any physical or mental injury or sexual
assault inflicted on a resident other
than by accidental means in a facility.
ACCESS The right to:
1. Enter any facility;
2. Communicate privately and without
restriction with any resident who
consents to the communication;
• 3. Seek consent to communicate
privately and without restriction with
any resident;
4. Inspect clinical and other records
of a resident with the express written
consent of the resident; and
S. Observe all areas of the facility
except the living area of any resident
who protests the observation.
ADMINISTRATOR A person who is charged with the general
administration and supervision of a
facility and licensed,if required,under.
the "Nursing Home Administrators Licens;
ing Act", as now or hereafter amended.
ADVOCATE A representative of a community
organization or agency who is
assisting residents in asserting their
rights or in obtaining full enjoyment
of their rights. Advocates may not
charge for their services nor may there.
be a comercial purpose.
AFFILIATE 1. With respect to a partnership,
each partner thereof;
• 2. With respect to a corporation,
each officer, director and stockholder
thereof;
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3. With respect to a natural person;
any person related in the first degree
of kinship to that person; each
partnership and each partner thereof
of which that person or any affiliate
of that person is a partner; and each
corporation in which that person or any
affiliate of that person is an officer,
director or stockholder.
APPLICANT
Any person making application for a
license.
DEPARTMENT
The Evanston -North Shore Health
Department.
DIRECTOR
The Public Health Director of the
Evanston -North Shore Health Department.
DISCHARGE
The full release of any resident from
a facility.
EMERGENCY
A situation, physical condition or one '
or more practices, methods or ti
operations which present imminent `
danger of serious physical or mental
harm to residents of a facility.
s
FACILITY
A private home, institution, building, t
OR
residence, or any other place, whether
LONG-TER.N1
operated for profit or not, or a
CARE
county home for the infirm and
FACILITY
chronically ill operated pursuant to
"The County Home Act", as now or
hereafter amended, or by a county
pursuant to "An Act in relation to
homes for the aged", approved July 21,
1959, as now or hereafter amended, or
any similar institution operated by a
political subdivision of the State of
Illinois, which provides, through its
ownership or management, personal care,,
sheltered care or nursing for 3 or
more persons, not related to the
applicant or owner by blood or
marriage. It includes skilled nursing
facilities and intermediate care
facilities as those terms are defined
in Title XVIII and Title XIX of the
Federal Social Security Act. Facility
does not include the following:
1. A home, institution, or other
place operated by the federal
government or agency thereof, or by
the State of Illinois.
2. A hospital, sanitarium, or other
institution whose principal activity
or business is the diagnosis, care,
and treatment of human illness through
the maintenance and operation as
organized facilities therefor, which
is required to be licensed under the
"Hospital Licensing Act", as now or
hereafter amended; or
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3. Any "facility for child care" as
defined in the "Child Care Act of
196911, as now or hereafter amended.
FIRE CHIEF
The Fire Chief of the Evanston Fire
Department.
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GUARDIAN
A person appointed as a guardian of
the person or guardian of the estate,
or both, of a resident under the
"Probate Act of 1975", as now or
hereafter amended.
IMMEDIATE
The spouse, an adult child, a parent,
FAMILY
an adult brother or sister or an adult
grandchild of a person.
LONG-TERM
See Facility.
CARE
FACILITY
MAINTENANCE
Food, shelter and laundry services.
NEGLECT
A failure of a facility to provide
adequate medical or personal care or
maintenance, which failure results
in physical or mental injury to a
resident or in the deterioration of a
resident's physical or mental
condition.
NURSE
A registered nurse or a licensed
practical nurse as defined in "The
Illinois Nursing Act", as now or
•
hereafter amended.
OWNER
The individual, partnership,
corporation, association or other
person who owns a facility. In the
event a facility is operated by a
person who leases the physical plant,
which is owned by another person,
"owner" means the person who operates
the facility, except that if the person
who owns the physical plant is an
affiliate of the person who operates
the facility and has significant
control over the day-to-day operations
of the facility, the person who owns
the physical plant shall incur jointly
and severally with the owner all
liabilities imposed on an owner under
this Act.
PERSONAL
Assistance with meals, dressing,
CARE
movement, bathing or other personal
needs or maintenance, or general
supervision and oversight of the
physical and mental well-being of an
individual, who is incapable of
maintaining a private, independent
residence or who is incapable of
managing his person whether or not a
guardian has been appointed for such
individual.
REASONABLE Any time between the hours of 10 A.M.
HOUR and 8 P.M. daily.
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RESIDENT
RESIDENT'S
REPRESENTATIVE
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SHELTERED
CARE
STATE ACT
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A person residing in and receiving
personal care from a facility.
A person other than the owner, or an
agent or employee of a facility not
related to the resident, designated in
writing by a resident to be his
representative, or the resident's
guardian, or the parent of a minor
resident for whom no guardian has been
appointed.
Maintenance and personal care.
Nursing Home Care Reform Act of 1979
as now or hereafter amended.
STATE Minimum Standards, Rules and
STANDARDS Regulations for Classification and
Licensure of Skilled Nursing Facilities,
Intermediate Care Facilities, and
Sheltered Care Facilities for the
Developmentally Disabled promulgated
pursuant to the State Act.
STOCKHOLDER Any person who, directly or
OF A indirectly, beneficially owns, holds or
CORPORATION has the power to vote, at least 50 of
any class of securities issued by the
corporation. ;
TITLE XVIII Title XVIII of the Federal Social
Security Act as now or hereafter
• amended.
TITLE XIX Title XIX of the Federal Social
Security Act as now or hereafter
amended.
TRANSFER A change in status of a resident's
living arrangements from one facility
to another facility.
TYPE 'A' A violation of this Chapter or the
VIOLATION State Act or State Standards which
creates a condition or occurrence
relating to the operation and
maintenance of a facility presenting
a substantial probability that death
or serious mental or physical harm to
a resident will result therefrom.
TYPE 'B' A.violation of this Chapter or of the
VIOLATION State Act or State Standards which
creates a condition or occurrence
relating to the operation and
maintenance of a facility directly
threatening to the health, safety or
welfare of a resident.
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TYPE 'C' A violation of this Chapter or of the
VIOLATION State Act or State Standards which
creates a condition or occurrence
relating to the operation and
maintenance of a facility which
indirectly threatens the health,
safety or welfare of a resident.
8-15-2 LICENSING REQUIREMENTS:
8-15-2-1 LICENSE REQUIRED. No person may establish,
operate, maintain, offer or advertise a
facility within the City of Evanston unless and until
he obtains a valid municipal license therefor as
provided herein, which license remains unsuspended,
unrevoked and unexpired. No public official or
employee may place any person in, or recommend that
any person be placed in or directly or indirectly
cause any person to be placed in any facility which is
being operated without said valid license.
8-15-2-2 LICENSE PROCEDURES. The procedure for
obtaining a valid municipal license shall
be as follows:
A. Application to conduct and operate a facility sha71
be made to the Department on forms furnished by
the Department. The application shall be under
oath and 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;
2. The name and location of the facility for
which a license is sought;
3. The name of the person or persons under whose
management or supervision the facility will be
operated;
4. The number and type or residents for whom
maintenance, personal care, or nursing is to
be provided; and
S. Such information relating to the number,
experience, and training of the employees of
the facility, any management agreements for
the operation of the facility, and of the
moral character of the applicant and employees
as the Department may deem necessary.
B. 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
Facilities Planning Act";
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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;
• 4. In the case of new construction or the
conversion of existing structures, preliminary
plans and specifications for the proposed
facility; and
S. An initial application fee of $500.00 to be
refunded should the application be denied plus
an annual license fee of 8200..00 plus $20.00
per licensed bed.
C. After the application is approved, the applicant
shall advise the Department every six (6) months
of any changes in the information originally
provided in the application.
D. Renewal license applications: At least 120 days,
but not more than 150 days prior to license
expiration, the licensee 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 in
circumstances of nonrenewal, revocation, or pending
enforcement activity. If the application for re-
newal is not timely.filed, the Department shall so
inform the licensee. The annual license renewal fee
shall be $200.00 plus $20.00 per licensed bed for
• all facilities issued a license_ after the effective,
date of this chapter.
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:
a. The name, 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 is a partnership or
corporation, the name and mailing address
of every partner and stockholder of the
owner.
b. The addresses of all other facilities, if
any, in which the applicant holds a
financial interest.
C. An agreement to update all information in
• the statement of ownership every six (6)
months.
2. An attested financial statement in accordance
with the State Act.
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a. The Department shall adhere to such
regulations for filing of financial
statements, including the information to
be required in such statements, as shall
be promulgated by the Illinois Department
• of Public Health and the Illinois
Department of Public Aid pursuant to
Section 3-208 of the State Act. An audited
financial statement may be required of a
particular facility if the Director
determines that additional information is
needed.
b. Information obtained under this Section
shall be made available, upon request, by
the Department to any State or Municipal
agency or legislative body to which such
information is necessary for investigations
or required for purposes of Federal, State
or local law or regulation.
C. The Department shall report to the Illinois
Department of Public Health any instance
in which a facility fails to file a
financial statement and shall request that
the State take action in accordance with
Section 3-208 of the State Act.
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
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.
8-15-2-3 LICENSE ISSU.A.NCE: The Director shall issue
a license if it is found:
A. That the individual applicant, or the corporation,
partnership or other entity if the applicant is
not an individual, is a person responsible and
suitable to operate or to direct or participate in
the operation of a facility by virtue of financial
capacity, appropriate business or professional
experience, a record of compliance with lawful
orders of the Department, and lack of revocation
of a license during the previous five years.
B. That the facility is under the supervision of an
administrator who is licensed if required under
• the "Nursing Home Administrators Licensing Act",
as now or hereafter amended; and
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C. That the facility is in compliance with this
Chapter.
8-15-2-4 Any license granted by the Director shall
state the maximum bed capacity for which it
• is granted, the date the license was issued, and the
expiration date. Such licenses shall be issued for a
period of one year. However, during the 12-month
period following the effective date of this Act, the
Director may issue licenses or renewals for periods of
less than one year in order to distribute the
expiration dates of such licenses throughout the
calendar year, and fees for such licenses shall be
prorated on the basis of the portion of a year for
which they are issued. Each license shall be issued
only for the premises and persons named in the
application and shall not be transferable or
assignable.
8-15-2-5 For all initial license applicants, the
Department shall issue only a probationary
license. A probationary license shall be valid for
120 days unless sooner suspended or revoked pursuant to'
Section 8-15-2-8 below. Within 30 days prior to the
termination of a probationary license, the Department
shall fully and completely inspect the facility and, `
if the facility meets the applicable requirements for
licensure, shall issue a license under Section 8-15-2-31
above. If the Department finds that the facility does
not meet the requirements for licensure but has made
substantial progress toward meeting those requirements,;
the license may be renewed once for a period not to
exceed 120 days from the expiration date of the ;
initial probationary license.
• 8-15-2-6 The issuance or renewal of a license after
notice of a violation has been sent shall
not constitute a waiver by the Department of its power
to rely on the violation as the basis for subsequent
license revocation or other enforcement action under
this Chapter arising out of the notice of violation.
8-15-2-7 Whenever ownership of a facility is
transferred from the person named in the
license to any other person:
A. The transferee must obtain a new probationary
license. The transferee shall notify the
Department of the transfer and apply for a new
license at least 30 days prior to final transfer.
B. The transferor shall notify the Department at
least 30 days prior to final transfer. The
transferor shall remain responsible for the
operation of the facility until such time as a
license is issued to the transferee.
C. The license granted to the transferee shall be
subject to the plan of correction submitted by the
previous owner and approved by the Department and
any conditions contained in a conditional license
issued to the previous owner. If there are
outstanding violations and no approved plan of
correction has been implemented, the Department
may issue a conditional license and plan of
correction as provided in Section 8-15-5-11.
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D. The transferor shall remain liable for all
penalties assessed against the facility which are
imposed for violations occurring prior to transfer
of ownership.
• 8-15-2-8 An application 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 members, or if a corporation, the conviction of
the corporation or any of its officers or
stockholders, or of the person designated to manage
or supervise the facility, of a felony, or of 2 or
more misdemeanors involving moral turpitude, as
shown by a certified copy of the record of the
court of conviction, if the Department determines,
after investigation, that such person has not been
sufficiently rehabilitated to warrant the public
trust; 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; or
D. Insufficient financial or other resources to
operate and conduct the facility in accordance
with this Chapter.
• 8-15-2-9 Immediately upon the denial of any
application or reapplication for a license
under this Section, the Department shall notify the
applicant in writing. Notice of denial shall include
a clear and concise statement of the violations on
which denial is based and notice of the opportunity
for a hearing under Section 8-15-6.
8-15-2-10 If the applicant desires to contest the
denial of a license, it shall provide
written notice to the Department of a request for a
hearing within 10 days after receipt of notice of
denial. The Department shall commence the hearing
under Section 8-15-6.
8-15-2-11 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 that there has been a substantial
failure to comply with this Chapter.
A. Notice under this Section shall include a clear
and concise statement of the violations on which
the non -renewal or revocation is based, the Chapter
provision or State Standard violated and notice of
the opportunity for a hearing under Section 8-lS-6..
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B. If a facility desires to contest the non -renewal 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.
• C. The effective date of non -renewal 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
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 under Section 8-15-2-11(B);
or
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.
8-15-3 FACILITY REQUIREMENTS:
. 8-15-3-1 The following resident rights shall apply to
all facilities:
A. No resident shall be deprived of any rights,
benefits, or privileges guaranteed by law, the
Constitution of the State of Illinois, or the
Constitution of the United States solely on account
of his status as a resident of a facility.
B. A resident shall be permitted to manage his own
financial affairs unless he or his guardian or if
the resident is a minor, his parent, authorizes
the administrator of the facility in writing to
manage such resident's financial affairs 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 the functions of said representative.
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.
isE. Each room containing more than one resident shall
contain sufficient functional privacy screens so as
to afford privacy to each resident therein.
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F. The facility shall provide adequate storage space
for the personal property of the resident.
1. The facility shall provide each resident with a
functional bedside cabinet with a drawer. This
requirement shall not affect the requirements
• to provide drawers in dressers for each
resident.
In one of the pieces of furniture required
there shall be provided a space which is
capable of being secured by a locking device
which is to be controlled by the resident to
which said furniture is assigned provided
however that where in the opinion of the
attending physician such secured space would be
contrary to the health or welfare of a resident,
such requirement may be abrogated during such
period of time when there exists a danger to
the health or welfare of such a resident. In
such instances, the facility shall provide
alternate means of safeguarding small items of '
value and shall make available daily access to
such valuables.
3. The facility shall develop written procedures`
for investigating complaints concerning theft
of residents' property and shall promptly
investigate all such complaints. If the
facility is unsuccessful in locating resident
property which is of value to the resident the
facility shall 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'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
physician or the physician attached to the facility
complete and current information concerning his
medical diagnosis, treatment and prognosis in 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 research
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 Illinois
Department of Public Health.
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C.
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I. Every resident shall be permitted to refuse medical
treatment and to 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 notify the facility's social
worker and the resident's family or resident
representative. The resident's refusal shall free
the facility from the obligation to provide the
treatment.
J. Every resident, 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 maintenance kept by the
facility or by his physician. The facility may
charge a reasonable fee for duplication of a
record.
K. A resident shall be permitted respect and privacy
in his medical and personal care program. Every
resident's case discussion, consultation,
examination and treatment shall be confidential
and shall be conducted discreetly, and those
persons not directly involved in the resident's `
care must have his permission to be present.
L. The needs and individual lifestyles of residents
shall be considered a priority. Routines and
schedules should be individualized and based on an
assessment of each resident, providing structure
or independence as appropriate. Notations on the
need for structure and appropriate types of
freedom from routines shall be noted in the
resident care plans.
M. Facilities shall allow residents access to their
room at all times.
N. 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 a physician in the resident's
clinical record.
0. An owner, licensee,
agent of a facility
resident. It is the
or agent who becomes
neglect to report it
8-15-3-1(Y).
administrator, employee or
shall not abuse or neglect a
duty of any facility employee
aware of such abuse or
as provided in Section
P. Every resident shall be permitted unimpeded,
private and uncensored communication of his choice
by mail, public telephone or visitation.
1. The administrator
correspondence is
mailed, and that
accessible.
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shall ensure that
conveniently received and
telephones are reasonably
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2. The administrator 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.
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 such restriction is placed
in the resident's clinical record by the
physician and that notice of such restriction `
shall be given to all residents upon admission.1.
However, all letters addressed by a resident to:
the Governor, members of the General Assembly,
Attorney General, judges, state's attorneys,
the Department, the Illinois Department of
Public Health, the Evanston Commission on Aging,
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
officials and attorneys mentioned above shall '
be delivered to the recipient without
examination by facility personnel.
S. The administrator shall ensure that married
residents 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 it is deemed medically
inadvisable by the resident's attending
physician and so documented in the resident's
medical records.
Q. 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 beliefs or practices, or
attendance at religious services, may be imposed
upon any resident.
R. Residents shall be allowed access to advocates as
follows:
1. Any employee or agent of a public agency, any
representative of a community legal services
program or any other member of the general
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 purpose is to do any of the
following:
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a. Visit, 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 in groups and 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.
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 resident to 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(R) above, the
administrator of a facility may refuse access
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 resident or the facility, or if
the person seeks access to the facility for
commercial purposes. Any person refused access
to the facility may within 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.
S. A resident may be discharged from a facility after
he gives the administrator, a physician, or a nurse
Of 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
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parent unless there is a court order to the
contrary. In such cases, upon the resident's
discharge, the facility is relieved from any
responsibility for the resident's care, safety or
well-being.
• T. 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 residents' advisory council,
governmental agencies or other persons without
threat of discharge or reprisal in any form or
manner whatsoever. The administrator 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.
U. A resident may refuse to perform labor for a
facility.
V. 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 be from time to
time established by state or federal
legislation.
2. Record and maintain payroll records of such
transaction available for inspection by the
Department.
W. 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-lS-3-1(0), or files a
complaint under Section 8-15-4-6(A) because of the
report or complaint.
Y. Any person, institution or agency participating in
good faith in the making of a report, or in the
investigation of such a report shall not be deemed
to have violated any privileged communication and
shall have immunity from any liability, civil,
criminal or any other proceedings, civil or
criminal as a consequence of making such report.
The good faith of any persons required to report,
or permitted to report, cases of suspected resident
abuse or neglect under this Chapter, shall be
presumed. '
Y. 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 direct contact 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.
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8-15-3-2 In addition, the following are requirements
for all facilities:
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;
S. 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;
7. Shall deposit any funds received from a
resident in excess of $100 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 $100
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;
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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
• facility.
11. If an adult resident is incapable of managing
his funds and does not have a representative or
guardian, shall notify the Office of the State
Guardian of the Guardianship and Advocacy
Commission; and
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:
(1) the person; or (2) the person's guardian, or
agent as defined in Section lla-23 of the "Probate
Act of 1975", as now or hereafter amended; or
(3) if the person is a minor, his parent. An adult
person shall be presumed to have the capacity to
contract for admission to a long term care facility
unless he has been adjudicated a "disabled person"
within the meaning of Section lla-2 of the "Probate
Act of 1975", as now or hereafter amended, or unless
• a petition for such an adjudication is pending in a
circuit court of Illinois.
If 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 Section; provided that a petition
for guardianship or for modification of 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. If a person
is unconscious or comatose, the contract for his
admission may be executed by a member of his
immediate family.
If a person is a resident of a facility who resided
in a facility on the effective date of this
amendatory Act and who has not executed a contract
as required by this Section, then such a contract
shall be executed on or before January 1, 1981.
A resident shall not be discharged or transferred
at the expiration of the term of a contract, except
• as provided in Section 8-15-3-2(F) below.
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1. A copy of the contract shall be given to the
resident or to the resident's representative
at the time of the resident's admission to
the facility, and a certified copy of the
contract shall be available in the facility
for inspection by the Department. A copy
of the contract for a resident who is supported
by non-public funds other than the resident's
own funds shall be made available to the
person providing the funds for the resident's
support. A copy of the contract for a
resident whose care is reimbursed with public
funds administered by the Department of Public
Aid shall be given to the Department of Public
Aid. If a facility chooses to use a general
form contract for more than one resident,
it need only supply to the Department of
Public Aid a copy of that form contract and
of any individual provisions affecting
individual residents.
2. 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.
3. No limited, specific or general power of
attorney granted to the licensee or his
employees by the applicant or his
representatives shall be a requirement for
admission or continued residence; and if
executed, shall be separately signed by the
applicant or his representative, and.shall
. be attached to the contract available for
inspection at the facility. If no power of
attorney has been granted, the contract must
so indicate.
4. The contract shall specify:
a. The term of the contract;
b. The services to be provided under the
contract and the charges for the services;
C. The services that may be provided to
supplement the contract and the charges
for the services;
d. The sources liable for payments due under
the contract, including a clear statement
of the rights, duties, and obligations of
the guarantor, if any;
e. The 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) ; and
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Cr. The name of the resident's representative
if any. The resident shall provide the
facility with a copy of the written
agreement between the resident and the
resident's representative 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.
S. The contract shall provide that if the
resident dies or is compelled by a change in
physical or mental health to leave the
facili.ty, 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
obligations under it with seven (7) days
notice. All charges shall be prorated as
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. `
6. Contracts shall provide that thirty (30) days
prior to any modification facilities will
give written notice to the resident or
resident's guardian and to any resident's
representative describing said modification.
7. Contract terms are binding and do not become
• void if ownership or administration changes.
C. Each facility shall establish a residents'
advisory council. The administrator shall
designate a member of the facility staff to
coordinate the establishment of the council.
After consultation with the council, the
administrator shall designate a member of the
facility staff to provide ongoing assistance to
the council.
1. The composition of residents' advisory
councils shall adhere to State Standards
for resident members. In addition, resident
advisory councils in facilities that have more
than 75% intermediate or skilled care residents
shall have at least two non-resident members.
Non-resident members shall not have a financial
interest in the facility. If resident members
are unsuccessful in finding acceptable non-
resident members, the resident council shall
inform the Director. The Director shall notify
the Evanston Commission on Aging who shall offer
assistance to the resident council in finding
acceptable non-resident members. The Director
may grant an exception to the requirement for
non-resident members only with the approval of
the Evanston Commission on Aging. Such
• exception shall be valid for a period not to
exceed one year.
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2. The council shall meet at least once each month
with the staff coordinator who shall provide
assistance to the council in preparing and
disseminating a report of each meeting to all
residents, the administrator, and the staff.
• 3. Notice of all council meetings shall be posted
in the facility.
4. Records of the council meetings will be
maintained in the office of the administrator
for public inspection.
S. The residents' advisory council may communicate
to the administrator the opinions and concerns
of the residents. The council shall review
procedures for implementing resident rights,
facility responsibilities and make
recommendations for changes or additions which
will strengthen the facility's policies and
procedures as they affect residents' rights
and facility responsibilities.
6. The council shall be a forum for:
a. Obtaining and disseminating information;e
b. Soliciting and adopting recommendations
for facility programming and improvements;
and !
C. Early identification and for recommending
orderly resolution of problems.
• 7. The council may present complaints as provided
in Section 8-15-4-6 on behalf of a resident to
the Department, the Illinois Department of
Public Health, the State Long Term Care
Facility Advisory Board or to any other person
it considers appropriate.
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.
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 for the
resident's stay, except as prohibited by Title
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 facility shall be preceded by the
discussion required under Section 8-15-3-2(F)7
below and by a minimum written notice of 21
• days. The 21-day requirement shall not apply
in any of the following instances:
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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;
C. A statement in not less than 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 -
North Shore Health Department within 10
days after receiving this notice. If you
request a hearing, it will be held not
later than 10 days after your request, and
you generally will not be transferred or
discharged prior to the expiration of 30
days following receipt of the original
notice of the transfer or discharge. A
• form to appeal the facility's decision and
to request a hearing is attached. If you
have any questions, call the Evanston -
North Shore 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
discharge in less than 21 days as described
under paragraphs a. and b. of Section
8-15-3-2(F)l above develops in the interim.
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 in whole or part through Title XIX,
to the Illinois Department of Public Aid.
0
8-15-3
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5. When the basis for an involuntary transfer or
discharge is the result of an action or inaction
by the Deaprtment of Public Aid with respect to
a recipient of Title XIX and a hearing request
is filed with the Department of Public Aid, the
• 21-day written notice period shall not begin
until a final decision in the matter is
rendered by the Department of Public Aid or a
court of competent jurisdiction and notice of
that final decision is received by the
resident and the facility.
6. When nonpayment is the basis for involuntary
transfer or discharge, the resident shall have
the right to redeem up to the date that the
discharge or transfer is to be made and then
shall have the right to 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 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. A resident subject to involuntary transfer or
discharge from a facility, the resident'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 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 10 days after a hearing
request is filed, and render a decision within
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-lS-3-2(F), the resident shall not be
required to leave the facility before the 34th
day following receipt of the notice required
under Section 8-15-3-2(F)2 or the loth day
following receipt of the Department's decision,
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whichever is later, unless a condition which
would have allowed transfer or discharge in
less than 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 90 days notice prior to voluntarily
closing a facility or closing any part of a
facility if closing such part will require the
transfer or discharge of more than 100 of the
residents. Such notice shall be given to the
Department, to any resident who must be trans-
ferred or discharged, to the resident's represen-
tative, and, if practicable, to a member of the
resident's family. Notice shall state the
proposed date of closing and the reason for
closing. The facility shall offer to assist the
resident in securing an alternative placement
and shall advise the resident on available
alternatives. 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 applicable 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 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
later than 48 hours after admission. Said handbook
shall be updated annually, however, at the time of
implementation of this Act, each resident shall be
given a written summary of all the rights enumerated
in Section 8-15-3.
1. A list of all rights and responsibilities
enumerated above in Sections 8-15-3-1 and
8-15-3-2, and those additional rights listed in
the State Act, Sections 3-601 through 3-607.
2. A statement of services offered by the facility.
3. A current guide to all required costs for
residence in the facility.
4. Policies and procedures of the facility for
implementing the rights and responsibilities
enumerated above in Sections 8-15-3-1 and
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.
S. The address and phone number of each of the
following agencies and a brief description of
is a.
services provided by each agency:
a. Evanston -North Shore Health Department
b. Illinois Department of Public Health
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C. Illinois Department of Public Aid
d. Illinois Department of Mental Health
e. Evanston Mental Health Board
• f. Cook County Legal Assistance Foundation,
Inc.
g. Local Social Security Office
h. Evanston Commission on Aging
i. Evanston Hospital Crisis Intervention
and Referral Service
j. Family Counseling 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 read 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:
1. Its current license;
2. A description, provided by the Department, of
complaint procedures established under Section
3-15-4-6 and the name, address, and telephone
number of a person authorized by the Department
to receive complaints;
3. A copy of an order pertaining to the facility
issued by the Department 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 5 years;
2. A copy of every order pertaining to the
facility issued by the Department or a court
• during the past 5 years;
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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 8-1S-2-2(E)l.
S. A record of personnel employed or retained by
the facility who are licensed, certified, or
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 2 years. ,_
K. The following 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
medical 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 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;
C. Provide evidence of employment or
occupation, if any, and residence for 2
years prior to his present employment;
d. Have completed at least 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 Illinois
Department of Public Health within 180
days of the effective date of the State
Act, or within 60 days of initial employment
in the capacity of 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
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employed at more than one facility for 2
years as 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.
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.
S. Proof of compliance by each employee with the
requirements set out in this Section shall bee
maintained for each such employee by each
facility in the individual personnel folder of
the employee.
b. Each facility shall certify to the Department
on a form provided by the Department the name
and residence address of each employee, and
that each employee subject to this Section
• meets all the requirements of this Section. ;
7. Any facility which is operated under Section
8-15-1-4(B) shall be exempt from the
requirements of this Section.
8-15-3-3 The following Standards shall apply in
addition to the State Standards and 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
staff -resident ratio requirements in the
State Standards.
b. In facilities of 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
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of seven o'clock (7:00) A.M. and seven
o'clock (7:00) P.M. for five days within
any week and shall be on duty on 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.
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
non-professional 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 Chapter 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
inservice training in restorative nursing
techniques to all other nursing
personnel.
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 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 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 compli-
ance with this Section shall be contained in
each employee's personnel file.
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4. When a resident's condition dictates, the
physician may give permission in writing for
the resident to administer medication himself,
except when such resident requires skilled care.
S. In all facilities there shall be additional
ancillary personnel to meet the total needs of
the residents.
• B. Dietary Services.
1. Resident Care Procedures
a. There shall be reasonable adjustment to the
food likes, habits, customs, condition, and
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
ches, 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 Consultant: 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 (1) 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.
(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
1SO-199 beds - 20 hours per month
200-249 beds - 24 hours per month
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250-299 beds - 28 hours per month
300 and over - 32 hours per month
b. The Director of Food Service shall be a
• qualified dietician; a graduate of a
dietetic technician or dietetic 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
service 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 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
responsibilities of Director of Food Service.
C. Social Services.
All facilities shall provide the following social
services:
• 1. Referral to appropriate agencies where there
are indicators that financial, psychiatric,
rehabilitative, legal or social service help
will be needed that the 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
facility including the availability of contact
with family members to keep them involved.
3. Assistance to staff and residents in discharge
planning and its implementation.
4. Assistance in providing inservice training to
long term care facility staff directed toward
understanding emotional problems and social
problems of residents and assistance in solving
these problems.
S. Assistance to staff and residents in using
community resources.
6. All facilities shall engage the services of
a clinical social worker according to the
following ratio of residents to hours of
service:
0-99 residents - 4 min./resident/week
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•
•
•
100-199 residents-S min./resident/week
200-299 residents-6 min./resident/week
300 or more residents-7 min./resident/week
At no time shall the amount of social
work time be less than the ratio required
for the number of residents in the
facility at that time.
A clinical social worker shall have a
master's degree in social work, six
months supervised clinical experience,
and current certification by the State
of Illinois. The degree requirements
herein provided may be waived 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 be waived for those
social workers who have been employed
at a long term care facility in
Evanston for at least 6 months prior
to the effective date of this Chapter.
D. Mental Health Services.
All facilities with residents who have been
discharged from psychiatric care within the last
three years, or with residents evidencing mental
retardation or with residents evidencing mental
problems as determined by the facility's consulting
physician and reviewed by the Care Review Committee
shall meet the following staff requirements.
Psychiatric care means inpatient -hospital care,
partial hospitalization, outpatient (including
alcohol, and drug abuse) and day hospital care.
A psychiatrist licensed to practice in Illinois
shall be under formal contract by the facility
to provide services determined by the Resident
Review Committee.
2. Additional clinical social work hours shall
be provided to residents defined above at
the rate of twenty-five minutes per resident
per week.
E. Activity Program.
All facilities shall have an activity program
directed by a full-time staff member who shall be
qualified to direct an activity program. Records
programming and patient participation shall be
maintained and shall include program goals,
attendance records and progress notes. The plan
activity programming shall incorporate community
resources and shall include group activities to
promote learning about interpersonal behavior.
F. Physical therapy.
Each facility shall make available to its
residents the services of a registered physical
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therapist currently licensed by the State of
Illinois who shall under physicians orders, spend
such time within the facility as such orders may
require.
G. Occupational Therapy/Recreational 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 evaluation of each resident within
30 days of admission or readmission to the
facility. The evaluation shall include an
assessment of communication skills, mobility,
physical strength and coordination, and
self -care status, and shall include
recommendations for care and treatment needed
to maintain or restore maximum functioning in
the above areas. The evaluation 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 inservice programs per
year which are designed to assist staff in
carrying out restorative procedures.
3. Consult with the Activity Director as needed to
plan activities which are supportive of
restorative care needs.
H. Records.
• All facilities shall maintain the following records
and procedures:
1. Admission Records: A medical history and
interim psychosocial 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. A complete
psychosocial assessment shall be completed
within 60 days of admission and also filed
with chart.
2. Review of Resident Care: There shall be
established in each facility a procedure for
review of resident care based on the evaluation
of the resident's immediate and long term needs.
This procedure shall be the responsibility of a
Care Review Committee consisting of at least
one supervisory nurse, nurse aide, social
worker, and activity worker. The resident's
physician shall be included as needed. Other
persons, including representatives from
physical therapy, occupational therapy,
recreation therapy, dietary, pharmacy, and
housekeeping 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
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plan. The Committee shall evaluate each
resident's immediate and long term needs and
prepare and review care plans for services to
restore and maintain maximum functioning and
shall designate a person or persons responsible
for carrying out the plan. The plan shall
• state procedures for assessment, plan of
treatment, and expected outcomes in regard to,
but not limited to:
a. Assessment of restorative needs.
b. Assessment of mental health status.
C. The treatment plan in operation.
d. Drug therapy review.
e. Referral needs and plans.
f. Discharge plans.
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) day-s
for the first sixty (60) days and at intervals
of not greater than ninety (90) days thereafter.
The initial review of all new residents shall
be done within 30 days of admission.
Appropriate adjustments in the resident's care
plan shall be instituted upon each evaluation.
Care plans will be kept at the nurse's stations
accessible to staff providing care to residents.
• 8-15-3-4 The following standards shall apply in
addition to State Standards for all
facilities hereafter constructed, or existing
structures which are hereafter converted to use as long
term care facilities, and all additions to existing
facilities.
A. Provide all corridors with six (6) tempered fresh
air changes per hour at a rate of two (2) cubic
feet per minute per square foot.
B. Provide all laundry, storage and counting rooms
with four (4) changes of fresh air and exhaust per
hour at the rate of one and one-half (1?2) cubic
feet per minute per square foot, unless said rooms
are vented directly outside by proper operable
windows.
C. Provide twenty-five (2S) square feet of outside
space per bed.
D. Provide a maximum total of one hundred (100) beds
for a sheltered care facility, and a maximum total
of one hundred fifty (150) beds for any combination
of skilled, intermediate or sheltered care facility.
No facility, whether new or existing, shall be
constructed, converted or altered, or create or
expand its facilities to house more than one
• hundred fifty (1S0) resident beds in a single
free-standing structure.
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E. Resident's living space shall meet the following
standards:
1. Two hundred twenty-five (225) square feet of
floor area per bed shall be provided. This
two hundred twenty-five (225) square feet of
living space shall include no less than one
hundred twenty (120) square feet of bed space
per single bedroom, one hundred (100) square
feet of bed space per multiple bedroom and
seventy five (75) square feet of recreational
and dining space per resident.
2. All long term care facilities shall provide
each resident with a functional closet or
wardrobe with a floor area of no less than four
(4) square feet. This area is in addition to
the above requirements.
F. There shall be one lavatory and one water closet
for each bedroom except that one such facility
directly accessible from each of two (2) rooms may
serve both, provided there are not more than four
(4) residents in the two (2) rooms. In addition,
there shall be one water closet for each twenty
(20) residents accessible from the corridor.
Where this results in four (4) units or more, they
are to be placed in two (2) separate rooms, one for
each sex. Each such room shall contain a lavatory.
Each resident's privacy shall be preserved.
G. There shall be one bathtub or shower for each six
(6) resident beds on each floor with direct access
thereto from the resident's room, or from the
• common hallway.
8-15-4 ENFORCEMENT:
In addition to the powers and responsibilities provided
elsewhere, the Department is responsible for the
following:
8-15-4-1 The Department shall enforce this Chapter
including the applicable provisions of the
State act and the State Standards. The Department
shall utilize the license classifications of facilities
according to the levels of service which are
established by the Illinois Department of Public Health
and shall issue licenses according to these
classifications.
8-15-4-2 The Department shall cooperate with units of
State government, including the Department
of Public Health, the Department of Public Aid, and the
Department of Mental Health and Developmental
Disabilities in monitoring facilities, with the goal
of assuring necessary, equitable and consistent
supervision of facilities without unnecessary
duplication of survey, evaluation, and consultation
services or of complaint investigations.
8-15-4-3 The Department, whenever it deems necessary,
but not less than annually, shall inspect,
is
survey and evaluate every facility to determine
8-15-4
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compliance with applicable licensure requirements and
standards. The annual inspection should occur within
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. A municipal employee charged with
inspecting, 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 is in violation of this
Chapter.
8-15-4-4 The Department shall require periodic
reports and shall have access to any books,
records, and other documents maintained by the facility
necessary to carry out this Chapter and the applicable
provisions of the State Act and State Standards.
8-15-4-5 Any holder of a license or applicant for a
license shall be deemed to have given
consent to any authorized officer, employee or agent �of
the Department to enter and inspect the facility in
accordance with this Section. Refusal to permit such
entry or inspection shall constitute grounds for denial,;
non -renewal or revocation of a license.
8-1S-4-6 The Department shall investigate all
complaints thoroughly and promptly. Such
investigation shall be carried out according to the
• following procedure.
A. Any person who believes that any provision of this
Chapter may have been violated, may request an
investigation. The request may be submitted to the
Department in writing, by telephone, or by personal
visit. An oral complaint shall be reduced to
writing by the Department.
B. The substance of the complaint shall be 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
pursuant to the complaint.
C. The complaint, a copy of the complaint, or a record:
published, released, or otherwise disclosed to the
facility shall not disclose the name of the
complainant unless the complainant or resident
consents in writing to the disclosure, or the
investigation results in a judicial proceeding, or
unless disclosure is essential to the investigation;
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.
•
8-15-4
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D. Upon receipt of a complaint, the Department shall
determine whether any provision of this Chapter or
of the State Act or State Standards has been or is
being violated. If there is a substantial proba-
bility that the complaint alleged is a Type 'A'
violation, the investigation of said complaint shall
be initiated within 24 hours. A determination about
a complaint which alleges a Type 'A' violation shall
be made by the Department, in writing, within seven
(7) days after the complaint's receipt. A deter-
mination about a complaint which alleges a Type 'B'
or 'C' violation shall be made by the Department,
in writing, within thirty (30) days after receipt of
the complaint. The determination shall state the
reasons therefor.
E. In all cases, the Department shall inform the com-
plainant of its findings within ten (10) days of its
determination. The Department shall also notify the
facility of such findings within ten (10) days of
the determination, but the name'of the complainant
or resident shall not be disclosed 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; and the licensure
form on which the violation is listed.
F. A written determination, correction order, or warn-
ing notice concerning a complaint shall be available
for public inspection, but the name of the complain-
ant or resident shall not be disclosed without his
consent-
G. An aggrieved party who is dissatisfied with the de-
termination or investigation by the Department may
request a hearing under Section 8-15-6. If a
facility requests a hearing under Section 8-15-6
which concerns a matter covered by a complaint, the
request for a hearing shall be submitted in writing
to the Department within thirty (30) days after the
mailing of the Department's findings as described in
Section 8-15-4-6(E). Upon receipt of the request,
the Department shall conduct a hearing as provided
under Section 8-15-6.
8-1S-4-7 The Department may transfer or discharge any
resident from any facility when any of the
following conditions exist:
A. Such facility is _operating without a license;
B. The Department has suspended, revoked or refused to
renew the license of the facility as provided under
Sections 8-15-2-8 or 8-15-2-11.
C. The facility has requested the aid of the Department
in the transfer or discharge of the resident and the
Department finds that the resident consents to
transfer or discharge;
D. The facility is closing or intends to close and ade-
quate arrangement for relocation of the resident has
not been made at least 30 days prior to closure; or
E. The Department determines that an emergency exists
which requires immediate transfer or discharge of
the resident.
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In deciding to transfer or discharge a resident from a
facility, the Department shall consider the likelihood
of serious harm which may result if the resident remains
in the facility. Residents shall be involved in
planning the transfer or discharge and shall choose
among the available alternative placements, except that
• where an emergency makes prior resident involvement
impossible the Department may make a temporary
placement until a final placement can be arranged.
Residents may choose their final alternative placement
and shall be given assistance in transferring to such
place. No resident may be forced to remain in a
temporary or permanent placement. Where the Department
makes or participates in making the relocation decision,
consideration shall be given to proximity to the
resident's relatives and friends. The resident shall
be allowed three (3) visits to potential alternative
placements prior to removal, except where medically
contraindicated or where the need for immediate
transfer or discharge requires reduction in the number
of visits.
8-15-4-8 Where the Department so transfers or
discharges residents, it shall arrange for
the preparation of the resident transfer or discharge
plans to assure safe and orderly removals and protect'
residents' health, safety, welfare and rights. In
nonemergencies and, where possible, in emergencies the
Department shall design and implement such plans in
advance of transfer or discharge.
8-1S-4-9 Where the Department transfers or discharges
residents, the Department shall:
• A. Provide written notice to the facility prior to the
transfer or discharge. The notice shall state the
basis for the order of transfer or discharge and
shall inform the facility of its right to an
informal conference prior to transfer or discharge
under this Section, and its right to a subsequent
hearing under Section 8-15-4-11 below. If a
facility desires to contest a nonemergency transfer
or discharge prior to transfer or discharge it
shall, within four (4) working days after receipt
of the notice, send a written request for an
informal conference to the Department. The
Department shall, within four (4) working days from
the receipt of the request, hold an informal
conference. Following this conference, the
Department may affirm, modify or overrule its
previous decision. Except in an emergency,
transfer or discharge may not begin until the
period for requesting a conference has passed or,
if a conference is requested, until after a
conference has been held; and
B. Provide written notice to any resident to be
removed, to the resident's representative, if any,
and to a member of the resident's family, where
practicable, prior to the removal. The notice
shall state the reason for which transfer or
discharge is ordered and shall inform the resident
of the resident's right to challenge the transfer
or discharge under Section 8-1S-4-11 below. The
;- Department shall hold an informal conference with
the resident or the resident's representative
8-1S-4 -37-
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prior to transfer or discharge at which the
resident or the representative may present any
objections to the proposed transfer or discharge
plan or alternative placement. Following this
conference, the Department may affirm, modify or
overrule its previous decision. Except in an
emergency, transfer or discharge may not begin
until after a conference has been held.
8-15-4-10 In any transfer or discharge conducted under
Section 8-15-4-7(E), the Department shall
notify the facility and any resident to be removed that
an emergency has been found to exist and removal has
been ordered, and shall involve the residents in
removal planning if possible. Following emergency
removal, the Department shall provide written notice to
the facility, to the resident, to the resident's
representative, if any, and to a member of the
resident's family, where practicable, of the basis for
the finding that an emergency existed and of the right
to challenge removal under Section 8-15-4-11.
8-15-4-11 Within ten (10) days following transfer or
discharge, the facility or any resident
transferred or discharged may send a written request
for a hearing under Section 8-15-6 to challenge the
transfer or discharge. The hearing shall commence
within thirty (30) days of receipt of the request.
Where a challenge is by a resident, the hearing shall
be held at a location convenient to the resident. No
resident transferred or discharged may be held liable
for the charge for care which would have been made had
• the resident remained in the facility. The Department
shall assist the resident in returning to the facility
if assistance is requested.
8-15-4-12 The Department may place relocation teams
in any facility from which residents are
being discharged or transferred for any reason, for
the purpose of implementing transfer or discharge
plans.
8-15-4-13 The Department may place an employee or
agent to serve as a monitor in a facility or
may petition the circuit court for appointment of a
receiver for a facility, or both, when any of the
following conditions exist:
A. The facility is operating without a license;
B. The Department has suspended, revoked or refused
to renew the existing license of the facility;
C. The facility is closing or has informed the
Department that it intends to close and adequate
arrangements for relocation of residents have not
been made at least thirty (30) days prior to
closure; or
D. The Department determines that an emergency exists,
whether or not it has initiated revocation or
nonrenewal procedures, if because of the
10 unwillingness or inability of the licensee to
remedy the emergency the Department believes a
monitor or receiver is necessary.
8-15-4 -38-
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The monitor shall observe operation of the facility,
assist the facility by advising it on how to comply
with this Chapter and shall report periodically to the
Department on the operation of the facility.
8-15-4-14 Where a resident, a resident's
representative or a resident's next of kin
believes that an emergency exists each of them
collectively or separately, may file a verified
petition to the Circuit. Court of Cook County for an
order placing the facility under the control of a
receiver.
8-15-4-lS The procedures for Court appointment of a
receiver shall be in accordance with the
State Act, Sections 3-503 through 3-517.
8-15-4-16 The following information is subject to
disclosure to the public from the
Department. This information shal-1 be available for
public inspection within five (5) working days
following the receipt of a written request unless
otherwise specified below.
A. Information submitted under Sections e-15-2-2(E)1
and 8-15-2-2-(E)2 except information concerning t"he
remuneration of personnel licensed, registered, or
certified by the Department of Registration and
Education and monthly charges 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, except that a
cost report submitted under Section 8-15-2-2(E)2
shall be disclosed only after the facility has been
given fourteen (14) days prior notice of the
request, reports of audits of facilities, and other
public records concerning costs incurred by,
revenues received by, and reimbursement of
facilities; and
D. Complaints filed against a facility and complaint
investigation reports, except that a complaint or
complaint investigation report shall not be
disclosed to a person other than the complainant
or complainant's representative before it is
disclosed to a facility, except that a complainant
or resident's name shall not be disclosed except
under Section 8-15-4-6(C) above.
8-15-4-17 The Department shall respect the
confidentiality of a resident's record and
shall not divulge or disclose the contents of a record
in a manner which identifies a resident, except upon
a resident's death to a relative or guardian, or under
• judicial proceedings. This Section shall not be
construed to limit the right of a resident to inspect
8-15-4
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or copy the resident's records. Confidential medical,
social, personal, or financial information identifying a
resident shall not be available for public inspection
in a manner which identifies a resident.
. 8-15-4-18 Each year the Department shall prepare a
Directory of facilities in Evanston to be
made available to the public. The information in the
Directory shall be forwarded to the Illinois Department
of Public Health for inclusion in an annual State-wide
directory. The Department may charge a fee for the
Directory. The Directory shall contain, at a minimum,
the following information:
A. The name and address of the facility;
B. The number and type of licensed beds;
C. The name of the cooperating hospital, if any;
D. The name of the administrator;
E. The facility telephone number; and
F. Membership in a provider association and
accreditation by any such organization.
8-15-4-19 The Department shall make at least one
report on each facility in Evanston
annually. All conditions and practices not in
compliance with applicable standards within the last
year shall be specifically stated. If a violation is
corrected or is subject to an approved plan of.
• correction, the same shall be specified in the annual
report. The Department shall forward said report to
the Illinois Department of Public Health and shall
send a copy to any person on receiving a written
request. The Department may charge a reasonable fee
to cover copying costs.
8-15-4-20 The Department shall not prescribe the
course of medical treatment provided to an
individual resident by the resident's physician in a
facility.
8-1S-S VIOLATIONS AND PENALTIES
8-15-5-1 If, upon inspection or investigation, the
Department determines that a facility is in
violation of this Chapter or the State Act or State
Standards, it shall promptly 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
inform the licensee of any action the Department may
take under the Act including the requirement of a
facility plan of correction under Section 8-15-5-3;
placement of a facility on a list prepared under Section
8-15-5-4; assessment of a penalty under Section
8-1S-5-S; a conditional license under Section 8-15-5-11;
or license suspension or revocation under Section -
8-15-2-11. The Department shall also inform the
licensee of rights to a hearing under Section 8-15 6.
8-15-5 -40-
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8-15-S-2 Each day of violation constitutes a separate
violation for purposes of assessing
penalties under Section 8-15-S-S. No penalty may be
assessed for a condition for which the facility has
received a variance or waiver of a standard under
Title XVIII or XIX.
• 8-15-5-3 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 unless a fixed period of time, not
exceeding fifteen (15) days, as determined by the
Department and specified in the notice of violation,
is required for correction.
B. At the time of issuance of a notice of a Type 'B'
or Type 'C' 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. The facility
shall have ten (10) days after receipt of the
notice of rejection in which to submit a modified
plan. If the modified plan is not timely submitted,.
• or if the modified plan is rejected, the facility ;
shall follow an approved plan of correction imposed
by the Department.
C. If the violation has been corrected prior to
submission and approval of a plan of correction,
the facility may submit a report of correction in
place of a plan of correction. Such report shall
be signed by the administrator under oath.
D. Upon a licensee's petition, the Department shall
determine whether to grant a licensee's request for
an extended correction time. Such petition shall
be served on the Department prior to expiration of
the correction time originally approved. The
burden of proof is on the petitioning facility to
show good cause for not being able to comply with
the original correction time approved.
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 8-1S-6. Whenever 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 a hearing may not be reheard at subsequent
• hearings under this Section.
8-15-5
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8-15-5-4 The Department shall prepare on a monthly
basis a list containing the names and
addresses of all facilities with an existing Type 'A'
violation or with five (S) or more existing violations
of any Type for which a plan of correction has not been
timely submitted to the Department under Section
8-15-5-3, or for which an approved plan of correction
has been disapproved or for which an approved plan of
correction has not been carried out. The list shall
specify the number and type of each facility's
violations.
A. A copy of the monthly list of violators shall be
sent to the Director of the Illinois Department of
Public Health for distribution as provided in
Section 3-304 of the State Act.
B. The Department shall notify each facility placed
on the list of such placement at least ten (10)
days prior to the issuance of the list. No
facility may be placed on the list unless a hearing
has been held under Section 8-1S-6 or the time for
requesting a hearing has passed and no request has
been made. A facility shall be removed from the
list when all corrections are made or when a plan
of correction for all deficiencies is approved by
the Department. The list shall indicate those
facilities which have been removed from the list
during the prior month.
C. No facility which is placed on the list of
violators issued under this Section may admit
residents until it is removed from the list.
• D. The Department may provide information from the
list to any agencies which make referrals to
facilities.
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
Department's action. The hearing shall commence as
provided under Section 8-15-6.
8-15-5-S The license of a facility which is in
violation of this or any rule adopted
thereunder may be subject to the penalties levied by
the Department as specified in this Section.
A. Unless a greater penalty is allowed under Sections
8-15-S-5(D), (G), and (H), a person who commits a
Type 'A' violation is subject to a penalty
computed at a rate not to exceed $4.50 per resident
in the facility plus fifteen (15) 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 fine
of not less than $1,000, whichever is greater.
B. Unless a greater penalty is allowed under Sections
8-15-5-5(D), (G), and (H), a person who commits a
Type 'B' violation is subject to a penalty computed
• at a rate not to exceed $3.00 per resident in the
facility, plus ten (10) 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.
8-15-S
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C. Unless a greater penalty is allowed under Sections
8-15-5-5(1)), (G), and (H), a person who commits a
Type 'C' violation is subject to a penalty computed
at a rate not to exceed $1.50 per resident in the
facility, plus five (5) 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.
D. A person who commits a Type 'A', 'B', or 'C'
violation which continues beyond the time specified
in Sections 8-15-5-3(A) and 8-15-5-3(B) is subject
to a penalty not to exceed three (3) times the
penalty computed per resident per day under Section
8-15-5-5(A), (B), or (C). respectively.
E. For the purpose of computing a penalty under
Sections 8-15-5-3(B) through 8-15-5-3(D), the
number of residents per day shall be based on the
average number of residents in the facility during
the thirty (30) days preceding the discovery of the
violation.
F. 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 $100.00, whichever is greater.
G. If the violation or group of violations results
from inadequate staffing, a penalty may be imposed
equal to the total difference between the cost of
• the staff actually employed and the estimated cost
of the staff required. The number of staff
required shall be set by Court Order or by the
Department if no Court Order exists. The
inadequate staff shall be presumed to exist from
the date of the notice of violation.
H. A facility which violates this Chapter, the State
Act, or a State Standard and which has received
notices of the same violations on two (2) or more
separate prior occasions within the prior two (2)
year period is subject to a penalty of three (3)
times the amount authorized by Section 8-15-5-5(A),
(B) or (C) for the class of violation involved.
A notice of violation found to be unjustified
after hearing may not be considered in determining
whether to apply this Section.
8-15-5-6 In determining whether a penalty is to be
imposed, if any, for a violation, the
Director shall consider the following factors:
A. The gravity of the violation, including the
probability that death or serious physical or
mental harm to a resident will result or has
resulted, the severity of the actual or potential
harm, and the extent to which the provisions of the
applicable statutes or regulations were violated;
• B. The reasonable diligence exercised by the licensee
and efforts to correct violations;
8-15-5 -43-
72-0-80
C. Any previous violations committed by the licensee;
and
D. The financial benefit to the facility of committing
or continuing the violation.
8-15-5-7 The Director may directly assess penalties
provided for under Section 8-15-5-5 of
this Chapter. If it is determined that a penalty
should be assessed for a particular violation or for
failure to correct it, a notice shall be sent to the
facility. The notice shall specify the amount of the
penalty assessed, the violation, the Chapter provision
or State Standard alleged to have been violated, and
shall inform the licensee of the right of hearing under
Section 8-15-6 of this Chapter. If the violation is
continuing, the notice shall specify the amount of
additional assessment per day for the continuing
violation.
8-15-5-8 In the case of a Type 'A' violation, a
penalty may be assessed from the date on
which the violation is discovered. In the case of a
Type ',B' or Type 'C' violation, the facility shall
submit a plan of correction as provided in Section
8-15-5-3. If a plan of correction is approved and
carried ,out, no penalty may be assessed for the
violation during the time period specified in the
approved plan of correction. If a good faith plan of
correction is not received within the time provided
by Section 8-15-5-3, a penalty may be assessed from the'
date of discovery of the Type 'B' or 'C' violation
until the date of the receipt of a good faith plan of
correction, or until the date the violation is
corrected, whichever is earlier. If a violation is not'
corrected within the time specified by an approved plan
of correction or any lawful extension thereof, a
penalty may be assessed from the date of discovery of
the violation, until the date the violation is
corrected.
8-15-5-9 A facility may contest an assessment of a
penalty by sending a written request for
hearing under Section 8-15-6. Upon receipt of the
request of the Department a hearing shall commence as
provided under Section 8-15-6.
8-15-5-10 All penalties shall be paid to the
Department within ten (10) days of receipt
of notice of assessment or, if the penalty is contested
under Section 8-15-5-9 above, within ten (10) days of
receipt of the final decision, unless the decision is
appealed and the order is stayed by the court order
under Section 8-15-6-4(B). A penalty assessed under
this Chapter shall be collected by the Department. If
the person or facility against whom a penalty has been
assessed does not comply with a written demand for
payment within thirty (30) days, the Director shall
issue an order to do any of the following:
A. Add the amount of the penalty to the facility's
licensing fee; if the licensee refuses to make the
payment at the time of application for renewal of
its license, the license shall not be renewed;
B. Bring an action in circuit court to recover the
amount of the penalty; or
8-15-5 -44-
72-0-80
C. Revoke the license of the facility.
8-15-.5-ll 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 'A', Type 'B' 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 review and approve a written plan
of correction. 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 on meeting the requirements of the plan
of correction.
B. Written notice of the decision to issue a
conditional license shall be sent to the facility
together with the proposed plan of correction. The
notice shall inform the facility of its right to an
informal conference prior to issuance of the
conditional license and its right to a full hearing
under Section 8-15-6.
1. If a facility desires to have an informal
conference it shall, within four (4) working
days of receipt of the notice send a written
request for an informal conference to the
Department. The Department shall, within four
(4) working days from receipt of the request,
hold an informal conference. Following this
conference, the Department may affirm or
overrule its previous decision, or modify the
terms of the conditional license and plan of
correction. The conditional license may be
issued after the informal conference or after
the time for requesting an informal conference
has expired, prior to any further hearing.
2. If after the informal conference the facility
desires to contest the basis for issuance of a
conditional license, or the terms of the
license or plan of correction, the facility
shall send a written request for hearing
within ten (10) days after issuance of the
conditional license. The hearing shall
commence as provided under Section 8-15-6.
C. A conditional license shall be issued for a period
specified by the Department, but in no event for
more than one'year. The Department shall
periodically inspect any facility operating under
a conditional license. If the Department finds
substantial failure by the facility to follow the
plan of correction, the conditional license may be
revoked as provided under Section 8-15-2-11.
D. If the Department determines that a conditional
license shall expire without renewal or replacement
of the conditional license by a regular license,
the Department shall so notify the licensee at
• least thirty (30) days prior to expiration of the
license. The licensee is entitled to a hearing
under Section 8-15-6 if requested prior to
expiration of the license.
8-15-5
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40
•
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8-15-5-12 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 or approved
plan of correction under this Chapter as the
maximum period given for correction, unless an
extension is granted and the corrections are made
before expiration of extension;
B. Intentionally prevent, interfere with, or attempt
to impede in any way the work of any duly
authorized representative of the Department in the
investigation and enforcement of this Chapter;
C. Intentionally prevent or attempt to prevent any
such representative from examining any relevant
books or records in the conduct of official duties
under this Chapter;
D. Intentionally prevent or interfere with any such
representative in the preserving of evidence of
any violation of this Chapter or of the State Act
or State Standards;
E. Intentionally 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. Wilfully file any false, incomplete or
intentionally misleading information required to
be filed under this Chapter or wilfully fail or
refuse to file any required information; or
G. Open or operate a facility without a license.
The Corporation Counsel of the City of Evanston may be
requested by the Director to initiate prosecutions
under this subsection.
8-15-5-13 The operation or maintenance of a facility
in violation of this Chapter is declared a
public nuisance inimical to the public welfare. The
Director, in the name of the City of Evanston through
the office of the Corporation Counsel of the City of
Evanston, may, in addition to other remedies herein
provided, bring action for an injunction to enjoin the
future operation or maintenance of any such facility.
8-15-6 HEARING:
8-15-6-1 Any person aggrieved by a decision of the
Department rendered in a particular case
("grievant") which affects the person's legal rights,
duties or privileges created under this Chapter may
have such decision reviewed in a hearing. The hearing
will be conducted according to the following
procedures:
A. A request for a hearing shall be
to the Director and shall include
mailing address of the grievant.
8-15-6
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made in writing
the proper
72-0-80
B. The City Manager shall designate a person to serve
as Hearing Officer to conduct a hearing to review
the decision. after notice of hearing under this
Section, the Hearing Officer shall not communicate,
directly or indirectly, in connection with any issue
of fact in that case or hearing with any person or
party except upon notice and opportunity for all
• parties to participate. However, the Hearing
Officer may have the aid and advice of one or more
personal assistants.
C. At least ten (10) days prior to the hearing the
Director shall send notice of the hearing to the
person requesting the hearing. The notice shall
specify the date, time, and place of the hearing
and the decision being reviewed. The notice to
the grievant shall be sent to the address set
forth in the request for hearing by certified
mail, return receipt requested, or by personal
service.
D. The hearing shall commence no later than thirty (30)
days after the receipt by the Director of a request
for hearing and shall end no later than ninety (90)
days after the commencement unless justice requires
otherwise.
E. The Hearing Officer may compel by subpoena or
subpoena duces tecum the attendance and testimony
of witnesses and the production of books and
papers, and administer oaths to witnesses.
F. The Hearing Officer shall permit the grievant
to appear in person and to be represented by
counsel at the hearing at which time the applicant
or licensee shall be afforded an opportunity to
• present all relevant matter in support of his
position. In the event of the inability of
either the applicant, licensee, or the Department
to procure the attendance of witnesses to give
testimony or produce books and papers, either the
applicant, licensee, or the Department may take
the deposition of witnesses in accordance with the
provisions of the laws of this State. All
testimony taken at a hearing shall be recorded
and all such testimony and other evidence
introduced at the hearing shall be a part of the
record of the hearing.
G. The Hearing Officer shall not be bound by common
law or statutory rules of evidence, or by
technical or formal rules of procedure, but shall
conduct hearings in the manner best calculated to
result in substantial iustice.
H. All subpoenas issued by the Hearing Officer may be
served as provided for in civil actions. The fees
of witnesses for attendance and travel shall be
the same as the fees for witnesses before the
circuit court and shall be paid by the party at
whose request the subpoena is issued. If such
subpoena is issued at the request of the
Department or by a person proceeding in forma
pauperis the witness fes shall be paid by the
Department as an administrative expense.
• I. In cases of refusal of a witness to attend or
testify or to produce books or papers concerning
any matter upon which he might be lawfully
examined, the circuit court of the county wherein
the hearing is held; upon application of any party
to the proceeding, may compel obedience by a
proceeding for contempt as in cases of a like
refusal to obey a similar order of the court.
8-15-6 -47-
72-0-80
J. The Department, at its expense, shall record the
testimony and preserve a record of all proceedings
under this Section. The notice of hearing, the
complaint and all other documents in the nature of
pleadings and written motions filed in the
• proceedings, the transcript of testimony, and the
findings and decision shall be the record of the
proceedings. The Department shall furnish a
transcript of such record to any person interested in
such record upon payment as determined by the
Department.
8-15-6-2 The Hearing Officer shall make findings of
fact in such hearing and shall make a
recommendation for a decision to the City Manager. The
City Manager shall render his decision within thirty (30)
days after termination of the hearing, unless additional
time not to exceed ninety (90) days is required by him
for a proper disposition of the matter. When the hearing
has been conducted by a Hearing Officer, the City Manager
shall review the record and findings of fact before
rendering a decision. All decisions rendered by the City
Manager shall be binding upon and complied with by the
Department, the facility, or the persons involved in the
hearing, as appropriate to each case.
8-15-6-3 The Department shall not be required to
certify any record or file any answer or
otherwise appear in any proceeding for judicial review
under Section 8-15-8 of this Chapter unless the party
filing the complaint deposits with the clerk of the court
the costs of such certification. Failure on the part of
the plaintiff to make such deposit shall be grounds for
dismissal of the action; provided, however, that persons
proceeding in forma pauperis with the approval of the
40 circuit court shall not be required to pay these fees.
8-15-7 WAIVERS
8-15-7-1 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. A facility
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 as provided in Section 8-15-6.
A decision to grant relief from a provision of this
Chapter shall be made only where the Hearing Officer has
found that a practical impossibility or extreme hardship
exists in complying with the provision under appeal and
that an acceptable alternative method of service
provision will be implemented.
8-15-7-2 A facility which has been granted relief from
a provision of this Chapter may request the
continuation of such relief, in a letter to the Director,
when the annual license renewal application is filed.
• The Director shall grant such relief if the facility has
submitted an adequate showing that the same conditions
exist at the time of license renewal as existed when the
relief was originally granted. Without said request,
such relief terminates at the end of the license year.
72-0-80
8-15-8 ADMINISTRATIVE REVIEW
The following procedures apply to the review of
administrative decisions:
A. Final administrative decisions after hearing shall
• be subject to judicial review exclusively as provided
in the "Administrative Review Act", approved Iday 8,
1945, as now or hereafter amended, except that any
petition for judicial review of Department action
under this Chapter shall be filed within fifteen (15)
days after receipt of notice of the final agency
determination. The term "administrative decision"
has the meaning ascribed to it in Section 1 of the
Administrative Review Act.
•
B. The court may stay enforcement of the Department's
final decision or toll the continuing accrual of a
penalty under Section 8-1S-S-5 if a showing is made
that there is a substantial probability that the
party seeking review will prevail on the merits and
will suffer irreparable harm if a stay is not
granted, and that the facility will meet the
requirements of this Chapter. Where a stay is
granted, the court may impose such conditions on the
granting of the stay as may be necessary to safeguard
the lives, health, rights, safety and welfare of
residents, and to assure compliance by the facility
with the requirements of this Chapter including an
order for transfer or discharge of residents under
Sections 8-15-4-7 through 8-15-4-10 or for
appointment of a receiver under Sections 8-15-4-13
through 8-15-4-15.
C. Actions brought under this Chapter shall be set for
trial at the earliest possible date and shall take
precedence on the court calendar over all other cases
except matters to which equal or superior precedence
is specifically granted by law.
8-15-9 The remedies provided by this Chapter are
cumulative and shall not be construed as
restricting any party from seeking any remedy,
provisional or otherwise, provided by law for the benefit
of the party or from obtaining additional relief based
upon the same facts.
SECTION 2: All Ordinances or parts of Ordinances in
conflict herewith are hereby repealed.
SECTION 3: This Ordinance shall be in full force and
effect twenty (20) days from and after its passage, approval and
publication in the manner provided by law.
-49-
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1980 , Introduced: 'T
0 - 41 -2_-2--Passed: 1980
APPROVED: 1980
ATTEST: //91� y
Approved as to form:
fi-otporation Counsel