77 Ill. Adm. Code 380.515
Reportable Performance Indicators
Section
380.515Â Reportable Performance Indicators
a)Â Â Â Â Â Â Â Â The
following information shall be made available to the Department upon entry to
the facility by a Department survey team:
1)Â Â Â Â Â Â Â Â Census
information;
2)Â Â Â Â Â Â Â Â Key
personnel of the facility and the facility's governing body;
3)Â Â Â Â Â Â Â Â A
roster of the facility's residents with room numbers;
4)Â Â Â Â Â Â Â Â Program
discharge summaries;
5)Â Â Â Â Â Â Â Â Accrediting
benchmark achievements;
6)Â Â Â Â Â Â Â Â Accrediting
performance improvement reports and compliance.
7)Â Â Â Â Â Â Â Â The
facility's staffing plan;
8)Â Â Â Â Â Â Â Â Staff
turnover rate;
9)Â Â Â Â Â Â Â Â The
facility's floor design;
10)Â Â Â Â Â Â Â Â The
facility's admissions and discharges;
11)Â Â Â Â Â Â Â Â Incident
reports prepared pursuant to Section 380.530;
12)Â Â Â Â Â Â Â Â The
facility's performance improvement project or projects;
13)Â Â Â Â Â Â Â Â Written
records on the facility's use of restraints;
14)Â Â Â Â Â Â Â Â Pharmacy
reports of adverse outcomes;
15)Â Â Â Â Â Â Â Â Medication
error reports;
16)Â Â Â Â Â Â Â Â The
facility's written policies and procedures; and
17)Â Â Â Â Â Â Â Â The
facility's identified offender list.
b)Â Â Â Â Â Â Â Â The
facility shall provide to the Department upon request all data elements that a
facility is required to submit to any State agency, managed care organization,
accrediting body, or any other third party.
c)Â Â Â Â Â Â Â Â The
facility shall submit the following reportable performance indicator information
concerning each level of service to the Department, DHS-DMH and the Department
of Healthcare and Family Services (HFS) at least monthly. Reportable
performance indicator information shall include, but not be limited to:
1)Â Â Â Â Â Â Â Â Admissions,
including referral sources and consumer living arrangements prior to admission;
2)Â Â Â Â Â Â Â Â Transfers
to other facilities, to facilities licensed under the Nursing Home Care Act, to
private hospitals for both medical and psychiatric treatment, and between
levels of service;
3)Â Â Â Â Â Â Â Â Discharges,
including the frequency of discharges to community-based behavioral health
providers, other community-based providers, private hospitals for both medical
and psychiatric treatment, State hospitals, detox centers, and involuntary
discharges;
4)Â Â Â Â Â Â Â Â All
emergency department visits for both medical and psychiatric treatment;
5)Â Â Â Â Â Â Â Â Re-admissions
to a facility within 30 days after discharge;
6)Â Â Â Â Â Â Â Â Suicides
and suicide attempts;
7)Â Â Â Â Â Â Â Â Deaths
of consumers, including deaths of consumers during hospital visits;
8)Â Â Â Â Â Â Â Â Incidents
of abuse, neglect, and maltreatment, including sexual assault; and
9)Â Â Â Â Â Â Â Â The
number of times restraints were used.
d)Â Â Â Â Â Â Â Â The
facility shall submit the results of consumer perception of care or quality of
life surveys to the Department, DHS-DMH and HFS at least biannually.
e)Â Â Â Â Â Â Â Â The
facility shall submit to the Williams Lead Defendant Agency an accurate census
of all Medicaid-eligible residents and the previous month’s voluntary and
involuntary discharges conducted under Section 380.220, including any voluntary
discharges and involuntary discharges scheduled within 48 hours of the end of
the reporting month. The monthly census must be submitted on the form
prescribed by the Williams Lead Defendant Agency using secure (encrypted)
email, no later than the fifth business day of each month.