77 Ill. Adm. Code 380.720
Plan of Operation
Section 380.720Â Plan of Operation
a)Â Â Â Â Â Â Â Â The
license applicant shall submit, with the license application, the plan of
operation, including, but not limited to, the following components of the
facility, respective of the level or levels of service to be provided:
1)Â Â Â Â Â Â Â Â A
proposal of certification for each level of service to be provided by a
facility;
2)Â Â Â Â Â Â Â Â A
summary of administration requirements as specified in Subpart D;
3)Â Â Â Â Â Â Â Â Services
and staffing:
A)Â Â Â Â Â Â Â Clinical
level of service and staffing, as appropriate to each level of service
provided, and pursuant to the respective level of service requirements in
Subpart B;
B)Â Â Â Â Â Â Â Documentation
of the required training for each staffing classification in each level of
service; and
C)Â Â Â Â Â Â Â Any
contractual arrangements;
4)Â Â Â Â Â Â Â Â Admission
process and criteria;
5)Â Â Â Â Â Â Â Â Discharge
planning and transition process;
6)Â Â Â Â Â Â Â Â Network
linkages with community-based behavioral health providers;
7)Â Â Â Â Â Â Â Â Contents
of consumer health and treatment records;
8)Â Â Â Â Â Â Â Â Consumer
rights and empowerment;
9)Â Â Â Â Â Â Â Â Pharmaceutical
services and self-medication program;
10)Â Â Â Â Â Â Â Program
space allocation;
11)Â Â Â Â Â Â Â Restraint
and therapeutic separation policies and procedures;
12)Â Â Â Â Â Â Â Physical
plant or buildings, and fire safety;
13)Â Â Â Â Â Â Â Health
services program;
14)Â Â Â Â Â Â Â Interdisciplinary
treatment teams;
15)Â Â Â Â Â Â Â Psychiatric
and psychological services; and
16)Â Â Â Â Â Â Â Quality
improvement plan.
b)Â Â Â Â Â Â Â Â The
plan of operation shall specify each target population group and service that
the facility plans to offer, as referenced in Subpart A. The description shall
identify:
1)Â Â Â Â Â Â Â Â Eligibility
for services;
2)Â Â Â Â Â Â Â Â The
number of consumers to be served;
3)Â Â Â Â Â Â Â Â An
identification of the particular needs of the population;
4)Â Â Â Â Â Â Â Â How
the facility's respective levels of service are designed to meet the needs of
the population; and
5)Â Â Â Â Â Â Â Â The
method and frequency of evaluating consumer progress.
c)Â Â Â Â Â Â Â Â The
plan of operation shall include a description of how a facility's respective
levels of service meet identified mental health needs in its service area. The
description shall demonstrate what makes the facility's levels of service
innovative compared to existing programs in the service area pursuant to
Section 380.700(i)(9).
d)Â Â Â Â Â Â Â Â The
plan of operation shall specify how a facility expects to obtain accreditation
via achieving the components in subsections (a), (b) and (c) for each year of
provisional licensure. Each provider shall, annually, specify operational
benchmarks toward achieving accreditation status for each year of the
provisional license period, with the correlating documentation for verification
of compliance.
1)Â Â Â Â Â Â Â Â During
the provisional licensure period, the Department will conduct surveys to
determine facility compliance with timetables and benchmarks, and with the
facility's provisional licensure application plan of operation. Timetables and
benchmarks shall comply with the requirements for accreditation by the national
accreditation entities listed in Section 380.730 and shall include, but not be
limited to, the following:
A)Â Â Â Â Â Â Â The
training of new and existing staff;
B)Â Â Â Â Â Â Â The
establishment of a data collection and reporting program for the facility's
QAPI program, pursuant Sections 380.510 and 380.515; and
C)Â Â Â Â Â Â Â Compliance
with NFPA Chapter 33 and with Section 380.670.
2)Â Â Â Â Â Â Â Â As
part of the surveys required in subsection (d)(1), the Department will conduct
reviews to determine compliance with timetables and benchmarks associated with
the accreditation process. Facilities shall meet timetables and benchmarks in
accordance with a facility's preferred accrediting entity's conformance
standard and recommendations to include, but not be limited to, a comprehensive
facility self-evaluation in accordance with one of the established national
accreditation programs listed in Section 380.730.
3)Â Â Â Â Â Â Â Â Facilities
shall submit all reporting and outcome data required by their preferred
accrediting entity to the Department upon request.
4)Â Â Â Â Â Â Â Â Except
for incidents involving the potential for serious harm as described in Section
380.750(c)(5), or death, or a facility's consistent and repeated failure to
take necessary corrective actions as described in Section 380.750(c)(6) within
60 days, findings in the facility's root cause analysis and the facility's QAPI
program in accordance with Section 4-104(22) of the Act and Section 380.510
shall not be used as a basis for non-compliance.