77 Ill. Adm. Code 390.200
Inspections, Surveys, Evaluations and Consultation
Section 390
Section 390.200Â Inspections,
Surveys, Evaluations and Consultation
a)Â Â Â Â Â Â Â Â The terms survey, inspection, and evaluation are synonymous.Â
These terms refer to the overall examination of compliance with the Act and
this Part.
1)Â Â Â Â Â Â Â Â All facilities to which this Part applies shall be subject to
and shall be deemed to have given consent to annual inspections, surveys, or
evaluations by properly identified personnel of the Department, or by other
properly identified persons, including local health department staff, as the
Department may designate.
2)
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.
Submission of a facility's current Consumer Choice
Information Report required by Section 2-214 of
the Act
shall be
verified at the time of inspection.
(Section 3-212(a) of the Act)
3)Â Â Â Â Â Â Â Â The licensee, or person representing the licensee in the
facility, shall provide access and entry to the premises or facility for
obtaining information required to carry out the Act and this Part. In addition,
the Department
shall have access to and may reproduce or photocopy at
its
cost any books, records, and other documents maintained by the
facility,
the licensee or their representatives
to the extent necessary
to carry out
the
Act
and this Part. (Section 3-213 of the Act)
4)Â Â Â Â Â Â Â Â A facility may charge the Department for photocopying at a
rate determined by the facility not to exceed the rate in Access to Records of
the Department of Public Health (2 Ill. Adm. Code 1127).
5)Â Â Â Â Â Â Â Â A
facility shall complete a Consumer Choice Information
Report and shall file it with the Office of State Long Term Care Ombudsman
electronically as prescribed by the Office. The Report shall be filed annually
and upon request by the Office of State Long Term Care Ombudsman.
This
report shall
be completed by the facility in full.
(Section 2-214(a) of
the Act)
b)
No person shall
:
1)
Intentionally prevent, interfere with, or attempt to impede
in any way any duly authorized investigation and enforcement of
the
Act
or
this Part;
2)
Intentionally prevent or attempt to prevent any examination
of any relevant books or records pertinent to investigations and enforcement of
the
Act
or this Part;
3)
Intentionally prevent or interfere with the preservation of
evidence pertaining to any violation of this Act or the rules promulgated under
the
Act
or this Part;
4)
Intentionally retaliate or discriminate against any
resident or employee for contacting or providing information to any state
official, or for initiating, participating in, or testifying in an action for
any remedy authorized under
the
Act
or this Part. (Section 3-318(a)
of the Act)
c)
A violation of
subsection (b)
is a business offense,
punishable by a fine not to exceed $10,000, except as otherwise provided in
subsection (2) of Section 3-103
of the Act and Section 390.120(c)
as to
submission of false or misleading information in a license application.
(Section 3-318(b) of the Act)
d)
In determining whether to make
more than the
required number of
unannounced
inspections, surveys and
evaluations of a facility, the Department shall
consider one or more of
the following:
1)
Previous inspection reports;
2)
The facility's history of compliance with
the Act and
this Part,
and correction of violations, penalties or other enforcement
actions
;
3)
The
number and severity of
complaints
received
about the facility;
4)
Any
allegations of resident abuse or neglect;
5)
Weather conditions;
6)
Health emergencies;
7)
Other reasonable belief that deficiencies
exist;
(Section 3-212(b) of the Act) and
8)Â Â Â Â Â Â Â Â Requirements pursuant to the "1864 Agreement" (42 U.S.C.
1395aa) between the Department and the U.S. Department of Health and Human
Services (HHS) (e.g., annual and follow-up certification inspections, life
safety code inspections and any inspections requested by the Secretary of HHS).
e)
The Department shall not be required to determine whether a
facility certified to participate in the Medicare program under Title XVIII of
the Social Security Act, or the Medicaid Program under Title XIX of the Social
Security Act, and which the Department determines by inspection to be in
compliance with the certification requirements of Title XVIII or XIX, is in
compliance with any requirement of
the
Act
and this Part
that is
less stringent than or duplicates a federal certification requirement.
(Section 3-212(b-1) of the Act)
f)
The Department shall,
in accordance with Section
3-212(a) of the Act,
determine whether a certified facility is in compliance
with requirements of the Act that exceed federal certification requirements.
(Section 3-212(b-1) of the Act)
g)
If a certified facility is found to be out of compliance
with federal certification requirements, the results of the inspection
conducted pursuant to Title XVIII or XIX of the Social Security Act
(Section 3-212 (b-1) of the Act) shall be reviewed to determine which, if any,
of the results shall be considered licensure findings, as follows:
1)Â Â Â Â Â Â Â Â The result identifies potential violations of the MC/DD Act
and this Part; and
2)Â Â Â Â Â Â Â Â The result, based on available information, would likely
represent a Type "AA", a Type "A", or a Type "B"
violation if tested against the factors described in Sections 390.272 and
390.274.
h)Â Â Â Â Â Â Â Â All results of an inspection conducted pursuant to Title XVIII
or XIX of the Social Security Act that the Department considers licensure
findings shall be provided to the facility at the time of exit or by mail in
accordance with subsection (i).
i)
Upon the completion of each inspection, survey, and
evaluation, the
appropriate
Department
personnel
who
conducted the inspection, survey, or evaluation shall submit a copy of their
report to the licensee
or the licensee's representative
upon exiting the
facility
or upon considering results of an inspection conducted pursuant to
Title XVIII or XIX of the Social Security Act as licensure findings. A copy of
the information gathered during a complaint investigation will not be provided
upon exiting the facility.
Comments or documentation provided by the
licensee, which may refute findings in the report, which explain extenuating
circumstances that the facility could not reasonably have prevented, or which
indicate methods and timetables for correction of deficiencies described in the
report shall be provided to the Department within 10 days of receipt of the
copy of the report.
(Section 3-212(c) of the Act)
j)Â Â Â Â Â Â Â Â Â Consultation consists of providing advice or suggestions to
the staff of a facility at their request relative to specific matters of the
scope of regulation, methods of compliance with the Act or this Part, or
general matters of patient care. A request for consultation by a facility or
facility staff does not obligate Department personnel to provide consultation.Â
A facility that requests and obtains consultation from the Department retains
legal responsibility for compliance with the Act and this Part.