Ill. Admin. Code tit. 77, § 2060.315 - Service Termination/Record Retention
a) DHS/SUPR shall be notified in writing at
least 30 calendar days prior to the date on which cessation of any licensed
service is scheduled to occur. If involuntary termination occurs due to
inability to operate (damage to facility, loss of staff, change in management,
corporate dissolution, or any other cause) the organization shall notify
DHS/SUPR in writing immediately upon termination.
b) Upon voluntary cessation of services, all
current clients/patients/residents shall be notified in advance and referrals
for continuation of services shall be made to other DHS/SUPR licensed
organizations. If cessation of services is involuntary,
clients/patients/residents shall be notified as soon as possible and given
referrals to other licensed organizations.
c) Upon cessation of services at any licensed
location, DHS/SUPR shall schedule an inspection to ensure that any controlled
substance inventory is transferred or destroyed in accordance with the U.S.
Drug Enforcement Administration (DEA) requirements in 42 CFR 1307 and 1317
through 1395 (2014), as applicable.
d) When an organization ceases operation of
any service at any location, all patient/client/resident records, relative to
that service, shall be maintained as follows:
1) If the organization has a current license
issued by DHS/SUPR for any other treatment or intervention service, the
organization may maintain the records from the service that has ceased
operation.
2) If the organization
has no other current license for any other treatment or intervention service,
all records shall be transferred for maintenance and storage to an DHS/SUPR
licensed organization providing a treatment or intervention service. Records
from closed hospital-based programs or medical practices can be maintained at
that facility.
e) Each
client/patient/resident, who has received services within the past six years,
shall be notified of service cessation via personal mail and email. If personal
mail or e-mail is not available, they shall be notified by public posting, or
media publication regarding the location where records will be maintained and
stored within 10 calendar days after cessation of service. DHS/SUPR shall also
be notified within 10 calendar days after cessation regarding record location
and any applicable contact information necessary to verify record
transfer.
f) Such records shall be
stored and maintained for a period of six years from the date of creation or
the date when last in effect, whichever is later.
g) Upon cessation of operations, the license
shall automatically become null and void and all documentation of licensure
shall be immediately surrendered to DHS/SUPR if the license has not reached its
expiration date.
Notes
Amended at 25 Ill. Reg. 11063, effective August 14, 2001
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a) The licensee shall design and utilize a quality improvement plan. Such plan shall be written and shall contain, at a minimum, a method of evaluation to assess achievement of the organization's mission and the functioning of the organization and its service delivery systems and utilization review process.
b) The quality improvement plan shall be approved by management or, if applicable, the board of directors of the organization and annually reviewed and revised as necessary.
c) The evaluation shall contain, at a minimum:
1) a mission statement for the organization;
2) specific and measurable goals, objectives, activities and outcome standards that are utilized by the organization to achieve its missions and projected results;
3) a description of how the organization will review and implement needed changes based on the results of the evaluation;
4) a method to review use of medication in any level of care;
5) a method of risk management that, at a minimum, includes:
A) review and analysis of any incident or significant incident reports as referenced in Section 2060.331 of this Part; and
B) design and implementation of necessary procedures to address both proactively and reactively any identified risks; and
6) a method of utilization review to measure appropriate patient placement.
d) The method of organization evaluation shall be submitted with the application for licensure. The results of the evaluation shall also be available for inspection by the Department and submitted at the time of application for renewal of licensure.
e) Utilization Review
1) For treatment licensees, utilization review shall be conducted at least quarterly and shall be conducted on a minimum 15% sample. If random sampling at 15% indicates problems, the organization will develop a specific remediation plan to correct the identified problems. Utilization review shall be conducted in accordance with continued stay and discharge criteria as established in the ASAM Patient Placement Criteria.
2) For DUI evaluation or designated program intervention licensees, utilization review shall:
A) be conducted at least quarterly on randomly selected cases consisting of at least 15% (but no less than five and no more than 20) of persons receiving each service; and
B) be based on the established criteria specified in this Part for the applicable category of intervention license relative to the substance abuse assessment or evaluation and subsequent intervention or referral.
f) All organizations required to conduct utilization review shall also:
1) specify all staff participating in utilization review;
2) specify how conflict of interest shall be addressed in any small organization where professional staff cannot always avoid reviewing their own cases; and
3) issue a report of finding from utilization review at least quarterly and make such report available to all professional staff.
g) Treatment licensees who are not otherwise required to report data electronically to the Department shall maintain statistics that, at a minimum, determine the total number of assessments, admissions, and discharges per patient by type of discharge and the average length of stay in each level of care.
h) DUI risk education services shall not be subject to utilization review as specified in subsection (e).
i) All treatment and intervention licensees shall develop and maintain a written policy and procedures manual that describes the operation of the organization. At a minimum, the manual shall explain how the organization will comply with all federal and State regulatory and contractual requirements, any additional requirements from independent accrediting bodies, and any other organizational policies and procedures. The manual shall be approved by the board of directors of the organization or, if not applicable, the organization representative and annually reviewed and revised as necessary. The manual shall be submitted to the Department at the time of licensure and upon request from Department staff. The manual shall also be reviewed during the first year of employment by all staff. Annually thereafter, the organization shall ensure that all staff shall review updated sections pertinent to such staff.
Notes
Amended at 25 Ill. Reg. 11063, effective August 14, 2001