2023 Illinois Compiled Statutes › Chapter 210 - HEALTH FACILITIES AND REGULATION › 210 ILCS 49/ - Specialized Mental Health Rehabilitation Act of 2013. › Article 4 - Licensing and Accreditation

(210 ILCS 49/Art. 4 heading)
ARTICLE 4.
LICENSING AND ACCREDITATION
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/Art. 4 Pt. 1 heading)
PART 1.
LICENSING
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-101)
Sec. 4-101. Licensure system. The Department shall be the sole agency responsible for licensure and shall establish a comprehensive system of licensure for facilities in accordance with this Act for the purpose of:
(1)     protecting the health, welfare, and safety of     consumers; and
(2)    ensuring the accountability for reimbursed     care provided in facilities.
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-102)
Sec. 4-102. Necessity of license. No person may establish, operate, maintain, offer, or advertise a facility within this State unless and until he or she obtains a valid license therefor as hereinafter provided, which license remains unsuspended, unrevoked, and unexpired.  No public official or employee may place any person in, or recommend that any person be in, or directly or indirectly cause any person to be placed in any facility that is being operated without a valid license.  All licenses and licensing procedures established under Article III of the Nursing Home Care Act, except those contained in Section 3-202,  shall be deemed valid under this Act until the Department establishes licensure.  The Department is granted the authority under this Act to establish provisional licensure and licensing procedures under this Act by emergency rule and shall do so within 120 days of the effective date of this Act. The Department shall not grant a provisional license to any facility that does not possess a provisional license on November 30, 2018 and is licensed under the Nursing Home Care Act on or before November 30, 2018.  The Department shall not grant a license to any facility that has not first received a provisional license.  The changes made by this amendatory Act of the 100th General Assembly do not apply to the provisions of subsection (c) of Section 1-101.5 concerning facility closure and relocation.
(Source: P.A. 100-1181, eff. 3-8-19.)
(210 ILCS 49/4-103)
Sec. 4-103. Provisional licensure emergency rules.   The Department, in consultation with the Division of Mental Health of the Department of Human Services and the Department of Healthcare and Family Services, is granted the authority under this Act to establish provisional licensure and licensing procedures by emergency rule.  The Department shall file emergency rules concerning provisional licensure under this Act within 120 days after the effective date of this Act.  Rules governing the provisional license and licensing process shall contain rules for the different levels of care offered by the facilities authorized under this Act and shall address each type of care hereafter enumerated:
(1) triage centers;
(2)   crisis stabilization;
(3)   recovery and rehabilitation supports;
(4) transitional living units; or
(5)  other intensive treatment and stabilization     programs designed and developed in collaboration with the Department.
(Source: P.A. 98-104, eff. 7-22-13; 99-712, eff. 8-5-16.)
(210 ILCS 49/4-104)
Sec. 4-104. Provisional licensure requirements.   Rules governing the provisional license and licensing process shall address, at a minimum, the following provisions:
(1) mandatory community agency linkage;
(2) discharge and transition planning;
(3) non-residential triage centers and stabilization     center requirements;
(4) crisis stabilization;
(5) transitional living units;
(6) recovery and rehabilitation supports;
(7) therapeutic activity and leisure training program;
(8) admission policies;
(9) consumer admission and assessment requirements;
(10) screening and consumer background checks,     consistent with Section 1-114.01, subsections (b) and (c) of Section 2-201.5, and Section 2-201.6 of the Nursing Home Care Act;
(11) consumer records;
(12) informed consent;
(13) individualized treatment plan;
(14) consumer rights and confidentiality;
(15) safeguard of consumer funds;
(16) restraints and therapeutic separation;
(17) employee personnel policies and records;
(18) employee health evaluation;
(19) health care worker background check, consistent     with the Health Care Worker Background Check Act;
(20) required professional job positions;
(21) consultation and training;
(22) quality assessment and performance improvement;
(23) consumer information;
(24)    reporting of unusual occurrences;
(25)   abuse and reporting to local law enforcement;
(26)   fire safety and disaster preparedness;
(27)   required support services, including, but not     limited to, physician, health, pharmaceutical, infection control, dietetic, dental, and environmental;
(28)   enhanced services requests and program     flexibility requests;
(29) participation in a managed care entity, a     coordinated care entity, or an accountable care entity; and
(30) appropriate fines and sanctions associated with     violations of laws, rules, or regulations.
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-104.5)
Sec. 4-104.5. Waiver of compliance. Upon application by a facility, the Director may grant or renew the waiver of the facility's compliance with a rule or standard for a period not to exceed the duration of the current license or, in the case of an application for license renewal, the duration of the renewal period. The waiver may be conditioned upon the facility taking action prescribed by the Director as a measure equivalent to compliance. In determining whether to grant or renew a waiver, the Director shall consider the duration and basis for any current waiver with respect to the same rule or standard and the validity and effect upon patient health and safety of extending it on the same basis, the effect upon the health and safety of consumers, the quality of consumer care, the facility's history of compliance with the rules and standards of this Act and the facility's attempts to comply with the particular rule or standard in question. Upon request by a facility, the Department must evaluate or allow for an evaluation of compliance with the Life Safety Code using the Fire Safety Evaluation System. In determining whether to grant or renew a waiver of a standard pertaining to Chapter 33 of the National Fire Protection Association (NFPA) 101 Life Safety Code, the Director shall use Fire Safety Evaluation Systems in determining whether to grant or renew the waiver. The Department may provide, by rule, for the automatic renewal of waivers concerning physical plant requirements upon the renewal of a license. The Department shall renew waivers relating to physical plant standards issued in accordance with this Section at the time of the indicated reviews, unless it can show why such waivers should not be extended for either of the following reasons:
(1) the condition of the physical plant has     deteriorated or its use substantially changed so that the basis upon which the waiver was issued is materially different; or
(2) the facility is renovated or substantially     remodeled in such a way as to permit compliance with the applicable rules and standards without a substantial increase in cost.
A copy of each waiver application and each waiver granted or renewed shall be on file with the Department and available for public inspection.
No penalty or fine may be assessed for a condition for which the facility has received a variance or waiver of a standard.
Waivers granted to a facility by the Department under any other law shall not be considered by the Department in its determination of a facility's compliance with the requirements of this Act, including, but not limited to, compliance with the Life Safety Code.
(Source: P.A. 100-365, eff. 8-25-17.)
(210 ILCS 49/4-105)
Sec. 4-105. Provisional licensure duration. A provisional license shall be valid upon fulfilling the requirements established by the Department by emergency rule.  The license shall remain valid as long as a facility remains in compliance with the licensure provisions established in rule. Provisional licenses issued upon initial licensure as a specialized mental health rehabilitation facility shall expire at the end of a 3-year period, which commences on the date the provisional license is issued. Issuance of a provisional license for any reason other than initial licensure (including, but not limited to, change of ownership, location, number of beds, or services) shall not extend the maximum 3-year period, at the end of which a facility must be licensed pursuant to Section 4-201. An extension for 120 days may be granted if requested and approved by the Department. Notwithstanding any other provision of this Act or the Specialized Mental Health Rehabilitation Facilities Code, 77 Ill. Adm. Code 380, to the contrary, if a facility has received notice from the Department that its application for provisional licensure to provide recovery and rehabilitation services has been accepted as complete and the facility has attested in writing to the Department that it will comply with the staff training plan approved by the Division of Mental Health, then  a provisional license for recovery and rehabilitation services shall be issued to the facility within 60 days after the Department determines that the facility is in compliance with the requirements of the Life Safety Code in accordance with Section 4-104.5 of this Act.
(Source: P.A. 103-1, eff. 4-27-23; 103-154, eff. 6-30-23.)
(210 ILCS 49/4-106)
Sec. 4-106. Provisional licensure outcomes.   The Department of Healthcare and Family Services, in conjunction with the Division of Mental Health of the Department of Human Services and the Department of Public Health, shall establish a methodology by which financial and clinical data are reported and monitored from each program that is implemented in a facility after the effective date of this Act. The Department of Healthcare and Family Services shall work in concert with a managed care entity, a care coordination entity, or an accountable care entity to gather the data necessary to report and monitor the progress of the services offered under this Act.
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-107)
Sec. 4-107. Provisional licensure period completion.  After the provisional licensure period is completed, no individual with mental illness whose service plan provides for placement in community-based settings shall be housed or offered placement in a facility at public expense unless, after being fully informed, he or she declines the opportunity to receive services in a community-based setting.
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-108)
Sec. 4-108. Surveys and inspections. The Department shall conduct surveys of licensed facilities and their certified programs and services. The Department shall review the records or premises, or both, as it deems appropriate for the purpose of determining compliance with this Act and the rules promulgated under this Act.  The Department shall have access to and may reproduce or photocopy any books, records, and other documents maintained by the facility to the extent necessary to carry out this Act and the rules promulgated under this Act.  The Department shall not divulge or disclose the contents of a record under this Section as otherwise prohibited by this Act.  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 Article.  Refusal to permit such entry or inspection shall constitute grounds for denial, suspension, or revocation of a license under this Act.
(1)    The Department shall conduct surveys to     determine compliance and may conduct surveys to investigate complaints.
(2)    Determination of compliance with the service     requirements shall be based on a survey centered on individuals that sample services being provided.
(3)    Determination of compliance with the general     administrative requirements shall be based on a review of facility records and observation of individuals and staff.
(4) The Department shall conduct surveys of licensed     facilities and their certified programs and services to determine the extent to which these facilities provide high quality interventions, especially evidence-based practices, appropriate to the assessed clinical needs of individuals in the various levels of care. (Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14.)
(210 ILCS 49/4-108.5)
Sec. 4-108.5. Provisional licensure period; surveys. During the provisional licensure period, the Department shall conduct surveys to determine compliance with timetables and benchmarks with a facility's provisional licensure application plan of operation.  Timetables and benchmarks shall be established in rule and shall include, but not be limited to, the following: (1) training of new and existing staff; (2) establishment of a data collection and reporting program for the facility's Quality Assessment and Performance Improvement Program; and (3) compliance with building environment standards beyond compliance with Chapter 33 of the National Fire Protection Association (NFPA) 101 Life Safety Code. Waivers granted by the Department in accordance with Section 4-104.5 of this Act shall be considered by the Department in its determination of the facility's compliance with the Life Safety Code.
During the provisional licensure period, the Department shall conduct State licensure surveys as well as a conformance standard review to determine compliance with timetables and benchmarks associated with the accreditation process. Timetables and benchmarks shall be met in accordance with the preferred accrediting organization conformance standards and recommendations and shall include, but not be limited to, conducting a comprehensive facility self-evaluation in accordance with an established national accreditation program.   The facility shall submit all data reporting and outcomes required by accrediting organization to the Department of Public Health for review to determine progress towards accreditation. Accreditation status shall supplement but not replace the State's licensure surveys of facilities licensed under this Act and their certified programs and services to determine the extent to which these facilities provide high quality interventions, especially evidence-based practices, appropriate to the assessed clinical needs of individuals in the 4 certified levels of care.
Except for incidents involving the potential for harm, serious harm, death, or substantial facility failure to address a serious systemic issue within 60 days, findings of the facility's root cause analysis of problems and the facility's Quality Assessment and Performance Improvement program in accordance with item (22) of Section 4-104 shall not be used as a basis for non-compliance.
The Department shall have the authority to hire licensed practitioners of the healing arts and qualified mental health professionals to consult with and participate in survey and inspection activities.
(Source: P.A. 100-365, eff. 8-25-17.)
(210 ILCS 49/4-109)
Sec. 4-109. License sanctions and revocation.
(a) The Department may revoke a license for any failure to substantially comply with this Act and the rules promulgated under this Act, including, but not limited to, the following:
(1)    fails to correct deficiencies identified as a     result of an on-site survey by the Department and fails to submit a plan of correction within 30 days after receipt of the notice of violation;
(2)    submits false information either on Department     forms, required certifications, plans of correction or during an on-site inspection;
(3)    refuses to permit or participate in a     scheduled or unscheduled survey; or
(4)    willfully violates any rights of individuals     being served.
(b)    The Department may refuse to license or relicense a facility if the owner or authorized representative or licensee has been convicted of a felony related to the provision of healthcare or mental health services, as shown by a certified copy of the court of conviction.
(c)     Facilities, as a result of an on-site survey, shall be recognized according to levels of compliance with standards as set forth in this Act.  Facilities with findings from Level 1 to Level 3 will be considered to be in good standing with the Department.  Findings from Level 3 to Level 5 will result in a notice of violations, a plan of correction and defined sanctions.  Findings resulting in Level 6 will result in a notice of violations and defined sanction.  The levels of compliance are:
(1)    Level 1: Full compliance with this Act and the     rules promulgated under this Act.
(2)    Level 2: Acceptable compliance with this Act     and the rules promulgated under this Act.  No written plan of correction will be required from the licensee.
(3)    Level 3: Partial compliance with this Act and     the rules promulgated under this Act.  An administrative warning is issued.  The licensee shall submit a written plan of correction.
(4)    Level 4: Minimal compliance with this Act and     the rules promulgated under this Act.  The licensee shall submit a written plan of correction, and the Department will issue a probationary license.  A resurvey shall occur within 90 days.
(5)    Level 5: Unsatisfactory compliance with this     Act and the rules promulgated under this Act. The facility shall submit a written plan of correction, and the Department will issue a restricted license.  A resurvey shall occur within 60 days.
(6)    Level 6: Revocation of the license to provide     services. Revocation may occur as a result of a licensee's consistent and repeated failure to take necessary corrective actions to rectify documented violations, or the failure to protect clients from situations that produce an imminent risk.
(d)    Prior to initiating formal action to sanction a license, the Department shall allow the licensee an opportunity to take corrective action to eliminate or ameliorate a violation of this Act except in cases in which the Department determines that emergency action is necessary to protect the public or individual interest, safety, or welfare.
(e)     Subsequent to an on-site survey, the Department shall issue a written notice to the licensee.  The Department shall specify the particular Sections of this Act or the rules promulgated under this Act, if any, with which the facility is not compliant.  The Department's notice shall require any corrective actions be taken within a specified time period as required by this Act.
(f)     Sanctions shall be imposed according to the following definitions:
(1)    Administrative notice: A written notice issued     by the Department that specifies rule violations requiring a written plan of correction with time frames for corrections to be made and a notice that any additional violation of this Act or the rules promulgated under this Act may result in a higher level sanction. (Level 3)
(2)    Probation: Compliance with this Act and the     rules promulgated under this Act is minimally acceptable and necessitates immediate corrective action.  Individuals' life safety or quality of care are not in jeopardy.  The probationary period is time limited to 90 days.  During the probationary period, the facility must make corrective changes sufficient to bring the facility back into good standing with the Department. Failure to make corrective changes within that given time frame may result in a determination to initiate a higher-level sanction.  The admission of new individuals shall be prohibited during the probationary period. (Level 4)
(3)    Restricted license: A licensee is sanctioned     for unsatisfactory compliance.  The admission of new individuals shall be prohibited during the restricted licensure period.  Corrective action sufficient to bring the licensee back into good standing with the Department must be taken within 60 days. During the restricted licensure period a monitor will be assigned to oversee the progress of the facility in taking corrective action.  If corrective actions are not taken, the facility will be subject to a higher-level sanction. (Level 5)
(4)    Revocation: Revocation of the license is     withdrawal by formal actions of the license.  The revocation shall be in effect until such time that the provider submits a re-application and the licensee can demonstrate its ability to operate in good standing with the Department.  The Department has the right not to reinstate a license.  If revocation occurs as a result of imminent risk, all individuals shall be immediately relocated and all funding will be transferred. (Level 6)
(5)    Financial penalty: A financial penalty may be     imposed upon finding of violation in any one or combination of the provisions of this Act.  In determining an appropriate financial penalty, the Department may consider the deterrent effect of the penalty on the organization and on other providers, the nature of the violation, the degree to which the violation resulted in a benefit to the organization or harm to the public, and any other relevant factor to be examined in mitigation or aggravation of the organization's conduct.  The financial penalty may be imposed in conjunction with other sanctions or separately.  Higher level sanctions may be imposed in situations where there are repeat violations.
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-110)
Sec. 4-110. Citation review and appeal procedures.
(a)     Upon receipt of Level 3 to 6 citations, the licensee may provide additional written information and argument disputing the citation with 10 working days.  The Department shall respond within 20 days to the licensee's disputation.
(b)    If a licensee contests the Department's decision regarding a Level 4 to 6 citation or penalty, it can request a hearing by submitting a written request within 20 working days of the Department's dispute resolution decision.  The Department shall notify the licensee of the time and place of the hearing not less than 14 days prior to the hearing date.
(c)     A license may not be denied or revoked unless the licensee is given written notice of the grounds for the Department's action. Except when revocation of a license is based on imminent risk, the facility or program whose license has been revoked may operate and receive reimbursement for services during the period preceding the hearing, until such time as a final decision is made.
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-111)
Sec. 4-111. Notwithstanding the existence or pursuit of any other remedy, the Director of the Department may, in the manner provided by law, upon the advice of the Attorney General who shall represent the Director of the Department in the proceedings, maintain an action in the name of the State for injunction or other process against any person or governmental unit to restrain or prevent the establishment of a facility without a license issued pursuant to this Act, or to restrain or prevent the opening, conduction, operating, or maintaining of a facility without a license issued pursuant to this Act.  In addition, the Director of the Department may, in the manner provided by law, in the name of the People of the State and through the Attorney General who shall represent the Director of the Department in the proceedings, maintain an action for injunction or other relief or process against any licensee or other person to enforce and compel compliance with the provisions of this Act and the standards, rules, and regulations established by virtue of this Act and any order entered for any response action pursuant to this Act and such standards, rules, and regulations.
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/Art. 4 Pt. 2 heading)
PART 2.
ACCREDITATION
(Source: P.A. 98-104, eff. 7-22-13.)
(210 ILCS 49/4-201)
Sec. 4-201. Accreditation and licensure. At the end of the provisional licensure period established in Part 1 of this Article 4, the Department shall license a facility as a specialized mental health rehabilitation facility under this Act that successfully completes and obtains valid national accreditation in behavioral health from a recognized national accreditation entity and complies with licensure standards as established by the Department of Public Health in administrative rule. Rules governing licensure standards shall include, but not be limited to, appropriate fines and sanctions associated with violations of laws or regulations. The following shall be considered to be valid national accreditation in behavioral health from a national accreditation entity:
(1)   the Joint Commission;
(2) the Commission on Accreditation of Rehabilitation     Facilities;
(3)     the Healthcare Facilities Accreditation     Program; or
(4) any other national standards of care as approved     by the Department.
(Source: P.A. 99-712, eff. 8-5-16; 100-201, eff. 8-18-17.)