Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 380 - SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE › Subpart D - ADMINISTRATION › Section 380.500 - Required Policies and Procedures

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				licensee shall be responsible for compliance with licensing requirements and
				for the organization, management, operation and control of the facility. The
				delegation of any authority by the licensee shall not diminish the
				responsibilities of the licensee.
b)
A facility shall establish written
				policies and procedures to implement the responsibilities and rights provided
				under
the Act and this Part.
The policies shall include the
				procedure for the investigation and resolution of consumer complaints. The
				policies and procedures shall be clear and unambiguous and shall be available
				for inspection by any person. A summary of the policies and procedures, printed
				in not less than 12-point font, shall be distributed to each consumer and
				representative
. (Section 3-208 of the Act) Written policies and
				procedures also shall be established and implemented for each of the following:
1) The administration and management of the
				facility;
2) Personnel policies and
				procedures, which shall include:
A) Job
				descriptions detailing qualifications and essential duties of each
				classification of employee, available to all personnel;
B) Employee orientation to the facility, job,
				consumer population, policies, procedures and staff;
C) Employee benefits;
D) Employee health and grooming;
				and
E) Verification of licensure,
				credentials, certification, education, training and references;
3) Policies and procedures for
				consumer admission, transfer, day passes and weekend passes, discharge and
				other care transitions; charge for services included in the basic rate; charges
				for other services and causes for termination of services. The facility shall
				comply with the rules of the State-designated assessment and authorization
				entity;
4) Policies and procedures
				governing consumer records, including, but not limited to:
A) Access to, duplication of, and
				dissemination of information from consumer records, with a specific policy and
				procedure for sharing information with behavioral health providers and
				consumers pursuant to applicable federal and State laws; and
B) Ensuring confidentiality of consumer
				information, pursuant to applicable federal and State laws and this
				Part;
5) Policies and
				procedures for reporting incidents and accidents, the abuse and neglect of
				consumers, and the theft of consumers' property and other data as required in
				Section
				380.530;
6) A written organizational chart showing
				each program, the person in charge of each program, the lines of authority,
				including responsibility and communication, and the staff assignments,
				including information on the governing structure;
7) Policies concerning the use of restraints
				only with informed consent, and other restraint and therapeutic separation
				policies and procedures pursuant to the Act and to Section
				380.160;
8) Policies concerning the administration of
				psychotropic medication only with informed consent, and other informed consent
				to medical and psychiatric treatment policies and procedures pursuant to the
				requirements in Section
				380.150 of this
				Part and Section 3-106(b) of the Act;
9) Policies and procedures to ensure that
				experimental research and treatment on consumers is conducted only in
				accordance with the oversight of an Institutional Review Board, pursuant to the
				requirements in Section
				380.580;
10) Dietary services, policies and
				procedures; and
11) Environmental
				services policies and procedures, including provision for the housekeeping and
				maintenance of a safe, clean environment for consumers, employees and the
				public.