Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 380 - SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE › Subpart A - GENERAL PROVISIONS › Section 380.100 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
Act - the Specialized Mental Health Rehabilitation Act of
				  2013.
Activities of daily living or ADL - a consumer's abilities to
				  bathe, dress and groom; transfer and ambulate; use the toilet; eat; and use
				  speech, language or other functional communication systems.
Abuse - any physical or mental injury or sexual
				  assault inflicted on a consumer other than by accidental means in a
				  facility.
(Section 1-102 of the Act)
Physical abuse means the infliction of injury or threat of
				  injury by a consumer upon himself or herself, or by another consumer, a staff
				  or a visitor on a consumer, that occurs other than by accidental means.
Verbal abuse means the use of demeaning, intimidating or
				  threatening words, written or oral, or gestures, by another consumer, a staff
				  or a visitor about, or toward, a consumer and in the presence of another
				  person.
Accreditation
- recognition by
any
				  of the following
that a program meets their nationally-recognized
				  standards of behavioral health care:
the Joint Commission
;
the Commission on Accreditation of Rehabilitation
				  Facilities
;
the Healthcare Facilities Accreditation
				  Program
;
or
any other national standards of care as approved by
				  the Department
. (Section 1-102 of the Act)
Active treatment - treatment that addresses an acute crisis
				  in a consumer and that facilitates a return to a community setting. Active
				  treatment includes, but is not limited to, therapy, family meetings, group
				  sessions and assessment.
Agent - a representative of a facility who is an owner,
				  licensee, executive director or employee.
Ambulatory - the ability to move from place to place
				  independent of staff assistance. A consumer may use assistive devices, such as
				  a cane, walker or wheelchair, and still be considered ambulatory, provided that
				  the consumer is able to move and transfer independently on a regular basis. A
				  consumer who needs temporary time-limited assistance, such as after surgery or
				  a medical illness, is also still considered ambulatory.
Applicant - any person making application for a
				  license or a provisional license under
the
Act
and
				  this Part
.
(Section 1-102 of the Act)
Assessment - a comprehensive clinical evaluation to determine
				  the strengths, preferences, clinical status, including the level of
				  functioning, and the clinical needs of a consumer. The assessment may also
				  fulfill the requirements of federal law or State consent decrees for assessment
				  or mental health preadmission screening and resident review prior to admission,
				  or resident reviews during treatment. The assessment shall be conducted by a
				  Licensed Practitioner of the Healing Arts and shall:
Determine the individualized intervention strategies that
				  will assist the consumer in advancing in his or her recovery;
Determine what supports are needed for the individual to live
				  in community-based settings; and
Determine the appropriate level of care for service
				  delivery.
Authorization - a determination of the level of treatment
				  services that best suits the clinical needs of the consumer.
Authorized representative - a person other than an owner,
				  agent or employee of a facility designated in writing by a consumer to be his
				  or her representative. A consumer may designate his or her guardian as an
				  authorized representative.
Biopsychosocial approach - a model for the treatment of
				  persons with mental illness that acknowledges the biological, psychological and
				  social influences on a person's psyche, relying on multiple disciplines for the
				  treatment and rehabilitation of persons with mental illness.
Certified Recovery Support Specialist or CRSS - an individual
				  who is certified and in good standing as a Recovery Support Specialist by the
				  Illinois Alcohol and Other Drug Abuse Professional Certification Association. A
				  CRSS, at a minimum, shall function as a mental health professional.
Community-based behavioral health services - services
				  provided to a consumer, e.g., by a community-based behavioral health provider,
				  while living in his or her own home or in a group living situation of 16 or
				  fewer beds. The services are designed to assist consumers in achieving
				  rehabilitative, resiliency and recovery goals in the least restrictive natural
				  settings possible. The services consist of interventions that facilitate
				  illness self-management, identification and use of adaptive and compensatory
				  strategies, skills-building, and the identification and use of natural supports
				  and community resources.
Consumer - a person, 18 years of age or older,
				  admitted to a
specialized
mental health rehabilitation
				  facility for evaluation, observation, diagnosis, treatment, stabilization,
				  recovery, and rehabilitation. "Consumer" does not mean any of the
				  following
:
an individual requiring a locked
				  setting;
an individual requiring psychiatric hospitalization
				  because of an acute psychiatric crisis;
an individual under 18 years of age;
an individual who is actively suicidal or violent
				  toward others;
an individual who has been found unfit to stand
				  trial;
an individual who has been found not guilty by reason
				  of insanity based on committing a violent act, such as sexual assault, assault
				  with a deadly weapon, arson, or murder;
an individual subject to temporary detention and
				  examination under Section 3-607 of the Mental Health and Developmental
				  Disabilities Code;
an individual deemed clinically appropriate for
				  inpatient admission in a
State
psychiatric hospital;
				  and
an individual transferred by the Department of
				  Corrections pursuant to Section 3-8-5 of the Unified Code of
				  Corrections
. (Section 1-102 of the Act)
Consumer record - a record that organizes all
				  information on the care, treatment, and rehabilitation services rendered to a
				  consumer in a specialized mental health rehabilitation facility
.
				  (Section 1-102 of the Act)
Controlled drugs - those drugs covered under the
				  federal Comprehensive Drug Abuse Prevention Control Act of 1970, as amended, or
				  the Illinois Controlled Substances Act.
(Section 1-102 of the
				  Act)
Crisis stabilization - a secure and separate unit
				  that provides short-term behavioral, emotional, or psychiatric crisis
				  stabilization as an alternative to hospitalization or re-hospitalization for
				  consumers from residential or community placement.
(Section 1-102 of
				  the Act)
Debrief - a meeting with a consumer and facility staff
				  following a period of restraint, holding or therapeutic separation in which the
				  impact of the intervention is assessed from a perspective of emotional impact,
				  outcome and possible alternatives to the use of restraint.
Department - the Department of Public
				  Health.
(Section 1-102 of the Act)
DHS - the Illinois Department of Human Services
DHS-DMH - the Illinois Department of Human Services-Division
				  of Mental Health
Dietetic Service Supervisor - a person who:
is a dietitian; or
is a graduate of a dietetic technician or dietetic assistant
				  training program, corresponding or classroom, approved by the American Dietetic
				  Association; or
is a graduate, prior to July 1, 1990, of a
				  Department-approved course that provided 90 or more hours of classroom
				  instruction in food service supervision and has had experience as a supervisor
				  in a health care institution that included consultation from a dietitian;
				  or
has successfully completed a Dietary Manager's Association
				  approved dietary manager course; or
is certified as a dietary manager by the Dietary Manager's
				  Association; or
has training and experience in food service supervision and
				  management in a military service equivalent in content to the programs in the
				  second, third or fourth paragraph of this definition.
Dietitian - a person licensed as a dietitian under the
				  Dietitian Nutritionist Practice Act.
Director - the Director of the Department of Public Health or
				  his or her designee.
Discharge - the full release of any consumer from a
				  facility.
(Section 1-102 of the Act)
Drug administration - the act in which a single dose
				  of a prescribed drug or biological is given to a consumer. The complete act of
				  administration entails removing an individual dose from a container, verifying
				  the dose with the prescriber's orders, giving the individual dose to the
				  consumer, and promptly recording the time and dose given.
(Section
				  1-102 of the Act)
Drug dispensing - the act entailing the following of
				  a prescription order for a drug or biological and proper selection, measuring,
				  packaging, labeling, and issuance of the drug or biological to a
				  consumer.
(Section 1-102 of the Act)
DSP - the Department of State Police.
Dual diagnosis - the condition of experiencing a mental
				  illness and a comorbid substance abuse problem.
Emergency - a situation, physical condition, or one
				  or more practices, methods, or operations
that
present
				  imminent danger of death or serious physical or mental harm to consumers of a
				  facility.
(Section 1-102 of the Act)
Evidence-based practice - the conscientious use of current
				  evidence in making decisions about the care of the individual consumer,
				  integrating individual clinical expertise with available external clinical
				  evidence from systematic research.
Executive director - a person who is charged with the
				  general administration and supervision of a facility licensed under
the
Act
and this Part. (Section 1-102 of the Act)
Face check - visual confirmation by a staff person to ensure
				  the consumer's safety and well-being, to be performed at intervals as
				  determined by the individualized treatment plan of the consumer.
Facility - a specialized mental health rehabilitation
				  facility
(SMHRF)
that provides at least one of the following
				  services: triage center; crisis stabilization; recovery and rehabilitation
				  supports; or transitional living units for 3 or more persons. The facility
				  shall provide a 24-hour program that provides intensive support and recovery
				  services designed to assist persons, 18 years or older, with mental disorders
				  to develop the skills to become self-sufficient and capable of increasing
				  levels of independent functioning. It includes facilities that meet the
				  following criteria
:
100% of the consumer population of the facility has a
				  diagnosis of serious mental illness
;
no more than 15% of the consumer population of the
				  facility is 65 years of age or older
;
none of the consumers are
				  non-ambulatory
;
none of the consumers have a primary diagnosis of
				  moderate, severe, or profound intellectual disability
;
and
the facility must have been licensed under the
				  Specialized Mental Health Rehabilitation Act or the Nursing Home Care Act
				  immediately preceding the effective date of
the
Act and
				  qualifies as an institute for mental disease under the federal definition of
				  the term
.
"Facility" does not include the
				  following
:
a home, institution, or place operated by the federal
				  government or agency
of the federal government
, or by the
				  State of Illinois
;
a hospital, sanitarium, or other institution whose
				  principal activity or business is the diagnosis, care, and treatment of human
				  illness through the maintenance and operation as organized facilities
for the treatment of mental illness that
is required to be licensed
				  under the Hospital Licensing Act
;
a facility for child care as defined in the Child
				  Care Act of 1969
;
a community living facility as defined in the
				  Community Living Facilities Licensing Act
;
a nursing home or sanatorium operated solely by and
				  for persons who rely exclusively upon treatment by spiritual means through
				  prayer, in accordance with the creed or tenets of any well-recognized church or
				  religious denomination; however,
the
nursing home or
				  sanatorium shall comply with all local laws and rules relating to sanitation
				  and safety
;
a facility licensed by the Department of Human
				  Services as a community-integrated living arrangement as defined in the
				  Community-Integrated Living Arrangements Licensure and Certification
				  Act
;
a supportive residence licensed under the Supportive
				  Residences Licensing Act
;
a supportive living facility in good standing with
				  the program established under Section 5-5.01a of the Illinois Public Aid Code,
				  except only for purposes of the employment of persons in accordance with
				  Section 3-206.01 of the Nursing Home Care Act
;
an assisted living or shared housing establishment
				  licensed under the Assisted Living and Shared Housing Act, except only for
				  purposes of the employment of persons in accordance with Section 3-206.01 of
				  the Nursing Home Care Act
;
an Alzheimer's disease management center alternative
				  health care model licensed under the Alternative Health Care Delivery
				  Act
;
a home, institution, or other place operated by or
				  under the authority of the Illinois Department of Veterans'
				  Affairs
;
a facility licensed under the ID/DD Community Care
				  Act
;
or
a facility licensed under the Nursing Home Care Act
				  after
July 22, 2013 (Section 1-102 of the Act)
Findings of root cause analysis - the conclusions of a
				  facility's root cause analysis that summarize how the incident, accident or
				  violation happened and reasons for the incident, accident or violation.
				  Reportable findings do not include investigatory notes, data, staff interviews
				  and other unrelated documentation that led to the conclusions of the root cause
				  analysis.
Governing body - the persons responsible for the overall
				  leadership, oversight and administration of a specialized mental health
				  rehabilitation facility
Guardian - a person appointed as a guardian of the
				  person or guardian of the estate, or both, of a consumer under the Probate Act
				  of 1975.
(Section 1-102 of the Act)
Identified Offender - a person who
:
Has been convicted of, found guilty of, adjudicated
				  delinquent for, found not guilty by reason of insanity for, or found unfit to
				  stand trial for, any felony offense listed in Section 25 of the Health Care
				  Worker Background Check Act, except for the following: a felony offense
				  described in Section 10-5 of the Nurse Practice Act; a felony offense described
				  in Section 5, 5.1, 5.2, 7, or 9 of the Cannabis Control Act; a felony offense
				  described in Section 401,
				  401.1, 404,
				  405,
				  405.1, 407, or
				  407.1 of the
				  Illinois Controlled Substances Act; and a felony offense described in the
				  Methamphetamine Control and Community Protection Act
; or
Has been convicted of, adjudicated delinquent for,
				  found not guilty by reason of insanity for, or found unfit to stand trial for,
				  any sex offense as defined in Section 10(c) of the Sex Offender Management
				  Board Act.
(Section 1-102 of the Act)
Illness Management and Recovery or IMR - an evidence-based
				  practice aimed at assisting individuals with mental illnesses in learning to
				  manage the symptoms of the illness to reduce interference with pursuit of
				  personal goals.
Individualized Treatment Plan or Treatment Plan or ITP - a
				  written compilation of the consumer's goals; the anticipated outcomes of
				  services; the intermediate objectives to achieve the goals; the specific SMHRF
				  services to be provided to the consumer; the amount, frequency and duration of
				  the services; and the staff responsible for providing the services.
Institute for Mental Disease or IMD - facilities that are
				  federally designated as institutes for mental diseases and that will be
				  licensed as specialized mental health rehabilitation facilities under the Act
				  and this Part, subject to the provisions in Section 1-101.5 of the Act.
Instrumental activities of daily living or IADL - activities
				  to support daily life within the home and community that require more complex
				  interactions than the self-care in ADLs, including, but not limited to,
				  communication, community mobility, health management, home management, meal
				  preparation and clean up, safety and emergency management, shopping and money
				  management.
Interdisciplinary Team or IDT - a group of persons,
				  representing those professions, disciplines or service areas that are relevant
				  to identifying a consumer's strengths, preferences and needs, that designs a
				  program to meet those needs.
Lead Defendant Agency - State of Illinois Agency named in
				  each fiscal year's Implementation Plan as the lead agency for the Williams and
				  Colbert Consent Decrees on behalf of the Defendants. For the purposes of this
				  definition, "Implementation Plan" refers to the plan set forth in the Consent
				  Decree, created and implemented by the Defendants, with the input of the
				  Monitor and Plaintiffs, to accomplish the obligations and objectives set forth
				  in the Decree.
Licensed Practitioner of the Healing Arts or LPHA - shall
				  have the meaning ascribed to it in the DHS-DMH rule Medicaid Community Mental
				  Health Services Program.
Licensed Practical Nurse - a person with a valid Illinois
				  license to practice as a practical nurse under the Nurse Practice Act.
Licensee - the person, persons, firm, partnership,
				  association, organization, company, corporation, or business trust to which a
				  license has been issued.
(Section 1-102 of the Act)
Linkage - A partnership between a facility and a
				  community-based behavioral health provider that includes the community-based
				  behavioral health provider from the time of a consumer's admission into a
				  facility (in crisis stabilization, transitional living units, and recovery and
				  rehabilitation supports), or as soon as possible following admission, in
				  developing and implementing the consumer's individualized treatment plan for
				  effective care coordination and transitioning the consumer to independent
				  living in the community, or to the least restrictive setting of the consumer's
				  choice. Linkage includes a face-to-face meeting between the consumer and the
				  community-based behavioral health provider with which he or she is linked prior
				  to discharge, except for consumers in the 23-hour triage center.
Mental Health Preadmission Screening and Resident Review or
				  MH PASRR - a comprehensive review conducted under the auspices of DHS-DMH prior
				  to the admission of a consumer with serious mental illness, at the end of 90
				  days following admission, at the end of six months, and then annually.
Mental Health Professional or MHP - shall have the meaning
				  ascribed to it in the DHS-DMH rule the Medicaid Community Mental Health
				  Services Program.
Misappropriation of a consumer's property - the
				  deliberate misplacement, exploitation, or wrongful temporary or permanent use
				  of a consumer's belongings or money without the consent of a consumer or his or
				  her guardian.
(Section 1-102 of the Act)
Neglect - a facility's failure to provide, or willful
				  withholding of, adequate medical care, mental health treatment, psychiatric
				  rehabilitation, personal care, or assistance that is necessary to avoid
				  physical harm and mental anguish of a consumer.
(Section 1-102 of the
				  Act)
On site - in a facility and in a particular level of service
				  within a facility.
Performance Improvement Project or PIP - an effort by a
				  facility to address a specific violation or problem, either in one service area
				  of a facility, or facility-wide. PIPs require a systematic gathering of
				  information to clarify issues and problems to improve the delivery of care to
				  consumers.
Person-centered care - an approach to mental health treatment
				  that involves collaboration between the consumer, treatment providers, and
				  other supporters of the individual, including the consumer's guardian and
				  substitute decision maker, and is focused on the goals the consumer has
				  identified for recovery in his or her treatment plan. Person centered care
				  focuses on building upon the strengths and resources of the consumer to achieve
				  recovery goals. Roles are defined for the consumer, the treatment providers,
				  and other supporters to assist in reaching these goals.
Personal care
or Activities of daily living
				  or ADL
- assistance with meals, dressing, movement, bathing, or other
				  personal needs, maintenance, or general supervision and oversight of the
				  physical and mental well-being of an individual who is incapable of maintaining
				  a private, independent residence or who is incapable of managing his or her
				  person, whether or not a guardian has been appointed for
the
individual. "Personal care" shall not be construed to confine or
				  otherwise constrain a facility's pursuit to develop the skills and abilities of
				  a consumer to become self-sufficient and capable of increasing levels of
				  independent functioning.
(Section 1-102 of the Act)
Psychiatric Medical Director - a physician who is licensed
				  under the Medical Practice Act of 1987 and who is board eligible or board
				  certified in psychiatry by the American Board of Psychiatry and
				  Neurology.
Psychotropic medication - medications used for antipsychotic,
				  antidepressant, anti-manic, anti-anxiety, or behavior modification, for
				  behavioral management purposes as listed in the American Medical Association
				  Drug Evaluation and the Physicians' Desk Reference.
Qualified Mental Health Professional or QMHP - shall have the
				  meaning ascribed to it in the DHS-DMH rule Medicaid Community Mental Health
				  Services Program.
Recovery and rehabilitation supports or
RRS
- a
unit with a
program that facilitates a consumer's
				  longer-term symptom management and stabilization while preparing the consumer
				  for transitional living units
or transition to the community
by improving living skills and community socialization.
(Section 1-102 of the Act)
Recovery - the process in which persons are able to live,
				  work, learn and participate fully in their communities. For some persons,
				  recovery is the ability to live a fulfilling and productive life despite a
				  disability. For others, recovery implies the reduction or complete remission of
				  symptoms.
Registered Nurse - a person with a license to practice as a
				  registered professional nurse under the Nurse Practice Act.
Rehabilitation Services Associate (RSA) - shall have the
				  meaning ascribed to it in the DHS-DMH rule Medicaid Community Mental Health
				  Services Program.
Restorative care - care that is designed to facilitate the
				  consumer's recovery and re-entry into the community.
Restraint
-
a physical restraint that is any manual method or
				  physical or mechanical device, material, or equipment attached or adjacent to a
				  consumer's body that the consumer cannot remove easily and restricts freedom of
				  movement or normal access to one's body; devices used for positioning,
				  including, but not limited to, bed rails, gait belts, and cushions, shall not
				  be considered to be restraints for purposes of this
Part
. For
				  the purposes of
the
Act
and this Part,
restraint shall be administered only after utilizing a coercive-free
				  environment and culture; or
a chemical restraint that is any drug used for
				  discipline or convenience and not required to treat medical symptoms
.
				  (Section 1-102 of the Act)
Root cause - a fundamental reason or reasons for an incident,
				  accident or violation, without which the incident, accident or violation would
				  not have occurred.
Root cause analysis - the process for determining how an
				  incident, accident or violation occurred.
Self-administration of medication - means
that
consumers shall be responsible for the control, management, and
				  use of
their
own medication.
(Section 1-102 of the
				  Act)
Serious mental illness - as used in this Part, any of the
				  following diagnoses:
DSM-5 diagnosis of a psychotic disorder, excluding those
				  caused by a general medical condition or substance use when of moderate or
				  severe intensity and associated with moderate or severe functional impairment
				  of a greater than 90-day duration.
DSM-5 diagnosis of bipolar or related disorder, excluding
				  those caused by a general medical condition or substance use, when of moderate
				  or severe intensity and associated with moderate to severe functional
				  impairment of a greater than 90-day duration.
DSM-5 diagnosis of a depressive disorder, excluding those
				  caused by a general medical condition or substance use, when of moderate or
				  severe intensity and associated with severe functional impairment of a greater
				  than 90-day duration.
DSM-5 diagnosis of borderline personality disorder associated
				  with moderate to severe functional impairment of a greater than 90-day
				  duration.
DSM-5 diagnosis of post-traumatic stress disorder associated
				  with moderate to severe functional impairment of a greater than 90-day
				  duration.
DSM-5 diagnosis of obsessive compulsive disorder associated
				  with moderate to severe functional impairment of a greater than 90-day
				  duration.
State Authorized Personnel - individuals who have a legal
				  duty to provide specified services to residents of long-term care facilities,
				  including, but not limited to, representatives of the Office of the State
				  Long-Term Care Ombudsman Program, the Office of State Guardian, and the Legal
				  Advocacy Service; and community-service providers or third parties serving as
				  agents of the State for purposes of providing telemedicine, transitional
				  services to community-based living, and any other supports related to existing
				  consent decrees and court-mandated actions.
Substitute decision maker - a person who possesses the
				  authority to make mental health decisions on behalf of the consumer under the
				  Powers of Attorney for Health Care Law, under the Mental Health Treatment
				  Preference Declaration Act, or the Probate Act of 1975.
Transitional living units - residential units within
				  a facility that have the purpose of assisting the consumer in developing and
				  reinforcing the necessary skills to live independently outside of the facility.
				  The duration of stay in
this
setting shall not exceed 120 days
				  for each consumer. Nothing in this definition shall be construed to be a
				  prerequisite for transitioning out of a facility.
(Section 1-102 of
				  the Act)
Therapeutic separation - the removal of a consumer
				  from the milieu to a room or area
that
is designed to aid in
				  the emotional or psychiatric stabilization of that consumer.
(Section
				  1-102 of the Act)
Triage center - a non-residential, 23-hour center
				  that serves as an alternative to emergency room care, hospitalization, or
				  re-hospitalization for consumers in need of short-term crisis
				  stabilization.
(Section 1-102 of the Act)
Unit - a crisis stabilization, recovery and rehabilitation
				  supports, or transitional living level of service within a facility.
Wellness Recovery Action Plan (WRAP) - an evidence-based
				  system developed by the Copeland Center for use by people dealing with mental
				  health and other challenges who want to attain the highest possible level of
				  wellness.
Williams Consent Decree - Williams et al. v. Pritzker et al.,
				  Case No. 05 C 4673, N.D. Illinois, Eastern Division.
Williams Consent Decree Class Members or Williams Class
				  Members - all Illinois residents who are eighteen (18) years old or older and
				  who have a Mental Illness; are institutionalized in a privately owned
				  Institution for Mental Diseases; and, with appropriate supports and services,
				  may be able to live in an integrated community setting.
Williams Consent Decree Defendant Agencies - the Illinois
				  Department of Human Services, the Division of Mental Health of the Illinois
				  Department of Human Services, the Illinois Department of Public Health, and the
				  Illinois Department of Healthcare and Family Services, including any successor
				  to these departments.