Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 370 - COMMUNITY LIVING FACILITIES CODE › Subpart G - RECORDS › Section 370.1210 - General

Current through Register Vol. 48, No. 28, July 12, 2024
a) An active record
				shall be kept for each resident. This record shall be kept current, dated,
				signed, complete, legible, and available at all times to the appropriate
				personnel of the facility and to the representatives of the Department and the
				Illinois Department of Mental Health and Developmental Disabilities. Each
				resident shall be evaluated by the facility's staff and an individual
				habilitation plan developed within fifteen (15) days of admission to the
				facility. Such evaluation shall include a written entry in the resident's
				permanent record regarding present work or training assignment outside the
				facility, social and vocational training program goals within the facility and
				probable length of stay needed in the facility to accomplish independent living
				goals.
b) Each resident's record
				shall be written in ink or typed, and each entry shall be dated and signed. The
				record shall include the following:
1)
				Identification sheet(s) and/or admission form(s) including resident's name,
				social security number, marital status, birthdate, age, birthplace, sex, home
				address, and religion; name, address and telephone number of referral agency,
				personal physician; next of kin or other responsible person.
2)
A) A
				statement that the resident is free of communicable diseases, including active
				tuberculosis. It shall be signed and dated by the physician. This shall be
				completed within one (1) month prior to, or within seventy-two (72) hours after
				admission.
B) Any additional
				information pertaining to the resident's medical and personal history that may
				be helpful in the management of the resident shall be included.
3) Results of an examination by a
				psychologist determining mental and functional level completed within the last
				year. If a current psychological evaluation is unavailable, the staff
				psychologist shall make such an evaluation within fifteen (15) days of the
				resident's admission.
4) Progress
				record towards goals documented a minimum of at least once monthly.
5) A full written report on any serious
				incident or accident involving a resident while on the premises. This report
				shall include the date and time of each incident or accident and the action
				taken concerning it. These incidents and accidents shall include medication
				errors and drug reactions and all situations requiring the emergency services
				of a physician, a hospital, the police, the fire department, the coroner, etc.
				The Department shall be notified by a phone call to the Regional Office of all
				such incidents or accidents. Such notification shall be made within twenty-four
				(24) hours of their occurrence. A written copy of this report shall be sent to
				the Department within seven (7) days of such incident or accident.
6) Consultants shall make written reports of
				their findings and recommendations at the time of each visit. These shall be
				included in the resident's progress record if concerned with an individual
				resident.
7) Discharge information
				shall be recorded within seventy-two (72) hours after the resident leaves the
				facility. This shall indicate the date, time, condition of the resident, to
				whom released and where going (home, another facility, etc.). This information
				may be part of the admission record form.