Long-Term Care Annual Report 2022

The Office of Health Care Regulation Bureau of Long-Term Care (BLTC) activities are supported by multiple divisions and 355 staff.  To meet the licensing and regulating responsibilities of the office, staff are situated across the state in regional offices.  A brief description of each division is provided below:

• Division of Compliance Assurance (CA): Responsible for processing surveys, enforcement actions, informal dispute resolutions, and liaison with the field operations staff. The staff work closely with partners at the Centers for Medicare & Medicaid (CMS) Chicago Regional Office to ensure the imposition and recommendation of enforcement actions. Staff in compliance assurance are also responsible for responding to requests for information via the Freedom of Information Act, the maintenance of all surveying/enforcement records, and support to the entire bureau. In 2021 a new division within CA was established to implement the statutes and regulatory activities associated with staffing rules and requests for RN waivers.
• Division of Licensure and Certification: Responsible for licensure activity, including new applications, changes in ownership, administrators, coordinating activities with both the field operations, compliance assurance, life safety and construction, processing closure notices, and maintaining databases. Processes re-certification documents with CMS and collaborates with other state agencies where licensing and regulatory activities intersect.
  
• Division of Assisted Living: Responsible for all licensing and regulatory activities associated with assisted living facilities. The division currently encompasses all field and enforcement activities under the applicable administrative code.
  
• Division of Life Safety Code and Construction: Given the dual regulatory responsibilities of this division both in long-term care and non-long-term care, its activities fall within the OHCR, but outside of the BLTC. Staff join OHCR as architects, engineers, and project designers but must also be certified by CMS and pass rigorous examinations to independently survey in the long-term care setting.
  
• Division of Long-Term Care Field Operations: The division is comprised of three distinct sections within the bureau and is responsible for the intake of all complaints, processing in various office databases, investigating complaints, conducting annual health surveys, investigating unlicensed facilities, leading various task forces related to abuse and neglect, and monitoring for federal and state regulatory compliance in long-term care facilities except for assisted living. These sections comprise the largest portion of the regulatory staff.
  
  • Special Investigations Unit (SIU), including the Central Complaint Registry (CCR).
    
  • Intermediate Care Facility/Individual Intellectually Disabled and Specialized Mental Health Rehabilitation Section (ICF/IID/SMHRF).
    
  • Field operations in seven regional offices located in Bellwood, Champaign, Edwardsville, Marion, Peoria, Rockford, and West Chicago.

The following statutory provisions describe the types of residents and long-term care facilities licensed and regulated by IDPH.

A private home, institution, building, residence, or any other place, whether operated for profit or not, or a county home for the infirm and chronically ill operated or any similar institution operated by a political subdivision of the state of Illinois, which provides, through its ownership or management, personal care, sheltered care, or nursing for three or more persons, not related to the applicant or owner by blood or marriage. It includes skilled nursing and intermediate care facilities (Nursing Home Care Act, 210 ILCS 45/1-113).

The ID/DD Community Care Act (210 ILCS 47) provides for the licensure of intermediate care facilities for persons with developmental disabilities, whether operated for profit or not, which provides, through its ownership or management, personal care or nursing for three or more persons not related to the applicant or owner by blood or marriage.  Developmental disabilities are characterized by significant limitations in both intellectual functioning (intelligence) and in adaptive behavior (ID/DD Community Care Act, 210 ILCS 47).

The MC/DD Act provides for the licensure of facilities for the medically complex persons with developmentally disabled individuals under the age of 22 (MC/DD Act,210 ILCS 46).

Under the CLF Licensing Act (210 ILCS 35), a transitional residential setting that provides guidance, supervision, training, and other assistance to ambulatory mildly and moderately developmentally disabled adults with the goal of eventually moving these persons to more independent living arrangements. A CLF shall not be a nursing or medical facility and shall house no more than 20 residents.

Under the Specialized Mental Health Rehabilitation Act of 2013 (210 ILCS 49/1-102), a SMHRF is a facility that provides at least one of the following services:

1. triage center
2. crisis stabilization
3. recovery and rehabilitation supports
4. transitional living units for three 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.

Under the Nursing Home Care Act sheltered care facilities provide maintenance and personal care (Nursing Home Care Act, 210 ILCS 45/1-124).

The following tables provide data for both 2020 and 2021 on the types of facilities including overall beds licensed and regulated by IDPH.

The Training and Technical Direction Unit assists surveyors to attain the knowledge, skills, and abilities to carry out survey functions. This includes assessing training needs, coordinating trainings, creating curriculum and educational materials, evaluating learning outcomes, and maintaining training records for all long-term care surveyors.

Federal CMS requires each state survey agency (SSA) to identify a state training coordinator and back up coordinator to be liaisons with the regional training administrator and the CMS central office. The state training coordinator oversees training concerns, logistics, scheduling, and oversight of the CMS Surveyor Training website. The unit is dedicated to ensuring the surveyors and compliance assurance team are provided with the training and resources necessary to ensure timely, consistent surveys, and swift enforcement action as these activities translate to improved regulatory compliance and resident outcomes.

Beyond ensuring the ongoing educational needs of the BLTC are met, the unit plays a crucial role in overseeing training of nursing assistant programs throughout all skilled nursing facilities. Responsibilities include:

• Approval of and daily administration of all advanced nursing assistant training programs (ANATP) and basic nursing assistant training programs (BNATP), instructors, and evaluators
• Approval of and daily administration of resident attendant (RA) programs and review of RA program submissions
  
• Approval of temporary nursing assistant (TNA) programs and review of TNA program submissions
  
• Monitoring and implementation of CMS updated guidance regarding nursing assistant training programs
  
• Identification and notification of nurse aide training site restrictions imposed as a result of serious regulatory deficiencies
  
• Responding to the Nurse Assistant Training and Competency Evaluation Program (NATCEP) waiver requests
  

Competency testing for nursing assistants is achieved primarily by successful completion of an IDPH-approved BNATP. BNATPs are offered in a variety of settings throughout the state, including community colleges, other educational institutions, and by health care providers. Advanced nursing assistant training program sponsors are currently supported by three community colleges and two hospitals.

Total Number of Active Basic Nursing Assistant Training Programs - 387

Total Number of Active Advanced Nursing Assistant Training Programs - 5

In 2021 of the 14,587 students eligible to sit for the competency/certification examination, 10,826 (74.2%) passed; 2,440 (16.7%) failed; and 1,321 (9.05%) were counted as “no-shows.”

Long-term care facilities are utilized as clinical practice sites for nurse aide training program students. Students learn related skills and apply that knowledge in providing care to residents in a facility. When a facility has certain sanctions imposed by the Centers for Medicare and Medicaid Services due to serious regulatory deficiencies, the facility is prohibited from serving as a clinical practice site. Further, the facility may also be restricted from conducting its own nurse aide training program (NATCEP). In 2021, 353 clinical practice site restriction notices were issued to facilities.

Facilities may request a waiver from IDPH of the NATCEP restrictions. The waivers are reviewed according to the guidelines set forth by federal CMS. In 2021, 10 waiver requests were received and approved.

RA programs train individuals to assist residents in a facility with eating, drinking, and limited personal hygiene. In 2021, IDPH approved 16 new programs submitted by a skilled care facility. Requirements for RA programs are found in 77 Illinois Administrative Code, Section 300.662. Currently, there are 92 active programs in the state.

Part 395 Long-Term Care Assistants and Aides Training Programs Code requires instructors and evaluators teaching in NATCEP to be approved by IDPH prior to instructing students. In 2021, 161 instructors and evaluators were approved. In 2021, community colleges conducted eight “Train-the-Trainer” courses of which 89 instructors and evaluators successfully completed. IDPH approved 132 additional instructors based on the requirements under the applicable administrative code.

IDPH continues to strive towards hiring additional long-term care surveyors to comply with Senate Bill 326 (Public Act 096-1372) and a goal of 300 long-term care beds per surveyor. Training materials are continuously revised to ensure the most up-to-date compliance information is made available to surveyors in a variety of platforms. Additionally, each newly hired surveyor is provided training tools to include webcast course listings, website access information, links to documents, attestation of survey observations, requirements for submission of the training documentation, and access to regulations.

Prior to attending State Basic Surveyor Orientation (BSO), a newly hired long-term care surveyor completes more than 75 hours of mandated webcasts related to the long-term care survey process and regulations and participates in at least three onsite annual certification surveys. A minimum of 6 to 12 months orientation time is required for a newly hired long-term care surveyor to become knowledgeable in the survey process. The time may vary depending on the learning needs of the new hire. To survey independently in certified facilities, surveyors must have successfully completed all training modules, the BSO, and successfully passed the CMS certification examination (SMQT).

In 2021, due to the COVID-19 pandemic, state Basic Surveyor Orientation (BSO) sessions were conducted virtually. Thirty-one new surveyors completed the state BSO in 2021. Topics covered in the BSO include complaint and investigation procedures training, immediate jeopardy, principles of documentation, infection control, involuntary discharges, and deficiency determination. The surveyor is also orientated on Automated Survey Processing Environment (ASPEN), which is a federal survey database/platform.

When state and federal courses are completed, surveyors are registered to complete the Surveyor Minimum Qualifications Test (SMQT). In 2021, 31 surveyors who were eligible successfully completed the SMQT. Following SMQT, surveyor training continues in the form of webinars, computer-based training, face-to-face instruction, and educational emails to further the foundational skills and to provide the most up-to-date changes from CMS related to rule revisions and clarifications.

Nursing facilities must comply with 77 Illinois Administrative Code 300, Subpart S Providing Services to Persons with Serious Mental Illness that allows for the admission of individuals under the age of 65 with a diagnosis of Severe Mental Illness (SMI). The Training and Technical Direction Unit did not receive any applications for Subpart S waivers in 2020.

The Training and Technical Direction Unit utilizes Federal Oversight and Support Survey (FOSS) results to determine surveyor training needs. Federal comparative surveys are independently conducted by regional office (RO) surveyors or CMS surveyor contractors within 60 days (usually) of the state’s survey. CMS completes the surveys to assess survey agency (SA) performance in the interpretation, application, and enforcement of federal requirements. When CMS surveyors identify a deficiency not cited by IDPH surveyors, there is a determination of whether the deficiency existed at the time of the state survey, and if it should have been cited by the IDPH survey team. In 2021, no FOSS were conducted by CMS owing to pandemic concerns.

Resource Support Surveys (RSS) are another type of survey conducted by CMS. The RSS provides guidance and direction to the state survey team by the regional office surveyor(s). Upon completion of the RSS, CMS compiles a report that contains an analysis of the deficiencies cited by the survey team to be used for educational purposes. In 2021, no RSS surveys were conducted by CMS owing to pandemic concerns.

The unit analyzes the Federal Monitoring Survey (FMS)/RSS report(s) to identify training needs and to develop training tools to enhance surveyors’ knowledge.

Training and Technical Direction (TTD) staff provide RAI/MDS education, technical direction, and support to long-term care survey staff and providers on an ongoing individual case basis. TTD staff also provide group opportunities for RAI/MDS education and direction in person and by Webex.

The RAI/MDS is an assessment tool used in long-term care to identify residents’ needs and is used to create and to update the plan of care for each individual resident. The RAI/MDS is required by federal CMS for residents in Medicare and/or Medicaid certified nursing homes and is used for reimbursement determination.

Education and direction provided in 2021 centered on the changes to the assessment sections nursing homes are required to complete. These changes are important to both providers and long-term care survey staff. Currently, a member of the IDPH training team serves on the National RAI Panel to provide support to Illinois providers and to survey staff with questions related to RAI/MDS.

CMS implemented a National Dementia Partnership Program “with the mission to improve quality of care for nursing home residents living with dementia.” The partnership consists of federal and state agencies, nursing homes, providers, advocacy groups, and caregivers. It continues to focus on the delivery of health care to individuals with dementia that is person-centered, comprehensive, and interdisciplinary. It also focuses on protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication, and a systematic process to evaluate individuals. Utilizing a multidimensional strategy, the partnership promotes developing new approaches in dementia care, reconnecting with people using person-centered care approaches, and restoring good health and quality of life in nursing homes.

IDPH, the Quality Improvement Association (Telligen), and the Illinois Health Care Association are co-team leaders for the partnership to improve dementia care. Coalition meetings are conducted a minimum of four times a year. Participants include representatives from provider and Alzheimer’s associations, activity directors, physicians, pharmacists, and social workers. During the meetings, current data are reviewed and analyzed related to antipsychotic use, trends, and training needs.

In 2001, CMS established a set of state survey performance standards (SPSS) to determine whether the state survey agencies (SSAs) were meeting the requirements for the survey and certification program. These standards were revised in 2006 and 2016. This evaluation does not restrict the CMS Regional Office (RO) from performing other oversight activities to assure that the SSAs are meeting the terms of the 1864 agreement. Furthermore, the SPSS neither creates new policy for the SSAs, nor does it nullify federal law, regulations, the State Operations Manual, or formal policy provided by CMS. In 2021 the OHCR met each of the scoring dimensions.

The areas scored include the dimensions of “Frequency,” “Quality,” and “Enforcement”

• Frequency: Tracks the frequency with which survey teams provide on-site, objective, and outcome-based verification that basic standards of quality are met by providers.
• Quality: Measures the quality of the surveys themselves, based on a review of survey findings, onsite observations of survey performance, and review of complaints/incidents.
  
• Enforcement: Measures the appropriateness and effectiveness of enforcement action by the survey agencies. If conditions and standards needed to assure quality are not met, remedies are promptly devised and implemented.
  

• Off-hour Surveys for Nursing Homes
  • No less than 10% of standard surveys begin during weekend or “off hours.” Of the 10%, 50% must be on the weekends.
• Frequency of Nursing Home Surveys
  • Standard health surveys are conducted within prescribed time limits. If the maximum number of months between all standard surveys is less than or equal to 15.9 months and the statewide average interval is less than or equal to 12.9 months, the measure is scored as “Met.”
• Timeliness of Upload into CASPER of Standard Surveys for Non-Deemed Hospitals and Nursing Homes
  • If the average is less than or equal to 70 calendar days for data entry of both nursing home and non-deemed hospital (including non-deemed CAHs) surveys, this measure is scored as “Met.”

• Documentation of Deficiencies for Nursing Homes, ESRD facilities, ICF/IIDs, and Non-deemed HHA’s and Hospitals
  • If the score for each requirement for nursing homes and non-nursing homes is greater than or equal to 85%, this measure is scored as “Met.”
• Q4 Identification of Health and Life Safety Code (LSC) Deficiencies on Nursing Home Surveys as Measured by Federal Comparative Survey Results
  • If the percent Agreement Rate is 90% or higher (without rounding up), this measure is scored as “Met.”
• Prioritizing and Timeliness Complaints and Facility Self-Reported Incidents
  
  • CMS guidelines for the prioritization of federal complaints, regardless of whether an onsite survey is conducted, and those incidents requiring an onsite survey are followed for nursing homes, non-deemed hospitals, non-deemed CAHs, non-deemed HHA, and ESRD facilities. All nursing home complaints and incident reports are investigated according to CMS policy for complaint/incident handling. If the score for each criterion is greater than or equal to 85%, the measure is scored as “Met.”

• E1 Timeliness of Processing Immediate Jeopardy (IJ) Cases
  • The state agency adheres to the 23-day termination process in which it determines there is an IJ that is not abated prior to the end of the survey. If the resulting percentage is greater than or equal to 95%, the standard is scored as “Met.”
• E2 Timeliness of Mandatory Denial of Payment for New Admissions (DPNA)
  • The state agency (SA) adheres to the enforcement processing time frames ensuring denial of payment for new admissions is imposed when a nursing home is not in substantial compliance three months after the date of the original survey. The SA must transfer the enforcement case to CMS by the 70^th day or the imposition notice is sent by the SA to the provider by the 70^th day. If the resulting percentage is greater than or equal to 80%, this standard is scored as “Met.”
• E4 Special Focus Facilities (SFFs) for Nursing Homes
  • Each state agency (SA) shall have the specified number of SFFs identified and conduct a standard survey of those facilities twice during the fiscal year. The SA recommends enforcement remedies to the regional office of CMS/State Medicaid Agency, in accordance with the SFF Procedures Guide. Once a SFF has graduated from the program, the SA has to replace it with another SFF within the 21-day period. E4 is considered “Met” if all evaluated criteria are met. If any of the criteria is not met, this performance standard is scored as “Not Met.”

The Division of Compliance Assurance (CA) is comprised of several distinct sections: FOIA/Hearing/Files, Support Services, Compliance Assurance, Staffing Ratios/RN Waivers, and Technical Support. CA is responsible for processing licensure and certification surveys and issuing enforcement penalties for long-term care facilities, such as skilled nursing, shelter care, veterans’ homes, intermediate care for the intellectually disabled, community living, specialized mental health rehabilitation facilities, supportive living, and MC/DD. The staff ensures the overall survey cycle that encompasses surveying, enforcement action, and re-licensure and/or certification are conducted within the state and federal statutorily mandated time frames. Licensure and certification activities were recently moved to a separate division in the BLTC given the significant number of activities and growth in facilities.

The Certification Section is responsible for processing and tracking initial certifications and annual recertifications of long-term care facilities. Additionally, the Certification Section is responsible for processing and tracking Life Safety Code Waiver requests; bed certification changes; changes of ownership and information, terminations, and closures; and Title XIX Collections and Civil Money Penalties. The Licensure Section processes applications for the licensure of new facilities, changes of ownership, licensure renewal applications, and bed level/services changes. Additionally, the Licensure Section provides statistical reports and collaborates/supports with the Certification Section to process various facility requests.

The FOIA/Hearing/Files section maintains records, processes Freedom of Information Act (FOIA) requests, and handles hearing requests. The Division of Compliance Assurance employs registered professional nurses to review surveys completed by Field Operations staff. Compliance Assurance is also responsible for Informal Dispute Resolution (IDR), Independent Informal Dispute Resolution (IIDR), state licensure violations, and recommending federal Civil Money Penalties. The technical support coordinator maintains the CMS Automated Survey Process Environment (ASPEN) program, works closely with staff to maintain software programs, maintains statistical databases, and tracks quality and performance data. Compliance Assurance works closely with providers, Centers for Medicare & Medicaid Services (CMS), and the Illinois Department of Healthcare and Family Services (HFS).

The federal Special Focus Facility (SFF) program is focuses on issues affecting the quality of life and quality of care of residents in nursing homes. Facilities are selected as an SFF due to serious deficiencies cited on repeated surveys. While CMS caps the number of SFF for state agencies, each state is allowed to participate in the selection of new facilities based on regulatory compliance and quality of care. Illinois’ current maximum cap is four facilities. Once a facility is selected as an SFF, a full survey is conducted not less than once every six months. If deficiencies are found during the survey, progressively stronger consequences are implemented until the nursing home either graduates from the SFF program or is terminated from the Medicare and/or Medicaid program(s).

To graduate from the SFF program, a facility must have two consecutive full surveys showing improvement. As a facility graduates from the program, a new facility is selected to replace it. In 2021, one SFF improved regulatory compliance necessary to graduate off the list and one facility voluntarily terminated CMS certification.

Requests under the Freedom of Information Act (FOIA) are received from the IDPH Division of Legal Services FOIA officer. FOIA requests must outline the specific information that is being sought. Any person has the right to request records of information under FOIA. This information can involve residents, patients, facilities, persons of interest, or citations/violations against a facility. Records with health information or identifiable information are protected from disclosure. This information is redacted before release to the requestor. Determinations of allowable information are made by the FOIA officer and federal CMS. For long-term care requests, the Statement of Deficiencies (Form CMS 2567) and the Plan of Correction (POC) are the two documents that can be directly released by IDPH. Per recent CMS guidance, IDPH may also release additional survey documents including the CMS 671 (Long-Term Care Facility Application for Medicare/Medicaid), the CMS 672 (Resident Census and Conditions of Residents), and other documents with no privacy concerns (e.g., policy memos or staffing schedules).

In 2021, the Division of Compliance Assurance handled 814 FOIA requests.

• 126 were for non-survey related information (e.g., not contained in the statement of deficiencies, floor layout of facilities, license information, etc.)
• 259 were unable to be fulfilled due to lack of information available (e.g., there was no complaint regarding the resident or facility requested)
• 425 were for the statement of deficiencies for a complaint investigation

The Division of Compliance Assurance receives federal hearing requests when a licensee or the designated attorney representing the facility has requested an appeal of penalties imposed by CMS. All documentation related to the survey is submitted to CMS within seven business days of the receipt of the request.

State hearing requests are received from the requestor – the licensee, an attorney representing the facility, or an individual not satisfied with survey results. All documents are compiled and sent to the IDPH Division of Legal Services within seven business days of the receipt of the request.

In 2021, the Division of Compliance Assurance processed 389 hearing requests, nearly double the number processed the preceding fiscal year:

• 131 from individual(s) not satisfied with survey results
• 258 by facility attorneys
• 71 federal hearings requests

Based on IDPH records used at the time to prepare this report, more than 1,000 facilities are regulated under the Illinois Nursing Home Care Act (NHCA), the ID/DD Community Care Act, the Medically Complex/Developmentally Disabled (MC/DD) Act, the Specialized Mental Health Rehabilitation Act, the Community Living Facilities Licensing Act, and/or federal requirements for Medicare (Title XVIII) and/or Medicaid (Title XIX) participation. Of these facilities, 828 are licensed under the NHCA. Of those 828 facilities, the majority (93.48%) participate in the federal certification program for Medicare and/or Medicaid.

Program staff process a wide range of provider requests. Licensure actions include upgrades of care levels, addition of approved services, adding or removing beds, or simply changing room bed location. Other actions include licensing new facilities and processing changes of ownership, facility closures, and replacement facilities. Licensure actions are finalized following approval by the Division of Life Safety and Construction, and successful completion of a health survey by staff from the Division of Field Operations. The table below summarizes licensure activity:

Article III, Part 3 of the Nursing Home Care Act (Violations and Penalties) states:

• If after receiving the report specified in subsection (c) of Section 3-212 the Director, or his designee, determines that a facility is in violation of this Act or of any rule promulgated there under, he shall serve a notice of violation upon the licensee within ten (10) days, thereafter. Each notice of violation shall be prepared in writing and shall specify the nature of the violation, and the statutory provision or rule alleged to have been violated (210 ILCS 45/3-301).
• Each violation shall be determined to be either a level ‘AA’, a level ‘A’, a level ‘B’, or a level ‘C’ violation, or administrative warning. The level ‘AA’ is the most severe.

• A "level AA violation" or a "Type AA violation" is a violation of the act or this part which creates a condition or occurrence relating to the operation and maintenance of a facility that proximately caused a resident's death (Section 1-128.5 of the Nursing Home Care Act)
• A "level A violation" or "Type A violation" is a violation of the act or this part which creates a condition or occurrence relating to the operation and maintenance of a facility that creates a substantial probability that the risk of death or serious mental or physical harm will result therefrom or has resulted in actual physical or mental harm to a resident (Section 1-129 of the Nursing Home Care Act)
• A "level B violation" or "Type B violation" is a violation of the act or this part which creates a condition or occurrence relating to the operation and maintenance of a facility that is more likely than not to cause more than minimal physical or mental harm to a resident (Section 1-130 of the Nursing Home Care Act)
• A "level C violation" or "Type C violation" is a violation of the act or this part which creates a condition or occurrence relating to the operation and maintenance of a facility that creates a substantial probability that less than minimal physical or mental harm to a resident will result therefrom (Section 1-132 of the Nursing Home Care Act)
• If the director or his designee determines that the report's findings constitute a violation or violations which do not directly threaten the health, safety, or welfare of a resident or residents, the department shall issue an administrative warning as provided in Section 300.277 of the Illinois Administrative Code (Section 3-303.2(a) of the Nursing Home Care Act)

In 2021, IDPH issued a total of 946 state licensure violations. IDPH imposed fines totaling $8,939,600 in 698 out of 946 violations. Also, in 2021, IDPH collected $2,571,067.68 in state licensure fines. For comparison purposes, in the preceding fiscal year IDPH imposed $4,006,750 in 196 out of the 352 violations and collected $1,008,940 in state licensure fines. The table below illustrates the level of state licensure violations imposed in 2021 and the trend of state licensure violations issued in a three-year period from 2019 to 2021.

The Nursing Home Care Act, ID/DD Act, and the MC/DD Act allow IDPH to issue two-year licenses to qualifying facilities. During 2021, IDPH issued a total of 754 renewal licenses. Facilities continuing to qualify are issued a two-year license. However, as new facilities are licensed, facilities change ownership, or become disqualified from participation, the number of one-year licenses increases. Because IDPH uses the certification survey for licensing and the certification program requires facilities to be surveyed approximately once per year, the certification survey sanctions affect the length of a facility’s license. Each facility’s certification survey results must be reviewed annually in addition to a review for licensure program sanctions to determine whether the facility meets the two-year license criteria.

Many long-term care facilities experience changes in licensure due to a change in the owner/operator of the facility, the addition to an Alzheimer's special care unit, bed increases and/or upgrades not requiring construction/renovation, a decrease in the number of licensed beds, or facility closure.

In 2021, eight bed changes resulted in skilled care beds increasing by 264, intermediate care beds decreasing by 256, and medically complex/developmentally disabled beds increasing by six beds. Additionally, one new facility accounted for an increase of 200 skilled beds.

Twelve long-term care facilities closed in 2021, resulting in a reduction of 583 skilled care beds, 105 intermediate care beds, 123 sheltered care beds, and 166 intermediate care for developmentally disabled beds.

Based on the number and/or level of violations, adverse licensure action(s) that may be taken include:

IDPH issues conditional licenses for violations as specified in the Nursing Home Care Act (210 ILCS 45/3-305):

• A licensee who commits a Type "AA" violation as defined in Section 1-128.5 is automatically issued a conditional license for a period of six months to coincide with an acceptable plan of correction and assessed a fine up to $25,000 per violation
• A licensee who commits a Type "A" violation as defined in Section 1-129 is automatically issued a conditional license for a period of six months to coincide with an acceptable plan of correction and assessed a fine of up to $12,500 per violation
  

IDPH may deny an application for license for:

• Failure to meet any of the minimum standards set forth by this act or by rules and regulations promulgated by IDPH under this act.
• Conviction of the applicant, or, if the applicant is a firm, partnership, or association, of any of its members. If a corporation, the conviction of the corporation or any of its officers or stockholders, or of the person designated to manage or supervise the facility, of a felony, or of two or more misdemeanors involving moral turpitude, during the previous five years as shown by a certified copy of the record of the court of conviction.
  
• Personnel insufficient in number or unqualified by training or experience to properly care for the proposed number and type of residents.
  
• Insufficient financial or other resources to operate and to conduct the facility in accordance with standards promulgated by IDPH under this act and with contractual obligations assumed by a recipient of a grant under the Equity in Long-term Care Quality Act and the plan (if applicable) submitted by a grantee for continuing and increasing adherence to best practices in providing high-quality nursing home care.
  
• Revocation of a facility license during the previous five years, if such prior license was issued to the individual applicant, a controlling owner, or controlling combination of owners of the applicant; or any affiliate of the individual applicant or controlling owner of the applicant and such individual applicant, controlling owner of the applicant, or affiliate of the applicant was a controlling owner of the prior license; provided, however, that the denial of an application for a license pursuant to this subsection must be supported by evidence that such prior revocation renders the applicant unqualified or incapable of meeting or maintaining a facility in accordance with the standards and rules promulgated by IDPH under this act.
  
• That the facility is not under the direct supervision of a full-time administrator, as defined by regulation, who is licensed, if required, under the Nursing Home Administrators Licensing and Disciplinary Act.
  
• That the facility is in receivership and the proposed licensee has not submitted a specific detailed plan to bring the facility into compliance with the requirements of this act and with federal certification requirements, if the facility is certified, and to keep the facility in such compliance.
  

Federal enforcement regulations established a classification system for certification deficiencies based on the severity of the problem and the scope, or the number of residents upon whom the non-compliance had or may have an impact. The four levels of severity, in ascending order, are potential for minimal harm, potential for more than minimal harm, actual harm, and immediate jeopardy. The scope of deficiencies is classified as isolated, pattern, or widespread (e.g., an “H” level deficiency would represent a problem where several residents were actually harmed because of the facility’s non-compliance with regulations). The 12 levels of scope/severity are identified using the letters A through L. The following is the scope/severity grid established to classify federal deficiencies. Immediate jeopardy (IJ) deficiencies represent the most serious examples of non-compliance that can occur in long-term care facilities. These deficiencies represent non-compliance that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

Skilled nursing facilities (SNFs), nursing facilities (NFs), and dually participating facilities (SNF/NFs) are required to maintain compliance with Medicare and Medicaid requirements. To avoid enforcement actions, including termination of their provider agreements, facilities have a responsibility to correct any deficiencies cited during a federal survey. Application of federal enforcement remedies is based upon the seriousness of the deficiency(s). Below is a brief description of remedies:

• Directed Plan of Correction (DPOC) - A plan the state or CMS develops to require a facility to take action within specified time frame to achieve compliance.
• Directed In-Service Training (DIST) - A remedy the state or CMS uses to require a facility to provide education, by an outside source, to correct the deficiency to achieve compliance.
  
• Denial of Payment for New Admissions (DPNA) - Cessation of payment implemented by CMS or the state Medicaid agency at 90 days in the survey cycle for a period of time between the date the remedy was imposed and the date the facility achieves compliance.
  
• Discretionary Denial of Payment for New Admissions (DDPNA) - Cessation of payment implemented by the discretion of CMS or the state Medicaid agency for any period between the date the remedy was imposed and the date the facility achieves compliance.
  
• State Monitor (SM) - A state monitor oversees the correction of cited deficiencies in the facility as a safeguard against further harm to residents when harm or a situation with a potential for harm has occurred.
  
• Civil Money Penalties (CMP) - CMS or the state imposes a monetary fine for the number of days that a facility is not in compliance with certification requirements or, in some cases, each example of non-compliance.
  
• Temporary Management (TM) - Reserved for when deficiencies constitute immediate jeopardy or widespread actual harm and a decision is made to impose an alternative remedy to termination. The temporary manager’s responsibility is to oversee correction of the deficiencies and to assure the health and safety of the facility’s residents while the corrections are being made or to oversee orderly closure of a facility.
  
• Termination - The most severe remedy utilized by CMS that terminates a facility from participation in the Medicare and/or Medicaid program.
  

In response to the impact of COVID-19 on nursing homes, CMS issued guidance to the state agencies requiring the imposition of enforcement remedies for regulatory deficiencies related to COVID-19 and infection control. These remedies were aimed at encouraging facilities to quickly return to compliance and included increased financial penalties, directed plans of correction and in-service training, and, in some instances, the requirement to secure a qualified infection preventionist.

As the state agency responsible for surveying certified nursing homes following the CMS guidelines, IDPH makes recommendations for Civil Money Penalties (CMPs) that CMS ultimately imposes. Similar to other monetary penalties, CMPs are designed to correct serious deficiencies quickly and to ensure sustained compliance. The following statistics are an illustration of the impact of civil money penalties:

The Centers for Medicare & Medicaid Services (CMS) returns a portion of federal civil money penalties to state agencies to distribute to nursing homes and other eligible groups such as the ombudsman for initiatives aimed exclusively at improving the quality of care and life of long-term care residents. According to CMS, CMP funds may be used for (but not limited to the following):

• Assistance to support and protect residents of a facility that closes or is de-certified
• Time-limited expenses incurred in the process of relocating residents to home and community-based settings or another facility when a facility is closed or downsized pursuant to an agreement with the state Medicaid agency
  
• Projects that support resident and family councils and other consumer involvement in assuring quality care in facilities
  
• Facility improvement initiatives, such as joint training of facility staff and surveyors, or technical assistance for facilities implementing quality assurance and performance improvement programs
  

IDPH submitted its plan to CMS for January 1, 2021 to December 31, 2021. The current balance is $17,372,205 with $2 million allocated for the Emergency Reserve Fund and $342,400 estimated for administrative use. The IDPH’s plan was approved by CMS on April 13, 2021. The state of Illinois currently has no funded projects.

IDPH is establishing a yearly grant cycle for CMP grants with solicitation and grant making occurring from January through June of each year and grant execution commencing on or around July 1 of each year. IDPH will not solicit any CMP projects for calendar year 2021 as it is developing its CMP grant program in 2021. In 2022, the solicitation process will follow the Grant Accountability and Transparency Act (GATA), 30 ILCS 708, and corresponding rules found in Title 44, Part 7000 of the Illinois Administrative Code. During calendar year 2021, IDPH will develop and adopt specific grant rules for CMP funds. Any additional requirements in the solicitation process will be included in the IDPH CMP grant rules. IDPH’s timeline for the CMP grant rules calls for the proposal by July 1, 2021, and adoption by December 31, 2021. IDPH’s’s grant rules and the Notice of Funding Opportunity (NOFO) will specify who is eligible to apply for the CMP grant funds and the types of projects that can be funded. During 2021, IDPH will develop for inclusion in the 2022 state plan standard language and requirements included in each NOFO.

Under the direction of CMS, IDPH imposes Discretionary Denial of Payment of New Admissions (DDPNA) instead of recommending a civil money penalty for surveys that meet specific criteria and involve substandard qualify of care deficiencies as determined by CMS. The benefit of imposing DDPNA, in these instances, is that it encourages rapid return to compliance.

Guidance at 42 Code of Federal Regulation (CFR) 488.331 requires states to offer skilled nursing facilities, nursing facilities, and dually participating Medicare/Medicaid facilities an informal opportunity to dispute survey findings. This process is called Informal Dispute Resolution (IDR).

The Centers for Medicare & Medicaid Services hold states accountable for the legitimacy of the IDR process, including the accuracy and reliability of the conclusions drawn with respect to survey findings. IDPH offers two options when requesting an IDR – a written review by quality review staff at no charge to the facility or a written or telephonic review by an independent contractor on a fee for service basis. The current independent contractor for IDRs is Michigan Peer Review Organization (MPRO).

In 2021, IDRs were requested for 709 deficiencies cited on 453 surveys. Most of these requests were for IDPH to conduct the IDR. IDPH conducted IDRs for 545 deficiencies cited on 375 surveys. This represents a significant increase in IDRs compared to 2020 (378 deficiencies cited on 259 surveys). The remaining IDRs were processed with an independent contractor using the independent informal dispute resolution process outlined in the following paragraphs.

Guidance at 42 CFR 488.331 and 488.431 offers facilities, under certain circumstances, an additional opportunity to informally dispute cited deficiencies through a process that is independent from the state survey agency (SSA) or, in the case of federal certification surveys, the CMS regional office. This process is called Independent Informal Dispute Resolution (IIDR). CMS offers facilities an IIDR for surveys in which a civil money penalty (CMP) was imposed against the facility.

IIDR is not intended to be a formal or evidentiary hearing, nor are the results of the process an initial determination that gives rise to appeal rights. IIDR results are recommendations to the state and CMS and are not subject to a formal appeal. The IIDR process is available to a facility at no charge as IDPH assumes the cost. IDPH’s current contractor for IIDRs is Michigan Peer Review Organization. In 2021, 49 IIDR requests were processed for 64 federal tags, which are numbered deficiencies that correspond to the specific violation within the Code of Federal Regulations.

IDPH is required to submit to the General Assembly an accounting of federal and state fines received in the preceding fiscal year by the fund in which they have been deposited. For each fund, the report shall show the source of monies deposited into each and the purpose and amount of expenditures from each fund (Source: P.A. 98-85, eff. 7-15-13). Amounts shown are for federal funds (063) and state funds (371), which are split 50/50.

• Long-Term Care Monitor/Receivership: $2,092,231.33 (Fund 285, 210 ILCS 45/3-501)
• Federal Medicaid/Medicare Fines Received: $1,769,042.90 (Fund 063/371)
  

• Civil Monetary Penalties: $0
• Long-Term Care Monitor/Receivership: $23,610,482.40 (23 IDPH staff salaries, fringe benefits, and travel)
  
• Equity and LTC Quality Fund: $0 (Fund 371)
  

• Long-Term Care Monitor/Receivership: $1,621,506.57 (Fund 285, 210 ILCS 45/3-501)
• Federal Medicaid/Medicare Fines Received: $4,041,387.96 (Fund 063/371)
  

• Civil Monetary Penalties: $0
• Long-Term Care Monitor/Receivership: $19,525,177.91 (IDPH staff salaries, fringe benefits, and travel)
  
• Equity and LTC Quality Fund: $0 (Fund 371)
  

Federal CMS’ expectations of IDPH as the state survey agency (SSA) include:

• Monitoring nursing homes’ ability to prevent pressure ulcers, dehydration, and malnutrition
• Providing a minimum quality of care and enhancing the quality of life
  
• Conducting surveys for providers with serious violations
  

Mandated certification surveys and investigations are conducted in accordance with federal survey procedures. Both licensure and certification requirements are reviewed during combined surveys. The Mission and Priority Document (MPD) from CMS states, “CMS reviews each state’s citation and enforcement data for recent years to ensure conformance with CMS policy and statutory requirements.”

In calendar year 2021, the Bureau of Long-Term Care (BLTC) conducted, reviewed, and processed 605 standard surveys, 4,999 complaint surveys, and 1,780 special surveys (including those extended due to immediate jeopardy, special focus, and infection control surveys) under the authority of Medicare and Medicaid of the Federal Social Security Act. The structure, format, and time of certification activities are mandated and regulated by the U. S. Department of Health and Human Services (HHS) through CMS.

While state licensure is mandatory per the Nursing Home Care Act (NHCA), federal certification is a voluntary program. Participation allows a facility to admit and to provide care for clients who are eligible for Medicaid or Medicare. Facilities providing long-term care located within a licensed hospital are not required to have an additional state license under the NHCA. Facilities operating as intermediate care facilities (ICF) for the developmentally disabled by the Illinois Department of Human Services (IDHS) also are not required to have an additional state license under the NHCA.

The Special Investigations Unit (SIU) consists of five separate areas working together for the protection of individuals residing in long-term care facilities. Resident abuse is one of the most serious findings IDPH addresses. Residents of long-term care facilities are highly vulnerable, and abuse can be devastating for residents and their families. The Nursing Home Care Act requires a facility employee or agent who becomes aware of abuse or neglect of a resident to immediately report the matter to IDPH and the facility administrator.

The intent of the SIU is to reduce the incidence of abuse in nursing homes by combining the resources of IDPH’s investigation program with those of criminal law enforcement and prosecution agencies. IDPH has established working relationships with the Illinois State Police Medicaid Fraud Control Unit (MFCU), Cook County State’s Attorney’s Office, and the U.S. Attorney’s Office in Springfield. With improvements in the federal database known as ASPEN Complaint/Incidents Tracking System (ACTS), IDPH can use the information to identify trends in the quality of long-term care that guide surveying activities.

The Central Complaint Registry (CCR) is a 24-hour toll-free nationwide complaint hotline mandated by the Illinois Nursing Home Care Act, Federal Statute (Chapter 5 of the State Operations Manual) and the Abused and Neglected Long-Term Care Facility Residents Reporting Act. The CCR acts as a repository for concerns or complaints across multiple programs (29) within IDPH. Based on the allegation of non-compliance, the mandated timeframe in which a complaint must be investigated is determined (24-hours, 7 days, or 30 days).

IDPH is mandated to investigate all complaints alleging abuse or neglect within seven days after the receipt of the complaint except for complaints of abuse or neglect that indicates a resident’s life or safety is in imminent danger. In these instances, the complaint must be investigated within 24 hours after receipt of the complaint. All other complaints must be investigated within 30 days after the receipt of the complaint. The CCR reviews, logs, and forwards the complaints to the appropriate regional office for scheduling and subsequent investigation.

Complaints are received from relatives, patients, citizens, legal representatives, and other agencies or associations, including, but not limited to, the ombudsman, Illinois Department on Aging, Illinois Department of Healthcare and Family Services, Illinois Department of Human Services, the Illinois Guardianship and Advocacy, Illinois Department of Financial and Professional Regulation, Office of the Attorney General, and advocacy groups. Calls not under the jurisdiction of the Office of Health Care Regulations are referred to another state agencies or IDPH divisions.

A complaint may have one or more allegation (assertion that the long-term care facility has failed to comply with a state or federal regulation). IDPH determines the validity of each allegation rather than each complaint in its entirety. An allegation is valid if what is stated on the complaint is found to be true. If the facility was following the regulations, a violation or deficiency will not be cited.

When a complaint is filed, the individual making the complaint has the option to file the complaint anonymously. In 2021, there were 1,172 long-term care, 59 ICF/DD, and 45 Specialized Mental Health Resident Facility (SMHRF) complaints filed anonymously. If a complaint chooses to provide contact information, the surveyor will attempt to call them to discuss the information given at the time the complaint was filed and to obtain any additional information. Complaints are received in a variety of ways, including the hotline, e-mail, facsimile, or mail.

Complainants may call to inquire about the status of the complaint, request a call from the surveyor, request clarification on the findings of a complaint, request a copy of the survey results letter, discuss the determination or the investigation, or request clarification how to file an appeal and request a hearing. It is critical that the caller is identified as the individual that filed the complaint.

The CCR receives many calls beyond those reporting a complaint. The most common reasons for these calls are the matter is not within IDPH jurisdiction and the call is then referred to the appropriate agency (e.g., HFS, IDHS, Labor Board). There were 3,684 referrals made to other agencies or programs, including the Illinois State Police, the Attorney General Healthcare Fraud Bureau, the state ombudsman with the Illinois Department on Aging, the Illinois Department of Human Services, and others.

In 2021, CCR received a total of 17,226 calls seeking assistance compared to 15,972 calls in 2020.

The corresponding chart demonstrates there has been an increase in the number of complaints received the last few years. In 2021, there were 9,732 complaints filed compared to 10,100 filed in 2020. The decrease of 368 complaints represents a 3.6% decrease.

The chart below demonstrates a comparison of total monthly number of calls received into the Nursing Home Complaint Hotline (CCR) for the last four fiscal years.

The table below shows the number and percentage of complaints in 2021 by provider type.

The highest number of complaints are those related to long-term care facilities at 7,265 (74%). As OHCR also licenses, inspects, and regulates hospitals, these facilities generated the second highest number of complaints at 1,284 (13%).

The following table shows the number of complaints by region / program in 2021. (Note: Total complaint number differentiation between the chart above and below is due to changes made after the initial intake of the complaints. These numbers also include no action necessary complaints.)

The following table shows the number of complaints in 2021 by some of the more critical allegation types.

The following table shows the number of complaints investigated within the respective time frame.

77 Illinois Administrative Code Part 300 requirements under Section 300.690

The facility shall maintain a file of all written reports of each incident and accident affecting a resident:

1. That is not the expected outcome of a resident's condition or disease process. A descriptive summary of each incident or accident affecting a resident shall also be recorded in the progress notes or nurse's notes of that resident.
2. The facility shall notify IDPH of any serious incident or accident. For purposes of this section, "serious" means any incident or accident that causes physical harm or injury to a resident.
   
3. The facility shall, by fax or phone, notify the appropriate IDPH regional office within 24 hours after each reportable incident or accident. If a reportable incident or accident results in the death of a resident, the facility shall, after contacting local law enforcement pursuant to Section 300.695, notify the appropriate IDPH regional office by phone.
   

For the purposes of this section, "notify the appropriate IDPH regional office by phone" means to talk with an IDPH representative who confirms over the phone that the requirement to notify the regional office by phone has been met. If the facility is unable to contact the appropriate IDPH regional office, it shall notify IDPH’s toll-free complaint registry hotline. The facility shall send a narrative summary of each reportable accident or incident to IDPH within seven days after the occurrence. All incidents received by IDPH are reviewed and triaged based on the seriousness of the incident.

The purpose of the Abuse Prevention Review Team (APRT) is to make an accurate determination of the causes of sexual assaults and unnecessary deaths, such as deaths related to abuse and/or neglect that occur in long-term care facilities, and to develop and implement measures to prevent future assaults or deaths. The teams conduct an in-depth, multi-disciplinary, and multi-agency review of cases where sexual assault is alleged and IDPH has determined the allegation to be valid or when an unnecessary resident death is investigated in conjunction with a complaint, incident, or annual survey.

Death cases referred by law enforcement, medical examiners, and coroners are also reviewed and tracked by the team. IDPH is responsible for ensuring that every death of a nursing home resident shall be reviewed by the IDPH region’s review team that has primary case management responsibility, if the deceased resident is one of the following:

• A person whose death is reviewed by IDPH during any regulatory activity, regardless of whether there were any federal or state violations
• A person whose care IDPH received a complaint about alleging that the resident’s care violated federal or state standards that contributed to the resident’s death
  
• A resident whose death is referred to IDPH for investigation by a local coroner, medical examiner, or law enforcement agency
  

Procedures have been established for tracking confirmed sexual assaults and unnecessary deaths, obtaining death certificates, and developing a database, as outlined in the Abuse Prevention Review Team Act (210 ILCS 28).

The Abuse Prevention Review Team Act (210 ILCS 28) mandates that “the Director, in consultation with the Executive Council and with law enforcement agencies and other professionals who work in the field of investigating, treating, or preventing nursing home resident abuse or neglect in the state, shall appoint members to two residential health care facility resident sexual assault and death review teams.” There are representatives from medical, nursing, social services, legal, law enforcement, ombudsman, and coroner to review confirmed or alleged cases of sexual assault and unnecessary deaths of nursing home residents. The agencies represented include IDPH, Illinois State Police, state’s Attorney’s office, Office of the Attorney General, and the Illinois Department of Financial and Professional Regulation. The members are appointed for a two-year term and are eligible for reappointment upon the expiration of the term. These team members volunteer their time and receive no compensation.

There are two review teams that meet quarterly. The northern team reviews deaths and sexual assault cases that occurred in facilities in the geographic area primarily north of Interstate 80. The southern team reviews sexual assault and death cases that occurred in facilities in the geographic area south of Interstate 80. However, in 2020, only three of the scheduled eight meetings were held due to COVID-19.

Placement of monitors is allowed through the Nursing Home Care Act (25 ILCS 45), the MC/DD Act (210 ILCS 46), and the ID/DD Community Care Act (210 ILCS 47), or as authorized by federal Centers for Medicare & Medicaid. IDPH may place a monitor in a facility under any of the following conditions:

• The facility is operating without a license.
• IDPH has suspended, revoked, or refused to renew the existing license of the facility.
  
• The facility is closing or has informed IDPH that it intends to close and adequate arrangements for the relocation of residents have not been made at least 30 days prior to closure.
  
• IDPH determines that an emergency exists, regardless of whether it has initiated revocation or nonrenewal procedures. Emergency means a threat to the health, safety, or welfare of a resident that the facility is unwilling or unable to correct (e.g., residents are being abused).
  

Section 300.270 b) of the Skilled Nursing and Intermediate Care Facilities code requires that a monitor must:

• Be in good physical health.
• Understand the needs of long-term care facility residents as evidenced by one year of experience in working, as appropriate, with elderly or developmentally disabled individuals in programs such as patient care, social work, or advocacy.
  
• Understand the act and this part that are the subject of the monitors’ duties as evidenced in a personal interview of the candidate.
  
• Not be related to the owners of the involved facility either through blood, marriage, or common ownership of real or personal property, except ownership of stock that is traded on a stock exchange.
  
• Have successfully completed a baccalaureate degree or possess a nursing license or a nursing home administrator’s license.
  
• Have two years full-time work experience in the Illinois long-term care industry.
  

The monitor (under the supervision of IDPH) will:

• Visit the facility as directed by IDPH.
• Review all records pertinent to the condition for which the monitor was placed.
  
• Provide IDPH with written and oral reports detailing the observed conditions of the facility.
  
• Be available as a witness for hearings involving the condition that resulted in their placement as a monitor.
  

The frequency of the monitor visits is based on the severity of violations and/or deficiencies cited. This frequency can be increased or decreased depending upon the facility’s progress and the correction of identified issues.

In 2021, no external monitors were placed in a facility licensed to provide intermediate and/or skilled care services. Monitor reports are critical components of IDPH’s ongoing effort to stay in touch with the day-to-day activities occurring in the monitored facilities and IDPH surveyors frequently serve as monitors in facilities with ongoing deficiencies and regulatory non-compliance. The reports are shared upon request with other state agencies in determining ongoing compliance and potential criminal issues.

The Nursing Home Care Act authorizes IDPH to investigate any location reasonably believed to be operating as a long-term care facility without a license. IDPH is made aware of these types of locations, as they are the subject of complaint investigations. When a location is found to be in violation for the first time, the owner is offered an opportunity to comply with the Nursing Home Care Act. If the owner fails to comply or is found to be in violation more than once, the location is then referred to the Office of the Attorney General for prosecution. In 2021, there were nine unlicensed complaints filed. A comparison of 2020 and 2021 of these activities is provided below.

The Nursing Home Care Act and Abused and Neglected Long-Term Care Facility Residents Reporting Act require allegations of suspected abuse, neglect, or misappropriation of a resident’s property by nurse aides, developmental disabilities aides, and certified child care-habilitation aides (hereafter referred to as aides) be reported to IDPH. The reports and supporting documentation are reviewed by the Abuse, Neglect, and Theft Committee. The decision to proceed with the case must be made by a majority vote.

Allegations of abuse, neglect, or misappropriation of property by aides are received by IDPH through incident reports, complaints, and survey results. Documentation from incident reports, complaint investigations, police reports, court records, and any additional information requested from the facility are reviewed to determine whether there is substantial evidence to proceed in pursuing an administrative finding on the alleged abuse, neglect, or misappropriation of a resident’s property.

If IDPH finds that there is substantial evidence to validate the allegation, the aide is sent a Notice of Finding via certified mail, which outlines the allegation and includes information on the right to a hearing to contest the finding or submit a written response to the fining in lieu of requesting a hearing. The aide has 30 days, from the date of the Notice of Finding, to request a hearing. If a hearing is requested and after the hearing the aide is found to have abused or neglected a resident or misappropriated resident property while working in a facility or if the aide does not request a hearing within 30 days of receiving the Notice of Finding, a final order is sent to the aide via certified mail.

The finding of abuse, neglect, or misappropriation is then designated on the Health Care Worker Registry together with a clear and accurate summary from the individual, if he or she chooses to make a statement. Long-term care facilities must develop and operationalize policies and procedures for:

• Screening and training of employees
• Screening of residents and families
  
• Protection of residents
  
• The prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and the misappropriation of property to prevent occurrences of abuse, neglect, and theft
  
• Providing a safer environment for residents
  

A memorandum is in place from CMS with guidance to state survey agencies (SA) of the regulatory requirement to share ASPEN Complaint Tracking System (ACTS) data, Long-Term Care Minimum Data Set (MDS) data, and survey documents with the state Medicaid Fraud Control Units (MFCU). ISP/MCFU investigators are more involved in IDPH investigations, which promotes cross-training of IDPH surveyors and ISP/MFCU investigators. IDPH maintains a growing relationship with local law enforcement, state’s attorneys, the FBI, and coroners. IDPH staff has attended association meetings, conferences, and informational one-on-one meetings to respond to issues and to concerns about preventing abuse and neglect in long-term care facilities. Because of the relationships, awareness of the problem of abuse, neglect, and theft in long-term care facilities has increased. Another benefit is local law enforcement officials are aware of the regulatory requirements of long-term care facilities and are becoming more comfortable interacting with providers.

In 2021, 322 incidents and complaints of abuse/neglect, theft, and/or fraud were referred by the Special Investigations Unit to ISP/MFCU. Thirty-seven reports were then reviewed by ISP/MFCU to determine which to investigate for possible criminal action. Of these, ISP/MFCU requested documents from 34 complaint/incident investigation packets to support and/or close their case(s).

State law requires long-term care facilities (LTCF) to conduct a criminal background check within 24 hours on newly admitted residents to assess whether they have been convicted of any felony offense, are registered or convicted sex offenders, are serving a term of parole, on mandatory supervised release, or on probation for a felony offense.

The Illinois State Police (ISP) and the Illinois Department of Corrections (DOC) sex offender websites are also to be utilized on new admissions to determine if the individual is a registered sex offender. If the background checks results are inconclusive, the facility is required to conduct a fingerprint-based check by a licensed fingerprint vendor. In the event of a resident’s poor health or lack of potential risk, the facility may apply for a waiver of the fingerprint background check.

For each resident with a qualifying offense, the facility submits a referral packet to the IDPH Identified Offenders Program for tracking and referral to ISP. IDPH collaborates with the ISP, which completes a criminal history report, and a forensic psychologist, who provides an identified offender report and recommendation. The identified offender report and recommendation are incorporated into the identified offender’s individual care plan. Convicted or registered sex offenders must reside in private rooms.

IDPH maintains a secure database of LTCF residents determined to be identified offenders. In 2020, there were a total of 2,275 unique identified offenders recorded as residing in a LTCF at some point during the year. While the reports from facilities may not be flawless, these data provide an indication of the volume of identified offenders receiving care in a LTCF.

IDPH also tracks waivers that are requested, granted, or denied. A waiver is granted if the resident is completely immobile as verified by a signed physician statement or has the existence of a severe, debilitating physical, medical, or mental condition that nullifies any potential risk. Once the request for the waiver is reviewed, a determination letter is sent to the facility. This waiver is valid only while the resident is immobile and the documentation supporting the criteria for the waiver exists. In 2021, there were 72 fingerprint waiver requests approved and eight denied.

In 2015, the General Assembly passed, and the governor signed into law Public Act 99-180 (210 ILCS 46). This act provides for the licensure of facilities for the medically complex for the developmentally disabled. With this act, long-term care facilities that serve an under age 22 population were removed from the ID/DD Community Care Act.

In 1994, responsibility for the Inspection of Care (IOC) was transferred to IDPH from the Illinois Department of Healthcare and Family Services (HFS). The IOC program is a federally mandated reimbursement activity in which field reviews are conducted at intermediate care facility/individual intellectually disabled (ICF/IID) facilities. The purpose of the reviews is to determine if Medicaid-reimbursed health care services are being carried out and to gather and to review data necessary to establish Medicaid reimbursement rates for each participating facility.

IDPH conducts annual and bi-annual certification/licensure surveys in ICF/IID facilities on a rolling basis. Of the 198 complaints received through the Nursing Home Hotline alleging failure to provide care in compliance with federal and state regulations, 102 were found to be substantiated and 96 were unsubstantiated.

The Specialized Mental Health Rehabilitation Act of 2013 (“SMHRA”) authorizes IDPH to license and survey long-term care facilities federally designated as institutions for mental disease (IMD) that specialize in providing rehabilitation services to individuals with serious mental illnesses (SMI). In FY21, there were 23 licensed SMHRFs in Illinois.

In 2014, Part 380 rules were adopted (Specialized Mental Health Rehabilitation Facilities Code). The six Subparts of Part 380 are general provisions, facility programs, program personnel, administration, support services and environment, and licensure requirements. The act and rule define four programs to serve consumers in different stages of illness: triage centers, crisis stabilization centers, recovery and rehabilitation support units, and transitional living units. IDPH conducts annual surveys at each SMHRF. In 2021, there were 276 complaint surveys conducted to investigate failure to provide care consistent with the regulations; 42 were found to be substantiated and 234 were found unsubstantiated.

The division has regulatory authority for 534 licensed establishments under the Assisted Living and Shared Housing Act (210 ILCS 9). Assisted living establishments provide community-based residential care for at least three unrelated adults (at least 80% of whom are 55 years of age or older) who need assistance with activities of daily living, including personal, supportive, and intermittent health-related services available 24-hours per day to meet the scheduled and unscheduled needs of each resident.

Division staff conduct annual licensure surveys, complaint surveys, incident report investigations, and follow up surveys. This is a state licensure program with no federal oversight as the residents of these establishments are private pay through a contractual agreement between the resident and the facility. Renewal applications and licensure fees are required annually for these providers. The number of establishments have continued to increase each year to meet the needs of aging baby boomers and oversight in anticipation of their need for care.

In 2021, 577 complaints alleging failure to comply with regulatory requirements were received and investigated. Of these investigated, 94 were substantiated and 483 were unsubstantiated. There were 23,856 incident and accident reports submitted and reviewed by IDPH. The total fines collected due to non-compliance with code rules for annual and complaint surveys was $194,700, which reflects a more aggressive use of enforcement activities aimed in ensuring sustained regulatory compliance and quality of care.

The long-term care administrative rules, which are maintained by the Division of Administrative Rules and Procedures (ARP), fall under the authority of six acts. Three sets of rules are under the authority of the Nursing Home Care Act, one rule is under the authority of the ID/DD Community Care Act, one rule is under the authority of the MC/DD Act, one rule is under the authority of the Specialized Mental Health Rehabilitation Act of 2013, one rule is under the authority of the Community Living Facilities Act, and one rule is under the authority of the Assisted Living and Shared Housing Act (see Appendix A). ARP also administers the Health Care Worker Background Check Act and its set of rules and the Health Care Worker Registry (Registry). In 2021, ARP was comprised of 11 staff, including the division chief and an administrative assistant, one professional staff and clerical staff who are devoted solely to the registry, and two professional staff who work on administrative rules and legislative issues for OHCR.

• Responded to more than 71,000 telephone and email requests for assistance and information regarding the Health Care Worker Registry.
• Added 146,789 new criminal background checks to the registry.
  
• Added 11,115 Certified Nursing Assistants (CNAs) to the registry.
  
• Added 3,958 Direct Service Personnel (DSP) to the registry.
  
• Added administrative findings for abuse, neglect, or theft for 69 health care workers to the registry.
  
• Processed 1,418 requests for the waiver of criminal convictions.
  
• Worked with staff from the IDPH Office of Preparedness and Response (OPR), along with their outside contractor and IDPH Information Technology staff, to provide up-to-date information on active CNAs. OPR is using the contractor to maintain a volunteer management system (Illinois Helps) that allows medical and non-medical volunteers to register. OPR matches volunteers listed as CNAs to the Health Care Worker Registry to verify certification. Twice-monthly updates to Illinois Helps began in April 2021.
  
• Provided training to other state surveying agencies to increase providers’ compliance with the Health Care Worker Background Check Act.
  
• Adopted numerous emergency rules and emergency amendments to the long-term facilities codes in response to the COVID-19 pandemic.
  
• Adopted permanent amendments to Skilled Nursing and Intermediate Care Facilities Code.
  
• Adopted a new Part, 77 Ill. Adm. Code 389, Authorized Electronic Monitoring in Long-Term Care Facilities Code.
  

The Division of Administrative Rules and Procedures staff works with program staff to identify necessary amendments for long-term care administrative rules, to address new or revised statutory requirements, to identify best practices, and to address industry requests that have been proposed through the Long-Term Care Facilities or DD Facility Advisory boards. During 2021, ARP and program staff worked on proposed amendments to the Skilled Nursing and Intermediate Care Facilities Code to address requirements pursuant to Public Acts 100-99, 100-293, 100-297, 100-432, 99-367, 100-1042, and 102-0004; infection prevention and control requirements; and other updates to align the code with statute. Amendments were also proposed to address requirements pursuant to Public Act 102-0004 in the Sheltered Care Facilities Code and Illinois Veterans' Homes Code. In addition to these proposed amendments, ARP staff worked on a variety of emergency amendments and emergency rules to authorize suspension of certain requirements and include new requirements in various long-term care administrative rules in response to the COVID-19 pandemic.

COVID-19 emergency amendments and rules adopted during time frame covered in this report include:

• Temporary Nursing Assistants – 77 Ill. Adm. Code 395.
• Military and out-of-state CNA requirements - 77 Ill. Adm. Code 395.
  
• Suspension of requirement that CNA be active on Health Care Worker Registry; military and out-of-state CNAs - 77 Ill. Adm. Code 955.
  
• Infection control/COVID-19 testing in long-term care facilities:
  
  • 77 Ill. Adm. Code 295
  • 77 Ill. Adm. Code 300
  • 77 Ill. Adm. Code 330
  • 77 Ill. Adm. Code 340
  • 77 Ill. Adm. Code 350
  • 77 Ill. Adm. Code 370
  • 77 Ill. Adm. Code 380
  • 77 Ill. Adm. Code 390
• COVID-19 training requirements:
  • 77 Ill. Adm. Code 295
  • 77 Ill. Adm. Code 300
  • 77 Ill. Adm. Code 330
  • 77 Ill. Adm. Code 340
  • 77 Ill. Adm. Code 350
  • 77 Ill. Adm. Code 370
  • 77 Ill. Adm. Code 380
  • 77 Ill. Adm. Code 390
• COVID-19 vaccination requirements:
  • 77 Ill. Adm. Code 295
  • 77 Ill. Adm. Code 300
  • 77 Ill. Adm. Code 330
  • 77 Ill. Adm. Code 350
  • 77 Ill. Adm. Code 370
  • 77 Ill. Adm. Code 380
  • 77 Ill. Adm. Code 390

The Health Care Worker Registry (HCWR) Section’s principal responsibility is to provide information to health care employers about unlicensed health care workers, including certified nursing assistant (CNA) certification; CNA administrative findings of abuse, neglect or theft; criminal background checks; disqualifying convictions; waivers that allow an exception to the prohibition of employment when there is a disqualifying conviction; and developmentally disabled aide training. The HCWR Section provides application forms and instructions needed to assist health care workers seeking to be a nurse aide in Illinois or who are seeking to be granted a waiver for disqualifying convictions that are revealed on an Illinois background check. The HCWR Section further supports the registry, which has a public and a private website, by staffing a call center and responding to email inquiries.

In 2021, the HCWR staff handled more than 18,000 telephone calls, and more than 53,000 email requests for assistance and information regarding the Health Care Worker Registry. Health care employers who are licensed or certified as long-term care facilities must check the registry before employing a non-licensed individual who will have or may have contact with residents or have access to the resident’s living quarters and access to resident’s financial, medical, or personal records. For the facility to hire the individual, a fingerprint-based fee applicant (Fee-App) background check must be conducted by an approved IDPH Livescan vendor. The individual may not work with disqualifying convictions unless the individual has been granted a waiver of those convictions. If the individual is to be hired as a CNA, the facility must verify the individual has met proper training and competency test requirements. The individual cannot have any administrative findings of abuse, neglect, or theft.

Once a Fee-App background check is in place for an individual on the registry, the Illinois State Police automatically sends any new convictions to the registry. If a new disqualifying conviction is received for an individual working on a waiver, the waiver is automatically revoked and the facility is notified that the person must be terminated.

The public can check the registry at https://hcwrpub.dph.illinois.gov/Search.aspx or by calling the toll-free number (1-844-789-3676). Health care employers can access IDPH’s HCWR Web Portal at http://portalhome.dph.illinois.gov.

The Nursing Home Care Act and the Abused and Neglected Long-term Care Facility Residents Reporting Act require allegations of suspected abuse, neglect, or misappropriation of a resident’s property by CNAs, DD aides, and habilitation aides be reported to IDPH. After these allegations have been investigated and processed through an administrative hearing, those who have a final order of abuse, neglect, or theft are published on the registry. For 2021, there was a total of 69 administrative findings – 53 of abuse, four of neglect, two of misappropriation of property, and 10 of financial exploitations.

IDPH licenses the following health care employers:

• Community living facilities
• Life care facilities
  
• Long-term care facilities
  
• Home health agencies, home services agencies, or home nursing agencies
  
• Hospice care programs or volunteer hospice programs
  
• Sub-acute care facilities
  
• Post-surgical recovery care facilities
  
• Children’s respite homes
  
• Freestanding emergency centers
  
• Hospitals
  
• Assisted living and shared housing establishments
  

The Health Care Worker Background Check Act requires unlicensed direct care employees hired by health care employers to have a fingerprint-based criminal history records check.

In addition, each long-term care facility must initiate a fingerprint-based criminal history records check for unlicensed employees with duties that involve or may involve contact with residents or access to the resident’s living quarters, or the financial, medical or personal records of residents.

If a criminal history records check indicates a conviction of one or more of the offenses enumerated in Section 25 of the act, the individual shall not be employed from the time the employer receives the results of the background check until the time the individual receives a waiver if one is granted by IDPH. An individual may request a waiver by completing a waiver application, providing a written explanation of each disqualifying conviction, providing documentation relating to payment of fines or completion of probation, and providing other relevant information.

IDPH will evaluate the information submitted with the waiver application and decide to grant or deny the waiver. The goal in evaluating waivers is to continue the prohibition of employment, imposed by the act, of those individuals who might pose a threat to the state’s most vulnerable citizens. When specific criteria are met, the individual may be granted a rehabilitation waiver automatically without submitting a waiver application. A waiver is revoked if an individual is convicted of a new disqualifying offense.

The following table depicts the number of background checks and waiver requests performed and/or granted in 2020-2022.

The Division of Life Safety and Construction (LSC) is made up of two sections – Design and Construction and Field Services. The Design and Construction Section conducts plan reviews and project inspections of licensed and certified health care facilities which includes investigations regarding complaints or incidents. The LSC also conducts federal surveys for the Centers of Medicare & Medicaid Services (CMS) for all non-long-term care facilities. The Field Services Section conducts annual life safety code surveys of certified Long-Term Care (LTC) facilities for CMS, as well as initial certification surveys and complaint/incident investigations.

The division’s web page contains information on forms and rules for ambulatory surgical treatment center’s (ASTC) licensure, hospital licensure, and nursing home licensure as it relates to the LSC. The link to Frequently Asked Questions, and Policies and Procedures can be found in Appendix D of this report.

Due to the COVID-19 pandemic, the division was limited to making only three life safety code presentations over the last year. Presentations were made virtually to the American Institute of Architects – Chicago, assisted living provider association, and the Hospital Engineers Association. The division chief participated, as a principal al voting member, in four National Fire Protection Association (NFPA) code development meetings that were held virtually. The NFPA meetings develop policy for upcoming code cycles that have been adopted by both CMS and the state of Illinois. IDPH has had representation on these committees for more than 16 years.

With the ongoing COVID-19 pandemic, health care construction and renovations projects for calendar year 2021 are below what would be normally expected in a non-COVID-19 year. Due to the moderate increase in project submissions to the division, plan review fees and project reviews saw a small increase for the 2021 calendar year.

The Facility Plan Review Fund allows IDPH to charge a fee for facility plan reviews. The Nursing Home Care Act (NHCA) and the Ambulatory Surgical Treatment Center Act (ASTCA) require a fee for major construction projects with an estimated cost greater than $100,000, while the Hospital Licensing Act (HLA) requires a fee for major construction projects with an estimated cost greater than $500,000. The cost difference between fees paid for plan review and the dollar amount required to support the division is made up by the state General Revenue Fund (GRF).

The Nursing Home Care Act, Hospital Licensing Act, and Ambulatory Surgical Treatment Center Act require a plan review to be completed within 30 days (design development drawings) and 60 days (working drawings) once the drawings have been submitted. Most projects require onsite inspections prior to use or occupancy. These inspections must be completed within 15 working days to 30 calendars days after acceptance of the facility’s project completion certifications, depending on facility type. Many projects require onsite inspections by architectural, mechanical, electrical, and clinical disciplines.

Life safety code surveyors have been fitted with the proper personal protective equipment (PPE) and the division is able to perform federal surveys and conduct onsite project inspections. Additionally, many health care facilities have modified their facilities, on a temporary basis, to safely house or treat the influx of COVID-19 patients. The division was instrumental in reviewing and approving the providers plans and safety requirements for these temporary COVID-19 units.

Life Safety and Construction completed plan reviews for provider submitted modifications of the physical environment for upgrading sheltered and intermediate care beds to skilled care beds. The division was able to issue a desk approval for many of these modifications without conducting an onsite inspection. This temporary process has aided many facilities to expedite the opening of temporary bed space during the COVID-19 pandemic.

FSS is responsible for conducting the required life safety code portion of the annual nursing home certification surveys and life safety code complaint surveys on behalf of the Centers for Medicare & Medicaid Services. In 2021, the FSS section conducted 915 annual surveys, completed 681 facility desk audit reviews, two complaint investigations, and three incident reviews. The FSS cited 7,872 federal deficiencies during the 915 annual surveys.

In 2021 there were two fire incidents reported to IDPH. One death was reported due to a portable liquid oxygen container exploding. Additional data on those incidents are provided below: