Section 2060.100  Purpose

 

The purpose of this Part is to:

 

a)         Authorize establishment of a comprehensive and coordinated continuum of intervention and treatment services, sensitive to the needs of local communities, for persons with or at risk for substance use disorders (SUDs).

 

b)         Effectuate the role of the Illinois Department of Human Services, Division of Substance Use Prevention and Recovery, hereafter referred to as DHS/SUPR, as the federally-recognized Single State Authority with statutory mandates to plan, license, and regulate substance use disorder intervention and treatment organizations.

 

c)         Promote the availability of culturally-relevant, evidence-based, developmentally- appropriate, trauma-informed care and substance use disorder services through the implementation of standardized criteria that foster and support multiple pathways to recovery.

 

d)         Establish regulations for licensure of substance use disorder intervention and treatment organizations, including organizations focused on harm reduction and opioid use disorder treatment.

 

e)         Monitor and help enforce federal guidelines and regulations for the treatment of opioid use disorders and to serve as the lead agency for such treatment in cooperation with the Federal Drug Enforcement Administration (DEA) and the Federal Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment.

 

Section 2060.110  Applicability

 

a)         This Part shall apply to persons engaged in substance use disorder treatment and intervention as defined in and authorized by the Illinois Substance Use Disorder Act [20 ILCS 301/15-5], hereafter referred to as the Act.  If any applicable federal law or regulation is less restrictive than rules in this Part, the more restrictive provisions shall apply.

 

b)         It is unlawful for any persons, other than those specified in the Act, to provide substance use disorder intervention and treatment services as defined in the Act and further defined in this Part unless the person is licensed to do so by DHS/SUPR.  The performance of these activities by any person, in violation of the Act, is declared to be harmful to public health and welfare, and to be a public nuisance.  DHS/SUPR may undertake investigations, as specified in Section 2060.210, to determine if intervention or treatment services are being conducted without the requisite license. [20 ILCS 301/15-5(a)]

 

c)         Incorporations by Reference

Any rules or regulations of an agency of the United States or of a nationally recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified, and do not include any later amendments or editions.

 

Section 2060.120  Definitions

 

Act – The Substance Use Disorder Act [20 ILCS 301].

 

Admission – Acceptance of a person into an intervention or treatment service, after completion of intake, assessment for a diagnosis and placement into a level of care, and after the person has given written informed consent for treatment, has been accepted for, and begins such treatment.

 

Adolescent – A person who is at least 12 years of age and under 18 years of age. For purposes of admission to adolescent treatment, a person between the ages of 18 and 22 may be admitted if the assessment includes justification based upon the person's behavior, life experience, and developmental appropriateness.

 

Adult – A person who is 18 years of age or older. For purposes of admission to adult treatment, adolescents who are 16 and 17 may be admitted if the assessment includes justification based upon the adolescent's behavior, life experience, and developmental appropriateness.

 

Alcohol and Drug Evaluation Uniform Report – The form, mandated by DHS/SUPR and produced from the electronic Driving Under the Influence (DUI) Services Reporting System (eDSRS), required to report a summary of the DUI evaluation to an Illinois Circuit Court or the Illinois Office of the Secretary of State.

 

The American Society of Addiction Medicine (ASAM) Criteria – Defined national standards for level of care placement, dimensional admission, treatment planning and assessment, continued services and transfer criteria for patients with substance use and co-occurring conditions that organize substance use treatment services into discrete and standardized levels of frequency and intensity across a continuum, as developed by the American Society of Addiction Medicine and documented in "The ASAM Criteria Third Edition: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions" (2013), available through the American Society of Addiction Medicine, 11400 Rockville Pike, Suite 200, Rockville, MD  20852. Effective July 1, 2025, the ASAM Criteria documented in "The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Fourth Edition" (2023), available through the American Society of Addiction Medicine, 11400 Rockville Pike, Suite 200, Rockville, MD  20852 shall be used for adult services licensed under this Part.

 

Assessment – The process of collecting and professionally interpreting data, from a person, significant other, and other collateral sources, about substance use and its consequences as a basis for establishing or ruling out a diagnosis in accordance with the DSM-5.  Assessment, utilizing the ASAM criteria, is also used to determine the severity of the disorder and identification of the appropriate level and intensity of substance use disorder treatment as well as needs for other services.  Assessment is on-going throughout treatment and is also used to make continued service and discharge recommendations.  Assessment is conducted by professional staff, as defined in Section 2060.320, of an DHS/SUPR licensed treatment organization.

 

Authorized Organization Representative – A person designated by the organization as the authority for the management, control, and operation of all services relative to each license.  This person is the primary recipient of communication from DHS/SUPR relative to the issued license and is responsible for the dissemination of those communications across the organization.

 

Biomedical – Biological and physiological aspects of a person's condition that require a physical health assessment and medical services.  In substance use disorder treatment, biomedical problems may be the direct result of a substance use disorder or be independent of and interactive with a disorder, thus affecting the total treatment plan and prognosis.

 

Case Management – A coordinated approach to the delivery of health and medical treatment, substance use disorder treatment, mental health treatment, and social services, linking patients with appropriate services to address specific needs and achieve stated goals.  In general, case management assists patients with other disorders and conditions that require multiple services over extended periods of time and who face difficulty in gaining access to those services. [20 ILCS 301/1-10]

 

Centers for Disease Control and Prevention (CDC) – the national public health agency of the United States under the Department of Health and Human Services. The mission of the CDC is centered on preventing and controlling disease and promoting environmental health and health education in the United States.

 

Client – A person who receives DUI evaluation, DUI risk education, and designated program services as defined in Sections 2060.510 through 530, or who receives early intervention services as defined in Section 2060.405.

 

Clinical Supervision – The dedicated time that professional staff as defined in Section 2060.320 spend with a supervisor or with supervisees discussing preparation for or performing clinical work.  Clinical supervision is the administrative, clinical, and evaluative process of monitoring, assessing, and enhancing clinical practice performance.  Clinical supervision shall be delivered in accordance with all other provisions specified in Section 2060.325.

 

Clinical Treatment – Substance use disorder treatment provided by professional staff, as defined in Section 2060.320, that includes assessment, individual or group counseling, treatment planning, continued service reviews, and recovery/discharge planning.  The organization may also determine that other specified activities require the services of professional staff.

 

Continuing Care Plan – A plan developed with the patient prior to discharge that identifies recommended activities, referrals, and other recovery support that will reinforce and enhance progress, to date.

 

Continuum of Care – A structure of interlinked treatment services, either offered by one organization or through referral to other organizations, that is designed to meet changing needs as the patient transitions through treatment and recovery.

 

Department – The Department of Human Services (DHS), Division of Substance Use Prevention and Recovery (SUPR).

 

Developmentally Appropriate – Treatment placement and services that reflect chronological, emotional, and psychological age and that address potential long-term deficits in developmental, psychological, and social growth that may have been compromised due to a substance use disorder.

 

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) – A book published by the American Psychiatric Association (APA) to help mental health providers diagnose mental disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DSM-5 (2022), is available through the American Psychiatric Association, 800 Maine Avenue, SW, Suite 900, Washington, DC  20024.

 

Director – The Director of the Department of Human Services, Division of Substance Use Prevention and Recovery (DHS/SUPR).

 

Disaster – Any human-made or natural event, such as a flood, tornado, fire, infectious disease outbreak, pandemic, shooting, or act of terrorism, that results in the interruption of organization operations or inability of the organization to continue operating or to temporarily relocate or close.

 

Discharge – When services are terminated either by successful completion or some other action initiated by the person or the organization.

 

Drunk and Drugged Driving Prevention Fund (DDDPF) – A special State Treasury fund, from which monies shall be appropriated to the Department and expended to reimburse licensed DUI evaluation and risk education programs for the costs of providing DUI offenders who are unable to pay for these services with free or reduced-cost services. Monies in the Drunk and Drugged Driving Prevention Fund may also be used to enhance and support regulatory inspections and investigations conducted by the Department. [20 ILCS 301/50-20]

 

DUI – Driving under the influence of alcohol, other drugs, or a combination thereof, as defined in the Illinois Vehicle Title and Registration Law [625 ILCS 5] or a similar provision of a local ordinance.

 

DUI Evaluation – The service provided to a person relative to a DUI that determines the nature and extent of the use of alcohol and/or other drugs as required by the Unified Code of Corrections [730 ILCS 5/5-4-1] and Section 11-501.01 of the Illinois Driver Licensing Law [625 ILCS 5/11-501.01] and in accordance with all requirements in Section 2060.510.

 

DUI Risk Education – Alcohol and other drug education services recommended for a minimum or moderate risk classification as determined by a DUI Evaluation and in accordance with all requirements in Section 2060.520.

 

Early Intervention – ASAM Level 0.5 services that are sub-clinical and pre-diagnostic and that include a written plan designed to further identify and address risk factors that may be related to problems associated with substance use or that may lead to a substance use disorder.  Early intervention assists persons in recognizing harmful consequences, facilitates emotional and social stability, and includes referrals for higher levels of care, when necessary.

 

Electronic DUI Service Reporting System (eDSRS) – The DHS/SUPR web-based application designed to generate the Alcohol and Drug Evaluation Uniform Report and other forms and reports associated with DUI evaluation or DUI risk education for individuals who have violated Illinois laws relative to driving under the influence of alcohol or other drugs.  The eDSRS also summarizes all evaluation and risk education statistics and submits bills for reimbursement from the DDDPF.

 

Episode of Care – The period of service between admission for and discharge from substance use disorder treatment.  If a patient is transferred between levels of care, as a part of continuous treatment within the same organization, this is still considered part of the same episode of care.

 

Evidence-Based – A process that incorporates an objective, balanced, and responsible use of current research and the best available data to guide policy and practice decisions with the goal of improving service outcomes. 

 

Facility – Means the building or premises that are used for the provision of licensable services, including support services, as set forth by rule.

 

Good Standing – The designation given by DHS/SUPR to an organization that has demonstrated ability to meet all applicable requirements specified in this Part.

 

Harm Reduction – An evidence-based approach that engages with people who use substances and equips them with life-saving tools and information to create a positive change and potentially save their lives.

 

Illinois Certification Board, Inc. (ICB) – The organization that issues a credential to professionals seeking to provide DHS/SUPR licensable substance use disorder intervention and treatment services.  This organization is also known as the Illinois Alcoholism and Other Drug Abuse Professional Certification Association (IAODAPCA).

 

Individualized Treatment – Care that is person-centered and collaboratively designed to meet a particular patient's needs and preferences guided by services that are directly related to a specific, unique patient assessment.

 

Infectious Disease – As defined by the Illinois Department of Public Health, an "Infectious Disease" is a disease caused by a living organism or other pathogen, including a fungus, bacteria, parasite, protozoan, prion, or virus. An infectious disease may, or may not, be transmissible from person to person, animal to person, or insect to person.  (See 77 Ill. Adm. Code 690.10).

 

Informed Consent – Legally valid written consent, given by a client, patient or legal guardian, that authorizes intervention or treatment services from a licensed organization and that documents agreement to participate in those services and knowledge of the consequences of withdrawal from such services.  Informed consent also acknowledges the person's right to a conflict-free choice of services from any licensed organization and the potential risks and benefits of selected services. [20 ILCS 301/1-10]

 

Intern – A paid or unpaid person working under a clinical supervisor in a licensed substance use disorder treatment organization in order to obtain the necessary experience required for the professional staff credentials as specified in Section 2060.320.

 

Intervention – Categories of service authorized by an intervention license are DUI evaluation, DUI risk education, designated program, and recovery homes for persons in any stage of recovery from a substance use disorder.

 

Medication Assisted Recovery (MAR) – The use of evidence-based FDA-approved medications (e.g., methadone, buprenorphine, naltrexone, disulfiram, acamprosate, or other medications) for persons with a substance use disorder who are recovery focused.  MAR recognizes that persons who are on medications for treatment of their SUD and who identify as in recovery are in recovery since often these medications are prescribed long term and are used after the acute phase of the disease. MAR encompasses the use of medications that may be administered in conjunction or not in conjunction with SUD psychosocial or recovery supports.

 

National Fire Protection Association Life Safety Code (NFPA 101) – A standard that establishes minimum requirements for building safety.  It is used to protect people from fire, smoke, and toxic fumes.  It applies to nearly all types of occupancies and structures, including residential, business, mercantile, healthcare, daycare, and assembly occupancies. The NFPA 101, Life Safety Code (2015) may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  02169

 

Organization – Any public or private agency, person, association, corporation, or other unit of State or local government acting individually or as a group that applies for or obtains licensure to operate one or more substance use disorder intervention or treatment services.

 

Patient – A person who receives a substance use disorder treatment service as defined in this Part from an organization licensed under this Part.

 

Personal Protective Equipment – Gloves, face masks, soap, disinfectants, towels, or other items necessary to protect staff and clients/patients/residents from or during an infectious disease outbreak.

 

Physician – A person licensed to practice medicine in all its branches pursuant to the Medical Practice Act of 1987 [225 ILCS 60].

 

Policies and Procedures – Written guidelines that outline the organization's plan for addressing an identified mandate or issue.  Policies communicate the connection between the organization's vision and values and its day-to-day operation.  A procedure explains a specific action plan for carrying out a policy.

 

Recovery – means a process of change through which individuals improve their health and wellness, live a self-directed life, and reach their full potential. [20 ILCS 301/1-10]

 

Recovery Support – means services designed to support individual recovery from a substance use disorder that may be delivered pre-treatment, during treatment, or post treatment. These services may be delivered in a wide variety of settings for the purpose of supporting the individual in meeting his or her recovery support goals. [20 ILCS 301/1-10]

 

Recovery Home – Recovery-oriented supportive housing, authorized by an DHS/SUPR intervention license, whose peer-led services, activities, and structured operations are directed toward maintenance of recovery for persons recovering from a substance use disorder.

 

Reoccurrence – A process in which a person, who has established recovery, experiences a recurrence of signs and symptoms of active substance use, often including resumption of the pathological pursuit of reward and/or relief through use of substances and other behaviors.  With reoccurrence, there is often disengagement from recovery activities.  Reoccurrence has historically been referenced as relapse.

 

Resident – A person who receives services in a recovery home authorized by an intervention license and in accordance with all standards referenced in Section 2050.540.

 

Residential Treatment – Organized treatment services that include a planned and structured regimen of care in a 24-hour residential setting.  Residential services exist on a continuum ranging from least intensive to the most intensive medically monitored service.  The ASAM levels of care licensed by DHS/SUPR as residential treatment are Levels 3.1, 3.2, 3.5, and 3.7.

 

Revocation – The termination of a treatment or intervention license, or any portion thereof, by DHS/SUPR.

 

Risk – The designation, in the context of intervention services, assigned to a person who has completed an alcohol and drug evaluation after a charge for DUI that describes the person's probability of continuing to operate a motor vehicle in an unsafe manner.

 

Secretary – The Secretary of the Illinois Department of Human Services or the Secretary's designee. [20 ILCS 301/1-10]

 

Significant Other – The spouse, immediate family member, relative, or person who interacts most frequently with the client or patient in a variety of settings.

 

Substance Abuse and Mental Health Services Administration (SAMHSA) – Federal agency responsible for guidance to the State Substance Use and Mental Health Authorities, including administration of the federal block grant, defining and identifying evidence-based practices, and translation of research to practice.

 

Substance Use Disorder (SUD) – means a spectrum of persistent and recurring problematic behavior that encompasses 10 separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and anxiolytics, stimulants, and tobacco, and other unknown substances leading to clinically-significant impairment or distress. [20 ILCS 301/1-10]

 

Support Staff – Any staff employed in a DHS/SUPR licensed organization that do not meet the requirements for professional staff as specified in Section 2060.320, but that have personal contact with SUD clients/patients/residents or their families as part of their employment responsibilities.

 

Toxicology – A chemical test that determines blood alcohol concentration (BAC) and/or a level of specified drug concentration.

 

Transfer – The process that occurs when a patient cannot, or is no longer eligible, to receive services at an organization or the movement of the patient from one level of care to another within the same organization.

 

Trauma – A result from an event, series of events, or set of circumstances experienced by a person as physically or emotionally harmful or life-threatening with lasting adverse effects on the person's functioning and mental, physical, social, emotional, or spiritual well-being.

 

Trauma-Informed Care (TIC) – A strength-based service delivery approach that focuses on understanding responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for organizations and survivors and that creates opportunities for survivors to rebuild a sense of control and empowerment.  Trauma-Informed Care recognizes the role trauma plays in the lives of clients/patients and seeks to shift the clinical perspective from "what's wrong with you" to "what happened to you" by recognizing and accepting symptoms and difficult behaviors as strategies developed to cope with trauma. 

 

Treatment – means the broad range of emergency, outpatient, and residential care (including assessment, diagnosis, case management, treatment, and recovery support planning) that may be extended to individuals with substance use disorders or to the families of those persons. [20 ILCS 301/1-10].

 

Volunteer – An individual working under administrative or clinical supervision in a licensed substance use disorder intervention or treatment organization.

 

Section 2060.200  Capacity and Organizational Readiness

 

a)         Organizations requesting licensure shall demonstrate sufficient capacity and fiscal, administrative, and organizational readiness to deliver SUD intervention or treatment services safely and effectively, and in a manner consistent with evidence-based and developmentally- and culturally-appropriate practices.

 

b)         To ensure compliance with this requirement, Policies and Procedures that document knowledge of and practical application of the rules herein are required upon application for licensure.  In addition, organizations shall demonstrate that the Medical Director, as applicable, and any other required professional staff are available and ready to begin delivering services on the date of licensure. DHS/SUPR may also interview key organization staff, review documentation, and/or conduct an on-site visit prior to licensure, to verify that the organization has the capacity and organizational readiness to obtain licensure.

 

c)         DHS/SUPR also requires, at the time of submission of the license application, an attestation that the applicant has read all applicable rules referenced in this Part.

 

Section 2060.205  Categories of Licenses

 

DHS/SUPR issues SUD intervention and treatment licenses to organizations as specified herein.  Any relocation of services attached to the license shall render such services as unlicensed and subject to the actions and penalties specified in Sections 2060.210 and 2060.265.  Licensed outpatient, DUI evaluation, DUI risk education, and designated program services can be delivered off-site without additional licensure if the services provided by the licensee do not exceed an average of 15 staff hours per week delivered at the same location.  Consistent with the rules herein, services may be provided to adults and adolescents.  Categories of licenses are as follows:

 

a)         Treatment:  A treatment license issued by DHS/SUPR authorizes SUD levels of care as specified in Sections 2060.405 and 2060.410.  The levels of care and populations (adult/adolescent) shall be specified on the license.

 

b)         Intervention:  An intervention license issued by DHS/SUPR authorizes one or more of the following services:

 

1)         DUI Evaluation:  Alcohol and drug use evaluation services for offenders charged with driving under the influence (DUI) offenses pursuant to the Illinois Vehicle Code [625 ILCS 5/11-501] or similar local ordinances that determine the offender's risk to public safety and make a subsequent corresponding recommendation for intervention to the Illinois courts or to the Office of the Secretary of State.

 

2)         DUI Risk Education:  Alcohol and drug risk education services for offenders charged with DUI offenses pursuant to the Illinois Vehicle Code [625 ILCS 5/11-501] or similar local ordinances.

 

3)         Designated Program:  Specialized case management that includes screening, assessment, engagement, referral, and monitoring services, pursuant to Article 40 of the Act, for criminal justice clients who qualify for diversion to SUD treatment instead of incarceration.

 

4)         Recovery Home:  Supportive housing with rules, peer-led groups, staff activities, and other structured operations directed toward support for and maintenance of recovery for persons in any stage of recovery from an SUD.

 

Section 2060.210  Unlicensed Practice

 

a)         Whenever DHS/SUPR determines that an unlicensed organization is engaging in or referring to themselves as an organization that delivers licensable services, as specified in Section 2060.205, it shall issue a letter ordering that organization to cease and desist from engaging in the activity.  The order to cease and desist shall specify the service or services that require licensure and shall include citation of relevant sections of the Act and this Part.

 

b)         The order to cease and desist shall be accompanied by notice that instructs the organization to submit written documentation to DHS/SUPR within 10 calendar days after receipt of the notice to support a claim that licensure is not required or that the organization is licensed or otherwise properly authorized to conduct the service.

 

c)         After the expiration of the 10-day period, if DHS/SUPR determines that the unlicensed organization is continuing to provide services that require licensure, the matter shall be referred to the appropriate State's Attorney or to the Office of the Attorney General for potential legal action against the unlicensed organization.

 

Section 2060.215  Application Forms

 

a)         An application for a new license, to relocate a facility, or to add an additional level of care or population to an existing license shall be made on forms supplied by DHS/SUPR. The application requires, at a minimum, a completed Substance Use Disorder Services Application for Intervention/Treatment License, and applicable attachments, which may include the following:

 

1)         IRS form W-9 and the letter from the IRS.

 

2)         Documentation from the Illinois Secretary of State or County Clerk, as applicable.

 

3)         Schedule A.

 

4)         If applicable, Board of Directors information.

 

5)         Organization Chart.

 

6)         Schedule E.

 

7)         Schedule L.

 

8)         Schedule C and documented proof of compliance with all applicable zoning and local building ordinances.

 

9)         If applicable, the most recent accreditation survey.

 

10)       Narrative description.

 

11)       For treatment services, as applicable, copies of linkage agreements.

 

12)       If applicable, for DUI evaluation and risk education only, copies of letters of agreement with circuit courts.

 

13)       For recovery homes only, copies of linkage agreements.

 

14)       For recovery homes only, copy of an operating budget.

 

15)       For recovery homes only, documentation of fire, hazard, liability and other insurance coverages appropriate to the administration of a recovery home.

 

16)       If applicable, a copy of the Medicaid Certification issued by the DHS Division of Mental Health pursuant to 59 Ill. Adm. Code 132.

 

17)       If applicable, proof of registration as a religious or charitable organization.

 

b)         The forms referenced in subsection (a) are obtained electronically at: http://www.dhs.state.il.us/OneNetLibrary/27896/documents/By_Division/OASA/2020/Substance_Use_Disorder_Services_Application.pdf.

 

c)         The application shall be signed by at least one representative vested with authority to act on behalf of the organization.

 

Section 2060.220  Application Fee

 

No application fee is required, except as specified in Sections 2060.260 and 2060.265.

 

Section 2060.225  Period of Licensure

 

a)         Each license issued by DHS/SUPR shall be effective for a maximum of three years.

 

b)         At any time during the licensure period, an additional treatment or intervention service for the site may be requested using the license application.

 

Section 2060.230  Authorized Organization Representative

 

a)         One person shall be designated by the organization as the authority for the management, control, and operation of all services relative to each license.  This person is identified as the authorized organization representative and is the primary recipient of communication from DHS/SUPR relative to the issued license and is responsible for the dissemination of those communications across the organization.

 

b)         The licensed organization shall notify DHS/SUPR, in writing, within 10 calendar days, of a new designation of the authorized organization representative, including their contact information: name, title, address, phone, and email address.

 

Section 2060.235  Ownership Disclosure Requirements/Organization Chart

 

a)         At the time of application, if the applicant is a for-profit organization, the names and addresses of all owners or controlling parties of the organization (whether they are persons, partnerships, corporate bodies, or subdivisions of other bodies) shall be fully disclosed, unless an owner or controlling party owns less than 5% stock.  This information shall also be required thereafter with each renewal application and shall be updated in the event of a change to this information during the licensure period. 

 

b)         At the time of application, if the applicant is a not-for-profit organization, there must be a Board of Directors and the name, e-mail address, and phone number of the Chair of the Board and all board members shall be disclosed.  This information shall also be required thereafter with each renewal application and shall be updated in the event of a change to this information during the licensure period. 

 

c)         At the time of application, and with each renewal application thereafter, the applicant shall submit a current organizational chart that indicates the management and operational structure of the organization.

 

d)         At the time of application, and with each renewal application thereafter, the applicant shall attest that no owner, operator, manager, or professional staff has had a federal registration to distribute or dispense methadone suspended or revoked, as applicable, or has had any governmental or professional license suspended or revoked relating to the operation of the organization or any licensed DHS/SUPR facility.

 

Section 2060.240  Application Processing/Review Requirements

 

a)         Upon receipt, DHS/SUPR will notify the organization regarding any error or omission on the application.  All requested information or corrections shall be submitted within 60 calendar days after such notification.  Failure to respond during this time-period will result in return of the application and termination of the process.

 

b)         DHS/SUPR may inquire about any data contained in the application when an examination discloses a disparity in the information in comparison to that on file with or received by DHS/SUPR concerning the organization, facility, staff, ownership, and/or board of directors.

 

c)         DHS/SUPR may, either before or any time after the issuance of a license, request that the organization obtain a life safety inspection by a licensed architect or request the cooperation of the State Fire Marshal, county health departments, local boards of health, or any other governing/regulatory organization to investigate, if DHS/SUPR is unable through its own resources to ascertain compliance with this Part.

 

d)         Prior to issuance of a license, DHS/SUPR may seek to verify that the physical, mental, and professional capability and integrity of management, ownership, and professional staff will assure that the applicant can deliver services with reasonable judgment, skill, and safety.  To make this determination, DHS/SUPR may consider, but is not limited to, the following:

 

1)         A verbal interview with management, medical, or professional staff;

 

2)         The accuracy of submitted information;

 

3)         Prior criminal conduct by personnel;

 

4)         Prior violations of this Part or any other DHS/SUPR rule by the organization or by personnel either as current employees of the organization or as employees of any other organization that has held or holds a license from DHS/SUPR;

 

5)         Evidence of emotional, psychological, or physical impairment which may substantially interfere with the provision of services due to a lack of understanding of the rules and regulations specified in this Part, or requirements for corrective action to the license application, or to previous violations; and

 

6)         The timeliness of responses to reasonable requests from DHS/SUPR.

 

e)         DHS/SUPR may investigate the background and/or verify the credentials of professional staff to assure that these individuals satisfy the applicable medical and/or professional requirements specified in this Part.

 

f)         If DHS/SUPR is not able to issue a license based upon the criteria outlined in this Section, the organization shall be notified in writing of the denial.  The organization may appeal the Department's decision and request a hearing as specified in Section 2060.398.

 

Section 2060.245  License Requirements

 

a)         The license certificate is the property of DHS.  Licenses are nontransferable and the license certificate shall be returned if there is a change in ownership or management that requires a new license, if there is a change in location, or if the license is suspended, revoked, or modified.

 

b)         The license issued by DHS/SUPR shall be displayed by the organization in a location that is visible to the public.

 

Section 2060.250  Renewal of Licensure

 

a)         Organizations shall be notified in advance of licensure expiration and sent a renewal application prior to the expiration.  Organizations shall review and update all information.  To maintain accurate information for the DHS/SUPR Helpline, the organization may update and remove any service that the organization has not delivered in more than 12 months.

 

b)         All renewal applications shall be submitted to DHS/SUPR at least 30 calendar days prior to the expiration date of the current license.  If the organization allows any license to expire, all services linked to that license shall cease within 15 calendar days after the expiration of the license.

 

c)         Prior to renewal of a license, DHS/SUPR may seek to verify that the organization is in good standing.  To make this determination, DHS/SUPR may consider, but is not limited to, the following:

 

1)         Verbal interview with management and professional staff;

 

2)         The accuracy of submitted information;

 

3)         Prior criminal conduct by personnel;

 

4)         Current un-resolved violations related to this Part;

 

5)         Evidence of emotional, psychological, or physical impairment which may substantially interfere with the provision of services due to a lack of understanding of the rules and regulations specified in this Part, or requirements for corrective action to the license application, or to previous violations; and

 

6)         The timeliness of responses to reasonable requests from DHS/SUPR.

 

d)         Prior to renewal, DHS/SUPR may also investigate the background and verify the credentials of professional staff to assure that these individuals satisfy the applicable medical or professional requirements in this Part.

 

e)         Organizations shall be notified in writing of approval for renewed license or of an incomplete, non-submitted, or non-renewed application.  If DHS/SUPR decides to renew the license for a period of less than three years or to deny renewal based upon the criteria outlined in this Section, the organization shall be notified in writing.  The organization may appeal the decision and request a hearing as specified in Section 2060.398.  Licensure shall remain in effect pending the final decision resulting from the hearing.

 

Section 2060.255  Change of Ownership/Days and Hours of Operation

 

a)         Each license issued by DHS/SUPR is valid only for the premises and name of the organization on the application and is not transferrable.  A license shall be become null and void when:

 

1)         There is a change in ownership involving more than 25% of the aggregate ownership interest within a one-year period; or

 

2)         There is a change of 50% or more in the board of directors of a not-for-profit organization within a one-year period.

 

b)         To ensure that there is no cessation of services, organizations shall submit written notification to DHS/SUPR as soon as possible but at least 10 calendar days prior to any of the changes in ownership described in subsection (a).

 

c)         The change in ownership referenced in this Section requires submission of a new license application.

 

d)         The organization shall notify the DHS/SUPR Helpline Portal via telephone or online whenever there is a permanent change in the days or hours of operation to ensure correct and current referral information.

 

Section 2060.260  Dissolution of the Corporation

 

a)         A license shall become null and void and have no further effect when there is a dissolution of the organization.  Written notification shall be given to DHS/SUPR prior to such dissolution and shall indicate where and with whom applicable records will be stored or transferred, including the location and the individual's contact information: name, title, address, phone, and email address.

 

b)         Failure to notify DHS/SUPR within this timeframe will result in a fee of $1,000 per license when the organization applies for a new license.

 

c)         The organization shall notify the DHS/SUPR Helpline Portal whenever there is a permanent closure.

 

d)         Any storage or transfer of applicable records and with whom shall be as specified in Section 2060.350 and Section 2060.370 including the location and the individual's contact information: name, title, address, phone, and email address.

 

Section 2060.265  Relocation of Facility and Services/Cessation of Services

 

a)         The organization shall notify DHS/SUPR in writing at least 30 calendar days prior to relocation of any facility or service or the cessation of any service authorized by the license issued to the facility.

 

b)         If DHS/SUPR is not notified as specified herein, a fee of $1,000 will be assessed for any relocation of a facility.

 

Section 2060.300  Federal, State, and Local Regulations and Court Rules

 

All organizations shall attest to compliance, on the license application, and shall comply with all applicable provisions of State and federal constitutions, laws, regulations, local laws, court rules and judicial orders, including, but not limited to, the:

 

a)         Illinois Human Rights Act [775 ILCS 5].  The organizations shall also take affirmative action to ensure no unlawful discrimination;

 

b)         Americans with Disabilities Act of 1990 [42 U.S.C. 12101];

 

c)         Environmental Barriers Act [410 ILCS 25] and the Illinois Accessibility Code (71 Ill. Adm. Code 400);

 

d)         Age Discrimination Act of 1975 [42 U.S.C. 3001];

 

e)         1991 Civil Rights Act [42 U.S.C. 1981]; and

 

f)         Health Care Worker Self-Referral Act [225 ILCS 47].

 

Section 2060.305  Rule Exception Requests

 

a)         Licensed organizations may submit a request to DHS/SUPR for an exception to any Section of this Part that is not statutorily mandated; however, to maintain uniformity in service delivery, DHS/SUPR will endeavor to keep such exceptions to a minimum.  Additionally, all rule exceptions are not permanent and may be time limited with an expiration date.

 

b)         Requests shall be made in writing by the authorized organization representative to the Director of DHS/SUPR.  The request for an exception shall indicate the specific rationale for the exception and supporting documentation, if applicable, and must include a time-limited corrective action plan that will remove the need for the exception.

 

c)         Prior to granting any exception, DHS/SUPR shall consider the following factors: the organization's service population and size, barriers to access if the exception is not granted, the type of services, impact on client/patient/resident well-being if the exception is not granted, the geographic location of the organization, the accreditation status of the organization, and an DHS/SUPR designation of good standing with all applicable State and federal rules and all regulations set herein.

 

d)         Exceptions are at the sole discretion of DHS/SUPR and the decision of the Director is final.

 

e)         DHS/SUPR may revoke any exception when the circumstances for the exception no longer exist or when any conditions imposed for the exception are not implemented or met by the organization or are subsequently prohibited by State or federal statute.

 

f)         The organization shall notify DHS/SUPR in writing within 10 calendar days after its determination that the exception is no longer needed.

 

Section 2060.310  Facility Requirements

 

a)         At the time of application for initial and renewal of licensure and during the period of licensure, all facility locations shall meet the following requirements:

 

1)         Compliance with any local zoning requirement documented in writing from the appropriate local authority where the facility is located; and

 

2)         Compliance with fire safety regulations in accordance with rules of the Office of the State Fire Marshal at 41 Ill. Adm. Code 100 and with the applicable sections of the National Fire Protection Association's NFPA 101, Life Safety Code: 2015 Edition as confirmed by an attestation from a local code official, OSFM, or an architect licensed in the State of Illinois on the Life Safety Inspection Report.  As applicable, organizations may request a time-limited exception to complete any necessary modifications required to meet the fire safety requirements specified in 41 Ill. Adm. Code 100.

 

b)         At all times, the days and hours of operation shall be displayed in a location visible to the public.

 

c)         Each facility shall maintain fire, hazard, and liability insurance coverage.

 

d)         Each facility shall provide a safe, functional, and sanitary environment that includes the establishment and maintenance of policies and procedures specific to the operation of the facility.

 

e)         Each facility licensed for treatment shall have areas for private and confidential assessment, individual and group counseling, and medical services that can be separately enclosed from the areas for administration, food service, recreation, break rooms, and public reception.

 

f)         Each facility shall have a disaster plan that ensures appropriate response, preparedness, and the continuation or re-location of services, if possible, after a disaster.  This plan shall also contain requirements for annual practice drills, identification of the role of the facility in a community-wide disaster, and have an emergency evacuation plan, including provisions for disabled persons.  Each organization shall document the date of annual practice drills and, as applicable, any corrective action.  The authorized organization representative or designee shall ensure that the plan is reviewed annually and distributed to all staff who need to access and review the plan.

 

g)         Each facility licensed for treatment shall have policies and procedures, developed by the Medical Director or the Medical Director's designee who meets the definition of a physician as specified in Section 2060.120, to ensure compliance with: the U.S. Department of Labor Rule for Occupational Exposure to Bloodborne Pathogens, 29 CFR 1910.1030 (January 18, 2001) and annual training requirements for healthcare workers; and the Centers for Disease Control (CDC) and Prevention, "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005; MMWR 2005; 54 (No. RR-17), December 30, 2005".  The policies and procedures, detailed in this Subpart, shall be reviewed, updated annually, and require that a tuberculosis (TB) risk assessment be conducted annually for each facility according to the CDC guidelines and utilizing Appendices B and C in the guidelines.  The policies and procedures shall also ensure that all staff have a TB test upon hire to establish a baseline and then only annually based upon the annual risk assessment.  Client/patient/resident screening and education regarding infectious disease shall follow all guidelines referenced in this subsection and be based upon the results of the annual risk assessment.

 

h)         Each facility shall have first aid supplies and personal protective equipment available in the event of a medical emergency or infectious disease outbreak.  The organization shall establish policies and procedures for each licensed facility that ensure compliance with the CDC's recommendations for infectious disease outbreak, as specified in CDC's "Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings" (April 14, 2024) and available at https://www.cdc.gov/infection-control/hcp/core-practices/index.html-.  Each facility shall also ensure that naloxone is readily available in the event of an opioid overdose.

 

i)          Each facility that provides 24-hour care shall ensure that it can provide for basic needs of patients/residents including, but not limited to, access to food and clean water.  If such facility also directly provides food service, it shall:

 

1)         Provide such service in accordance with the Dietitian Nutritionist Practice Act [225 ILCS 30], either as an employee or through a contractual agreement;

 

2)         Have a written plan for the provision of food service, as developed by the licensed professional referenced in subsection (i)(1), that describes the organization and the delivery of food service or arrangements for the provision of such services;

 

3)         Ensure that all nutritional aspects of patient/resident care are under the direction and supervision of the licensed professional referenced in subsection (i)(1);

 

4)         Provide a dining area that is separate from the kitchen area, is supervised and staffed to help patients/residents when needed, and is sized and equipped to accommodate the age and number of persons served;

 

5)         Ensure that the preparation and cooking of regularly scheduled hot meals is restricted to kitchen areas that are designed and equipped to meet the requirements of the services provided, including receiving, storage, preparation, dish and pot washing, and waste disposal; and

 

6)         Ensure access to a handwashing sink and toilet and that all equipment and appliances are installed to permit thorough cleaning of all equipment, walls, baseboards, and non-absorbent floor material and that each kitchen has an Underwriters Laboratory (UL)-approved five-pound class B:C dry chemical fire extinguisher.

 

j)          If laundry is done at the facility, the organization shall ensure that there is space for soiled linen sorting, laundry equipment, including washers and dryers, and clean linen storage space. If laundry is done outside the facility, the organization shall ensure that a soiled linen storage area is provided. 

 

k)         Each facility licensed for residential treatment (including withdrawal management) shall have a written policy that will ensure that gender-specific and gender-identity needs of patients served are addressed, and ensure, as applicable, that:

 

1)         Each bedroom is kept clean and organized;

 

2)         Bedroom occupancy addresses personal safety, preferences, and gender identity of residents;

 

3)         Bedroom occupancy prioritizes child safety in situations where children are in residence with a parent receiving treatment;

 

4)         The organization has policies and procedures to ensure the safety of children who are in residence with a parent receiving treatment;

 

5)         A separate bedroom is provided for any adolescent aged 16 or 17 who is receiving treatment in an adult treatment facility or for any person between the ages of 18 and 22 who is receiving treatment in a treatment facility for adolescents;

 

6)         A minimum of 80 square feet is provided in a single bedroom and 60 square feet per bed in a multi-bedroom with no more than four beds per room;

 

7)         At least three feet of space is provided at the foot or head and one side of each bed and at least three feet between each bed;

 

8)         Bunk beds are not used for any withdrawal management service;

 

9)         All beds are non-folding, at least 36 inches wide, and have a flame-retardant mattress;

 

10)       No bedroom is in an attic or in an area with a floor more than three feet below the adjacent ground level;

 

11)       Each room has a wardrobe, locker, or closet for each occupant;

 

12)       Each bedroom has a swinging door no less than 32 inches in width that opens directly into a corridor or to the outside;

 

13)       Each bedroom is an outside room with not less than the equivalent of 10% of its floor area devoted to windows that are covered with curtains, blinds, or shades;

 

14)       No bedroom opens directly into a kitchen or necessitates passing through a kitchen to reach any part of the facility;

 

15)       Each bathroom contains a toilet and sink and that each tub or shower is enclosed with space for drying and dressing (the sink may be omitted from a bathroom that services two adjacent bedrooms if each of these rooms contains a sink);

 

16)       Bedroom doors leading to corridors shall not be lockable from the inside;

 

17)       One sink, one toilet, and one bathtub or shower is provided per every eight beds on each floor where bathrooms are not adjacent to a bedroom;

 

18)       All bathrooms are well lighted and vented to the outside either by means of a window that can be opened or by an exhaust fan;

 

19)       No bathroom, other than for staff, shall open directly into a kitchen, pantry, food preparation area, or food storage room; and

 

20)       A bathroom is accessible to each central bathing area and that a minimum of one sink, one toilet, and one bathtub or shower for patients shall be provided on each floor.

 

Section 2060.315  Service Termination/Record Retention

 

a)         DHS/SUPR shall be notified in writing at least 30 calendar days prior to the date on which cessation of any licensed service is scheduled to occur.  If involuntary termination occurs due to inability to operate (damage to facility, loss of staff, change in management, corporate dissolution, or any other cause) the organization shall notify DHS/SUPR in writing immediately upon termination.

 

b)         Upon voluntary cessation of services, all current clients/patients/residents shall be notified in advance and referrals for continuation of services shall be made to other DHS/SUPR licensed organizations.  If cessation of services is involuntary, clients/patients/residents shall be notified as soon as possible and given referrals to other licensed organizations.

 

c)         Upon cessation of services at any licensed location, DHS/SUPR shall schedule an inspection to ensure that any controlled substance inventory is transferred or destroyed in accordance with the U.S. Drug Enforcement Administration (DEA) requirements in 42 CFR 1307 and 1317 through 1395 (2014), as applicable.

 

d)         When an organization ceases operation of any service at any location, all patient/client/resident records, relative to that service, shall be maintained as follows:

 

1)         If the organization has a current license issued by DHS/SUPR for any other treatment or intervention service, the organization may maintain the records from the service that has ceased operation.

 

2)         If the organization has no other current license for any other treatment or intervention service, all records shall be transferred for maintenance and storage to an DHS/SUPR licensed organization providing a treatment or intervention service.  Records from closed hospital-based programs or medical practices can be maintained at that facility.

 

e)         Each client/patient/resident, who has received services within the past six years, shall be notified of service cessation via personal mail and email.  If personal mail or e-mail is not available, they shall be notified by public posting, or media publication regarding the location where records will be maintained and stored within 10 calendar days after cessation of service.  DHS/SUPR shall also be notified within 10 calendar days after cessation regarding record location and any applicable contact information necessary to verify record transfer.

 

f)         Such records shall be stored and maintained for a period of six years from the date of creation or the date when last in effect, whichever is later.

 

g)         Upon cessation of operations, the license shall automatically become null and void and all documentation of licensure shall be immediately surrendered to DHS/SUPR if the license has not reached its expiration date.

 

Section 2060.320  Staff Qualifications

 

a)         Any staff person who delivers clinical treatment services as defined in Section 2060.410 or early intervention services as defined in Section 2060.405 in a licensed setting shall hereafter be referenced as "professional staff" and, shall, upon hire:

 

1)         Hold certification as a Certified Alcohol and Drug Counselor from the Illinois Certification Board (ICB);

 

2)         Be a licensed professional counselor or a licensed clinical professional counselor pursuant to the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107];

 

3)         Be a physician licensed to practice medicine in all its branches pursuant to the Medical Practice Act of 1987;

 

4)         Be a licensed clinical psychologist pursuant to the Clinical Psychology Practice Act [225 ILCS 15];

 

5)         Be a licensed social worker (LSW) or licensed clinical social worker (LCSW) pursuant to the Clinical Social Work and Social Work Practice Act [225 ILCS 20];

 

6)         Be a licensed marriage and family therapist pursuant to the Marriage and Family Therapy Act [225 ILCS 55]; or

 

7)         Be a board-certified psychiatric-mental health nurse practitioner (PMHNP-BC) or a physician assistant with a Certificate of Added Qualifications (CAQ) in psychiatry in accordance with the requirements specified by the American Nurses Credentialing Center or the National Commission on Certification of Physician Assistants. 

 

b)         Any staff person who provides DUI evaluations as specified in Section 2060.510, DUI risk education as specified in Section 2060.520, or designated program services as specified in Section 2060.530 shall:

 

1)         Meet at least one of the qualifications specified in subsection (a); or

 

2)         Hold certification as an Assessment and Referral Specialist (CARS) or a Certified Criminal Justice Addictions Professional (CCJP) from the Illinois Certification Board (ICB).

 

c)         Organizations that deliver medically monitored withdrawal management (ASAM Level 3.7 care) shall have at least one staff, 24 hours a day, who is:

 

1)         Appropriately licensed and credentialed under the Nurse Practice Act [225 ILCS 65] to administer medication in accordance with an order from a physician, nurse practitioner, or physician assistant and to conduct an alcohol- and drug-focused nursing evaluation at the time of patient admission and throughout the length of stay; or

 

2)         A certified emergency medical technician pursuant to Section 4.12 of the Emergency Medical Services (EMS) Systems Act [210 ILCS  50/4.12] who has completed at least 40 clock hours of formal training in the field of substance use disorder treatment.

 

d)         Any other staff who provide direct patient care that is not defined as a clinical treatment service shall be supervised by professional staff in accordance with the requirements in Section 2060.325.

 

e)         Paid and unpaid interns or volunteers may be used to deliver clinical services and in all cases shall be supervised by professional staff as specified in Section 2060.325.  Additionally, the number of volunteers and interns on duty shall not exceed the number of professional staff on duty.  Supervision must be documented by time, date, duration, and supervisory signature in the intern or volunteer personnel record and must be separate from regular patient staffing.  This supervision shall also be verifiable by time, date, duration, and supervisory signature on all clinical services documented by the intern or volunteer in the patient record.

 

f)         Any new staff, including interns, who provide clinical treatment services or assessment services in a licensed designated program who do not, when hired, meet the requirements of subsections (a) or (b), shall:

 

1)         Obtain one of the required credentials no later than two years from the date of employment or internship. Previous work experience, paid or unpaid, in the SUD field is considered cumulative and shall be counted as part of this two-year requirement;

 

2)         Not work in any clinical supervisory capacity until such requirements are met;

 

3)         Not provide any clinical treatment service or assessment service that is not supervised by a professional staff as specified in Section 2060.325, until such person has obtained the credential specified in subsections (a) or (b).  Organizations shall have policies and procedures that identify the methodology and time frame utilized for continued supervision of any non-credentialed clinical staff.  Supervision shall be documented in the staff personnel record by time, date, duration, and supervisory signature and include a brief synopsis of the covered content.  Supervision shall also be verifiable by time, date, duration, and supervisory signature on all clinical services documented by the supervisee in the client/patient record;

 

4)         Be prohibited from providing clinical treatment services or assessment services in a designated program after the required two-year period until the requirements of subsections (a) or (b) are met; and

 

5)         Sign and adhere to the established code of ethics developed by the applicable certifying or licensing body.

 

g)         The organization shall inform and obtain the written consent of each client/patient who will be receiving services from any staff working under supervision and ensure that the client/patient gives written consent to have services delivered in this manner.

 

h)         Notwithstanding the requirements specified in this Section, staff who provide DUI evaluations and DUI risk education shall meet the requirements specified in subsections (a) or (b) when hired.

 

i)          Staff who will provide services as a recovery home operator or manager, as specified in Section 2060.540, shall, upon hire, hold certification as a National Certified Recovery Specialist (NCRS) from the National Association for Alcoholism and Drug Abuse Counselors (NAADAC), or as, a Certified Peer Recovery Support Specialist (CPRS), a Certified Recovery Support Specialist (CRSS), or any other alcohol or drug (AOD) credential from ICB or receive such certification within two years of the date of employment under the supervision of staff holding one or more of the credentials specified in this subsection.

 

j)          It is the responsibility of each organization to verify with documentation that all applicable staff referenced herein meet the requirements outlined in this Section.

 

Section 2060.325  Supervision

 

a)         Each licensed treatment organization shall ensure management and oversight of all professional staff by a clinical supervisor who meets the staff requirements specified in Section 2060.320(a).  Supervision may be in-person or virtual and include group supervision.  Professional staff shall have access to a clinical supervisor for immediate consultation and supervision of clinical services.

 

b)         Each licensed DUI evaluation, DUI risk education, or designated program intervention organization shall designate a supervisor who meets at least one of the requirements specified in Section 2060.320(a) or (b).  Supervision may be in-person or virtual and include group supervision.

 

c)         All intervention and treatment professional staff referenced in this Section shall receive monthly supervision.

 

1)         If group supervision is utilized, the size of the group shall be conducive to the topic being discussed.

 

2)         Supervision shall be documented in the personnel record of the person receiving supervision or in a format identified by the organization with time, date, duration, and supervisory signature and include a brief synopsis of the content covered.

 

d)         Supervision for interns or any employee who has not obtained the appropriate credential for "professional staff" shall be conducted in accordance with the provisions specified in Section 2060.320(f)(3).

 

Section 2060.330  Staff Development and Training Requirements

 

a)         The organization shall ensure, through implementation of an annual plan, that staff development and training is made available to all staff, as applicable or required in this Section.  The organization's staff development and training plan shall address the need for cultural, linguistic, and special population proficiency as it relates to those client/patients or residents that the organization serves.  In-service training shall also be part of the plan to ensure that information obtained by staff at required training is disseminated to other organization staff, as applicable.  In-service training refers to training and development programs offered by organizations to employees from time to time to improve their skills, knowledge, and competency while they are still on the job.

 

b)          All organizations shall provide orientation, within the first 10 working days after employment and annually thereafter, to all staff, including paid and unpaid interns and all volunteers, that shall include, at a minimum, an overview of all organization policies and procedures, including:

 

1)         The specific duties assigned to each employee;

 

2)         All emergency preparedness plans;

 

3)         Familiarization with existing staff backup and support;

 

4)         All required training;

 

5)         A general overview of Part 2060;

 

6)         Information on bloodborne pathogens, Hepatitis C and universal precautions, the importance of tuberculosis control and personal hygiene, the responsibilities, and requirements for all staff regarding infectious disease control;

 

7)         Information on infectious disease relative to the etiology and transmission of infection and associated risk behaviors, the symptomology of infectious disease and clinical progression of HIV infection to AIDS and the relationship of infectious diseases to substance use disorders, the purposes, uses, and meaning of available testing and test results, and sensitivity to the issues of a patient with infectious disease;

 

8)         An overview of the principles and regulations governing patient confidentiality (42 CFR 2) and the Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. 1320 et seq.), client/patient rights, all related federal and State statutes, and all recordkeeping requirements regarding confidential information;

 

9)         A review and copy of the organization's quality improvement plan and policies and procedures manual as referenced in Section 2060.340;

 

10)       A review of the mandatory reporting requirements as specified by the Illinois Department of Children and Family Services (DCFS) and how those requirements relate to job specifications and any applicable professional staff, including paid/unpaid interns or volunteers; and

 

11)       Opioid overdose education and training that includes how to recognize an overdose and instruction on how to administer naloxone.

 

c)         All new staff, including paid/unpaid interns and volunteers, who will provide clinical treatment services shall attend at least one training offered by DHS/SUPR relative to application of the ASAM Criteria within the first six months of employment.  All other staff providing clinical treatment services shall have documentation of ASAM training or obtain such training.  Thereafter, all such staff shall attend ASAM training at least once every five years, unless an earlier timeframe is determined by DHS/SUPR.  This ASAM training shall be offered by DHS/SUPR free of charge.

 

d)         All new professional or support staff, including paid/unpaid interns and volunteers, who work in intervention or treatment organizations shall attend a Part 2060 training offered by DHS/SUPR within the first six months of employment.  All other existing staff providing these services shall attend a Part 2060 training.  Thereafter, all such staff shall attend a Part 2060 training at least once every five years unless an earlier timeframe is determined by DHS/SUPR.  All Part 2060 training shall be offered free of charge.

 

e)         All staff providing DUI evaluation or risk education services shall attend one DUI training offered or approved by DHS/SUPR within the first six months of employment.  Thereafter, all such staff shall attend DUI training offered or approved by DHS/SUPR at least once every five years unless an earlier timeframe is determined by DHS/SUPR.

 

f)         Staff who meet the requirements of Section 2060.320(a) or (b) shall obtain a minimum of six continuing education credits that are specific to SUD evidence-based practices and/or any specific population or service offered by the organization during each credentialing cycle.  The mandatory training referenced in subsections (c), (g), (h) and (i) can be used to meet this requirement.

 

g)         If the organization self-identifies as offering treatment services for individuals with special needs due to gender, sexual orientation, English language proficiency, age, or medical or psychiatric diagnosis, it shall ensure that at least one professional staff obtains a minimum of six continuing education credits that are targeted to the applicable specialty service during each credentialing cycle.

 

h)         Any professional staff who provide clinical supervision shall obtain a minimum six continuing education credits specific to supervision skills during each credentialing cycle.

 

i)          Professional staff who provide assessment and specialized case management services under the authority of a designated program license shall obtain a minimum of six continuing education credits during each credentialing cycle that are specific to evidence-based practices that have proven to be effective interventions at the intersection of criminal justice and behavioral health.

 

Section 2060.335  Personnel Requirements and Procedures

 

a)         All professional staff as specified in Section 2060.320(a) and (b) or any staff working under supervision as specified in Section 2060.320(f) shall:

 

1)         Be at least 18 years of age; and

 

2)         Not have been convicted of any felony under any law of the United States two years prior to the date of employment or anytime during employment unless an exception is granted by DHS/SUPR as specified below in subsection (d).

 

b)         All professional staff as specified in Section 2060.320(a) and (b) who provide DUI evaluation or risk education shall not have a suspension or revocation of driving privileges for an alcohol- or drug-related driving offense for at least two years prior to the date of employment or anytime during employment.  If the suspension or revocation occurs during employment, such person cannot resume the provision of services until two years from the date of the revocation or suspension.

 

c)         Verification of the requirements specified in subsection (a) and the staff qualifications specified in Sections 2060.320 and 2060.415 shall be documented on the DHS/SUPR Schedule L and E, respectively, upon employment and submitted, as applicable, at the time of application for licensure and upon renewal.

 

d)         An exception may be requested from DHS/SUPR for any person who does not meet the requirements specified in subsection (a).  Exception requests will be evaluated on criteria including, but not limited to, time since the offense occurred, evidence of rehabilitation, and the number and type of convictions.  A Schedule L for the person shall accompany the exception request and the organization shall have a policy to ensure that delivery of services is prohibited for such person unless the exception is granted or for any staff who does not meet the requirements specified in subsection (a) any time during employment.

 

e)         Each organization shall establish and maintain a comprehensive set of personnel policies and procedures that are approved by management or, if applicable, the Board of Directors.  These policies and procedures must, at a minimum, address hiring, training, evaluation, promotions, disciplining and termination, and the process for handling employee or client/patient/resident complaints or grievances.  Additionally, the policies and procedures shall include the process for handling instances of suspected or confirmed client/patient/resident abuse/assault and or neglect by staff.  The reporting procedure shall also include when to report to law enforcement and the requirements for notifying DHS/SUPR.  The organization shall ensure that personnel policies and procedures are readily available to all staff, including interns and volunteers, and that any changes are distributed to staff at least once annually.

 

f)         Each organization shall provide documentation that any new or revised personnel policies and procedures are reviewed and approved, at least once annually, by the authorized organization representative or management designee, or as applicable, organization ownership or Board of Directors.

 

g)         Each organization shall have a policy and procedure for addressing, intervening, and reporting to DHS/SUPR or the applicable credentialing body, when there is any staff violation of the code of ethics established by the organization and/or the applicable certifying or licensing body that negatively impacts client/patient/resident care or could impact any staff credential or license.

 

h)         Each organization shall establish and maintain job descriptions detailing the duties and qualifications for all positions, including volunteers, interns, and unpaid personnel.

 

i)          The organization shall determine the criteria for full- and part-time employees, contractual employees, interns, and volunteers and have such criteria in writing.

 

j)          Upon hire, and prior to every license renewal cycle, the organization shall perform background checks for all employees, contractual employees, volunteers, and interns. At a minimum, the review shall include:

 

1)         Conducting a background check using the free online National Sex Offender Registry at https://www.nsopw.gov/ for all staff;

 

2)         Conducting an additional background check using the Child Abuse and Neglect Tracking System (CANTS), maintained by the Illinois Department of Children and Family Services (DCFS) and authorized by the Abused and Neglected Child Reporting Act [325 ILCS 11.1(15)] for any staff that have contact with children or adolescents or provide clinical services or any other supportive services for a child or adolescent who is receiving intervention or treatment, or is receiving childcare at a facility or is residing at a facility with a parent receiving intervention or treatment services.

 

3)         Complying with a procedure that precludes hiring of persons based on the reasons specified in this Section and as set forth in 89 Ill. Adm. Code 385.50(a) and of those convicted of, or with pending charges of, crimes as set forth in 89 Ill. Adm. Code 385.60(a).  The organization shall also have and follow procedures allowing for waiver of these restrictions based on 89 Ill. Adm. Code Sections 385.50(b), 385.60(d) through (e), and 385.70(b); and

 

4)         Complying with policies and procedures to ensure the protection of other staff or client/patient/residents during the interim between initial submission of the staff background check and obtaining the results.  These policies must identify any staff limitations regarding the delivery of SUD intervention or treatment services during this interim.  The organization is responsible for all such hiring and service delivery decisions and the results thereof and for following recordkeeping procedures consistent with 89 Ill. Adm. Code 385.90.

 

k)         The organization shall, at a minimum with each license renewal cycle, comply with all requirements for background checks specified in this Section for all applicable staff and update all Schedules L and E, as applicable.

 

l)          The organization shall establish and maintain individual personnel records for all employees, volunteers, and interns, paid and unpaid, that minimally include the following components:

 

1)         Documentation of current education, experience, licensure, and/or certification;

 

2)         Employment status of the individual (e.g., hire date, full- or part-time status, promotion date, change in job description, termination date);

 

3)         Documentation of Schedule L or E, as applicable, and all relevant background checks and or exception requests;

 

4)         Documentation of required training;

 

5)         Documentation of required supervision with time, date, and duration;

 

6)         Review of individual employee's performance in accordance with organization policy; and

 

7)         A copy of the applicable professional code of ethics for the employee's credentials or as specified in Section 2060.320(f)(5).

 

m)        The organization shall maintain the personnel record for a period of five years from the last date of employment.

 

Section 2060.340  Quality Systems Requirements

 

a)         The organization shall design and implement a quality improvement plan that incorporates all requirements specified in this Part.  The quality improvement plan shall be approved by the authorized organization representative or management designee and, if applicable, controlling ownership or board of directors and annually reviewed and revised as necessary.

 

b)         The quality improvement plan shall be written and shall contain, at a minimum:

 

1)         A mission statement for the organization's DHS/SUPR licensed services;

 

2)         A method of evaluation to assess achievement of the organization's mission;

 

3)         Identified strategies designed to achieve successful intervention and treatment outcomes;

 

4)         A policy and procedure for obtaining and responding to feedback from persons served and community stakeholders;

 

5)         A method to review and evaluate the use of medications utilized in any level of care that are directly provided by the organization;

 

6)         A method of risk management that, at a minimum, includes:

 

A)        Review and analysis of any incident or significant incidents and the correct reporting procedure as specified in Section 2060.385;

 

B)        Design and implementation of necessary procedures to address any identified risks; and

 

C)        As applicable to Opioid Treatment Programs that are licensed by DHS/SUPR to dispense Methadone, a "Diversion Control Plan" in accordance with the requirements specified in Section 2060.420(g)(5); and

 

7)         A utilization management plan, as specified in subsection (c), for the ongoing review and assessment of delivered services and outcomes. Utilization management is required for all authorized treatment and intervention licenses for designated programs, and DUI evaluation licensees.  It is not required for intervention licenses for DUI risk education or recovery home licensees.

 

c)         Utilization management shall be conducted by a person who did not deliver or supervise the services under review.  This person can work directly for the organization or be a contractor.  In all cases, utilization management for treatment services shall be conducted by persons who meet the qualifications specified in Section 2060.320(a) or (b) for DUI evaluation or designated program services.  Utilization management shall be conducted at least quarterly in accordance with the following:

 

1)         For treatment licensees, a random sample of a minimum 15% or 50 patient records (whichever is less) that received services or were closed during the applicable quarter and that are representative of all authorized levels of care and locations.  Utilization management for these records shall review the following:

 

A)        The medical or clinical necessity supporting the placement or continued service in the current level of care;

 

B)        The appropriateness and clinical necessity for treatment plan goals and objectives as they relate to assessed need;

 

C)        Verification of the time, date, and duration of all services and the signature requirements in each patient record as specified in this Part; and

 

D)        Timely delivery of assessed clinical and case management services.

 

2)         For DUI evaluation or designated program intervention licensees, a random sample of a minimum 15% or 20 client records (whichever is less) that received services or were closed during the applicable quarter and that are representative of each authorized service and location.  Utilization management for these records shall review the following:

 

A)        The appropriateness of the diagnosis or risk category assignment, as applicable, based upon the established criteria specified in this Part for the applicable authorized services provided by an intervention licensee relative to an SUD assessment or risk category assignment; and

 

B)        The appropriateness of the subsequent recommended intervention or referral for treatment, based upon the diagnosis or risk assignment, as applicable.

 

3)         If the random sampling of client or patient records indicates incorrect information, the organization shall develop and implement a corrective action plan to address the identified problems.

 

4)         The organization shall issue a report, at least quarterly, that documents the findings from utilization management and make all such reports available, at least annually, to all credentialed staff, controlling ownership, and board of directors.

 

d)         All organizations shall develop and maintain a written policies and procedures manual that describes all operational procedures.  At a minimum, the manual shall contain an organization chart and a description of the process the organization will use to ensure compliance with all applicable rules referenced in this Part and any other local, State, and federal regulatory requirements.  This manual shall be approved by controlling ownership or the board of directors, and any new or revised policies shall be reviewed annually.  The organization shall also ensure that staff receive and review updated sections to the manual at least annually.

 

e)         Treatment licensees who are not otherwise required to report data electronically shall maintain statistics that, at a minimum, summarize the demographic information specified in Section 2060.370(d)(9) and that summarize for each licensed treatment facility:

 

1)         Total number of patients, by level of care;

 

2)         The average length of time between initial date of contact and the first treatment service;

 

3)         Total number of assessments and admissions, by level of care;

 

4)         Total number of substance use diagnoses, by type;

 

5)         The average length of stay in each level of care; and

 

6)         Discharges by type and level of care.

 

f)         The statistics maintained pursuant to subsection (e) shall be made available upon request by DHS/SUPR and/or during inspections.

 

Section 2060.345  Service Fees and Policy

 

a)         The organization shall establish one fee schedule that specifies the standard fee charged for each treatment, intervention, or support service (e.g., toxicology screens, administrative functions such as copying, etc.) and a policy regarding billing and collection.

 

b)         The fee schedule shall be made available to each person receiving the service and signed and dated by that person.  The fee schedule shall indicate the estimated amount the person will be responsible to pay, along with any relevant payment schedule for each service.

 

c)         The fee schedule shall be updated annually or whenever there are changes that impact the amount of payment due from the person.

 

d)         The organization shall ensure that the person is made aware of benefits that they might qualify for that could subsidize the cost of their services.  This includes identification of any third-party payment benefits, including Medicaid, other health insurance or State or federal funds, and how to make application for them.  The organization shall also ensure that the person is made aware of any third-party billing that will be utilized and informed of the right to opt out of this type of billing and, instead, self-pay for the service.

 

e)         Organizations that do not have certifications or contracts with third-party payors for which the person has or is eligible for coverage or benefit shall make referral options available to such person for services from alternate organizations who have the applicable coverage.  All referrals shall be made as specified in Section 2060.380.

 

f)         Billing or documentation errors made by the organization shall not result in additional cost to the individual receiving the service.

 

Section 2060.350  Confidentiality – Patient Information

 

a)         The organization shall have written policies and procedures to control access to and use of records and information that are governed by the Confidentiality of Substance Use Disorder Patient Records regulations (42 CFR 2) and Article 30-5(bb) of the Act and to control access to and use of protected health information governed by the Health Insurance Portability and Accountability Act (HIPAA), 42 U.S.C. 1320 et seq., and the regulations promulgated thereunder at 45 CFR 160, 162 and 164.  All policies and procedures shall be consistent with said regulations and statutes and include a standard release form to obtain patient consent for release of confidential information.  Nothing in this Part shall be construed as having the effect of imposing HIPAA requirements on an organization to whom HIPAA does not apply.

 

b)         The regulations referenced in this Section apply to any records concerning any person who has been a patient, regardless of whether or when that person ceased to be a patient.

 

c)         When DHS/SUPR requests a record or information subject to the regulations in 42 CFR 2 for audit, evaluation, research, or other authorized purposes, it shall, in writing:

 

1)         Indicate the purpose for obtaining the information;

 

2)         Agree to maintain the information in accordance with security requirements of said laws;

 

3)         Agree to comply with limitations on disclosures in said laws;

 

4)         Agree to destroy the information upon completion of its use and as and when permitted by the State Records Act [5 ILCS 160]; and

 

5)         Indicate the authorized personnel to whom such information is to be submitted.

 

d)         Organizations providing a DUI evaluation or risk education intervention service shall disclose offender information, as allowed by law, as these services are not covered under 42 CFR 2.  However, the informed consent procedures specified in Section 2060.360 shall be utilized to allow for such disclosure to Illinois court officials, the Illinois Office of the Secretary of State, and DHS/SUPR for adjudicating and court monitoring of DUI cases, resolution of driver's license suspensions or revocations, and for monitoring authorized services.

 

Section 2060.355  Confidentiality – Patient Protection – HIV Antibody and AIDS Status

 

a)         The organization shall have written policies and procedures controlling access to records and information governed by the AIDS Confidentiality Act [410 ILCS 305] (AIDS Act), and the AIDS Confidentiality and Testing Code (77 Ill. Adm. Code 697) (AIDS Code) that protect the identity and test results of a person who receives an HIV test.

 

b)         This Section does not apply to HIV/AIDS risk education that is provided to all persons.  This Section does apply to information regarding requests for or participation in HIV/AIDS pre- and post-test counseling.

 

c)         An HIV antibody or AIDS test cannot be required as a condition of SUD treatment and a person cannot be required to disclose or to sign an authorization for release of information concerning their HIV antibody test or HIV status as a condition of SUD treatment.

 

d)         A person who wishes to be tested for HIV antibodies shall be informed that they may undergo testing anonymously and given information about organizations that conduct testing.

 

e)         Unless disclosure is otherwise authorized by State or federal statute or rule, no information governed by the AIDS Act and the AIDS Code shall be released by an organization or by any member of its staff to any other person or entity unless there is a legally-effective consent or another exception in accordance with the statute or rule.  Release of information which is allowed by consent or by statute and rule shall be done only to the extent provided within the consent.

 

f)         The organization shall have a policy regarding how and what shall be recorded if a person self discloses HIV status during treatment or if the person requires the administration of medications or other services by staff that provide AIDS treatment.  The policy shall protect the confidentiality of the person, protect their right to give consent for disclosure of HIV status, and shall limit disclosure to only what is necessary to accomplish the purpose of the disclosure.  The organization shall ensure that the informed consent form required in Section 2060.360 contains the authorization requirement for disclosure of this information.

 

g)         Documentation of any HIV or AIDS counseling service or testing shall be kept confidential in accordance with the AIDS Act.  Organization staff shall not have access to such counseling and testing records unless otherwise authorized in writing by the patient's consent.

 

Section 2060.360  Informed Consent

 

a)         Each organization shall have an informed consent procedure to obtain legally valid signed consent from the person or legal guardian for intervention or treatment services and that documents agreement to participate in those services, knowledge of the consequences of withdrawal from such services, and that allows for authorization or decline of the access to and/or release of confidential medical information.  Consent may be obtained electronically. 

 

b)         The informed consent must also acknowledge the right to a conflict-free choice of services from any licensed organization and an understanding of the potential risks and benefits of selected services.

 

c)         The informed consent shall contain a section that allows, as applicable, for authorization or decline (for self or significant others or family members) of participation in or the use of the following:

 

1)         Experimental medications;

 

2)         Experimental assessment procedures;

 

3)         Recording on audiovisual equipment;

 

4)         Participation in research projects; and

 

5)         Testing for HIV.

 

d)         The informed consent shall be signed and dated by the person receiving the service prior to the initiation of authorized intervention or treatment services.

 

e)         A copy of the informed consent shall be provided to the person receiving the service, upon request.

 

f)         The informed consent may be combined with the client/patient/resident rights document as referenced in Section 2060.365 if there are separate signature authorizations for each document.

 

Section 2060.365  Client/Patient/Resident Rights

 

a)         To ensure that a client/patient/resident's rights are protected, each organization shall have a written statement that describes the rights of such persons as specified in Article 30 of the Act.  The rights document can be a form provided by DHS/SUPR or be designed by the organization, but shall contain, at a minimum, the following components:

 

1)         That access to services shall not be denied on the basis of, including but not limited to, race, color, sex, religion, national origin, ancestry, age (40 and over), order of protection status, marital status, sexual orientation (including gender-related identity), HIV status, physical or mental disability, unfavorable discharge from military service, pregnancy, citizenship status, employment status, familial status, or arrest record;

 

2)         That there is access to services, either through direct service or referral, for any person on MAR or who has specific needs related to MAR;

 

3)         Assurance that HIV/AIDS status and testing remains confidential;

 

4)         Assurance that all treatment services remain confidential, as specified in 42 CFR 2;

 

5)         The right to nondiscriminatory access to services, as specified in the American with Disabilities Act of 1990;

 

6)         The right to give or withhold informed consent for intervention or treatment services;

 

7)         The right to refuse a specific treatment procedure and to be informed of the consequences of such refusal; and

 

8)         The right of any adolescent to consent to treatment without approval of the parent or legal guardian in accordance with the Consent by Minors to Medical Procedures Act [410 ILCS 210].

 

b)         Prior to the initiation of services, the client/patient/resident shall attest by signature and date that they have reviewed and received a copy of the written statement of rights and this signatory document shall be maintained in the client/patient/resident record.

 

c)         The statement of client/patient/resident rights shall be displayed in an area accessible to clients/patients/residents.

 

d)         The organization shall inform each client/patient/resident of the route of appeal available when a person disagrees with the organization's decision or policies and of how to file a formal complaint with DHS/SUPR.

 

e)         The organization shall comply with the right of any adolescent to consent to treatment services without approval of the parent or legal guardian in accordance with the Consent by Minors to Medical Procedures Act [410 ILCS 210].

 

f)         As required by Sections 2060.350 and 2060.355, the client/patient/resident shall be given written notice of the uses and disclosures of protected health information that will be collected and maintained, and the rights provided by law.

 

Section 2060.370  Recordkeeping Requirements

 

a)         The organization shall maintain records, including, but not limited to, the following:

 

1)         Intervention/treatment service records;

 

2)         Organizational records including policies and procedures;

 

3)         Personnel records; and

 

4)         All other documents required in this Part.

 

b)         Required records shall be maintained, and accessible to DHS/SUPR, for a period of not less than six years from the date of the last service.  "Accessible to DHS/SUPR" means that organizations shall retain ownership of all records referenced above, regardless of any external contract or agreement for recordkeeping, billing, etc.  If an inspection is initiated within the required retention period, the records shall be retained until the inspection is completed and all issues are resolved.  This provision is not construed as a statute of limitations.  Organizations may elect to keep records beyond the six-year period or shall delete records in a manner consistent with confidentiality requirements.

 

c)         Required records shall be readily available for inspection and copying by DHS/SUPR, as applicable.

 

d)         Organizations shall adhere to the following regarding client/patient records:

 

1)         All records shall be maintained electronically or in written form and shall be protected in a locked room, locked file, safe, or similar container or in computer records with secure, limited access.  If maintained electronically, a hard copy of required information shall be made available upon request by DHS/SUPR;

 

2)         If the record is not maintained electronically, each signature on a hard copy record shall be in ink or typed and dated.  All additional entries shall be typed or in ink and indicate the time and duration of each service.  Additionally, if the organization provides services that are authorized by DHS/SUPR at multiple facilities, one record can document all such services;

 

3)         Records shall be kept in the facility where the person is receiving services and shall be directly accessible to the staff providing the service;

 

4)         The compilation, storage of, and accessibility to records, including electronic records, shall be governed by written policies and procedures in accordance with 42 CFR 2, HIPAA, and all other applicable State and federal laws;

 

5)         All information, regardless of format, shall be secured from theft, loss, or fire and records maintained electronically shall have a back-up system to safeguard records in the event of operator or equipment failure;

 

6)         Electronic or digital signature on records is acceptable when the organization has established the necessary policies and procedures to:

 

A)        Safeguard the issuance and identity of users;

 

B)        Ensure uniqueness in issuance of signature;

 

C)        Regularly review the usage of signature;

 

D)        Ensure adequate safeguards within the system upon application of signatures to documents; and

 

E)        Audit users to remove unnecessary, unused, and abusers on a regular frequency;

 

7)         Any entry made on the record that is in any other language than English shall have an accompanying English translation;

 

8)         The record shall contain the signatory documents that indicates the person was informed of their rights and that informed consent was given for any service;

 

9)         The record shall contain, in a standardized format, the following demographic information:

 

A)        Unique identifier or Registered Identification Number (RIN), if applicable;

 

B)        Initial date of contact;

 

C)        Name, street address, city, state, zip code;

 

D)        Telephone number;

 

E)        Date of birth;

 

F)         Sex or gender identity;

 

G)        Race and ethnicity;

 

H)        Veteran status;

 

I)         Marital status;

 

J)         Educational level;

 

K)        Type of health insurance;

 

L)        Employment status;

 

M)       Annual income for any person that requests a subsidized or reduced fee for services and all proof of income documents unless this information is kept in a separate financial record;

 

N)        A dated, signed service fee statement, as specified in Section 2060.345(b), unless this information is kept in a separate financial record;

 

O)        Primary language; and

 

P)         Referral source and, as applicable, release of information forms.

 

10)       The record shall contain all other required documentation specified by service type in Subparts D and E of this Part; and

 

11)       The organization shall have a process to ensure that records comply with the requirements referenced in this Part.  As such, the recordkeeping system shall be reviewed at least annually and any necessary corrective action made part of the quality improvement plan referenced in Section 2060.340(a).

 

Section 2060.375  Emergency Care

 

a)         The organization shall have a written plan which specifies how emergency care will be provided for a psychiatric/medical problem or for an unforeseen interruption of some or all services.

 

b)         The plan shall specify how emergency care will be provided by the organization or through referral and shall identify staff who are authorized to initiate emergency care, the method for exchange of records when necessary, the method of transfer for care, if applicable, to another facility, and the method of notification to clients/patients/residents or other authorized entities regarding the emergency and any subsequent necessary transfers.

 

c)         The plan shall include how staff, clients/patients/residents, and significant others will be provided information concerning overdose prevention medication and access to it and continued access to MAR, as applicable, in the event of emergency transfer.

 

Section 2060.380  Referral Procedure

 

a)         The organization shall have policies and procedures to ensure that each client/patient/resident is informed of SUD services provided by other appropriately licensed organizations and that options are available to access services or levels of care that are not available within the organization.  These procedures shall contain the following:

 

1)         A release of information form that documents the written, dated signature of the client/patient/resident for communication, referral, transfer, or re-release of any relevant portion of the record, including consent or non-consent for the release of confidential medical information, if applicable; the reason for referral; a summary of services received to date; additional services needed or requested; and any necessary continued coordination of services;

 

2)         A process to inform about and assist clients/patients/residents with access to reasonable community resources, vocational rehabilitation, education, and employment services, if requested or identified as an assessed need;

 

3)         The method by which a client/patient/resident may request a referral to the DHS/SUPR Helpline (1-833-2-FIND-HELP); and

 

4)         A process to ensure that all clients/patients/residents are offered an evaluation by a qualified prescriber regarding MAR, including a determination if it is medically necessary.

 

b)         All referrals made for SUD intervention or treatment services, as defined in this Part, shall only be made to organizations licensed under this Part, to those individuals or organizations that are specifically exempted from licensure as specified in Section 15-5 of the Act or to similarly licensed and regulated organizations in other states.

 

c)         Organizations shall also establish policies and procedures to ensure compliance with the Health Care Worker Self-Referral Act [225 ILCS 47] which prohibits entering into an arrangement under which a patient seeking mental health or SUD treatment is referred to a mental health or SUD organization in exchange for a fee, a percentage of the organization's revenues that are related to the patient, or any other remuneration that takes into account the volume or value of the referrals.

 

Section 2060.385  Incident and Significant Incident Reporting

 

a)         An incident is any action that led to, or is likely to lead to, an adverse effect on client/patient/resident services because it is a deviation from established procedures.  These incidents shall be documented in writing immediately, reported to supervisory staff, as applicable, and available for review by DHS/SUPR staff as necessary or during inspection.

 

b)         A significant incident is any occurrence which, regardless of the type of service the client/patient/resident may be receiving:

 

1)         Requires the services of the coroner;

 

2)         Renders the facility inoperable;

 

3)         Involves the alleged sexual or physical abuse or assault of staff or a client/patient/resident;

 

4)         Involves any alleged act that requires mandatory reporting to the professional staff licensing or credentialing body; or

 

5)         Involves any sanction imposed against the licenses or certification of any professional staff member.

 

c)         DHS/SUPR shall be notified verbally in person or over the phone of any significant incident within 24 hours after its occurrence.

 

d)         A written report of any significant incident shall be submitted to DHS/SUPR within ten calendar days after the occurrence and, if applicable, a copy of the coroner's report shall be submitted within five calendar days of receipt by the organization or as part of submission of the written report.

 

Section 2060.390  Complaints

 

a)         A complaint may be filed by clients/patients/residents or organization staff with DHS/SUPR regarding non-compliance with this Part.

 

b)         When the license is issued, DHS/SUPR will also issue a poster that contains the contact information, including DHS/SUPR's phone number and email.

 

c)         This poster shall be displayed at the licensed site in a location that is visible to the public.

 

d)         Complaints may be received verbally but shall be documented in writing by the complainant, with supporting documentation if applicable, before official DHS/SUPR action is undertaken; however, nothing herein shall prohibit DHS/SUPR from immediate investigation of a verbal complaint if deemed necessary by DHS/SUPR or other State or federal investigatory entities.

 

e)         DHS/SUPR shall notify the organization of any complaints it receives about the organization or its services.

 

Section 2060.392  Compliance Inspections

 

a)         DHS/SUPR shall conduct inspections of licensed organization facilities and services to ensure adherence with all regulations in this Part.

 

b)         Inspections may occur at any reasonable time but in general shall be routinely scheduled and, unless otherwise determined by DHS/SUPR, may also include a pre-licensure facility inspection.

 

c)         Inspections of treatment and intervention service records as well as the practical application of administrative policies and procedures to determine compliance with all intervention/treatment standards contained within this Part are conducted on site or virtually at the discretion of DHS/SUPR.  A facility inspection may also be conducted.  Inspections are conducted as close to real time as possible using a sample of client/patient/resident records or, depending on the nature of the review, all records during an identified period of time.  Upon completion of the inspection, organizations are determined to be in good standing or are issued written documentation of the violations with a time for corrective action as specified in Section 2060.396.

 

d)         During any period of corrective action, the organization may request or may be required to participate in technical assistance from DHS/SUPR or its technical assistance/training organizations.

 

e)         DHS/SUPR employees are authorized to enter the facility with access to all areas and all records related to DHS/SUPR authorized services.  DHS/SUPR employees may also make inquiries of organization staff and client/patients/residents.  (See 20 ILCS 301/45-5)

 

f)         If the organization denies consent to inspect, DHS/SUPR will seek access pursuant to Section 45-5 of the Act.  Refusal to consent to any type of inspection or to allow copying or photographing may also be sanctioned in accordance with Section 2060.396.

 

g)         When inspections are part of routine procedure, organizations shall be notified in advance.

 

Section 2060.394  Investigations

 

a)         DHS/SUPR may, at its own initiation, and shall upon the sworn complaint in writing of any person setting forth charges which, if proved, indicate criminal activity and/or would constitute grounds for sanction as specified in Section 2060.396, conduct its own announced or unannounced investigation.

 

b)         DHS/SUPR employees are authorized to enter the facility with access to all areas and all records related to DHS/SUPR.  DHS/SUPR employees may also make inquiries of organization staff and clients/patients/residents.  (See 20 ILCS 301/45-10)

 

c)         DHS/SUPR may also refer such matters for investigation to the appropriate legal authority.

 

Section 2060.396  Sanctions

 

a)         Failure to comply with the requirements of this Part may result in imposition of a sanction on the DHS/SUPR license.

 

b)         DHS/SUPR action to impose a sanction may occur during or after the specified time for corrective action when there is failure on the part of the organization to ameliorate all or a portion of the identified violations except in cases in which DHS/SUPR determines that immediate action is necessary to protect the public interest, safety, or welfare.  (See 20 ILCS 301/45-20(a)(1))

 

c)         Upon conclusion of the period of corrective action, DHS/SUPR shall consider one or more of the following factors in determining whether to pursue a sanction:

 

1)         The extent and nature of the violations;

 

2)         The effort made by the organization to respond to a complaint inquiry by DHS/SUPR and the effort to comply with corrective action, including the ability to complete corrective action within the established time frame;

 

3)         Any history of repeated non-compliance with regulatory requirements; and

 

4)         The potential for harm to a client/patient/resident or the public as a result of the violations or failure to complete corrective action.

 

d)         Nothing contained herein shall preclude DHS/SUPR from imposing a sanction against an organization that has complied with corrective action.  In such case, the factors enumerated in subsection (c) shall be considered by DHS/SUPR in determining whether and to what extent the following sanctions should be imposed:

 

1)         Administrative Warning:  The written administrative warning establishes a probationary period, identifies the violations, the required continued corrective action, and includes a warning that additional violations or lack of corrective action may result in a more severe sanction.  A time frame will be established by DHS/SUPR for completion of the corrective action; however, this time frame shall not preclude DHS/SUPR from requiring a restriction on new admissions and all services during the probationary period if deemed necessary for client/patient/resident safety.

 

A)        On or before completion of the probationary period specified in the administrative warning, DHS/SUPR shall determine if the organization has successfully addressed or eliminated the violations and is now in good standing.  When this occurs, the organization shall be notified in writing.

 

B)        If the organization does not complete the corrective action within the probationary period, DHS/SUPR may elect to extend the probation and/or impose additional sanctions as specified in this Section.

 

2)         Summary Suspension:  If DHS/SUPR finds that there is an imminent danger to the public health or safety which requires emergency action, and if DHS/SUPR incorporates a finding to that effect in its order, summary suspension of a license may be ordered pending proceedings which shall be instituted within 14 days to determine whether the summary suspension shall remain in effect until conclusion of a formal hearing on the merits. [20 ILCS 301/45-30].

 

3)         Suspension:  After a hearing, as specified in Section 2060.398, and formal action by an administrative law judge, DHS/SUPR will issue a license suspension which is a temporary withdrawal of a license or service for a specified time or indefinitely, during which corrective action is taken to rectify violations that led to the suspension.  Upon conclusion of the corrective action, DHS/SUPR will either reinstate or pursue revocation of the license.

 

4)         Revocation:  After a hearing, as specified in Section 2060.398, and formal action by an administrative law judge, DHS/SUPR will issue a license revocation which is termination of a license or service.  Upon revocation, the organization or any ownership of that revoked organization shall not re-apply for any type of DHS/SUPR license for a period of five years and any such re-application shall contain verifiable proof that violations will not re-occur.

 

Section 2060.398  Hearings

 

a)         An organization may request a formal administrative hearing regarding action on the part of DHS/SUPR to suspend, revoke, or not issue or renew a license, except in cases in which DHS/SUPR determines that immediate action to summary suspend is necessary to protect the public interest, safety, or welfare.

 

b)         All hearings regarding DHS/SUPR licenses shall follow the procedures set forth in 89 Ill. Adm. Code 508.

 

c)         Any organization receiving a "Notice of Opportunity for Hearing" shall file for such hearing within 30 calendar days of notice or the hearing rights afforded under this rule shall be deemed waived.

 

d)         Both the burden of going forward with evidence and the burden of proof rest with the party requesting a hearing.  The burden of proof is to show by a preponderance of the evidence that the DHS/SUPR decision is contrary to the evidence on record when taken as a whole.

 

e)         Any organization that requests a hearing to contest a proposed sanction by DHS/SUPR shall have that action stayed pending the final administrative hearing decision.

 

Section 2060.400  Structure and Philosophy

 

a)         SUD treatment is part of the DHS/SUPR recovery-oriented continuum of care and is offered in varying degrees of intensity based upon the individualized continuum treatment plan developed for the patient and the requirements for each level of care as specified herein.  In all cases, treatment must be patient-centered, individual care that is trauma informed and that recognizes and builds upon the patient strengths and strategies they have developed to survive in often inhospitable environments with culturally dominant messages that often devalue them.  SUD treatment helps counter those experiences by providing relationships, connections, and space where patients are treated with dignity, where their experience in the real world is witnessed, and where their strengths and needs are seen and valued.

 

b)         Organizations shall inform all patients of their treatment and recovery philosophy regarding abstinence, harm reduction, and MAR.  This information shall also be communicated through the DHS/SUPR Helpline portal in order to assist with referrals.  Organizations that do not provide treatment based upon harm reduction and MAR shall have policies and procedures that ensure that patients seeking this type of treatment are not denied access to care and not subject to discrimination based upon their preference for a form of treatment not offered or endorsed by the organization.

 

c)         Treatment services are segregated by age (adult or adolescent), but some flexibility is allowed for adults and adolescents to participate together when it is determined to be developmentally appropriate as defined in Section 2060.120 and documented accordingly in the assessment and subsequent treatment plans.

 

d)         All levels of care authorized under a treatment license shall be structured and delivered in accordance with the guidelines specified in the ASAM Criteria as defined in Section 2060.120.  Treatment services, including individual and group sessions, offered within a level of care shall be linked to the assessed needs of each patient and not reflect programmatic structures (i.e., where all patients receive identical treatment in a pre-determined time frame or content).

 

Section 2060.405  Levels of Care – Early Intervention

 

Early Intervention is authorized by a treatment license as follows:

 

a)         Early intervention services may be sub-clinical and pre-diagnostic and/or designed to screen, identify, and address risk factors that may be related to problems associated with SUDs and to assist individuals in recognizing harmful consequences.  These services facilitate emotional and social stability and involve referrals for treatment, as needed.  The assessment and all clinical services shall be delivered by professional staff who meet the requirements specified in Section 2060.320(a).  Other Early Intervention services are not required to be delivered by professional staff as defined in Section 2060.320(a).

 

b)         Early intervention includes a planned and structured regime of services based upon identified risk factors.  The length of service may be pre-determined by an external referral source (e.g., courts, impaired driver intervention, student assistance programs) and/or based upon the individual's ability to comprehend the information provided and to use that information to make behavioral changes to avoid continued problems.

 

c)         Services may begin upon completion of an ASAM assessment that does not result in an SUD diagnosis and/or an immediate need for treatment.  The ASAM assessment must identify at least one risk factor that could result in the development of an SUD.

 

d)         All services must relate to the risk factors identified in the ASAM assessment and shall follow all other service requirements as specified in this Part.

 

e)         All services shall be identified in an Early Intervention service plan that is developed with the client.  The plan must identify interventions that address the identified risk factors and include strategies to assist the client in reduction or elimination of the at-risk behavior.

 

f)         The Early Intervention service plan shall be developed during the first service following the ASAM assessment and admission and reviewed for continuing service after every 10 hours of services or every 60 calendar days, whichever occurs sooner.

 

Section 2060.410  Levels of Care – Treatment

 

a)         Level 1 – Outpatient – Clinical services that are non-residential and that include assessment, treatment planning, continued assessment and service reviews, SUD individual and group treatment and discharge planning. Supportive services that enhance recovery may also include case management, MAR, patient education, and recovery support planning. All services shall be delivered according to the requirements specified in this Part.  The frequency and intensity of such services are determined by patient need but are generally provided in regularly scheduled sessions of fewer than nine hours of clinical services per week for adults and fewer than six hours of clinical services per week for adolescents.

 

b)         Level 2 – Intensive Outpatient – Clinical services that are non-residential and that include assessment, treatment planning, continued assessment and service reviews, SUD individual and group treatment, and discharge planning.  Supportive services that enhance recovery may also include case management, MAR, patient education, and recovery support planning.  All services shall be delivered according to the requirements specified in this Part.  The frequency and intensity of such services are determined by patient need but are generally 9-19 hours of clinical services per week for adults and 6-19 hours of clinical services per week for adolescents.

 

c)         Level 2.5 – Partial Hospitalization – Clinical services that are non-residential and that include assessment, treatment planning, continued assessment and service reviews, SUD individual and group treatment, and discharge planning.  Supportive services that enhance recovery may also include case management, MAR, patient education, and recovery support planning.  Services typically average five hours of individualized clinical service per day that are a mix of individual and group counseling based upon the assessed needs of the patient.  Level 2.5 generally includes 20 or more hours per week of intensive clinical services with direct access to psychiatric, medical, and laboratory services which help to meet identified needs that might warrant daily monitoring or management but that can be appropriately addressed in an outpatient setting.

 

d)         Level 3.1 – Clinically-Managed Low Intensity Residential – Low intensity clinical services that include assessment, treatment planning, continued assessment and service reviews, SUD individual and group treatment, and discharge planning in a residential setting.  Supportive services that enhance recovery may also include case management, MAR, patient education, and recovery support planning.  Historically referenced as halfway houses or residential extended care, organizations shall identify, through administrative policy, staff/patient ratios that ensure patients can access all recommended hours of treatment.  Level 3.1 requires staff, awake and on duty, 24-hours a day, seven days per week, with clinical services delivered by professional staff at least five hours per week that primarily focus on the application of recovery skills, relapse prevention, and emotional coping strategies.  Services are most appropriate for patients who need time and structure to practice and integrate their recovery and coping skills in a residential supportive environment.

 

e)         Level 3.2 – Clinically-Managed Residential Withdrawal Management – Level 3.2 care requires staff, awake and on duty, 24-hours a day, seven days per week, who provide supervision, observation, and support in a residential setting for patients who are intoxicated or experiencing withdrawal.  Withdrawal management allows for the induction/stable dose of MAR or withdrawal from a licit or illicit substance with no MAR if that is not indicated or per patient preference.  Services emphasize peer and social support rather than medical or nursing care and follow clinical protocols for referral and transfer of patients whose conditions deteriorate and appear to need medical or nursing interventions.  Clinical services, delivered by professional staff, include assessment, treatment planning, continued assessment and service reviews, SUD individual and group treatment, and discharge planning. Supportive services that enhance recovery may also include case management, MAR, patient education, and recovery support planning.  Historically referenced as social setting detoxification, Level 3.2 services focus on stabilization, enhancing the patient's understanding of SUDs, and referral to the appropriate level of care for continuation of treatment.

 

f)         Level 3.5 – Clinically-Managed Medium to High Intensity Residential Services – Level 3.5 care requires staff, awake and on duty, 24-hours a day, seven days per week.  Clinical services range from medium to high intensity in a residential setting and organizations shall identify, through administrative policy, staff/patient ratios that ensure patients can access all recommended hours of treatment.  Services include assessment, treatment planning, continued assessment and service reviews, SUD individual and group treatment, and discharge planning.  Supportive services that enhance recovery may also include case management, MAR, patient education, and recovery support planning.  Level 3.5 services are tailored to the patient's readiness to change and are most appropriate for patients whose SUD is so severe that it requires a 24-hour supportive treatment environment to initiate or continue a recovery process that has failed to progress.  Services help patients stabilize and focus on the development of recovery skills so that they do not immediately continue to use in an imminently dangerous manner upon transfer to a less intensive level of care.  Lengths of services are variable with services designed to support ongoing recovery rather than resolve all identified social and psychological problems.  Clinical services must be offered daily and average a minimum of 25 hours per week, 7 days per week, over the length of stay.

 

g)         Level 3.7 – Medically-Monitored Inpatient Withdrawal Management – Level 3.7 care requires staff, 24-hours a day, awake and on duty, seven days per week, who meet the requirements specified in Section 2060.320(c).  This level of withdrawal management allows for the induction or stable dose of MAR or withdrawal from a licit or illicit substance with no MAR if that is not indicated or per patient preference.  All services are delivered primarily by medical and nursing professionals for patients whose withdrawal signs and symptoms are sufficiently severe to require 24-hour evaluation in a residential setting.  Medical services are delivered under a defined set of physician-approved and -monitored procedures or protocols.  Clinical services include assessment, treatment planning, continued assessment and service reviews, SUD individual and group treatment, and discharge planning.  Supportive services that enhance recovery may also include case management, MAR, patient education, and recovery support planning.  Level 3.7 services focus on stabilization until withdrawal signs and symptoms are sufficiently resolved and the patient can be safely managed at a less intensive level of care or, conversely, referred for more acute medical management in an inpatient setting.

 

Section 2060.415  Medical Director/Medical Staff

 

a)         All organizations providing services authorized by a treatment license shall designate a medical director, licensed and in good standing, who shall oversee all medical requirements and procedures, as applicable and as referenced in this Part.  The medical director shall have the following staff qualification relative to each service or level of care specified below:

 

1)         The medical director for any Opioid Treatment Programs (OTP), as specified in subsection (i), shall be a physician licensed to practice medicine in all its branches pursuant to the Medical Practice Act of 1987 [225 ILCS 60].

 

2)         The medical director for any Level 3 treatment service, as specified in Section 2060.410(d) through (g), shall be a physician licensed to practice medicine in all its branches pursuant to the Medical Practice Act of 1987 or a licensed advanced practice registered nurse pursuant to the requirements specified in the Nurse Practice Act [225 ILCS 65/65-43].

 

3)         The medical director for any Level 1, 2, or 2.5 treatment service, as specified in 2060.410(a) through (c), shall be a physician licensed to practice medicine in all its branches pursuant to the Medical Practice Act of 1987, a licensed advanced practice registered nurse pursuant to the Nurse Practice Act, or a licensed physician assistant pursuant to the Physician Assistant Practice Act of 1987 [225 ILCS 95/1].

 

b)         The medical director may be full- or part-time or serve on a consulting or voluntary basis.  At the time of application for license, the DHS/SUPR Schedule E must be completed for the medical director.

 

c)         DHS/SUPR shall be notified any time there is a change in medical director, within ten calendar days of such change.  When this occurs, a Schedule E shall also be submitted.  All Schedule Es must be kept on file by the organization and available for review upon request by DHS/SUPR.

 

d)         The organization shall immediately notify DHS/SUPR in writing when there is a leave of absence or permanent change of the medical director.

 

e)         The medical director and all other medical and nursing staff shall read and comply with this Part.

 

f)         The medical director shall develop and approve all medical services for the organization and develop clinical protocol for mandated treatment as specified in Section 2060.450(b)(1).

 

g)         The organization shall ensure that the medical director and all medical staff under the medical director's supervision comply with the requirements in Section 2060.330(b) regarding employee orientation, Sections 2060.335(a), (j), and (k) regarding personnel requirements, Section 2060.420(g)(5) regarding the Diversion Control Plan required for Opioid Treatment Programs (OTP), and Section 2060.310(g) regarding infectious disease control.

 

Section 2060.420  Medical Services

 

a)         The medical director shall oversee and authorize protocol for all medical services that are referenced herein and offered by the licensed treatment organization.  Any other physician, nurse practitioner, or physician assistant delivering any of the medical services referenced herein shall be supervised according to the requirements outlined in the Medical Practice Act of 1987, the Nurse Practice Act [225 ILCS 65/65-43], or the Physician Assistant Practice Act [225 ILCS 95], as applicable, unless otherwise specified.

 

b)         Medical Review:  The medical director shall determine the medical criteria that, if identified in Dimension 1, 2, or 3 of the ASAM assessment or anytime during an ongoing episode of care, would delay or prohibit admission to or continuation of treatment until a medical review is conducted.  The purpose of the medical review is to determine the immediate need for emergency care or a physical or psychiatric examination and to determine if and or when the patient can continue with services in a manner that is safe for the patient, other patients, and organization staff.  In addition to any other criteria identified by the medical director, a medical review shall be required for any patient under the age of twelve, any pregnant woman in need of withdrawal management, and any patient with signs or symptoms of an infectious disease.  If determined necessary, medical review shall be documented by time, date, and signature in the patient record.  The method for this review and receipt of this documentation shall be determined by the organization.

 

c)         The medical director shall also develop a format to ensure that the following information is collected from all patients as part of Dimension 1, 2, and 3 ASAM assessment inquiry:

 

1)         Primary complaint per patient;

 

2)         Date of the last physical exam and identification of the patient's primary care physician;

 

3)         History of any SUD;

 

4)         History of any withdrawal symptoms;

 

5)         Evidence and/or history of any infectious or communicable disease, including current symptoms;

 

6)         History of concurrent medical symptoms, complications, or conditions, including sexual activity and risk for pregnancy or other sexually transmitted infections (STIs);

 

7)         Determination of the need to verify pregnancy status, as applicable;

 

8)         History of concurrent psychiatric symptoms, complications, or conditions, including suicide or homicide potential;

 

9)         History of trauma, including physical, verbal, emotional, and sexual;

 

10)       Hospitalizations; and

 

11)       Medications currently prescribed and any allergies.

 

d)         Physical Examinations:  The medical director shall develop protocol and authorize procedures for any physical examination, the components of the physical examination, and the professional requirements for any individual who will conduct physical examinations and review laboratory results, in the same facility, under the supervision of the medical director.

 

1)         Physical examinations and associated laboratory tests are required during or after admission, and every 12 months thereafter, for any patient who will be prescribed Methadone or other medications for MAR.  For any patient receiving MAR from another provider other than the licensed organization, another physical is not required but documentation of the previous and ongoing physicals shall be available for review in the patient record.

 

2)         Physical examinations are not required for patients in Level 1, 2, or 3.1 care unless they are receiving MAR or unless required after medical review.  If required, the physical shall be completed within 7 calendar days after admission unless a different timeframe is determined by the medical director.

 

3)         Physical examinations are required for any patient in Level 3.2, 3.5, or 3.7.  Such physical examinations shall be part of the initial treatment plan and shall be completed within 24 hours after admission if the patient is pregnant and/or on MAR or in Level 3.2 or 3.7 withdrawal management.  All other patients shall receive a physical within 72 hours after admission, unless a different timeframe is determined by the medical director.  Patients may provide documentation of a physical examination completed within 30 calendar days prior to admission for review and acceptance by the medical director in lieu of this requirement.

 

4)         Each patient shall receive a referral and contact information for any medical, surgical, obstetric, prenatal, or psychiatric treatment deemed necessary as a result of the physical examination.  Documentation of this referral shall be included in the patient record.

 

e)         Medication Assisted Recovery:  The medical director shall develop procedures to ensure that all such patients receive information about their options for any type of MAR and that appropriate referrals are made for any type of MAR not offered by the organization.  Such procedures shall also ensure that patients are not denied access to treatment services or required to participate in such services because of their MAR for an OUD or any other SUD.

 

f)         Medication Dispensary Services:  The organization shall follow the policy and procedures developed by the medical director, for any patient in Level 3 care, relative to the administration of all prescription and non-prescription medication and shall ensure that patients are not denied access to medications during their SUD treatment.  Medication dispensary services shall be in accordance with the Medical Practice Act of 1987 [225 ILCS 60]; the Pharmacy Practice Act [225 ILCS 85]; the Illinois Controlled Substances Act [720 ILCS 570]; the Special Packaging of Household Substances for Protection of Children, commonly known as the Poison Prevention Packaging Act (15 U.S.C. 1471); Substances Requiring Special Packaging (16 CFR 1700.14); and rules and regulations of the U.S. Drug Enforcement Administration (21 CFR 1300).  The administration or dispensing of patient-owned medications during any Level 3 care service shall comply with the following:

 

1)         Patients shall surrender all medications upon admission;

 

2)         Medications brought by patients shall not be administered unless they can be identified;

 

3)         Self-administration of medication shall be permitted and observed;

 

4)         Self-administration of medication shall be documented and include the date, time, dosage of all medications, and signature of the staff person who observed the self-administration;

 

5)         In those cases where patients are unable to self-medicate, medication shall be dispensed or administered as specified by the medical director;

 

6)         All medications surrendered by the patient at admission that are not used shall be packaged, sealed, stored, or disposed of in accordance with established procedure, or if approved by the medical director, returned to the patient at the time of discharge; and

 

7)         Medications for minors who are in residence with patients shall be reviewed by the medical director or physician, nurse practitioner, advanced practice registered nurse or physician assistant working under their supervision.  Permission to keep medication at bedside in their possession and to self-administer to a dependent child shall be given by the medical director or physician, nurse practitioner, advanced practice registered nurse or physician assistant working under their supervision.

 

g)         Opioid Treatment Program (OTP): DHS/SUPR authorizes, regulates, and inspects organizations that also provide Methadone for patients diagnosed with an opioid use disorder (OUD). These organizations shall meet the following requirements:

 

1)         Satisfy all applicable requirements under 42 CFR 8 (www.samhsa.gov/medication-assisted-treatment) and all Federal Drug Enforcement Administration (DEA) requirements (https://www.deadiversion.usdoj.gov/) specific to the treatment of an OUD and the delivery, storage, security, and accountability of Methadone.  Documentation of SAMHSA approval, DEA registration, and accreditation must be maintained on-site and available for DHS/SUPR review on demand.  The organization shall notify DHS/SUPR in writing immediately upon any change or delay in accreditation approval status.  DHS/SUPR authorization for Methadone use in any level of care is considered conditional for a maximum of one year or until confirmation of the applicable accreditation approval and authorization from the DEA is received by DHS/SUPR.  If the organization is not able to achieve full compliance within the maximum one-year period, authorization to continue admissions will be suspended and the licensed organization may be subject to additional sanctions as specified in Section 2060.396;

 

2)         Forward to DHS/SUPR as the State Methadone Authority, copies of all Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT)-approved accrediting body survey reports, organization responses to these surveys, accrediting body responses and subsequent documentation of accrediting body awards or denials.  DHS/SUPR shall review these documents and require corrective action as specified in Section 2060.396;

 

3)         Be responsible for the following if automated dispensing machines are used:

 

A)        Calibrating the machine on a weekly basis according to manufacturer procedures/specifications;

 

B)        Limiting access to medical order entries (changes in dosage, pickup orders) to licensed physicians only;

 

C)        Printing daily activity reports for patient dispensing, bottle control, and no shows;

 

D)        Taking physical drug inventories and updating the machines daily; and

 

E)        Printing all reports when requested by DHS/SUPR;

 

4)         Organizations who treat patients receiving Methadone in any level of care shall be subject to all applicable clinical treatment requirements specified in this Subpart and in 42 CFR 8.12(f)(5)(i) (Counseling Services); however, patients who are reluctant or who refuse to participate in clinical services shall not be denied Methadone while the organization simultaneously attempts to provide motivational or engagement treatment strategies;

 

5)         Each organization shall maintain a current Diversion Control Plan (DCP) as part of its quality improvement plan referenced in Section 2060.340(6)(c).  At a minimum, the DCP shall include specific measures to reduce the possibility of diversion of controlled substances from legitimate treatment use and assign specific responsibility to the medical director and staff for implementation.  Organizations are responsible for testing each component of the DCP and documenting the results at least quarterly.  The DCP shall incorporate a "Daily/Weekly Medication Accounting Sheet" and an "Exception Medication Record" which may be maintained electronically.  Any other reports required by the DEA (21 CFR 1300 et seq.), whether manual or automated, must be printed and signed daily by dispensing staff;

 

6)         Each organization shall require OTP patients to undergo a complete, fully-documented physical examination by a physician, nurse practitioner, or physician assistant before admission to the OTP and ingestion of the initial dose of Methadone; however, a physician must review and sign off on all physicals and see the patient prior to admission and administration of the first dose.  The physician is the only staff member who can order Methadone treatment and assign the medication dose.  The physical examination shall cover major organ systems and the patient's overall health status and shall document indications of infectious disease, pulmonary, liver, and cardiac abnormalities, vital signs, general appearance of head, eyes, ear, nose, throat, chest, abdomen, extremities, and skin and physical evidence of drug use, and a medical judgment of the extent of the opioid use disorder.  Women shall receive a pregnancy test at the organization site or by referral to a health center.  The results of all tests, laboratory work, and other processes related to the initial medical examination shall be reviewed with the patient and documented in the patient record within fourteen days of admission.  Physical exams and associated laboratory tests are required every 12 months for all OTP patients;

 

7)         The organization shall ensure that the initial dose of Methadone does not exceed 30 milligrams and the total dose for the first day does not exceed 40 milligrams unless the medical director documents in the patient's record that a 40 milligrams dose was not enough to suppress opiate abstinence symptoms;

 

8)         A recipient identification number (RIN) must be obtained from DHS/SUPR for each OTP patient which shall be used in all circumstances requiring patient identification (e.g., medication logs, take-home bottles, exception requests, and general correspondence);

 

9)         A minimum of eight random toxicology tests per year, including the initial toxicology test shall be administered to each patient (42 CFR 8).  Organizations shall ensure that a result from an initial toxicology test that is negative for opioids is not exclusionary criteria for admission to OTP and also not the sole determinant of an OUD diagnosis.  Organizations shall also ensure that toxicology tests that are positive for opioids or other substances are addressed promptly with patients by clinicians and as a part of continued risk assessment and treatment planning;

 

10)       Each organization shall submit opiate dispensing information on a weekly basis;

 

11)       Each organization shall have a policy regarding take-home medication in accordance with SAMHSA regulations and exceptions under 42 CFR 8.  The organization shall request and have appropriate CSAT approvals for any policy exceptions to regulations as well as policies regarding supplies of take-home medication.  An exception may be made to the policy regarding take-home medication which would permit a temporary or permanently reduced attendance schedule, if in the reasonable clinical judgement of the physician:

 

A)        The patient has been found to be responsible in handling narcotic drugs and has a physical disability which interferes with the patient's ability to conform to the applicable mandatory attendance schedule; or

 

B)        The patient has been found to be responsible in handling narcotic drugs and there are exceptional circumstances such as illness or infectious disease, family crises, travel, or other hardship;

 

12)       The rationale for each exception pursuant to subsection (g)(11) and the physician's approval must be documented by signature and date in the patient record.

 

13)       Each organization shall have policies and procedures regarding staff and patient safety during all hours of operation.  Organizations utilizing security guards or metal detectors shall have specific policies and procedures relative to their operation or scope of responsibilities.

 

Section 2060.425  Withdrawal Management

 

a)         The medical director shall develop protocols and authorize procedures for patients experiencing withdrawal symptoms or in need of medically-managed services in any level of care authorized by the DHS/SUPR license.  The protocols shall be inclusive of the staff qualifications specified in Section 2060.320(c).

 

b)         The medical director shall develop a standing order for the treatment plan for any medical services that may be required during withdrawal management.  The standing order for withdrawal management treatment shall be designed to assist patients in achieving stability in a safe environment, with access to medical intervention, if necessary, for the length of time the patient is receiving withdrawal management.

 

c)         An ASAM assessment shall begin as soon as the patient is physically and emotionally stable enough to participate and shall determine the diagnosis and if the patient will be transferred to a higher or lower level of care.

 

d)         The length of services or time spent receiving withdrawal management services is dependent on the patient's emotional and physical stability and a determination of when they are ready to begin or resume participation in the recommended level of care.  This determination shall be made through a continuing service review every 24 hours after confirmation of the initial diagnosis and level of care and in accordance with the requirements specified in Section 2060.475.

 

e)         The organization shall ensure that information about medication assisted treatment and referral, if applicable, is provided to every patient requesting or receiving withdrawal management.

 

Section 2060.430  Intake

 

a)         Prior to the initiation of the ASAM assessment, or, in the case of an impaired patient, as soon as stabilization permits, the following information shall be provided to the patient and obtained from the patient:

 

1)         Collection of all required demographics, as specified in Section 2060.370(d)(9);

 

2)         The hours and days of operation when services are available;

 

3)         Identification of any third-party payment benefits;

 

4)         Collection of income verification, if applicable;

 

5)         A fee schedule in accordance with the requirements in Section 2060.345 that also identifies any cost to the patient that may not be covered by third party insurance including Medicaid and Medicare; and

 

6)         The admission and exclusionary criteria applicable to the individual's conduct or care or that may prohibit a person from receiving necessary services from the licensed organization.

 

b)         The organization shall identify the qualifications and training for any staff who will initiate and complete the intake process.

 

Section 2060.435  Assessment

 

a)         Assessment precedes admission to treatment and then is ongoing throughout treatment as continuing service review.  The initial goal of assessment is to obtain sufficient information to determine the need for stabilization, obtain a diagnosis, and an initial recommendation for placement in a level of care so that the patient can access and initiate services as soon as possible.

 

b)         Assessment is conducted in accordance with the six dimensions of the ASAM Criteria and includes the biopsychosocial assessment and risk/severity rating and an immediate need profile.  The apparent severity of the patient's condition and impairment shall guide how comprehensive the initial biopsychosocial assessment for placement needs to be prior to admission.

 

c)         Assessment is a clinical service and shall be conducted by professional staff.

 

d)         Assessment shall include a review of any specific conditions or recommendations from a referral source including any prior screenings, evaluations, or assessments.

 

e)         Assessment shall include a review of any specific conditions of any court order or other referral that may require completion of a specified level of care or number of hours.  If a court order or referral differs from the level of care or number of hours that are subsequently determined by the assessment, the organization shall have procedures in place to reconcile with the court or referral source and allow admission in accordance with the requirements specified in Section 2060.450 regarding mandated treatment.

 

f)         The assessment shall be organized according to the six dimensions of the ASAM Criteria and conclude with a diagnosis, as defined in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), and a recommendation for placement in a level of care.

 

Section 2060.440  Treatment Plans

 

a)         Upon admission to any treatment level of care, the assessment shall be reviewed, and updated if needed, with the patient, to develop an individual person-centered treatment plan that is age, developmentally, gender identity, and culturally appropriate.  The biopsychosocial assessment and immediate needs profile shall guide the development of the plan.

 

b)         Development of the initial treatment plan shall begin during the first day of residential care in Level 3.1 or 3.5 and with the first treatment service in Level 1, 2, and 2.5.  As specified in Section 2060.425(b), standing orders for treatment plans for Level 3.2 and 3.7 are acceptable.  All treatment plans shall address the patient's presenting concern, the most immediate needs identified in the assessment, and the goals and objectives that will assist the patient with stabilization and in transitioning to less intensive levels of care and recovery support.

 

c)         If confirmation of the initial treatment plan is required, as specified in Section 2060.445, such confirmation shall take place within the required time frames specified in that Section.

 

d)         All treatment plans shall be signed and dated by the patient, the professional staff who completed the plan, and, as applicable, any professional staff who provided the confirmation.

 

e)         All treatment plans shall address needs identified in the assessment that have been prioritized with the patient.  Each identified priority shall list at least one goal for resolution or reduction of the problem with measurable and observable objectives for achievement.  The treatment services that will be used to meet the goals and objectives shall be identified and include the location, intensity, and duration of those services with a timetable for achievement that is within the time frame of the patient's expected participation.

 

f)         All treatment plans shall identify the need and frequency of or referrals for case management or any other activities or consultations planned for the patient or any other family members or significant others.

 

g)         All treatment plans shall identify any referral for recovery support and specify the individual or entity that will provide the service.

 

h)         All treatment plans shall be updated to reflect resolution or establishment of identified problems or goals and in accordance with the continued service review criteria specified in Section 2060.475.

 

i)          All treatment plans shall identify the type of measurement (hours or days) used for continued service reviews and this measurement shall remain unchanged until the next review.

 

Section 2060.445  Confirmation of Diagnosis, Initial Placement, and Initial Treatment Plan

 

a)         The medical director, or the physician, nurse practitioner, or physician assistant working under the medical director's supervision, shall review the assessment, confirm the diagnosis, initial placement in care and initial treatment plan, for any patient who was identified for medical review as specified in Section 2060.420(b).

 

b)         If not identified for medical review and confirmation, as specified above, review of the assessment, confirmation of diagnosis, initial patient placement, and initial treatment plan is only required for staff who do not meet the qualifications specified in Section 2060.320(a)(2) through (7).  Confirmations for staff who only have the professional staff qualification specified in Section 2060.320(a)(1) shall be conducted by any professional staff who meet the qualifications in Section 2060.320(a)(2) through (7).

 

c)         When confirmation is required pursuant to subsections (a) or (b) , these confirmations shall be made within 24 hours of admission for any patient in Level 3.2 or 3.7 withdrawal management care unless the patient is unable to participate and the medical director authorizes a longer timeframe, within 72 hours of admission for any patient in Level 2.5 or 3.5 care and within 7 calendar days of admission for patients in Level 1, 2, or 3.1 care.

 

d)         All confirmations shall be authorized by signature and date in the patient record, indicating that the assessment has been reviewed and specifying agreement or a change in the recommended diagnosis and level of care.

 

Section 2060.450  Mandated Treatment

 

a)         Patients with SUDs often initiate services resulting from a court order or employment that require completion of a specified early intervention (Level 0.5) or treatment level of care or a finite number of service hours; however, these directives shall not remove the responsibility of the organization to administer an ASAM assessment, as specified in Section 2060.435, and to communicate to the referral source or any third-party payor any subsequent recommended change in level of care or the length of individual treatment.  These directives may also require increased case management and reporting with referral sources.

 

b)         Organizations that accept patients with mandated treatment requirements shall:

 

1)         Adhere to criteria and associated clinical protocol developed and approved by the medical director that will allow admission and initial placement in the mandated level of care contained in the directive so that the patient can promptly initiate services;

 

2)         Have policies and procedures for the timely receipt and use of any prior screening or assessment information to minimize duplication of services;

 

3)         Follow all requirements for any required medical review and confirmation of diagnosis, initial placement, and treatment plan as specified in Section 2060.445;

 

4)         Follow all requirements in Subpart D regarding the delivery of SUD clinical services;

 

5)         Ensure that the patient and referral source has been informed that third-party insurance coverage may not authorize treatment in a level of care not deemed medically or clinically necessary;

 

6)         Obtain all necessary patient authorizations to ensure effective and timely communication with the referral source regarding patient progress, recommended changes in intensity or duration of treatment, discharge from treatment, and the patient's continuing care plan; and

 

7)         When possible, obtain agreements with referral sources regarding resolution of any discrepancy between the mandated treatment directive and the subsequent assessment, diagnosis, placement, and continued service recommendations.

 

Section 2060.455  Group Treatment

 

a)         Prior to admission, patients shall be informed of the amount of group treatment that may be part of any level of care and shall be given the option to participate in any recommended group treatment.  If the patient exercises the option to not participate in a level of care based on the amount of group treatment, the organization shall offer a less restrictive level of care.  Counseling and didactic groups for substance use disorder treatment are as follows:

 

1)         Counseling groups are a therapeutic activity with the primary purpose of allowing patients or significant others an opportunity to process issues related to their treatment in a group setting.  Counseling groups can have a specific focus but are generally process oriented and less educational.  All counseling groups shall be facilitated by professional staff.  Justification for any patient who participates in a counseling group shall be documented as an assessed need and relate to the treatment plan.  Counseling groups shall at no time exceed 16 patients per group.

 

2)         Didactic groups are a therapeutic activity with the primary purpose of educating patients or significant others on a specific treatment-related topic in a group setting.  All didactic groups shall be led or supervised by professional staff or by other professionals with credentials specific to the subject matter of the didactic group following a lesson plan or outline approved by the organization.  For example, a licensed dietitian might lead a group on nutrition.  Justification for any patient who participates in a didactic group shall be documented as an assessed need and relate to the treatment plan.  Didactic groups shall generally not exceed 24 people.

 

b)         Organizations shall have a sign-in and sign-out process for each group session.  Each patient participating in the group shall sign-in and sign-out and indicate the time and identity by full or partial name.  The organization's process shall include the date, duration of each group session, group topic, and the name of professional staff and credentials.  Group sign-in and sign-out documentation shall be made available to DHS/SUPR for review upon request and maintained in original form by the organization.

 

Section 2060.460  Patient Education

 

a)         Each organization shall ensure that patient education is part of each patient's treatment plan or offered prior to development of the treatment plan.  Patient education may be provided individually or in a group and shall be provided to each patient at least once during an episode of care and documented in the patient record.

 

b)         Mandatory elements of patient education shall include, at a minimum, information about:

 

1)         The benefits and risks of MAR;

 

2)         As applicable, all medications authorized by the medical director for treatment of SUD, OUD, or any co-occurring disorder;

 

3)         Toxicology testing protocol, as applicable;

 

4)         The organization's treatment and recovery philosophy and description of recovery support services;

 

5)         Treatment protocol and all rules and consequences relative to patient conduct;

 

6)         Infectious disease risk reduction, including information about the prevention of tuberculosis, Hepatitis C, HIV/AIDS, and other sexually-transmitted infections.  Education shall also include infectious disease etiology and transmission, associated risk behaviors (including information about needle sharing, sexual transmission, transmission to infants, etc.), symptomology, and clinical progression and the relationship to SUD behavior;

 

7)         The availability of counseling and testing services for infectious disease and the specific regulations regarding confidentiality relative to HIV/AIDS;

 

8)         As applicable, overdose prevention training relative to recognition of and response to an opioid overdose and the use and administration of naloxone; and

 

9)         Information about the effect of alcohol, cannabis, illicit drugs, and prescription medications on overall health and safety and their impact on safely operating a motor vehicle.

 

c)         Upon completion of all mandatory education specified in this Section, documentation indicating the type of education and the date received shall be noted in the patient record.

 

Section 2060.465  Recreational Activities

 

a)         Recreational activities are allowed as part of the patient's treatment in any level of care if they are identified as an assessed need and can contribute to ongoing recovery support.

 

b)         All recreational activities shall be conducted in the presence of and under the direct supervision of staff who have basic knowledge of the activity and its relevance to the patient's treatment.

 

c)         Recreational activities shall not average more than  of the treatment services for any patient in any ASAM level of care.

 

d)         Recreational activities shall be documented by time, date, and duration in the patient record.

 

Section 2060.470  Progress Notes and Documentation of Service Delivery

 

a)         Patient progress shall be documented by note in the patient record and shall be consistent with the assessment and treatment plan goals and objectives.  At a minimum, progress notes include a chronological documentation of progress in treatment, any change in patient behavior, and a description of the patient's response to treatment.  Progress notes also document patient outcomes, toxicology results, missed dosing for patients on MAR, referrals for case management, recovery support, and any other incident that may have an impact on patient progress in treatment.

 

b)         Progress notes shall document each service delivered, location of the service delivery and the date, time, and duration of each service.

 

c)         Progress notes shall include the name and credentials of the individual who provided the service.  As applicable, progress notes shall also be signed and dated by the individual making the entry.  Electronic signatures or initials must meet all specifications for electronic signature specified in Section 2060.370(d)(6).

 

d)         Service delivery can be summarized in a progress note prior to each continued service review for patients in Level 1 or 3.1 care, every 14 calendar days for patients in Level 2 care, and daily for patients in Level 3.2, 3.5 or 3.7 care.

 

e)         Any progress note that includes a subjective interpretation of the patient's progress shall include a description of the actual behavior.

 

Section 2060.475  Continued Service Review Criteria

 

a)         A continued service review is an examination and comparison of the current treatment plan and all subsequent progress notes as they relate to each of the six dimensions of the ASAM criteria and the identification of any new problems that need to be addressed.  The resolution of current goals and objectives or the identification of new problems will determine:

 

1)         Amendments to the treatment plan;

 

2)         Continuation in the current level of care;

 

3)         Transfer to a different level of care;

 

4)         Discharge; or

 

5)         Determination of the next review date.

 

b)         A continued service review may occur at any time to determine continued service in the current level of care or to update components of the treatment plan if needed; however, at a minimum, continued service review shall occur:

 

1)         Every 60 calendar days or after every 10 hours of treatment (whichever occurs first) for patients in Level 1 and 3.1 care;

 

2)         Every 30 calendar days or after every 27 hours of treatment (whichever occurs first) for any patient in Level 2 care;

 

3)         Every 14 calendar days or after every 40 hours of treatment (whichever occurs first) for any patient in Level 2.5 care;

 

4)         Every 7 calendar days for any patient in Level 3.5 care;

 

5)         Every 24 hours for any patient in Level 3.2 or 3.7 care, unless another time frame is specified by the medical director; or

 

6)         For patients receiving medication in an opioid treatment program (OTP), and not receiving any clinical treatment service in any of the above referenced levels of care, every 30 days during the first 90 days of medication and every 90 days thereafter for any patient who has demonstrated 90 days of stable participation and for whom there has been no biomedical complication or change.

 

c)         The continued service review shall include the participation of the patient and be documented by progress note in the patient record.  The documentation shall be signed and dated by the patient and professional staff who conducted the review and dated and signed by the medical director, physician, nurse practitioner, or physician assistant working under their supervision only if there is a significant bio-medical change in ASAM Dimension 1 or 2 that requires medical or nursing monitoring or if there is a significant change in an identified mental health problem in ASAM Dimension 3 that requires a change in medication management or monitoring.

 

d)         When a continued service review recommends patient transfer to another level of care or discharge, such change will be completed within 48 hours after the date of the continued service review.

 

Section 2060.480  Continuing Care Plan and Discharge

 

a)         Organizations shall develop a continuing care plan with input from the patient and, if possible, prior to discharge for any patient no longer meeting the criteria for continued active treatment at that organization.  The continuing care plan shall contain the following information as appropriate for each individual patient:

 

1)         Strategies to avoid a recurrence of problematic substance use that also identifies actions to re-engage in treatment should this occur;

 

2)         Activities planned by the organization to support continued recovery;

 

3)         Specific and measurable patient involvement if accountability by the patient is required for any case management or monitoring organization (e.g., courts, probation offices, the Illinois Secretary of State, parole officers, employers, the Illinois Department of Children and Family Services, etc.); and

 

4)         If not already provided, identification of community and recovery support services that can help to maintain, support, and enhance progress made in treatment and the patient's recovery capital, including referrals for stable housing, if needed.

 

b)         Organizations shall develop discharge and exclusionary criteria consistent with customary clinical standards.  All patients shall be informed of the criteria at intake, as specified in Section 2060.430.

 

c)         Upon completion of treatment services from the organization, a discharge summary shall be completed for each patient within 15 calendar days after discharge.  The most recent continued service review can be substituted for the discharge summary; however, in both cases, the document shall contain the following:

 

1)         The reason for discharge;

 

2)         Progress of the patient relative to each goal and objective in the treatment plan;

 

3)         An assessment statement of the patient's condition at discharge, including any continued use of prescribed medication; and

 

4)         The patient's continuing care plan.

 

d)         If possible, a copy of the discharge summary and continuing care plan should be provided to the patient upon discharge but, in all cases, made available to the patient upon request.

 

Section 2060.500  General Requirements

 

a)         Organizations that are licensed for an intervention service, as identified in this Subpart, shall also meet all applicable requirements in Subparts A, B, and C of this Part unless otherwise specified.

 

b)         Any organization that provides an intervention service to any client/resident under a specific administrative or court order that mandates the type of intervention shall comply with the following:

 

1)         Have protocols that allow the client/resident to promptly initiate the mandated service;

 

2)         Deliver the intervention service in accordance with the mandate in the administrative or court order;

 

3)         Communicate with the referral source regarding any recommended change in the intervention service, if the recommendation differs from that identified in the administrative or court order;

 

4)         Communicate with the referral source, if it is identified that the client/resident needs additional hours of intervention or needs to initiate treatment services; and

 

5)         Obtain all necessary contact information to ensure effective and timely communication with the referral source regarding the client/resident participation in and or successful or unsuccessful completion of the intervention service and any additional recommendations.

 

Section 2060.510  DUI Evaluation

 

a)         The purpose of the DUI evaluation is to conduct an initial screening to obtain significant and relevant information from a DUI offender about the nature and extent of the use of alcohol and other drugs, in order to:

 

1)         Identify the offender's risk to public safety for the referring circuit court or the Illinois Office of the Secretary of State (SOS); and

 

2)         Make a recommendation of intervention, treatment, or a combination thereof for the DUI offender to the referring circuit court or SOS.

 

b)         DUI evaluation services shall be provided to any offender, regardless of ability to pay, in accordance with 20 ILCS 301/50-20 as follows:

 

1)         If an offender provides proof of income that meets the federal poverty income guidelines issued annually by the U.S. Department of Health and Human Services and adopted by DHS/SUPR, the organization shall bill the Drunk and Drugged Driving Prevention Fund (DDDPF) through the eDSRS for reimbursement of the evaluation.  Acceptable documents to prove income include, but are not limited to, the most recent income tax return or any documents attesting to any change in status from the last income tax filing, such as payroll stubs, proof of unemployment, or verification of disability or Medicaid coverage.

 

2)         Reimbursement from the DDDPF is subject to availability of funds.  If notified by DHS/SUPR that funding from the DDDPF is not available, organizations shall identify, on the fee schedule required in Section 2060.345, the amount that will be assessed to the DUI offender and the collection procedure.

 

3)         The fee schedule shall also specify the amount that may be assessed to the DUI offender if the organization's standard evaluation fee exceeds the DHS/SUPR rate of reimbursement from the DDDPF; however, the assessed amount shall not exceed the difference between the organization's standard fee and the DHS/SUPR reimbursement rate.

 

4)         In all cases, if reimbursement from the DDDPF or from the DUI offender who has proven inability to pay is not received by completion of the service, the organization shall still release the evaluation to the referring circuit court or to the offender for an SOS hearing.

 

5)         Evaluations can be held by the organization for any DUI offender who has not proven inability to pay and who refuses to pay the cost of the evaluation.

 

6)         Organizations choosing not to submit reimbursement claims from DDDPF shall still provide services to DUI offenders with proven inability to pay in accordance with this Part and the organization shall bear the cost of the service.

 

c)         The DUI evaluation shall include the ability to observe client behavior.  The identity of the client and the significant other, if interviewed, shall be verified through picture identification.

 

d)         Each DUI offender shall be provided the DHS/SUPR brochure that explains the DUI evaluation process and it shall be read by or to the offender prior to the initiation of the service.  Each DUI offender shall also be provided a standard form, produced by the DHS/SUPR eDSRS, that is for DUI offender informed consent and that, in addition to the specifications required in Section 2060.360, contains the following:

 

1)         States that any information provided by the DUI offender will be released to the referring circuit court, the Office of the Secretary of State and DHS/SUPR, and that no offender consent is required for this disclosure;

 

2)         Identification by the DUI offender of where they obtained any previous evaluations as a result of the most current DUI offense and to provide a copy of those evaluations, if completed; and

 

3)         A signature line for the DUI offender that, by signature, indicates understanding of the DUI evaluation process and disclosure requirements.  A copy of this form shall be placed in the DUI offender's client record.

 

e)         If the DUI offender refuses to sign informed consent or provide copies of other completed evaluations, written notice of that refusal shall be sent to the referring circuit court or to the Office of the Secretary of State, as applicable, and the evaluation process shall be terminated.

 

f)         The organization shall have written policy and procedure to ensure the prohibition of disclosure of any DUI evaluation to any other party other than the DUI offender, the circuit court, the Illinois Office of Secretary of State, and DHS/SUPR without the written consent of the DUI offender.

 

g)         The interview, to obtain the necessary information to complete the evaluation, shall be structured and scheduled to ensure that, prior to completion, the following occurs:

 

1)         Collection of a comprehensive chronological history of alcohol and or other drug use from first use to present, including all prescription and over-the-counter medications, and exposure to intoxicating compounds and illicit drugs.  The frequency and pattern of use by type and amount shall be identified as well as any change in the use pattern and the reason for the change.  Collection of this information shall be obtained in a format separate from the Alcohol and Drug Evaluation Uniform Report and available for DHS/SUPR review upon request;

 

2)         A determination of the extent to which the alcohol and or drug use has caused marital, family, legal, social, emotional, vocational, physical, or economic distress or impairment;

 

3)         An analysis of the DUI offender's verbal description of:

 

A)        Alcohol and drug related legal history, driving history (all offenses), and any related alcohol or drug use or other chemical test results and the type of alcohol or other drugs that resulted in all arrests, including the most recent DUI arrest;

 

B)        History of alcohol or other drug evaluations or screenings, SUD treatment, and recovery support involvement, including self-help groups;

 

C)        Family history of SUDs and use of alcohol and or other drugs;

 

D)        Alcohol- and drug-related criminal record;

 

E)        History of any arrests or convictions for boating under the influence (BUI) or snowmobiling under the influence (SUI); and

 

F)         Any rescinded statutory summary suspensions and any other dismissed alcohol- and drug-related driving arrests and the reasons for the rescinded action or dismissal.  This information shall be considered as part of the overall analysis of the DUI offender's history, but shall not be used or substituted for the alcohol- and drug-related driving dispositions specified in subsection (g)(4)(B) in determining a risk level.

 

4)         An analysis of:

 

A)        Objective test results from either the Driver Risk Inventory (DRI), the Adult Substance Use and Driving Survey-Revised for Illinois (ASUDS-RI), or any other test approved for use by DHS/SUPR in accordance with Section 2060.305;

 

B)        The DUI offender's current driving record, as documented on the Alcohol/Drug-Related Driving Offenses summary form from the Office of the Secretary of State or a copy of the actual Court Purposes driving abstract supplied to the referring circuit court by the Office of the Secretary of State; and

 

C)        The Law Enforcement Sworn Report (issued to the DUI offender at the time of the arrest for DUI) that identifies the chemical test result, BAC, or the refusal to submit to chemical testing relative to the most current DUI arrest.

 

h)         Based upon all information obtained during the evaluation, the organization shall determine the DUI offender's risk to public safety.  The assignment of risk is considered an initial finding that may be subject to change whenever additional information is obtained during any subsequent evaluation.  The risk assignment shall be minimal, moderate, significant, or high, as follows:

 

1)         Minimal Risk: The offender has:

 

A)        No prior convictions or court-ordered supervisions for DUI, BUI, or SUI, no prior statutory summary suspensions, and no prior reckless driving conviction or court-ordered supervision reduced from DUI, BUI, or SUI.  This rule includes offenses that occur in other states as well as Illinois, and regardless of whether the offense has been recorded on the offender's Illinois driving record; and

 

B)        A BAC of less than .15, as a result of the most current DUI, BUI, or SUI arrest; and

 

C)        No identified pattern of alcohol- or drug-impaired driving; and

 

D)        No other symptoms of a substance use disorder.

 

2)         Moderate Risk:  The offender has:

 

A)        No prior convictions or court-ordered supervisions for DUI, BUI, or SUI, no prior statutory summary suspensions, and no prior reckless driving conviction or court-ordered supervision reduced from DUI, BUI, or SUI.  This rule includes offenses that occur in other states as well as Illinois, and regardless of whether the offense has been recorded on the offender's Illinois driving record;

 

B)        A BAC of .15 to .19 or an implied consent refusal, as a result of the most current DUI, BUI, or SUI arrest; or

 

C)        At most, one symptom of a substance use disorder.

 

3)         Significant Risk:  The offender has:

 

A)        Prior to the must current offense, one prior conviction or court-ordered supervision for DUI, BUI, or SUI, or one prior statutory summary suspension, or one reckless driving conviction, or court-ordered supervision reduced from DUI, BUI, or SUI.  This rule includes offenses that occur in other states as well as Illinois, and regardless of whether the offense has been recorded on the offender's Illinois driving record; and

 

B)        A BAC of .20 or higher, as a result of the most current arrest for DUI, BUI, or SUI; or

 

C)        Two or three symptoms of a substance use disorder.

 

4)         High Risk:  The offender has:

 

A)        Prior to the most current offense, any combination of two or more of the following alcohol or drug-related offenses: court-ordered convictions or court-ordered supervisions for DUI, BUI, or SUI or prior statutory summary suspensions or reckless driving convictions or supervisions reduced from DUI, BUI, or SUI that arise out of separate incidents.  This rule includes offenses that occur in other states as well as Illinois, and regardless of whether the offense has been recorded on the offender's Illinois driving record; or

 

B)        Four or more symptoms of a substance use disorder.

 

i)          After a determination of risk, a corresponding intervention shall be recommended; however, the recommendation shall be viewed as the minimum necessary and, as such, not the determinate intervention.  Any subsequent information relevant to the DUI offender's substance use, impaired driving, or arrest history discovered during the DUI offender's participation in risk education or early intervention shall be considered pertinent in formulating a recommendation for further services necessary to reduce the risk to public safety.  Initially, the following interventions for each risk level shall be selected and recommended:

 

1)         Minimal Risk:  Successful completion of a minimum of ten hours of DUI risk education, as defined in Section 2060.520.

 

2)         Moderate Risk:  Successful completion of a minimum of ten hours of DUI risk education, as defined in Section 2060.520; a minimum of 12 hours of SUD early intervention from an organization authorized in accordance with the specifications in Section 2060.110 and, as further defined in Section 2060.405, provided no more than three hours per day over a minimum of four weeks; successful completion of any and all additional recommended early intervention or treatment and, as applicable, ongoing participation in all activities specified in the continuing care plan.

 

3)         Significant Risk:  Successful completion of a minimum of ten hours of DUI risk education, as defined in Section 2060.520; successful completion of a minimum of 20 hours of SUD treatment from an organization authorized in accordance with the specifications in Section 2060.110 and, as further defined in Section 2060.410 and, upon completion of all recommended treatment and, after discharge, active on-going participation in all activities specified in the continuing care plan.

 

4)         High Risk:  Successful completion of a minimum of 75 hours of SUD treatment from an organization authorized in accordance with the specifications in Section 2060.110 and as further defined in Section 2060.410; successful completion of all recommended treatment and, after discharge, ongoing participation in all activities specified in the continuing care plan.

 

j)          A summary of the DUI evaluation, the assigned risk level, and the corresponding intervention shall be documented on the DHS/SUPR Alcohol and Drug Evaluation Uniform Report which is produced by the eDSRS.  All sections of this form shall be complete and signed by the evaluator and the DUI offender.  The eDSRS is the only mechanism that shall be used to produce the Alcohol and Drug Evaluation Uniform Report and, other than original signatures, shall have no other handwritten information on the report.  Handwritten information invalidates the Uniform Report and it cannot be used for the purposes described herein.  If it is necessary to submit additional information other than that contained on the Uniform Report, a separate addendum signed by the evaluator can be attached to the Uniform Report.

 

k)         Upon completion of the evaluation:

 

1)         A copy of the Alcohol and Drug Evaluation Uniform Report containing original signatures shall be provided to the DUI offender upon completion of payment or as otherwise specified in subsection (b)(4).

 

2)         Any DUI offender that receives a recommendation of SUD early intervention or treatment shall be referred for the appropriate service to an organization authorized in accordance with the specifications in Section 2060.110 and as further defined in Sections 2060.405 and 2060.410.

 

3)         Any DUI offender that receives a recommendation of DUI risk education shall be referred to an organization authorized for this service by DHS/SUPR.

 

4)         All DUI offenders shall verify that they have been shown, prior to referral, a list of appropriately-licensed organizations that can deliver the recommended intervention, unless being shown a referral list is contrary to local court rules.  This verification of conflict-free choice of organizations shall be by DUI offender signature on the DHS/SUPR Referral List Verification form.

 

l)          The evaluation is complete when all of the information required in subsections (a) through (k) has been obtained and the Alcohol and Drug Evaluation Uniform Report is signed by the DUI offender.  The Alcohol and Drug Evaluation Uniform Report shall be provided directly to the referring circuit court unless another repository is specified by court rule.

 

m)        Evaluations shall be scheduled and completed so that the Alcohol and Drug Evaluation Uniform Report can be sent directly to the referring circuit court at least five calendar days prior to the DUI offender's court date unless otherwise specified by court rule.

 

n)         The evaluator shall be available to provide testimony relative to the DUI evaluation when summoned by the circuit court.

 

o)         The referring circuit court or the Office of the Secretary of State, whichever is applicable, shall be notified by the evaluator within five calendar days when a DUI offender does not complete or refuses to sign the evaluation or does not return to sign the evaluation after 30 calendar days from date of last contact.  This information shall be communicated using the DHS/SUPR Notice of Incomplete/Refused DUI Evaluation form.  A copy of the incomplete or refused evaluation or partial narrative format shall be attached to the form.

 

p)         In addition to the requirements specified in Section 2060.370, the following documents shall also be contained in the DUI offender's record:

 

1)         A copy of the DUI offender's Alcohol and Drug Evaluation Uniform Report and narrative information documented on a format that supports the conclusions in the Uniform Report;

 

2)         A copy of the Driver Risk Inventory (DRI) or the ASUDS-RI test;

 

3)         Documentation to support any subsequent change in risk assignment or intervention;

 

4)         A copy of the Informed Consent Release form;

 

5)         Documentation of the DUI offender's driving record and any chemical test or refusal results;

 

6)         a copy of the Notification of Incomplete/Refused Evaluation form, if applicable; and

 

7)         a copy of the Referral List Verification form.

 

Section 2060.520  DUI Risk Education

 

a)         DUI risk education can be provided either in person or online, in accordance with the requirements of this Section.  The purpose of DUI risk education is to provide orientation regarding the impact of substance use on driving skill and to further explore the personal ramifications of substance use.

 

b)         DUI risk education services shall be provided to any DUI offender regardless of ability to pay, in accordance with 20 ILCS 301/50-20 and as follows:

 

1)         If a DUI offender provides proof of income that meets the most recent guidelines adopted by DHS/SUPR, the organization shall bill the DDDPF through the eDSRS for reimbursement for the risk education.  Acceptable documents to prove income include, but are not limited to, the most recent income tax return or any documents attesting to any change in status from the last income tax filing, such as payroll stubs, proof of unemployment, or verification of disability or Medicaid coverage.

 

2)         Reimbursement from the DDDPF is subject to availability of funds.  If funding from the DDDPF is not available, organizations shall identify, on the fee schedule required in Section 2060.345, the amount that will be assessed to the DUI offender and the collection procedure.

 

3)         The fee schedule shall also specify the amount that may be assessed to the DUI offender if the organization's standard fee for DUI risk education exceeds the DHS/SUPR rate of reimbursement from the DDDPF; however, the assessed amount shall not exceed the difference between the organization's standard fee and the DHS/SUPR reimbursement rate.

 

4)         In all cases, if reimbursement from the DDDPF or from the DUI offender who has proven inability to pay is not received by completion of the service, the organization shall still release proof of DUI risk education completion to the referring circuit court or to the offender for a SOS hearing.

 

5)         Proof of completion of DUI risk education can be held by the organization for any DUI offender who has not proven inability to pay and who refuses to pay the cost of the risk education.

 

6)         Organizations choosing not to submit reimbursement claims from DDDPF shall still provide services to DUI offenders with proven inability to pay in accordance with this Part and the organization shall bear the cost of the service.

 

c)         The DUI risk education curriculum can be designed by the organization or be part of a nationally-recognized and standardized package designed to educate impaired drivers through classroom or online instruction.  The curriculum used shall be submitted to DHS/SUPR at the time of application for licensure, upon any curriculum modification or change in method of delivery, and at each renewal.  At a minimum, the curriculum shall contain the following:

 

1)         Physiological and pharmacological impact of alcohol and other substance use, including any residual impairment on driving performance;

 

2)         Information about alcohol and other frequently used drugs, legal and illegal, and how they contribute to the overall incidence of criminal justice cases, accidents and fatalities, domestic violence, etc.;

 

3)         The impact of all drugs, legal and illegal, and the immediate impact on driving when used separately or in combination with alcohol;

 

4)         A video or in-person presentation on victim impact;

 

5)         Information about SUDs and the impact on individuals and families including factors that influence the formation of patterns of use and the development of disorders;

 

6)         The impact of trauma, both past and present, and how that may affect substance use behavior;

 

7)         Information about current Illinois impaired driving laws and associated penalties and the Illinois Secretary of State hearing process for restricted driving privileges or full reinstatement;

 

8)         Information about treatment and recovery support services and how to contact them for any problem that may increase the risk for a future substance use-related difficulty; and

 

9)         A minimum of ten hours of instruction, divided into at least four sessions held on different days with no session exceeding three hours in length. Photo identification is required for each participant. Identity verification is required for online instruction. If online instruction is utilized, it shall include periodic quizzes or poll questions to ensure active participation.

 

d)         Audio-visual presentations shall not comprise more than 25% of the total class time.

 

e)         No more than 24 participants shall be permitted in any one class session.

 

f)         Written rules that address the following shall be developed and provided to each DUI offender upon enrollment:

 

1)         Criteria for enrollment;

 

2)         Criteria for involuntary termination;

 

3)         Responsibilities of the DUI offender regarding attendance and classroom or online etiquette and behavior;

 

4)         Sobriety and non-prescription drug use during class; and

 

5)         Course outline, content, and class schedule.

 

g)         Prior to enrollment in DUI risk education, the organization shall obtain a copy of the DUI offender's completed Alcohol and Drug Uniform Report indicating that risk education has been recommended.

 

h)         The organization that completed the evaluation or, if applicable, the early intervention, shall be notified in writing if information is discovered or disclosed while the DUI offender is enrolled in DUI risk education that indicates that the offender was not correctly evaluated and is in need of additional services.  This written notification shall also be made to the referring circuit court or the Illinois Office of the Secretary of State, as applicable.

 

i)          A pre- and post-test shall be administered to the DUI offender to assess the effectiveness of the service and any increase in knowledge.  The pre- and post-test format shall be submitted to DHS/SUPR at the time of application for licensure and at each renewal.  In all cases, the post-test to verify successful completion, as specified herein, shall be in person or administered using a remote or virtual secure live proctored format.

 

j)          The referring circuit court or the Illinois Office of the Secretary of State, as applicable, shall be notified within five calendar days when a DUI offender is involuntarily terminated from DUI risk education.  This information shall be communicated using the DHS/SUPR Notice of Involuntary Termination from DUI risk education form produced by eDSRS.

 

k)         In order to successfully complete DUI risk education, the DUI offender shall attend each session in its entirety and in proper sequence and achieve a score on the post-test of at least 75%.  Each DUI offender attending in-person shall sign an attendance verification for every class on the date attended and include the session number, topics, time, and duration of the session.  Organizations using an online curriculum shall have a method to obtain this same information for each session.

 

l)          Upon successful completion, a DUI Risk Education Certificate of Completion shall be issued to each DUI offender.  The certificate is produced by the eDSRS.  All sections of this certificate shall be completed and signed by the DUI risk education instructor.

 

m)        The DUI risk education instructor shall be available to provide testimony relative to the offender's participation in risk education when summoned by the referring circuit court, the Illinois Office of the Secretary of State, or as requested by the DUI offender or their attorney.

 

n)         In addition to the requirements specified in Section 2060.370, the following documents shall also be contained in the DUI offender's client record:

 

1)         A copy of the Alcohol and Drug Evaluation Uniform Report;

 

2)         The pre- and post-test specifying percentage scores;

 

3)         A copy of the DUI risk education certificate of completion;

 

4)         A copy of the Notice of Involuntary Termination from DUI Risk Education form, as applicable; and

 

5)         A copy of any written notification regarding a change in the risk level assignment and recommended intervention.

 

Section 2060.530  Designated Program

 

a)         The DHS/SUPR designated program license authorizes organizations to provide SUD assessment and specialized case management services to Illinois courts for any individual charged with or convicted of an eligible offense and who may elect diversion to treatment, under the supervision of the designated program, as an alternative to incarceration, or as a condition of release after incarceration, pursuant to the specifications in Article 40 of the Substance Use Disorder Act.  The designated program shall provide the services specified in this Section in a uniform manner to circuits of the Illinois courts throughout the State, either directly or by subcontract or referral.

 

b)         Staff who provide designated program services shall meet at least one of the professional staff requirements specified in Section 2060.320(a) or (b).

 

c)         Organizations authorized to provide designated program services shall establish policies and procedures, and submit them at the time of application for licensure or anytime thereafter if changes are made, that shall:

 

1)         Identify the proposed court or jurisdiction where designated program services will be delivered;

 

2)         Specify how each service in this Section will be provided in relation to the operation of the referring circuit court;

 

3)         Include a copy of any applicable court rules or procedures for the provision of the service; and

 

4)         Identify how the designated program will adhere to these court rules and procedures.

 

d)         Specialized Case Management:  The designated program shall have procedures for and deliver specialized case management as follows:

 

1)         Scheduling:  Manage scheduling so that designated program clients are given priority to initiate services as close as possible to the date of referral;

 

2)         Authorizations:  Obtain all authorizations for informed consent and release of any confidential information in accordance with specifications in Sections 2060.350 and 2060.360;

 

3)         Demographics:  Collect demographic data in accordance with the specifications in Section 2060.370(d)(10);

 

4)         Assessment:  Conduct an assessment, in accordance with the specifications in Section 2060.435, to determine if the client is likely to be rehabilitated through SUD treatment.  The designated program shall ensure that the assessment:

 

A)        Evaluates the client's current severity of the disorder and comorbid conditions;

 

B)        Identifies any criminogenic needs that should be targeted in treatment;

 

C)        Determines if the client would benefit from additional social services or recovery supports or has a current need for MAR; and

 

D)        Recommends the appropriate level of care for the client.

 

5)         Recommendation:  Make a recommendation in a findings letter to the referring circuit court regarding the result of the assessment and if the client is likely to benefit from participation in SUD treatment.  Such notification shall be made to the probation office unless otherwise ordered by the court.  Written notification regarding the result of the assessment and its subsequent recommendation shall also be given to the client.

 

6)         Referral:  Make appropriate referral for SUD treatment, so that clients can begin such services as soon as possible.  In making such referral, the designated program shall:  disclose which referrals are self-referrals to the same organization holding the designated program authorization, ensure that the client is given other treatment options and make the client aware of their right to a choice of services from any licensed organization.

 

7)         Case Planning:  Identify case planning goals that link to any need identified in the assessment and that include all referrals for treatment, other social services, or recovery support, including housing, education, and employment.

 

8)         Individual and Group Monitoring:  Identify all contacts scheduled with the client during the period of time that the client is under the supervision of the designated program.  Ensure, through regular contact with the treatment organization, that all individual and group services delivered by the designated program are not duplicative of any treatment services that the client may also be simultaneously receiving.

 

9)         Service Delivery:  Provide individual and group services designed to engage, motivate, or support the client's participation during their period of supervision under the designated program.  These services shall address needs identified in the ASAM assessment related to other social determinants of health and encourage the client's continued participation in any recommended treatment.

 

10)       Tracking and Measuring Compliance:  Identify the methods that the designated program will use to track and measure compliance, including a specification of the criteria the client must meet to continue participation in the designated program.  The criteria shall also include the factors that would require re-assessment or amended recommendations to the referring circuit court.

 

11)       Recovery Support:  Identify any recovery support needs the client may have that will assist in reducing barriers to accessing treatment or other needed services or for participation in individual or group monitoring with the designated program. Make referrals or arrangements for these supports as needed.

 

12)       Communications:  At a minimum, monthly reports shall be sent to the referring circuit court that indicate:  the status of the client, progress made toward completion of any designated program individual or group activities, information on admission to treatment and progress in achieving treatment goals and objectives, and any changes in status from the last report, including the date of last communication with the client, if applicable.

 

13)       Court Appearances:  Designated program staff shall be made available for all requested court appearances including any status or violation hearing.  All such activity shall be documented in each client file, including any decisions of the court and any subsequent required actions.

 

e)         Documentation:  Client records shall be maintained, as specified in Section 2060.370.  In addition, each client record shall include:

 

1)         All informed consent and consent to release information forms;

 

2)         A copy of the assessment with recommended intervention;

 

3)         Copies of all correspondence;

 

4)         The service plan for the client, progress notes, and documentation of all attendance;

 

5)         Any toxicology results;

 

6)         Documentation of status reports (written or verbal) from treatment organizations;

 

7)         Documentation of all designated program staff court appearances; and

 

8)         Any documents related to the client's discharge from designated program services.

 

f)         Discharge:  The designated program shall establish procedures for discharge of the client from all services.  These procedures, at a minimum, shall:

 

1)         Identify the process for review of a client's progress in treatment to determine if a change of status is justified;

 

2)         Identify the factors that determine successful or unsuccessful discharge;

 

3)         Contain the specific instances that would lead to discharge or a change in status;

 

4)         Identify the process for notification to the client and the referring circuit court when there is a change in status or prior to and upon successful or unsuccessful discharge; and

 

5)         Identify the procedure that will be used to ensure that written reports of successful discharge are sent to the referring circuit court within 10 calendar days after discharge and that reports of unsuccessful discharge are sent within three calendar days after discharge.

 

Section 2060.540  Recovery Homes

 

a)         Recovery homes are a service authorized by a DHS/SUPR intervention license and provide housing for residents recovering from an SUD.  Services, in addition to housing, help to build upon the strengths and strategies residents may have developed to survive in often inhospitable environments with culturally dominant messages that often devalue them.  Recovery homes help to counter those experiences by providing relationships, connections, and spaces where residents are treated with dignity, where the resident's experience in the real world is witnessed, and where the resident's strengths and needs are seen and valued.  Recovery home staff assist with access to other ancillary recovery support or skill building activities that can help residents in obtaining or maintaining a lifestyle free of an SUD.  Structured operations are directed toward initiation or maintenance of recovery for persons who exhibit treatment resistance, a potential for symptom recurrence, or lack a suitable recovery living environment.  Residents may also have recently completed SUD treatment, may still be receiving outpatient treatment, or may be participating in MAR.

 

b)         Recovery homes shall inform all residents of their recovery philosophy and any subsequent residency requirements regarding abstinence, harm reduction, and MAR.

 

c)         Recovery homes licensed by DHS/SUPR shall adhere to applicable requirements in Subparts A, B, and C of this Part and meet the following criteria:

 

1)         Ensure that the licensed recovery home is listed on the DHS/SUPR Recovery Residence Registry;

 

2)         Provide a homelike environment for congregate living;

 

3)         Have a procedure and documentation to ensure that all residents have a substance use diagnosis and need assistance to strengthen or maintain recovery capital relative to the SUD;

 

4)         Have a procedure and documentation to ensure that residents receiving recovery home services are actively seeking assistance in obtaining and helping fellow residents maintain an SUD recovery-oriented lifestyle and, ultimately, permanent stable housing;

 

5)         Offer regularly-scheduled community gatherings and recovery education groups, led by peers, held a minimum of five days per week with activities that include self-help groups or other recovery activities designed to meet each resident's specific social or cultural needs;

 

6)         Ensure that each resident has an individual recovery plan that contains measurable goals and objectives that, at a minimum, identify steps to secure stable permanent housing, needed support services and activities, and employment and vocational skill building services.  Each plan shall also address how it will help build support within the recovery home for each resident and how treatment can be accessed, if necessary;

 

7)         Have an established referral network for use by residents for any necessary medical, mental health, SUD, vocational, or employment resources, including one referral agreement, if applicable, with an organization that provides medication assisted treatment;

 

8)         Have a policy and procedure to ensure prompt intervention and referral for necessary medical or treatment services if a resident has a reoccurrence of SUD symptoms;

 

9)         Have a budget that specifies monthly operating expenses and that demonstrates sufficient income to meet these expenses plus an emergency reserve of a minimum sum equivalent to the total of two months of operating expenses; and

 

10)       Have written documentation of compliance with all applicable local zoning and building ordinances and the applicable fire and life safety requirements specified in Section 2060.310(a)(2).

 

d)         Recovery homes shall have at least one full-time recovery home operator who is responsible for the daily operations at the recovery home and who meets the credentialing requirements specified in Section 2060.320(a) or (i).

 

e)         Recovery homes shall have at least one recovery home manager on site who oversees all recovery home activities under the direction of the recovery home operator.  All recovery home managers shall meet the credentialing requirements specified in Section 2060.320(a) or (i).

 

f)         The recovery home operator may also function as the recovery home manager, as long as the requirements of both positions are met.

 

g)         Recovery homes may use residents for staff coverage if they meet the credential specified in Section 2060.320(i), are compensated for their time through payroll, rent subsidy, or both, and if such obligation does not interfere with the ability of the resident to secure full-time employment.

 

h)         Recovery homes shall conduct a background check to ensure that no staff or resident is on the National Sex Offender Registry at https://www.nsopw.gov/ if children or adolescents are living in or receiving services.

 

i)          Recovery homes shall make every effort to ensure that residents have permanent stable housing upon discharge.  These efforts include, but are not limited to, agreements or ongoing active contact with local recovery support and housing organizations.