Temporary Self-Assessment Process and New Site Inspection Process

BALC Memorandum

July 22, 2020

Official Notice

Re: Temporary Self-Assessment Process and New Site Inspection Process

Dear Providers:

This memo serves as a notice to inform all IDHS licensed or certified community provider agencies that the Bureau of Accreditation, Licensure & Certification (BALC) will be conducting self-assessments and new site inspections beginning in July 2020.  We wanted to notify provider agencies in advance of our plans to start these processes in a temporary format to accommodate the current COVID 19 pandemic challenges (i.e. self-assessments, virtual inspections, social distancing, PPE, etc.).

Temporary Self-Assessment Process

The self-assessment process is being utilized as a method for compliance with rule and to ensures health and safety of the individuals we all serve. This new process is a compressive approach that includes both new and old technologies. This process is subject to change as IDHS develops and vets new processes and procedures. In addition, BALC Surveyors may utilize on-site visits as determined to be needed. We are in this all together and have the same goal which is to ensure the health and safety of the individuals. BALC is aware that there may be some challenges during this process therefore, all parties must exercise patience and understanding.

When it is time for your agency's self-assessment, a BALC Surveyor assigned to complete the self-assessment will contact your agency's head office to share some preparation details and to advise that the agency will be receiving a call the next business day to begin the process. In addition, BALC will request that all agencies ensure a staff representative from all departments the agency deems necessary are available for the entrance conference. At the entrance conference all designated person(s) for BALC to coordinate with must be identified. This person(s) must be available by phone and email throughout the process which is expected to last three to four days. They will be responsible for ensuring the self-assessments is completed prior to its return to the surveyor and all requested documentation is provided before the exit conference.

Remote New Site Inspection Process

Temporarily, new site inspections will be conducted remotely via virtual technology (i.e. Facetime, Zoom, etc. Though Facetime is preferred) to be determined when a BALC Surveyor contacts the agency to schedule the inspection. BALC will need two agency staff representatives available onsite at the new site inspection location to assist with the inspection process. One staff will operate the video technology and one staff will assist with the inspection tasks. This is expected to last no more than half a day.

How a self-assessment extension is different than a typical license renewal

  • During this pandemic BALC has initiated self-assessments. The self-assessment will be in place of a renewal until BALC can go back in the field.
  • During the self-assessment a Notice of Violations (NoV) can still be issued.  BALC will continue to work with agencies to ensure agency's correct any violations indicated on the NOV.
  • Any decision made during the temporary processes is subject to change.

Previously, IDHS granted extensions for licensure/certification of all agencies with an expiration month of November 2019 - August 2020, through December 31, 2020.  Those extensions are still valid but as BALC conducts your self-assessment your agency will receive another letter with a new extension date. 

IDHS will be granting extensions for licensure/certification of all agencies with an expiration month of September 2020 - December 2020, please use this correspondence as your official notice in lieu of an extension letter. This extension expires on January 31, 2021 or until BALC does a self-assessment whichever happens first.

Thank you all for your cooperation during these challenging times of the COVID 19 pandemic.

For any questions or concerns, please feel free contact Angela Johnson at Angela.l.johnson2@illinois.gov or Charlene Brown at Charlene.r.brown@illinois.gov.