Purpose
The Bureau of Accreditation, Licensure, and Certification (BALC) is improving its efforts to assure environmental safety for individuals in homes and day services it licenses or certifies. To accomplish this objective, beginning with the next license renewal survey, we will be making the changes described below.
New Cycle for Fire Marshal Inspections
BALC licensure surveys will continue to proceed according to when licenses or certifications expire. Community Integrated Living Arrangement (CILA) and Community Day Services (CDS) providers with a valid license that have not made any significant structural changes will not receive a fire marshal inspection during their next survey cycle. Significant structural changes include but are not limited to electrical work, replacing the sprinkler system, or updating a hard-wired smoke detection system. Going forward, the fire marshal inspection will occur only once every four years rather than every two years.
Implementation of NEW Mitigation and Penalties Process
Going forward, licensure/certification extensions will be granted on a limited one-time basis but they will no longer be issued routinely. While this process will eventually be rolled out to CDS providers at this time this process only impacts CILA providers.
Effective August 1, 2021, CILA providers with failed life safety code inspections will be given 30 days to notify BALC of survey readiness, and another 30 days to provide a written mitigation plan outlining plans to correct non-compliant fire safety citations as described below. The mitigation plan supports BALC's work to monitor progress towards remediation of fire safety citations.
*Important note: Providers who make a good faith effort towards remediation of fire safety citations will not be penalized.
Related Timeline:
- 8/1/21: BALC notifies providers outlining mitigation process and shares document to complete regarding citations.
- 9/1/21: Providers return Excel document (Columns A-G only) with non-compliant fire citations (as indicated by Office of State Fire Marshal [OFSM] report). They do not need to submit mitigation plans. If they do not have any citations, they should inform BALC of this, too. Providers who do not notify BALC of their plans to mitigate fire safety citations may be penalized, as outlined below.
- 9/30/21: Written mitigation plans are due (in Excel document on the second tab labeled "Due October 1" ). BALC will schedule fire marshal re-inspections for providers that submit acceptable mitigation plans.
Get the Mitigation Plan Excel document to complete here (xlsx)
For providers that pass the fire inspection, BALC will proceed with the licensure survey.
Providers that fail the fire inspection or do not notify BALC of survey mitigation plan by 09/30/2021 will begin the penalties process described below.
*Providers that fail a re-inspection for a repeat violation will be placed into the Penalties Process. Definition of repeat violation is outlined in the FAQs
Penalties Process:
- Penalty Level #1: Hold on admissions
- Provider has 30 days to remediate the violations for reinspection. Failure to do so will result in moving to the next penalty level.
- If the provider fails the reinspection survey, the provider will move to the next penalty level.
- Penalty Level #2: Suspension on payment
- Provider has 30 days to remediate the violations for reinspection. Failure to do so will result in moving to the next penalty level.
- If the provider fails the reinspection survey, the provider will move to the next penalty level.
- Penalty Level #3 Site de-certification/license revocation
- BALC will give the provider two weeks to remediate the violations for reinspection. Failure to do so will result in BALC proceeding to de-certifying the non-compliant site.
- With additional lack of compliance, licensure revocation will be reviewed on a case-by-case basis.
Penalties will not be invoked for Providers who make a good faith effort towards remediation of fire safety citations. We recognize some citations may be time-intensive and costly. Therefore, if a credible mitigation plan is submitted and followed within the timeline outlined above, no penalties will be issued.
NOTE: Providers will not be held accountable if delays are encountered due to scheduling delays at the Office of the State Fire Marshall.?For example: if a provider is at Penalty Level #1, it will not progress beyond Level #1 until the inspection is completed. A delay because the OSFM is not able to conduct the inspection will not result in a provider moving to Penalty Level #2.
BALC will be hosting a recorded webinar that will cover the mitigation and penalties process on August 9th from 11:30am-12:30pm. You can register for the webinar by selecting the link below.
https://illinois.webex.com/illinois/onstage/g.php?MTID=eff2cabbde54681f7dfb17f16527d54b5
If have any concerns with achieving compliance within the designated timeframe, please contact BALC. You may contact BALC at DHS.BALC@illinois.gov for any questions or concerns.
Effective Date:
The penalties process and quadrennial fire inspection survey processes will be effective September 1, 2021.
