CDS & CMHC Environmental Safety and Mitigation Plan Requirement (5-11-22)

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 surveys will continue to proceed according to when licenses or certifications expire for Community Integrated Living Arrangement (CILA), Community Mental Health Centers (CMHC) and Community Day Services (CDS) providers.

Going forward, fire marshal inspections will occur only once every four years rather than every year for CDS sites and every two years for CILA sites as long as the provider has not made any significant structural changes. Significant structural changes include but are not limited to electrical work, replacing the sprinkler system, or updating a hard-wired smoke detection system. Significant structural changes will require an inspection by the fire marshal.

CMHC sites will continue to be inspected by the fire marshal every three years.

Implementation of NEW Mitigation and Penalties Process

Going forward, licensure/certification continuations will be granted on a limited, one-time basis, and they will no longer be issued routinely. This process was implemented for CILA providers September 2021. BALC is now implementing the process for CDS providers and CMHC providers.

Any CDS or CMHC provider that has already received a failed life safety inspection (OSFM) on any site prior to June 1, 2022 will be required to submit the date on which they expect to have all violations corrected which cannot exceed December 31, 2022. A mitigation plan is not required for violations that occurred prior to June 1, 2022. However, if repeat violations occur, the agency would enter the penalty phases as described below.

Any CDS or CMHC that receives a failed life safety inspection on or after June 1, 2022, will be given 30 days to notify BALC of re-inspection readiness, and/or 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:

  • 6/1/22: BALC reminds providers about the mitigation process and shares sample mitigation document to complete regarding citations and a spreadsheet with sites that received failed OSFM report prior to June 1st.
  • 6/1/22: Beginning on this date, written mitigation plans are due 30 days from receipt of any failed OSFM report. For example, if a failed OSFM report is received on 6.5.22, the mitigation plan for that site is due by 7.5.22. BALC will schedule fire marshal re-inspections for providers that submit acceptable mitigation plans and a Fire Inspection Request.
  • 7/1/22: Providers with OSFM failures received prior to 6.1.22 are required to submit target dates for correcting the failures.

For providers that pass the fire inspection, BALC will proceed with the licensure survey.

Providers that fail a fire inspection for any site and do not submit a mitigation plan to BALC within 30 days from receipt of the failed OSFM report will begin the penalties process described below. Providers will also be required to send weekly updates on the progress of their mitigation plan efforts beginning the week after they first submit their mitigation plan. Failure to submit weekly reports may also result in penalties as described below.

Providers that do not submit their target date(s) for correcting violations in failed reports prior to 6.1.22 will begin the penalties process described below.

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 Marshal. 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 hosted a webinar covering the mitigation and penalties process on May 11th from 11:00am-12:00pm. 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 mitigation requirement will be effective July 1, 2022.