The Bureau of Accreditation, Licensure & Certification (BALC) COVID-19 Temporary Certifications and Procedures Form (pdf) is to be completed by providers requesting approval from BALC to utilize one of the COVID-19 TEMPORARY Certifications and Procedures that are available:
- Open a TEMPORARILY Licensed CILA site
- TEMPORARILY CILA at a CDS.
- TEMPORARILY consolidate people living and being served from other residential sites.
- TEMPORARILY increase capacity at a CILA
Temporary Certifications and Procedures Form Stipulation & Guidelines:
By completing and submitting the Temporary Certifications and Procedures Form:
- I acknowledge I am an authorized representative of our agency as specified on the Form.
- I acknowledge our agency is following guidelines and instructions as specified by BALC for the individuals and site(s) specified in the Form.
- I further stipulate our agency has considered and exhausted all other options such as filling any open capacity at other homes, extending staff hours, hiring temporary employees, and opening a home owned by the agency but not yet licensed through BALC.
- I agree our agency will not initiate moving individuals until approved by the BALC.
In order for BALC to determine feasibility, if any of the below are not met, I will include a narrative to explain how the agency will alternatively meet the criteria:
- I acknowledge that this site will provide all individuals privacy during bathing & toileting, sufficient lighting, their own bed with bedding, and storage for personal items. The site must be equipped to meet the needs of all individuals who are residing there. Examples: appropriate staffing, bathroom with ADA requirements, 1-to-1 supervision, assistance during daily activities, full functioning kitchen, and proper medication storage.
- I acknowledge that this site has been reconfigured to optimize safety for the individuals. This includes, but is not limited to: properly working furnace, air conditioning, ventilation system, hot water tank, appropriate water temperature between 100 and 110 degrees, the water source has been tested if it is well sourced, vermin free, garbage containers are appropriately secured, appropriate amounts of soap and cleaning supplies.
- Posted signage needs to include the following:
- COVID-19 Hotline - 1.800.889.3931
- COVID-19 Email: dph.sick@Illinois.gov
- Phone Number Local Police
- Phone Number Fire Department
- Phone Number Poison Control
- Phone Number Medial / Rescue
If the Temporary License requires a Fire Inspection, IDHS will review the inspection results once the Fire Marshal conducts their inspection. An inspection failure does not mean your application has failed. BALC will reach out to you to discuss how you plan to mitigate the risks to the individuals under your care
Note: If this is an emergency site and you need a site converted and licensed please reach out to Angela & Charlene via email: Charlene.R.Brown@illinois.gov or Angela.L.Johnson2@illinois.gov
In the interim, you need to do what is best for all the individuals under your agency's care in the consideration of health and safety.
If granted approval of a Temporary license an initial approval period will be set for three months from the date of approval. At the end of the initial approval period you will be contacted by a BALC surveyor to schedule another virtual inspection and to reassess your needs in order to continue use of the Temporary license. Please keep this timeline in mind as you evaluate your options and prepare to return to standard services and procedures.
Virtual Inspections will be a part of the Temporary License process. All applicants for a Temporary License must be able to conduct a virtual inspection upon application and, if approved, throughout the temporary licensure period as deemed necessary by BALC.
When complete, the COVID-19 Temporary Certifications and Procedures Form is sent to: DHS.BALC@illinois.gov After receipt and thorough review of the requirements, BALC will render a decision and inform the agency.
Date Submitted: Enter the date your agency is submitting the Temporary Certifications and Procedures Form.
Site Type: Enter the type of site or procedure you are requesting with this form. This is important. Without this indication we cannot process the request.
- If you are using this form to request a consolidation, complete the sections with information about the site you are consolidating to.
Agency Name: Enter your agency's name or ICF/IDD Facility Name. Use the officially recognized agency name. Do not use an agency "umbrella" corporate name.
Agency ID or ICF Facility ID: Enter your agency's 3- or 4-digit Identification Number; or enter your ICF/IDD 9-digit Facility Identification number.
Street Address: Enter the Street Address of the proposed site.
City & Zip Code: Enter the City and Zip Code of the of the proposed site.
Agency Staff Person's Name Completing This Form: Enter the Name of the agency staff person completing this form.
Site Location Phone Number: The phone number of the proposed site.
Staff Person's Title: Enter the Title of the agency staff person completing this form.
Staff Person's Phone Number: Enter the Area Code, Phone Number and Extension (if applicable) of the agency staff person completing this form.
Staff Person's Email Address: Enter the Email Address of the agency staff person completing this form.
Requested Capacity: Maximum number of individuals you are requesting to reside at your site during the COVID-19 pandemic.
Non-Ambulatory Capacity: Non-Ambulatory capacity is determined by the number of full accessible bathrooms which can accommodate people who are non-ambulatory.
Staff Initials - REQUIRED: By initialing the form the staff person completing this form agrees they have read and agree to the guidelines specified in the Temporary Certifications and Procedures Form Instructions.
Floor Plan: In addition to completing all sections of the form, you are required to provide a floor plans of each site indicating bedrooms, bathrooms, and exits.
Common Sleeping Area - (TOTAL):
- Complete section regarding dimensions of total sleeping area if using a common space.
Sleeping Area - (Rooms):
- Complete section regarding dimensions and details of sleeping rooms
- List the number of bathrooms.
- If a bathroom has more than one stall list the number of stalls.
- Are there accessible showers on site? If no, what is your plan for bathing?
- Clients must have access to a shower. Consider transporting consumers to their CILA for bathing purposes rather than utilizing an inadequate shower at a CDS.
On Site Staffing Available:
- Please provide information on staffing available at the time of application, broken down by shift.
CILA at a CDS
- If you are applying to temporarily license your CDS as a CILA please indicate whether your CDS is currently operational. Please note, you will not be allowed to operate as both a CDS and a temporary CILA.
- Briefly explain why your agency needs to open a temporary CILA at a CDS?
Virtual Inspection Capacity
- BALC will provide a WebEx link to connect the surveyor with your team. Will this work at the proposed temporary site or do you need to utilize another platform and if so what platform?
For Consolidation Requests
- All requests for consolidation require the completion of Page 3 of the application form. Please complete page 3 with information about the individuals currently at the site and the individuals being temporarily moved to the site.
- Ensure that beds are at least 10 feet apart unless physical barriers are present, then beds need to be 6 feet apart.
- Require all clients sleep head-to-toe.
- If an office or other walled area is to be converted to a bedroom below are occupancy guidelines:
- If a room is between 75 and 109 square feet, the room is considered single occupancy only.
- If the room has more than 110 square feet, it can accommodate a second person. Beds/cots/futons must be at least 6 feet apart, and individuals should sleep with their pillow positions staggered or head-to-toe.
Will each Sleeping/Bedroom be free from traffic to other areas
- Are bathroom entrances only accessible through an individual(s) sleeping area.
Full Functioning Kitchen: Full kitchen must include full size refrigerator, working stove, cooktop, pots, pans, cutlery, food storage, adequate food supply based on capacity.
Medication Storage: Proper storage includes both refrigerated and unrefrigerated medication. Both storage sites must be separate from common areas and be secured.
All staff must be properly credentialed.
IDPH COVID-19 Website - http://dph.illinois.gov/covid19
IDPH Clinical Guidance - http://www.dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/coronavirus/health-care-providers
State of Illinois Coronavirus Response Page - https://coronavirus.illinois.gov/s/
State of Illinois COVID-19 Prevention In Long-Term Care Facilities - https://coronavirus.illinois.gov/s/prevention-in-long-term-care-facilities
State of Illinois Prevention During Adult Day Programs - https://coronavirus.illinois.gov/s/prevention-during-adult-day-programs
Once the Fire Marshal conducts their inspection, IDHS will review the inspection results. An inspection failure does not mean your application has failed. BALC will reach out to you to discuss how you plan to mitigate the risks to the individuals under your care.
Once the Fire Marshal has done an inspection for residential use you are not granted certification automatically, your site must be evaluated by IDHS.
If fire inspection violations are found a decision on which violations require correction will be made and communicated after the Fire Inspection has taken place.
BALC must hear from provider within 24 hours if there are individuals already moved into an unapproved temporary facility.
Please ensure that six feet of social distancing is being observed. In addition, the use of barriers to cordon off individual sleeping areas is encouraged.
Bed/futons/or cots are required. No sleeping bags, pull out beds, or other furniture not intended to be for sleeping are allowed.
Implement these additional mitigation strategies and best practices
- Have staff hand supplies or food to clients, rather than clients reaching into common supplies.
- If feasible, stagger meals to reduce crowding.
- If feasible, stagger bathroom schedule to reduce the number of people using the facilities at the same time.
- Encourage staff and clients to disinfect bathroom surfaces after use.
- Create a schedule for using common spaces.
- Increase distance between persons. If possible, keep them a minimum of 6 feet apart from each other.
Ensure good practices for cleaning:
- Change mop heads, rags, and other cleaning items frequently.
- Wipe down commonly used surfaces (for example, doorknobs, keyboards, remote controls, desks) before each use with disposable wipes.
- Clean all common areas at least daily; clean heavily used surfaces more frequently
- Wash linens, clothing, and other items as appropriate in accordance with the manufacturer's instructions. If possible, launder items using the warmest appropriate water setting for the items and dry items completely. Dirty laundry that has been in contact with an ill person can be washed with other people's items.
*These additional instructions for best practices come courtesy of the Chicago Guidance for Homeless Shelters: