Section 255.100  Definitions

 

"Act" means the Hospital Report Card Act.

 

"Actual nurse staffing assignment roster" means the nurse-patient assignment on each unit that reflects direct nursing services provided within a 24-hour time period to each patient, excluding any information that might identify a particular patient or nurse. 

 

"Acute care" means the treatment of a condition or disease for a short period of time in which a patient is treated for a brief but severe episode of illness with the goal of discharging the patient.

 

"Appropriately trained" means has completed the orientation course for the job title as specified by the employing hospital.

 

"Artificial life support" means a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged.  

 

"Assigned" means that the registered professional nurse, licensed practical nurse, or other nursing personnel have responsibility for the provision of care to a particular patient within their scope of practice.

 

"Assistive nursing personnel" means personnel assigned responsibility for the provision of nursing care to a particular patient within their scope of practice, other than registered professional nurses or licensed practical nurses.

 

"Average daily census" means the average number of inpatients receiving service on any given 24-hour period beginning at midnight in each clinical service area of the hospital.  (Section 10 of the Act)  Average daily census shall be calculated as the sum of inpatients every day at midnight for the quarter, divided by the number of days in the quarter.

 

"Average daily hours worked" means the total number of direct care nursing hours paid in the quarter per clinical service area, divided by the total number of calendar days in the quarter, to obtain the average number of worked hours per calendar day.

 

"Behavioral health" means the clinical service areas in which inpatients are receiving care and treatment for mental illnesses, substance abuse disorders or dependence, co-occurring mental illness and substance abuse disorders, or organic brain disorders, such as Alzheimer's Disease or senile dementia with psychotic or depressive symptoms.  For the purposes of this Part, behavioral health clinical service areas do not include the following areas and their subcategories: critical care; maternal-child; medical-surgical; pediatrics; perioperative; and telemetry.

 

"Clinical service area" means a grouping of clinical services by a generic class of various types or levels of support functions, equipment, care, or treatment provided to inpatients. Hospitals may have, but are not required to have, behavioral health, critical care, maternal-child care, medical-surgical, pediatrics, perioperative services, and telemetry. (Section 10 of the Act) These services shall be measured in patient day units.  "Perioperative" clinical service areas are defined in the definition of "perioperative" in this Part.

 

"Critical care" means the clinical service areas organized, operated, and maintained to provide for monitoring and caring for patients with severe or potentially severe physiologic instability requiring technical support and often requiring artificial life support.

 

"Critical care service area" means adult and pediatric critical care patient populations, but does not include intensive care newborn nursery services.  For the purposes of this Part, critical care clinical service areas do not include the following areas and their subcategories: behavioral health; maternal-child; medical-surgical; pediatrics; perioperative; and telemetry.

 

"Current nursing staff schedules" means the prospective staffing schedules for each patient care unit, excluding any information that might identify a particular nurse, made in advance of a designated time frame, e.g., weekly, monthly or quarterly.

 

"Department" means the Department of Public Health.  (Section 10 of the Act)

 

"Direct-care nurse" and "direct-care nursing staff" include any registered nurse, licensed practical nurse, or assistive nursing personnel with direct responsibility to oversee or carry out medical regimens or nursing care for one or more patients. (Section 10 of the Act)

 

"Direct patient care responsibilities" means the activities of direct care nurses and direct care assistive nursing personnel who are assigned to a patient or patients.

 

"Direct supervision" means a situation in which an individual is responsible for directing the actions of another individual in the facility and is physically close enough to be readily available, if needed, by the supervised individual.  "Direct supervision" shall be conducted by a registered professional nurse.

 

"Employee" means any full-time or part-time direct care nursing staff employee who works a regularly scheduled number of hours in a defined pay period.  Not included are direct care nursing staff who work on an as-needed basis and are not guaranteed work hours, including, but not limited to, casual, per diem, and registry personnel.

 

"Full-time equivalent" means hospital-employed licensed nursing hours budgeted to work in a seven-day time period divided by 37.5, or in a 14-day time period divided by 75, or annually divided by 1950.

 

"Indirect patient care responsibilities" means the activities of nurses, such as nurse managers, charge nurses, clinical nurse specialists and other ancillary licensed nursing personnel, when they are not assigned to direct patient care activities.

 

"Hospital" means a health care facility licensed under the Hospital Licensing Act.  (Section 10 of the Act)

 

"Hospital Quality Alliance" means the public-private collaboration that collects and reports hospital quality performance information and makes it available to consumers through Centers for Medicare and Medicaid Services (CMMS) information channels.

 

"Inpatient" means a person admitted for at least one overnight stay to health facilities, usually hospitals, that provide board and room, for the purpose of observation, care, diagnosis or treatment.

 

"Intensive Care Unit" or "ICU" means a hospital facility for provision of intensive nursing and medical care of critically ill patients, characterized by high quality and quantity of continuous nursing and medical supervision and by use of sophisticated monitoring and resuscitative equipment.  An ICU may be organized for the care of specific patient groups, e.g., neonatal or newborn ICU, neurological ICU, or pulmonary ICU.

 

"Licensed nursing hours per inpatient day" means, for the quarter, the total number of productive hours worked by licensed nursing personnel with direct care responsibilities, divided by the total inpatient days.

 

"Licensed practical nurse" or "LPN" means a person meeting the requirements for licensure by the Department of Financial and Professional Regulation as a licensed practical nurse pursuant to the Nurse Practice Act.

 

"Maternal-child" means the clinical service areas that are designed, equipped, organized and operated in accordance with the requirements of the Hospital Licensing Act relating to the medical-surgical care of a patient prior to and during the act of giving birth to either a living child or a dead fetus and the continuing care of both patient and newborn infant.  For the purposes of this Part, intensive care newborn nursery services are included in maternal-child clinical service areas.  Maternal-child clinical service areas do not include the following clinical service areas and their subcategories:   behavioral health; critical care; medical-surgical; pediatrics; perioperative; and telemetry.

 

"Medical-surgical" means the clinical service areas in which patients who require less care than that which is available in intensive care units or telemetry units have available 24-hour inpatient general medical services, post-surgical services, or both general medical and post-surgical services.  These units may include mixed patient populations of diverse diagnoses and diverse age groups.  For the purposes of this Part, medical-surgical clinical service areas do not include the following areas and their subcategories:  behavioral health; critical care; maternal-child; pediatrics; perioperative; and telemetry.

 

"Nursing care"  means care that falls within the scope of practice set forth in the Nurse Practice Act or is otherwise encompassed within recognized professional standards of nursing practice, including assessment, nursing  diagnosis, planning, intervention, evaluation, and patient advocacy.  (Section 10 of the Act)

 

"Nursing hours per inpatient day" means, for the quarter, the total number of productive hours worked by registered nurses, licensed practical nurses, and assistive nursing personnel, in each case, with direct patient care responsibilities, divided by the total inpatient days. 

 

"Observation care" means those services furnished by a hospital on the hospital's premises, including use of a bed and at least periodic monitoring by a hospital's nursing or other staff, that are reasonable and necessary to evaluate an outpatient's condition or determine the need for a possible admission to the hospital as an inpatient.  In general, the duration of observation care services does not exceed 24 to 48 hours, depending on the hospital, physician and health plan.

 

"Pediatrics" means the clinical service areas in acute care hospitals that are designed, equipped, organized and operated to render non-intensive care to the 0-17 age population performed at the direction of a physician on behalf of the patient by physicians, dentists, nurses, and other professional and technical personnel.  For the purposes of this Part, pediatric clinical service areas in acute care hospitals do not include the following areas and their subcategories:  behavioral health; critical care; maternal-child; medical-surgical; perioperative; and telemetry.  Pediatric hospitals may incorporate any or all of these clinical service areas in fulfilling their role of specialty treatment facilities for the medical care of infants, children, and adolescents.  Pediatric hospitals shall consider all care provided as pediatric without regard for where in the facility the service was rendered.  For patients in specialty pediatric hospitals, age requirements are extended to include those patients who, due to condition, care and treatment requirements, continue to be considered pediatric.  Clinical service area comparisons for pediatric hospitals shall follow the guidelines of national pediatric organizations.  An adult or specialty hospital operating a pediatric hospital within the larger hospital shall report using its National Provider Identifier and taxonomy codes to allow differentiation of nursing hours and more meaningful comparisons.

 

"Perioperative" means the clinical service areas that are designed, equipped, organized and operated to provide care for inpatients during the preoperative, intraoperative and immediate postoperative periods of a hospital stay.  For the purposes of this Part, perioperative clinical service areas do not include the following areas and their subcategories:  behavioral health; critical care; maternal-child; medical-surgical; pediatrics; and telemetry.

 

"Productive hours" means the actual work hours, exclusive of vacation, holidays, sick leave and any other absences, with the following inclusions and exclusions. 

 

Agency, per diem and registry RNs with direct patient care responsibility shall be included in the number of productive hours for the mandated reports.

 

The number of productive hours for mandated reports shall not include nurse managers, charge nurses who are not assigned direct patient care responsibilities, or any other licensed nursing personnel who do not have a direct care patient assignment.

 

The number of productive hours for mandated reports shall not include licensed nurses who are participating in orientation.

 

"Registered professional nurse" or "RN" means a person meeting the requirements for licensure by the Department of Financial and Professional Regulation as a registered professional nurse pursuant to the provisions of the Nurse Practice Act.

 

"Separated" means any licensed nursing employee who is permanently removed for any reason, including voluntary, involuntary or employee transfer, from the payroll allotted for a clinical service area.

 

"Staffing levels" means the numerical nurse to patient ratio by licensed nurse classification within a nursing department or unit. (Section 10 of the Act)

 

"Telemetry unit" means a unit organized, operated and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals.  "Telemetry unit" does not include fetal monitoring or fetal surveillance.  For the purposes of this Part, telemetry clinical service areas do not include the following areas and their subcategories:  behavioral health; critical care; maternal-child; medical-surgical; pediatrics; and perioperative care.

 

"Technical support" means specialized equipment and/or personnel providing for invasive monitoring, telemetry, or mechanical ventilation, for the immediate amelioration or remediation of severe pathology.

 

"Unit" means a functional division or area of a hospital in which nursing care is provided. (Section 10 of the Act) 

 

(Source:  Amended at 40 Ill. Reg. 1833, effective January 5, 2016)

 

Section 255.110  Referenced Materials

 

The following statutes are referenced in this Part:

 

a)         Hospital Licensing Act [210 ILCS 85]

 

b)         Nurse Practice Act [225 ILCS 65]

 

c)         Hospital Report Card Act [210 ILCS 86]

 

d)         Freedom of Information Act [5 ILCS 140]

 

(Source:  Amended at 40 Ill. Reg. 1833, effective January 5, 2016)

 

Section 255.120  Confidentiality

 

All disclosures by hospitals shall be in accordance with the provisions for disclosure and protection of information under the Act and shall not contain information identifying a patient, employee, or licensed professional.

 

Section 255.150  Staffing Levels

 

a)         The number of registered professional nurses, licensed practical nurses, and other nursing personnel assigned to each patient care unit shall be consistent with the types of nursing care needed by the patients and the capabilities of the staff.  Patients on each unit shall be evaluated near the end of each change of shift by criteria developed by the nursing service.  There shall be staffing schedules reflecting actual nursing personnel required for the hospital and for each patient unit.  Staffing patterns shall reflect consideration of nursing goals, standards of nursing practice, and the needs of the patients.  (Section 15(a) of the Act)

 

b)         Current nursing staff schedules shall be available upon request at each patient care unit. Each schedule shall list the daily assigned nursing personnel and average daily census for the unit. (Section 15(b) of the Act)  The schedules shall be provided to the public for inspection in accordance with subsection (h) of this Section by providing a hard copy of the schedule, which may be in the form of scheduling logs, schedule postings, print outs of electronic screens, and sign-up sheets, but shall not contain information identifying a patient, employee, licensed nurse, or other licensed professional.  Hospitals may also make schedules available by other means in addition to the hard copy format.  The average daily census that must be referenced on each prospective schedule should reflect the unit's average daily census from the prior fiscal year data.

 

c)         Hospitals and the Department shall notify the public of the right to access nurse staffing information and provide information for obtaining nurse staffing information.  The Department shall include this information on its web site.  Hospitals shall provide this information through one or more communication channels, for example, disseminate patient education materials or include information on obtaining nurse staffing information on the hospital web site.

 

d)         The actual nurse staffing assignment roster for each patient care unit shall be available upon request at the patient care unit for the effective date of that roster.  (Section 15(b) of the Act)  The actual nurse staffing assignment rosters will be provided to the public for inspection in accordance with subsection (h) of this Section by providing a hard copy of the roster.  Hospitals may also make rosters available by other means in addition to the hard copy format. Hospitals shall have the ability to satisfy requests for the current rosters or schedules by providing the information at each unit. Requests for non-current rosters or schedules may be satisfied by directing the requestor from the unit to a hospital location where the information is kept for the purpose of providing information to the public.

 

e)         All records required under this Section, including anticipated staffing schedules and the methods to determine and adjust staffing levels, shall be made available to the public upon request.  (Section 15(c) of the Act)  Methods for determining and adjusting staffing levels may be contained in hospital policies and procedures, administrative regulations, staff plans, accreditation standards, collective bargaining agreements and commercially developed patient acuity tools and protocols.  Nothing in this Part requires hospitals to adopt any particular staffing level methodology. This information shall be made available to the public for inspection as provided in subsection (h) of this Section at a central location or at specific patient care units.

 

f)         All records required under Section 15 of the Act shall be maintained by the facility for no less than 5 years. (Section 15(d) of the Act)

 

g)         Requests for information under this Section may be communicated to the hospital by any reasonable means, including, but not limited to, written, telephone or on-site inquiries.  Hospitals shall be prepared to receive requests and respond accordingly as outlined in subsection (h) of this Section.  Hospitals may require these requests to be made in writing in order to document the specifics of each request.  If individual hospitals choose to require requests to be made in writing, the hospitals shall then develop a simple form that will fulfill this writing requirement.

 

h)         Copies of schedules, rosters, or other nurse staffing records made available to the public must not contain information identifying a patient, employee, licensed nurse, or other licensed professional.  Information required to be made available to the public under this Section shall be made available as follows:

 

1)         For requests related to an individual person's pending or current inpatient hospital stay:

 

A)        The current nursing staff schedule may be requested at any time and shall be made available within two hours after the request.

 

B)        The current actual nurse staffing assignment roster may be requested at any time and shall be made available within 2 hours after the request during normal business hours during the week and within 4 hours on weekends and evening hours.

 

2)         For requests unrelated to an individual person's pending or current inpatient hospital stay:

 

A)        Other nurse staffing records, including the methods to determine and adjust staffing levels, historical records, and records in off-site storage, may be requested at times specified by the hospital, but at least Monday through Friday from 9:00 a.m. to 5:00 p.m.  The hospital shall comply with a written request for these records within seven business days after its receipt.  These records shall be made available at a central location on hospital grounds.

 

B)        If the hospital is unable to provide the requested records in the time frame required by subsection (h)(2)(A) of this Section, the hospital shall notify the individual making the written request within the time limits specified in subsection (h)(2)(A) of this Section of the reason for the delay and the date by which the requested records shall be made available.

 

Section 255.200  Orientation and Training 

 

a)         All health care facilities shall have established an orientation process that provides initial job training and information and assesses the direct care nursing staff's ability to fulfill specified responsibilities. (Section 20(a) of the Act) Documentation of training and orientation processes and ongoing assessments of the direct care nursing staff's ability to fulfill specified responsibilities shall be maintained by health care facilities for five years.

 

b)                  Personnel who have not completed the established orientation course for a position may not work in the position without direct supervision by a registered professional nurse.

 

c)                  Staff training information will be available upon request, without any information identifying a patient, employee, or licensed professional at the hospital, for personnel who work in inpatient direct care areas for each of the following employee classifications: direct-care nursing staff, transport and housekeeping services, dietary personnel, and licensed allied health professionals. (Section 20(c) of the Act)

 

1)         The information shall provide the following by employee classification:  the requisite education, training, licensure and/or certifications necessary to secure employment; coursework, competencies, training and/or certifications required to successfully complete the established orientation process; and continuing education or training required to maintain employment, listed by topic, that applies to patient care, safety or infection control.

 

2)         This information shall be made available to the public for inspection upon request at a central location on hospital grounds or at specific patient care units as deemed appropriate by the hospital.  The information shall be available Monday through Friday from 9:00 a.m. to 5:00 p.m.

 

Section 255.250  Hospital Reports

 

a)         Individual hospitals shall prepare a quarterly report including all of the following (Section 25(a) of the Act):

 

1)         Direct care hours, by reporting individually all of the following:

 

A)        Total inpatient days, which is the sum of each daily census for the time period.

 

B)        Total direct care RN hours, which equals the sum of the paid productive hours for direct care RN employees, including agency, per diem and registry RNs.

 

C)        Total direct care LPN hours, which equals the sum of the paid productive hours for direct care LPN employees, including agency, per diem and registry LPNs.

 

D)        Total direct care hours for assistive nursing personnel, which is the sum of the paid productive hours for direct care assistive nursing personnel, including agency, per diem and registry assistive nursing personnel.

 

E)        Nursing hours per patient day for direct care, which is the sum of total direct care RN hours and total direct care LPN hours and total direct care assistive nursing personnel hours divided by total inpatient days.  (Section 25(a)(1) of the Act)

 

F)         Licensed nursing hours per patient day − by RNs and LPNs (RN hours per patient day, LPN hours per patient day), which is:

 

i)          the total direct care hospital employed RN hours divided by the total inpatient days for the quarter;

           

ii)         the total direct care commercial agency contracted RN hours divided by the total inpatient days for the quarter;

 

iii)        the total direct care hospital employed LPN hours divided by the total inpatient days for the quarter; and

 

iv)        the total direct care commercial agency contracted LPN hours divided by the total inpatient days for the quarter.

 

G)        Average daily hours worked (Section 25(a)(1) of the Act) − by RNs and LPNs (average daily RN hours worked, average daily LPN hours worked), which is:

 

i)          the total direct care hospital employed RN hours divided by the number of calendar days for the quarter,

 

ii)         the total direct care commercial agency contracted RN hours divided by the number of calendar days for the quarter,

 

iii)        the total direct care hospital employed LPN hours divided by the number of calendar days for the quarter, and

 

iv)        the total direct care commercial agency contracted LPN hours divided by the number of calendar days for the quarter.

 

H)        Average daily census per clinical service area, which is the total inpatient days divided by the days in the quarter.  (Section 25(a)(1) of the Act)

 

2)         Infection-related measures for the facility for the following clinical procedures (Section 25(a)(2) of the Act) for patients ages 18 and over in hospitals providing services where these treatments are clinically appropriate.

 

A)        Surgical outcome measures by reporting postoperative wound infection diagnosed during index hopitalization.

 

B)        Central vascular catheter-related bloodstream infection rates in designated critical care units.

 

C)        Patients diagnosed with postoperative ventilator-associated pneumonia (VAP) during index hospitalization.

 

b)         Individual hospitals may also, but are not required to, submit the following optional reports:  (Agency, per-diem and registry RNs must be included in the number of productive hours for the optional report.  The optional report may not include licensed nursing orientees in the number of productive hours.)

 

1)         Total number of nursing hours per patient day and licensed nursing hours per patient day for those licensed nursing personnel with indirect patient care responsibilities. The licensed nursing hours per patient day will be reported separately for registered professional nurses and licensed practical nurses. Hospitals may also submit the number of licensed nursing hours per patient day that are associated with caring for outpatient and observation patients.

 

2)         Average daily hours worked and average daily census for the quarter per clinical service area.

 

c)         Individual hospitals shall prepare annual reports including vacancy and turnover rates for licensed nurses per clinical service area for direct care nurses as follows: (Section 25(b) of the Act) 

 

1)         Vacancy Rate:

The vacancy rate submitted for licensed nurses per clinical service area must equal the number of full-time equivalent openings for licensed nursing personnel on January 1 of each year, divided by the number of full-time equivalents for licensed nursing personnel budgeted as of January 1. Budgeted positions include both filled positions and vacant positions for which the hospital is recruiting on January 1.  The vacancy rate does not include those licensed nursing employees who are on family, medical or disability leave or who provide per diem services to the hospital.  The vacancy rate shall be reported separately for registered nurses and licensed practical nurses.

 

2)         Turnover Rate:

The turnover rate submitted for licensed nurses per clinical service area must equal the number of separated employees for licensed nursing personnel for the calendar year preceding January 1, divided by the number of employees for licensed nursing personnel on the hospital's payroll for the same clinical service area as of the preceding January 1.  The turnover rate does not include those licensed nursing employees who are on family, medical or disability leave or who provide per diem services to the hospital.  The turnover rate shall be reported separately for registered nurses and licensed practical nurses.

 

(Source:  Amended at 40 Ill. Reg. 1833, effective January 5, 2016)

 

Section 255.260  Compliance (Repealed)

 

(Source:  Repealed at 40 Ill. Reg. 1833, effective January 5, 2016)

 

Section 255.270  Reporting

 

a)         Quarterly reports shall be submitted to the Department by April 30, July 31, October 31, and January 31 each year for the previous quarter. Data in quarterly reports must cover a period ending not earlier than one month prior to submission of the report.  Annual reports shall be submitted by December 31.  All reports shall be made available to the public on-site and through the Department. (Section 25(d) of the Act) The annual report required by statute to be submitted by December 31 will consist of the first three final, edited quarterly reports for the calendar year, and will be considered provisional.  Final, edited quarterly reports must be submitted to the Department according to the following calendar schedule:  1^st quarter (January through March) by the following July 1; 2^nd quarter (April through June) by the following October 1; 3^rd quarter (July through September) by the following January 1; and 4^th quarter (October through December) by the following April 1.  Final, edited annual reports containing all final, edited quarterly reports must be submitted to the Department by the following April 1.  The Department shall make final, edited quarterly reports and final, edited annual reports available on its public website (www.idph.state.il.us) and in accordance with provisions for inspection and copying of public records required by the Freedom of Information Act provided that such information satisfies the provisions of subsection 25(c) of the Hospital Report Card Act.  (Section 20 of the Act)  Each hospital shall provide copies of final, edited quarterly reports and final, edited annual reports specific to its facility within seven days after the receipt of a written request.

 

b)         If the hospital is a division or subsidiary of another entity that owns or operates other hospitals or related organizations, the annual public disclosure report shall be for the specific division or subsidiary and not for the other entity. (Section 25(e) of the Act)

 

c)         The Department shall disclose information under this Section in accordance with provisions for inspection and copying of public records required by the Freedom of Information Act provided that such information satisfies the provisions of Section 25(c) of the Act. (Section 25(f) of the Act)

 

d)         Notwithstanding any other provision of law, under no circumstances shall the Department disclose information obtained from a hospital that is confidential under Part 21 of Article 8 of the Code of Civil Procedure.  (Section 25(g) of the Act)

 

e)         No hospital report or Department disclosure may contain information identifying a patient, employee, or licensed professional. (Section 25(h) of the Act)

 

Section 255.280  Enforcement

 

Any hospital that fails to comply with the provisions and responsibilities detailed in the Act or this Part shall be subject to the compliance provisions in the Hospital Licensing Act.  In particular, Section 7 of the Hospital Licensing Act states, in part, that the Director, after notice and opportunity for hearing to the applicant or licensee, may deny, suspend, or revoke a permit to establish a hospital or deny, suspend, or revoke a license to open, conduct, operate, and maintain a hospital in any case in which the Director finds that there has been a substantial failure to comply with the provision of the Hospital Licensing Act, the Hospital Report Card Act, the Illinois Adverse Health Care Events Reporting Law of 2005 or the standards, rules, and regulations established by virtue of any of those Acts.  (Section 7(a) of the Hospital Licensing Act)