Section 210.1000  Definitions

 

The following terms have the meaning ascribed to them here whenever the term is used in this Part.

 

Act – the Alternative Health Care Delivery Act [210 ILCS 3].

 

Ambulatory Surgical Treatment Center (ASTC) – any institution, place or building licensed pursuant to the Ambulatory Surgical Treatment Center Act (Ill. Rev. Stat. 1991, ch. 111 1/2, pars. 157-8.1 et seq.) [210 ILCS 5]. (Section 3 of the Ambulatory Surgical Treatment Center Act)

 

Board – the State Board of Health.  (Section 10 of the Act)

 

Charitable Care – the intentional provision of free or discounted postsurgical recovery care center services to persons who cannot afford to pay.

 

Comparable Health Care Providers – other facilities holding the comparable Illinois Department of Public Health license.

 

Demonstration Program or Program – a program to license and study alternative health care models authorized under the Act. (Section 10 of the Act)

 

Dentist – a person licensed to practice under the Illinois Dental Practice Act (Ill. Rev. Stat. 1991, ch. 111, pars. 2301 et seq.) [225 ILCS 25].

 

Department – the Illinois Department of Public Health.  (Section 10 of the Act)

 

Dietician – a person who:

 

is registered or eligible for registration by the American Dietetic Association; or

 

has a baccalaureate degree with major studies in food and nutrition, dietetics, and food service management, has one year of supervisory experience in the dietetic service of a health care institution, and participates annually in continuing dietetic education.

 

Director – the Director of Public Health or his designee.  (Section 10 of the Act)

 

Hospital – any institution, place, building or agency licensed pursuant to the Hospital Licensing Act (Ill. Rev. Stat. 1991, ch. 111½, pars. 142 et seq.) [210 ILCS 85]. (Section 3 of the Hospital Licensing Act)

 

Inspection – any survey, evaluation, or investigation of the Postsurgical Recovery Care Center Model's compliance with the Act and this Part by the Department or designee.

 

Licensee – the person or entity licensed to operate the Postsurgical Recovery Care Center Model.

 

Medical Staff – physicians, dentists and podiatrists granted admitting privileges in accordance with Section 210.1900(a).

 

Operator – the person responsible for the control, maintenance and governance of the Model, its personnel and physical plant.

 

Owner – the individual, partnership, corporation, association or other person who owns the Model.

 

Patient's Representative – a person authorized by the patient or by law to act on behalf of the patient.

 

Pharmacist – a person licensed as a registered pharmacist under the Pharmacy Practice Act (Ill. Rev. Stat. 1991, ch. 111, pars. 4121 et seq.) [225 ILCS 85].

 

Podiatrist – a person who is licensed to practice under the Podiatric Medical Practice Act of 1987 (Ill. Rev. Stat. 1991, ch. 111, pars. 4251 et seq.) [225 ILCS 100].

 

Physician – a person licensed to practice medicine in all its branches under the Medical Practice Act of 1987 (Ill. Rev. Stat. 1991, ch. 111, pars. 4400-1 et seq.) [225 ILCS 60].

 

Postsurgical Recovery Care Center Model or Model – a designated site which provides postsurgical recovery care for generally healthy patients undergoing surgical procedures that require overnight nursing care, pain control, or observation that would otherwise be provided in an inpatient setting. (Section 35(2) of the Act)

 

            Program Narrative – a description of the facility's proposed operation to clarify or explain choices related to such items as space, equipment, finishes or other specifications in the architectural plans.  The program narrative shall include, but is not limited to the:

 

            number of beds;

 

            medical needs of proposed patients;

 

            proposed food service operation;

 

            proposed laundry operations; and

 

            interrelations of various functions.

 

Qualified Consulting Committee – a committee whose members are qualified physicians who establish the required standards commensurate with the size, scope, extent and complexity of service programs and procedures for which the program is licensed.

 

Registered Nurse – a person who is licensed as a registered professional nurse under the Illinois Nursing Act of 1987 (Ill. Rev. Stat. 1991, ch. 111, pars. 3501 et seq.) [225 ILCS 65].

 

Substantial Compliance – meeting requirements except for variance from the strict and literal performance, which results in unimportant omissions or defects given the particular circumstances involved.  This definition is limited to the phrase as used in Section 210.1200.

 

Section 210.1050  Referenced Materials

 

The following Illinois statutes and administrative rules of the Department of Public Health are referenced in this Part.

 

a)         Hospital Licensing Act and Hospital Licensing Requirements (77 Ill. Adm. Code 250)

 

b)         Ambulatory Surgical Treatment Center Act and Ambulatory Surgical Treatment Center Licensing Requirements (77 Ill. Adm. Code 205)

 

Section 210.1100  Demonstration Program Elements

 

a)         The Postsurgical Recovery Care Center Demonstration Program (Program) shall be reviewed annually by the Board to determine if it should continue operation for a period up to five years, commencing with the effective date of this Part.

 

b)         A Postsurgical Recovery Care Center Model shall be licensed pursuant to this Part to be considered a participant in the Program.

 

c)         A postsurgical recovery care center Model shall be no larger than 20 beds.  (Section 35 of the Act)

 

d)         Applications for participation in the Program shall be considered only when a vacancy exists in one of the allocated Program slots for the relevant geographic area.

 

e)         At the midpoint and end of the program, the Board shall evaluate and make recommendations to the Governor and the General Assembly, through the Department, regarding the program, in accordance with Section 20(b) of the Act. (Section 20(b) of the Act)

 

f)         The Department shall deposit all application fees, renewal fees and fines collected under the Act and this Part into the Regulatory Evaluation and Basic Enforcement Fund in the State Treasury. (Section 25(d) of the Act)

 

Section 210.1200  Application for and Issuance of a License to Operate a Postsurgical Recovery Care Center Model

 

a)         The applicant shall have been licensed as a hospital pursuant to the Hospital Licensing Act or as an ambulatory surgical treatment center pursuant to the Ambulatory Surgical Treatment Center Act on or before August 20, 1991, and have held a valid license continuously since that time.

 

b)         Applications for a license to operate a Postsurgical Recovery Care Center Model shall be in writing on forms provided by the Department.  The application shall be made under oath and shall contain the following:

 

1)         Proof of a Certificate of Need to establish and operate a Postsurgical Recovery Care Center Model issued by the Health Facilities Planning Board under the Illinois Health Facilities Planning Act (Ill. Rev. Stat. 1991, ch. 111½, pars. 115 et seq.) [20 ILCS 3960];

 

2)         The name and address of the hospital or ambulatory surgical treatment center licensee, which shall be the name of the Model licensee;

 

3)         The name of the proposed Model;

 

4)         The address of the proposed Model;

 

5)         A precise description of the site of the proposed Model and, if it is located within the hospital or ambulatory surgical treatment center, the unit or area, including room numbers, of the portion of the facility designated as the Postsurgical Recovery Care Center Model;

 

6)         The number of postsurgical recovery care beds;

 

7)         The name and address of the registered agent or other individual authorized to receive Service of Process for the Model licensee;

 

8)         The name, address and Illinois license numbers of the following persons:

 

A)        Administrator,

 

B)        Medical Director,

 

C)        Supervisory Nurse;

 

9)         A copy of the transfer agreement with a licensed hospital within 15 minutes travel time of the proposed Model;

 

10)       Documentation of compliance with Section 210.2500, Laboratory, Pharmacy and Radiological Services;

 

11)       Documentation of Compliance with Section 210.2800, Food Service;

 

12)       The Model's admission protocol and transfer criteria as required by Section 210.1800;

 

13)       Information regarding any conviction of the owner or operator of the proposed Model of a felony or of any other crime under the laws of any state or of the United States arising out of or in connection with the operation of a health care facility; and

 

14)       Information regarding any encumbrance on a health care license issued in Illinois or any other state to the owner or operator of the proposed Model.

 

c)         Schematic architectural plans must be submitted for approval prior to submission of the application.

 

d)         An application for initial and renewal licensure shall be accompanied by an application fee of $500 plus $100 for each Postsurgical Recovery Care Center Model bed.

 

e)         Upon receipt and review of a complete application for licensure, the Department shall conduct an inspection to determine compliance with the Act and this Part.

 

f)         If the proposed Model is found to be in substantial compliance with the Act and this Part, the Department shall issue a license for a period of one year. (Section 30 of the Act)

 

1)         The license shall not be transferable; it is issued to the licensee and for the specific location and number of beds identified in the application.

 

2)         The license shall become automatically void and shall be returned to the Department if the Model's hospital or ambulatory surgical treatment center license is revoked, nonrenewed or relinquished, denied, forfeited, or suspended.

 

g)         An application for license renewal shall be filed with the Department 90-120 days prior to the expiration of the license, on forms provided by the Department.

 

1)         The renewal application shall comply with the requirements of subsections (a), (b) and (d) of this Section; and

 

2)         Upon receipt and review of a complete application for license renewal, the Department may conduct a survey.  The Department shall renew the license in accordance with subsection (f) of this Section.

 

h)         The Department may issue a provisional license to any Postsurgical Recovery Care Center model that does not substantially comply with the provisions of the Act and this Part:

 

1)         A provisional license may be issued only if the Department finds that:

 

A)        The model has undertaken changes and corrections which upon completion will render the model in substantial compliance with the Act and this Part; and

 

B)        The health and safety of the patients in the Model will be protected during the period for which the provisional license is issued (Section 30(c) of the Act).

 

2)         The Department shall advise the applicant or licensee of the conditions under which the provisional license is issued, including:

 

A)        The manner in which the model fails to comply with the provisions of the Act and this Part;

 

B)        The changes and corrections that shall be completed;

 

C)        The time within which the necessary changes and corrections shall be completed (Section 30(c) of the Act); and

 

D)        The interim actions that are necessary to protect the health and safety of the patients.

 

i)          The Postsurgical Recovery Care Center Model license or provisional license shall be prominently displayed in an area accessible to the public.

 

j)          A Postsurgical Recovery Care Center Model licensed under this Part shall operate in conformance with the Hospital Licensing Act or Ambulatory Surgical Treatment Center Act and the rules promulgated thereunder, corresponding to its primary facility license, for all matters and requirements not specifically addressed in this Part.

 

Section 210.1300  Obligations and Privileges of Postsurgical Recovery Care Center Models

 

a)         Postsurgical Recovery Care Center Models shall, within 30 days of licensure, seek certification under Titles XVIII and XIX of the federal Social Security Act.  (Section 30(d) of the Act)

 

b)         Postsurgical Recovery Care Center Models shall provide charitable care consistent with that provided by comparable health care providers in the geographic area.  For the purpose of this Part, comparable health care providers shall include hospitals and ambulatory surgical treatment centers.  (Section 30(d) of the Act)

 

c)         A licensed Postsurgical Recovery Care Center Model that continues to be in substantial compliance after the conclusion of the demonstration program shall be eligible for annual license renewals unless and until a different licensure program for that type of health care model is established by legislation. (Section 30(c) of the Act)

 

d)         No facility or person shall hold itself out to the public as a "Recovery Care Center" or "Postsurgical Recovery Care Center" unless it is licensed as a Postsurgical Recovery Care Center Model under the Act. (Section 36 of the Act)

 

Section 210.1400  Inspections and Investigations

 

a)         The Department shall perform licensure inspections of Postsurgical Recovery Care Center Models, as deemed necessary, to ensure compliance with the Act and this Part. (Section 25(c) of the Act)

 

b)         All Postsurgical Recovery Care Center Models to which this Part applies shall be subject to and shall be deemed to have given consent to all inspections by properly identified personnel of the Department, or by other such properly identified persons as the Department might designate.  In addition, representatives of the Department shall have access to and may reproduce or photocopy any books, records, and other documents maintained by the Model or the licensee to the extent necessary to carry out the Act and this Part.

 

c)         The Department shall investigate an applicant or licensee whenever it receives a verified complaint in writing of any person setting forth facts which, if proven, would constitute grounds for the denial of an application for a license, refusal to renew a license, or suspension or revocation of a license.  (Section 50 of the Act)

 

d)         The Department may also investigate an applicant or licensee on its own motion or based upon complaints received by mail, telephone, or in person. (Section 50 of the Act)

 

Section 210.1500  Notice of Violation and Plan of Correction

 

a)         Upon determination that the licensee or applicant is in violation of the Act or this Part, the Department shall issue a written Notice of Violation and request a plan of correction.  The notice shall specify the violation(s), and shall instruct the licensee or applicant to submit a plan of correction to the Department within 10 days after receipt of the Notice.

 

b)         Within the ten-day period, a licensee or applicant may request additional time for submission of the plan of correction.  The Department may extend the period for submission of the plan of correction for an additional 30 days, when the Department finds that corrective action by the Model to abate or eliminate the violation(s) will require substantial capital improvement.  The Department will consider the extent and complexity of necessary physical plant repairs and improvements and any impact on the health, safety, or welfare of the patients of the Model in determining whether to grant a requested extension.

 

c)         Each plan of correction shall be based on an assessment by the Model of the conditions or occurrences that are the basis of the violation(s) and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.  Evidence of such assessment and evaluation shall be maintained by the Model.  Each plan of correction shall include:

 

1)         A description of the specific corrective action the Model is taking, or plans to take, to abate, eliminate, or correct the violation(s) cited in the Notice;

 

2)         A description of the steps that will be taken to avoid future occurrences of the same and similar violation(s); and

 

3)         A specific date by which the corrective action will be completed.

 

d)         Submission of a plan of correction shall not be considered an admission by the Model that the violation(s) has occurred.

 

e)         The applicant or licensee may submit additional information in response to the Notice of Violation that it believes will clarify the condition or alleged violation(s).  The Department will consider the information in reviewing the applicant's or licensee's response and the plan of correction.

 

f)         The Department shall review each plan of correction to ensure that it provides for the abatement, elimination, or correction of the violation.  The Department shall reject a submitted plan only if it finds any of the following deficiencies:

 

1)         The plan does not address the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.

 

2)         The plan is not specific enough to indicate the actual actions the Model will be taking to abate, eliminate, or correct the violation.

 

3)         The plan does not provide for measures that will abate, eliminate, or correct the violation.

 

4)         The plan does not provide steps that will avoid future occurrences of the same and similar violations.

 

5)         The plan does not provide for timely completion of the corrective action, considering the seriousness of the violation, any possible harm to the patients, and the extent and complexity of the correction action.

 

g)         The Department shall notify the licensee or applicant if the plan of correction is rejected, including specific reasons for the rejection of the plan.  The Model shall submit a modified plan that addresses the requirements of subsection (c) of this Section within five days after receipt of notice of rejection.

 

h)         If a licensee or applicant fails to make a timely submission of a modified plan of correction, or such modified plan is not acceptable to the Department, a plan of correction shall be specified and imposed by the Department.

 

i)          The Department shall verify the completion of the corrective action required by the plan of correction within the specified time period during subsequent investigations, surveys, and evaluations of the Model.

 

Section 210.1600  Adverse Licensure Action

 

a)         Before denying a license application, refusing to renew a license, suspending a license, revoking a license, or assessing an administrative fine, the Department shall notify the applicant or the licensee in writing.  The notice shall specify the charges or reasons for the Department's contemplated action, and shall provide the applicant or licensee an opportunity to file a request for a hearing within 10 days after receiving the notice.  (Section 50 of the Act)

 

1)         A failure to request a hearing within 10 days shall constitute a waiver of the applicant's or licensee's right to a hearing. (Section 50 of the Act)

 

2)         The hearing shall be conducted by the Director or an individual designated in writing by the Director as an Administrative Law Judge, and shall be conducted in conformance with the Department's Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100) and Section 65 of the Act.  (Section 55 of the Act)

 

b)         A license may be denied, suspended, revoked, the renewal of a license may be denied or administrative fine assessed, for any of the following reasons:

 

1)         Violation of any provision of the Act or this Part.

 

2)         Conviction of the owner or operator of the Postsurgical Recovery Care Center Model of a felony or of any other crime under the laws of any state or of the United States arising out of or in connection with the operation of a health care facility.  The record of conviction or a certified copy of it shall be conclusive evidence of conviction.

 

3)         An encumbrance on a Health Care License issued in Illinois or any other state to the owner or operator of the Postsurgical Recovery Care Center Model.

 

4)         Revocation of any facility license issued by the Department during the previous five years or surrender or expiration of the license during the pendency of action by the Department to revoke or suspend the license during the previous five years, if the prior license was issued to the individual applicant or a controlling owner or controlling combination of owners of the applicant or any affiliate of the individual applicant or controlling owner of the applicant or affiliate of the applicant was a controlling owner of the prior license.  (Section 45 of the Act)

 

c)         An action to assess an administrative fine may be initiated in conjunction with or in lieu of other adverse licensure action.

 

d)         The amount of an administrative fine shall be determined based on consideration of the following:

 

1)         The nature and severity of the violation(s);

 

2)         The Model's diligence in correcting the violation(s);

 

3)         Whether the Model had been previously cited for similar violation(s);

 

4)         The number of violations;

 

5)         The duration of uncorrected violation(s); and

 

6)         The impact or potential impact of the violation(s) on patient health and safety.

 

e)         The administrative fine shall be calculated in relation to the number of days the violation existed, or continues to exist if it has not been corrected.  The total amount of the fine assessed shall fall within the following parameters:

 

1)         For a violation that occurred as a single event or incident – between $100 and $5,000 per violation.

 

2)         For a violation that was or is continuing beyond a single event or incident – between $100 and $500 per day per violation.

 

Section 210.1700  Admission Practices

 

The Model shall establish and follow admission criteria that provide for:

 

a)         The admission of postsurgical patients to the Model that is consistent with the recommendations of the qualified consulting committee in Section 210.1900 and as approved by the Department as defined in Section 210.1800 (Section 36 of the Act).

 

b)         The nondiscrimination of patients based on disability, race, religion, sex, source of payment, and any other basis recognized by applicable State and federal laws.

 

Section 210.1800  Approval of Protocols for the Admission of Postsurgical Patients

 

a)         An admission protocol specifying the criteria for admitting a postsurgical patient to the Model shall be included in the application as provided in Section 210.1200.  The admission protocol must address at least the following:

 

1)         All patients shall be admitted to the Model by a member of the medical staff with admitting privileges, and shall be under the professional care of a member of the medical staff.

 

2)         Criteria for admission that include limiting services provided as follows:

 

A)        the patient must have been discharged from the post anesthesia care unit or recovery room of the ASTC or hospital where the procedure was performed.  The patient may not be directly admitted to the Model from the operating room;

 

B)        patients must be three years of age or older;

 

C)        patients with an active, acute or chronic infectious condition shall not be eligible for admission;

 

D)        patients must fall within anesthesia class I or II or fall within anethesia class III with only mild to moderate systematic disease but medically stable;

 

E)        patients must require a postoperative overnight stay;

 

F)         patients will require a stay of not more than 48 hours (may be extended to 72 hours when the necessity of the extension is documented by the treating physician and approved by the Medical Director);

 

G)        the level of care needed by the patient is consistent with the definition of a  Postsurgical Recovery Care Center Model, and hospitalization is not required;

 

H)        the patient is physiologically stable at the time of admission and has experienced no intraoperative or postoperative complications that would cause the patient to be ineligible for admission based on the Act and this Part; and

 

I)         the patient does not require the administration of blood.

 

3)         The types of surgical procedures performed in ambulatory surgical treatment centers or hospitals which the Postsurgical Recovery Care Center Model intends to admit, including documentation that the expected postoperative stay is less than 48 hours and the postoperative complication rate is minimal.

 

4)         At the time of admission the patient's medical record must include:

 

A)        a current history and physical examination conducted or approved by members of the medical staff;

 

B)        patient diagnosis:

 

C)        a discharge summary from the referring facility or physician, including the surgical procedure performed, the type of anesthesia used, medications given, recovery events and any other pertinent information regarding the patient's status;

 

D)        physician orders;

 

E)        documentation concerning advance directives; and

 

F)         any other underlying medical condition that could be relevant to the patient's care.

 

b)         The admission protocol and any subsequent revisions shall be approved by the applicant's consulting committee prior to submission to the Department, and documentation of the approval must be submitted with the request for the Department's approval.

 

c)         The initial and any revised admission protocols may not be put into effect without prior approval of the Department as provided in this Section.

 

d)         The Department shall review all admission protocols submitted with the application, renewal application and any separate submission under this Section to assure that the admission protocol provides for the admission of only postsurgical patients who can safely be cared for outside of a licensed acute care hospital.  The Department will disapprove any admission protocol that allows an admission that would be life threatening in nature or that does not meet the requirements set forth in Section 210.1800(a).

 

e)         Upon receipt of the information from the Model, the Department will either approve the admission protocol, or disapprove the admission protocol as provided under subsection (d) of this Section.  The Department will seek the recommendations of medical specialty and other professional consultants concerning the safety of specific admission protocols when it determines that such consultation is necessary.  The Department will also consider any additional information submitted by medical specialists and other professionals and by medical specialty and other professional societies in making these determinations.

 

Section 210.1900  Standards of Professional Practice

 

a)         A qualified consulting committee shall be appointed in writing by the operator and/or owner of the Postsurgical Recovery Care Center Model and shall establish and enforce standards for professional work in the Model and standards of competency for medical staff.  The consulting committee shall meet not less than quarterly and shall document all meetings with written minutes.  These written minutes shall be maintained at the Model and shall be available for inspection by the Department.

 

1)         The consulting committee shall review development and content of the written policies and procedures of the Postsurgical Recovery Care Center Model, the procedures for granting privileges, and the quality of the postsurgical recovery care services provided. Evidence of such review shall be recorded in the minutes.

 

2)         Credentials shall be provided by those physicians, dentists, and podiatrists seeking admitting privileges.  These credentials shall be reviewed by the consulting committee, and specific practice privileges shall be available for the Model's staff use and public information within the Model.

 

3)         Each member of the medical staff granted specific admitting privileges shall provide documentation indicating the name of the Illinois licensed hospital(s) where they have privileges,  which include approval to perform at least the same level of services which the physician seeks to provide in the Model.  Such statements or documentation shall be available for inspection by the Department.  A list of privileges granted each medical staff member of the Postsurgical Recovery Care Center Model shall be available at all times for use by the staff of the Postsurgical Recovery Care Center Model and for inspection by Department staff.

 

b)         A physician shall be designated "Medical Director."

 

1)         The Medical Director shall assure compliance with the policies and procedures pertaining to medical procedures, approved by the consulting committee.

 

2)         The Medical Director shall be responsible for the implementation of medical policies and procedures contained in the Model's policies and procedures governing the professional personnel involved in direct care of patients.

 

3)         The Medical Director shall establish and assure compliance of standards for the observation of patients by nursing personnel during the postoperative period.

 

c)         A qualified physician shall be on-call and able to be physically present in the Model within 15 minutes after a request from the nurse in charge at all times when patients are present in the Postsurgical Recovery Care Center Model.

 

d)         The qualified consulting committee in a licensed ambulatory surgical treatment center may act as the consulting committee in the Postsurgical Recovery Care Center Model.

 

Section 210.2000  Length of Stay

 

a)         The maximum length of stay for patients shall not exceed 48 hours unless the treating physician, dentist, or podiatrist requests an extension of time from the Postsurgical Recovery Care Center Model's Medical Director on the basis of medical or clinical documentation that an additional care period is required for the recovery of a patient and the Medical Director approves the extension of time. (Section 35 of the Act)

 

b)         No patient shall stay in the Postsurgical Recovery Care Center Model longer than 72 hours.  If a patient requires an additional care period, the patient shall be transferred to an appropriate facility. (Section 35 of the Act)

 

c)         Reports on variances from the 48 hour limit shall be sent to the Department for evaluation within 30 days after the patient's discharge. (Section 35 of the Act)  The report shall not identify the patient or physician but shall detail the following:

 

1)         patient diagnosis and the surgical procedure performed;

 

2)         the reason(s) for the extended stay;

 

3)         actual length of stay;

 

4)         documentation of the Medical Director's approval;

 

5)         documentation of consulting committee review of the case and the results of the review.

 

Section 210.2100  Patient's Rights

 

a)         A patient shall not be deprived of any rights, benefits, or privileges guaranteed by law based solely on his/her status as a patient of the Model.

 

b)         The Model shall notify the patient's representatives whenever the patient suffers from a surgical complication, illness, or accident.

 

c)         Every patient shall be permitted to refuse medical treatment and to know the consequences of such action.

 

d)         Every patient or patient's representative shall be permitted to inspect and copy all of the patient's clinical and other records concerning the patient's care and maintenance kept by the Model or by the patient's physician.

 

e)         All patients shall be permitted respect and privacy in their medical and personal care program.  Every patient's case discussion, consultation, examination, and treatment shall be confidential and shall be conducted discreetly.  Those persons not directly involved in the patient's care must have the patient's permission to be present.

 

f)         Every patient shall be permitted unimpeded, private, and uncensored communication of his/her choice by mail and telephone.  The Model shall ensure that correspondence is promptly received and mailed, and that telephones are reasonably accessible.

 

Section 210.2200  Personnel

 

a)         A registered nurse with postgraduate education or at least three years of experience within the last five years in the postanesthesia recovery unit or medical/surgical unit of an acute care hospital or in an ambulatory surgical treatment center shall be designated as the Supervising Nurse and shall direct and supervise the nursing personnel and the nursing care of the patients.

 

b)         The licensee shall provide a sufficient number of properly trained and supervised staff to meet the needs of each patient.  At least two licensed nurses, one of whom is a registered nurse, must be on duty when patients are present.

 

c)         The licensee shall define, through job descriptions, minimum education and experience, requirements for all staff, consultants and contract staff providing services to the Postsurgical Recovery Care Center Model.  All nursing staff must:

 

1)         be certified for basic cardiopulmonary life support; and

 

2)         have a minimum of two years of experience within the last five years in the post-anesthesia recovery unit or medical/surgical unit of an acute care hospital or in an ambulatory surgical treatment center.

 

d)         The licensee shall provide an initial orientation and routine, pertinent training to all staff. This training may include return demonstration, one-on-one training, small group exercises, or lecture.  All training shall be documented with:

 

1)         date,

 

2)         starting and ending time,

 

3)         instructors,

 

4)         short description of content, and

 

5)         participants' written and printed signatures.

 

e)         The Model shall establish an employee health program that includes the following:

 

1)         an assessment of the employee's health and immunization status at the time of employment;

 

2)         policies regarding required immunizations;

 

3)         policies and procedures for the periodic health assessment of all personnel.  These policies must specify the content of the health assessment and the interval between assessments and must comply with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).

 

f)         Prior to employing any individual in a position that requires a State license, the licensee shall contact the Illinois Department of Professional Regulation to verify that the individual's license is active. A copy of the license shall be placed in the individual's personnel file.

 

g)         The licensee shall check the status of all applicants with the Nurse Aide Registry prior to hiring.

 

(Source:  Amended at 26 Ill. Reg. 11965, effective July 31, 2002)

 

Section 210.2250  Health Care Worker Background Check

 

A facility shall comply with the Health Care Worker Background Check Act [225 ILCS 46] and the Health Care Worker Background Check Code (77 Ill. Adm. Code 955).

 

(Source:  Amended at 30 Ill. Reg. 835, effective January 9, 2006)

 

Section 210.2300  Patient Care

 

a)         All persons shall be admitted to the Model by a member of the medical staff and shall be under the professional care of a member of the medical staff.

 

b)         No medication, treatment or diagnostic test shall be administered to a patient except on the written order of a member of the medical staff.  Verbal orders shall be signed before the medical staff member leaves the Model.  Telephone orders shall be countersigned within 24 hours.

 

c)         Policies and procedures must be developed and implemented that address the following:

 

1)         An initial nursing assessment shall be performed by a registered nurse on admission of the patient to the Model.

 

2)         A nursing care plan shall be developed and implemented that addresses the needs of the patient and is coordinated with the patient's medical management plan.

 

3)         Visiting rules shall be developed that protect the health, safety and privacy of the patients.

 

A)        Visiting hours shall be communicated to the patient and posted in an area(s) visible to all persons entering the Model.

 

B)        No visitor shall knowingly be admitted who has a known infectious disease, who has recently recovered from such a disease, or who has recently had contact with such a disease.

 

C)        Smoking by visitors shall be prohibited except in specially designated areas.

 

4)         Emergency Care and Transfers

 

A)        Policies and procedures shall be developed which establish the extent of emergency treatment to be provided in the Model, including basic life support procedures and transfer arrangements for patients who require care beyond the scope provided by the Model.

 

B)        There shall be monitoring equipment, suction apparatus, oxygen, and cardiopulmonary resuscitation equipment available in the Model.

 

C)        Patient transfers to a hospital shall be by a licensed ambulance service.

 

D)        Appropriate medical records and a summary of the events precipitating the transfer must accompany the patient.

 

E)        The Model must have a written disaster plan of operation with procedures to be followed in the event of fire, natural disaster or other threat to patient safety.

 

5)         Policies and procedures shall be developed and implemented concerning the administration, storage, and disposal of medications.

 

d)         Written discharge instructions shall be provided to each patient based upon the patient's health care needs and the medical staff's instructions.

 

e)         Patients shall be discharged only on the written signed order of a member of the medical staff.

 

Section 210.2400  Infection Control

 

a)         The Model must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.  There must be an active program for the prevention, control and investigation of infections and communicable diseases.

 

b)         A person or persons shall be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable disease.  Policies and procedures shall be developed to address the following:

 

1)         Medical, nursing and non-professional staff behaviors to prevent and control the transmission of infections or communicable diseases.

 

2)         Measures to handle infectious cases that develop in the Model.

 

3)         Reporting and care of cases of communicable diseases shall be in accordance with 77 Ill. Adm. Code 690, the Control of Communicable Diseases Code.

 

4)         A systematic plan of checking and recording cases of infection, known or suspected, which develop in the Model.

 

c)         The Model shall ensure maintenance of a sanitary environment with all equipment in good working order.  Written procedures shall include:

 

1)         Provision for garbage, refuse and medical waste removal in such a manner that will not permit the transmission of a contagious disease, create a nuisance or fire hazard or provide a breeding place for vermin or rodents;

 

2)         Insect and rodent control;

 

3)         Maintenance of water, heat, ventilation and air conditioning, and electrical service;

 

4)         The use, cleaning and care of equipment and supplies; and

 

5)         Housekeeping and cleaning measures and schedule.

 

d)         Laundry shall be processed in accordance with Sections 250.1740, 250.1750 and 250.1760 of the Hospital Licensing Requirements.

 

Section 210.2500  Laboratory, Pharmacy and Radiological Services

 

a)         Each Postsurgical Recovery Care Center Model shall meet the following:

 

1)         Possess a valid Clinical Laboratory Improvement Amendments (CLIA) certificate for those tests performed by the Model; and

 

2)         Have a written agreement with a laboratory that possesses a valid CLIA certificate to perform any required laboratory procedures that are not performed in the center.

 

b)         Blood shall not be administered in the Model, but blood products may be administered in the Model.

 

c)         Pharmacy services shall be provided directly by the Model or by contract with a pharmacy licensed pursuant to the Pharmacy Practice Act.

 

d)         Pharmacy services not provided by contract must be under the direction of a registered pharmacist employed by the Model on a full-time, part-time or consulting basis.

 

e)         All drugs and medicines shall be stored and dispensed in accordance with applicable State and federal laws and regulations.

 

f)         Radiologic services sufficient to perform and interpret the radiological examinations necessary to meet the needs of the patients must be provided.

 

g)         All x-rays shall be read by a member of the medical staff or a consulting radiologist approved by the consulting committee.

 

Section 210.2600  Records and Reports

 

a)         Accurate and complete clinical records shall be maintained for each patient, and all entries in the clinical record shall be made at the time when care, treatment, medications or other medical services are given.  The record shall include, but not be limited to, the following:

 

1)         patient identification;

 

2)         admitting information including the patient's history and physical examination findings, discharge summary from the ambulatory surgical treatment center or hospital where the surgical procedure was performed as required by Section 210.1800(a) of this Part;

 

3)         signed physician, dentist, or podiatrist orders;

 

4)         laboratory and radiology tests results;

 

5)         medication and medical treatments;

 

6)         physician and consultant or allied health personnel progress notes;

 

7)         nursing observation, progress notes and vital sign charting;

 

8)         discharge instructions and condition at discharge;

 

9)         documentation concerning advance directives; and

 

10)       signed discharge summary.

 

b)         Records must be stored in a safe manner that will assure safety from water seepage or fire damage and will safeguard from unauthorized access.

 

c)         All original records or copies of such records shall be maintained in accordance with a Postsurgical Recovery Care Center Model policy that complies with State and federal laws.

 

d)         Each Postsurgical Recovery Care Center Model shall submit to the Department clinical statistical data that include the following:

 

1)         the total number of patients admitted to the Postsurgical Recovery Care Center Model;

 

2)         the number of patients admitted itemized by the surgical procedure and anesthesia class that was performed prompting the admission;

 

3)         the number and type of complications, including the specific procedure associated with each complication;

 

4)         the number of patients requiring transfer to another health care facility for treatment of complications or other reasons.  List the procedure, type of health care facility, and the complication or reason which prompted each transfer; and

 

5)         the number of deaths, including the surgical procedure performed prior to admittance and the events leading up to the patient's death.

 

e)         This clinical data shall be submitted to the Department quarterly, with reports due no later than January 15, April 15, July 15, and October 15 for the preceding quarter.

 

Section 210.2700  Transfer Agreement

 

a)         In order to handle cases of complications, emergencies or exigent circumstances, the Postsurgical Recovery Care Center Model shall maintain a contractual relationship, including a transfer agreement, with a general acute care hospital. (Section 35 of the Act)

 

b)         The Postsurgical Recovery Care Center Model shall be located within 15 minutes travel time from the general acute care hospital with which the Model maintains a transfer agreement. (Section 35 of the Act)

 

Section 210.2800  Food Service

 

a)         Postsurgical Recovery Care Center Models may use food service facilities located within facilities licensed under the Hospital Licensing Act or the Nursing Home Care Act (Ill. Rev. Stat. 1991, ch. 111½, pars. 4151-101 et seq.) [210 ILCS 45]. Procedures and equipment shall be in place to assure the safe transport and service of meals and snacks.

 

b)         All other Postsurgical Recovery Care Center Models shall procure meals and snacks from a source that complies with the following:  Sections 250.1610, 250.1620, 250.1630, 250.1640, 250.1650, 250.1660, 250.1670, and 250.1680 of the Hospital Licensing Requirements.  Procedures and equipment shall be in place to assure the safe transport and service of meals and snacks.

 

c)         To the extent medically possible, a minimum of three meals, or their equivalent, shall be served daily.

 

d)         Menus must be approved by a dietician who is employed by the Postsurgical Recovery Care Center Model on a full-time, part-time or consultant basis.  Dietary consultation shall be provided to patients as needed or requested.

 

e)         Therapeutic or modified diets must be served as ordered.

 

f)         A patient's intake of food and liquids shall be monitored and documented as dictated by the patient's condition and the surgical procedure performed.

 

Section 210.2900  Physical Plant

 

a)         If part of a hospital:

 

1)         Postsurgical Recovery Care Center Models built after January 1, 1994 shall meet the program narrative (see Section 250.2430(a)(4)) and comply with the following Sections of the Hospital Licensing Requirements:  250.2410, 250.2420, 250.2430, 250.2440(d)(1-4), 250.2450, 250.2460, 250.2470, 250.2480, 250.2490(a)-(h) and (j)-(k) and 250.2500.

 

2)         If subsection (a)(1) of this Section does not apply, the Postsurgical Recovery Care Center Model shall meet the program narrative and comply with the following Sections of the Hospital Licensing Requirements: 250.2620, 250.2630(d)(1)-(4), 250.2640, 250.2650, 250.2660, 250.2670 and 250.2680.

 

b)         If not part of a licensed hospital, postsurgical recovery care center models shall meet the program narrative and comply with:

 

1)         Chapters 1-7, 12, 31 and 32 of the 1991 Edition (no later amendments or editions included) of the National Fire Protection Association (NFPA) Code for Safety to Life from Fire in Buildings and Structures (also known as "The Life Safety Code") which may be obtained from the National Fire Protection Association, Batterymarch Park, Massachusetts 02269; and

 

2)         The following Sections of the Hospital Licensing Requirements:  250.2410, 250.2420, 250.2430, 250.2440 (d)(1)-(4), 250.2450, 250.2460, 250.2470(a), (b), and (c)(1), (2), and (4), 250.2480, 250.2490(a)-(h), (j) and (k), and 250.2500.

 

Section 210.3000  Quality Assessment and Improvement

 

a)         The licensee shall develop and implement a quality assessment and improvement program designed to meet at least the following:

 

1)         Ongoing monitoring and evaluation of the quality and accessibility of care and services provided by the Model or under contract, including but not limited to:

 

A)        admission of patients appropriate to the capabilities of the Model,

 

B)        patient satisfaction,

 

C)        costs for delivery of services, and

 

D)        infection control;

 

2)         Identification and analysis of problems;

 

3)         Identification and implementation of corrective action or changes in response to problems.

 

b)         The licensee shall afford the Department and the Board access to any materials or documents generated pursuant to the Model's quality assessment and improvement program or that otherwise relate to patient demand, utilization and satisfaction; healthcare costs; healthcare cost effectiveness; financial viability of the Model; and access to healthcare services.  Reports shall not identify the patient or physician.  Additionally, the Board shall collect uniform billing data substantially the same as specified in Section 4-2(e) of the Illinois Health Finance Reform Act.  A copy of the data shall be forwarded by the Board to the Illinois Health Care Cost Containment Council. (Section 20 of the Act)  Such information shall be used by the Department and the Board to evaluate and assess Postsurgical Recovery Care Center Models in relation to the Demonstration Program, and shall be afforded the same confidential status as is provided information concerning medical studies in Article VIII, Part 21 of the Code of Civil Procedure (Ill. Rev. Stat. 1991, ch. 110, pars. 1-101 et seq.) [735 ILCS 5].