TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.100 DEFINITIONS
Section 250.100 Definitions
Act – the
Hospital Licensing Act [210 ILCS 85].
Advanced
Practice Registered Nurse – a person licensed to practice under Article 65 of
the Nurse Practice Act.
Advanced
Practice Provider – an advanced practice registered nurse or a physician
assistant.
Allied Health
Personnel – persons other than medical staff members, licensed or registered by
the State of Illinois or recognized by an organization acceptable to the
Department and recognized to function within their licensed, registered or
recognized capacity by the medical staff and the governing authority of the
hospital.
Dentist – any
person licensed to practice dentistry as provided in the Illinois Dental
Practice Act.
Department – the
Illinois Department of Public Health.
Dietetic
Service Director − a person who:
is a
dietitian;
is a
graduate of a dietetic and nutrition school or program authorized by the
Accreditation Council for Education in Nutrition and Dietetics, the Academy of
Nutrition and Dietetics, or the American Clinical Board of Nutrition;
is a
graduate, prior to July 1, 1990, of a Department-approved course that provided
90 or more hours of classroom instruction in food service supervision and has
had experience as a supervisor in a health care institution which included
consultation from a dietitian;
has
successfully completed an Association of Nutrition & Foodservice
Professionals approved Certified Dietary Manager or Certified Food Protection Professional
course;
is
certified as a Certified Dietary Manager or Certified Food Protection
Professional by the Association of Nutrition & Foodservice Professionals;
or
has
training and experience in food service supervision and management in a military
service equivalent in content to the programs in the second, third or fourth
paragraph of this definition.
Dietitian
− a person who is a registered dietitian or registered dietitian nutritionist
as defined in the Dietitian Nutritionist Practice Act.
Drugs – the
term "drugs" means and includes:
articles
recognized in the official United States Pharmacopoeia, official National
Formulary, or any supplement to either of them and being intended for and
having for their main use the diagnosis, cure, mitigation, treatment or
prevention of disease in man or other animals;
all other
articles intended for and having for their main use the diagnosis, cure,
mitigation, treatment or prevention of disease in man or other animals;
articles
(other than food) having for their main use and intended to affect the
structure or any function of the body of man or other animals; and
articles
having for their main use and intended for use as a component or any articles
specified in this definition, but does not include devices or their components,
parts or accessories.
Federally
designated organ procurement agency – the organ procurement agency designated
by the Secretary of the U.S. Department of Health and Human Services for the
service area in which a hospital is located; except that in the case of a
hospital located in a county adjacent to Wisconsin which currently contracts
with an organ procurement agency located in Wisconsin that is not the organ
procurement agency designated by the U.S. Secretary of Health and Human
Services for the service area in which the hospital is located, if the hospital
applies for a waiver pursuant to 42 U.S.C. 1320b-8(a), it may designate an
organ procurement agency located in Wisconsin to be thereafter deemed its
federally designated organ procurement agency for the purposes of the
Act. (Section 3(F) of the Act)
Follow-up healthcare
– healthcare services related to a sexual assault, including laboratory
services and pharmacy services, rendered within 180 days after the initial
visit for medical forensic services. (Section 1a of the Sexual Assault
Survivors Emergency Treatment Act)
Hospital – the
term "hospital" shall have the meaning ascribed in Section 3(A) of
the Act.
Hospitalization
– the reception or care of any person in any hospital either as an inpatient or
as an outpatient.
House Staff
Member – an individual who is a graduate of a medical, dental, osteopathic, or
podiatric school; who is licensed as appropriate; who is appointed to the
hospital's medical, osteopathic, dental, or podiatric graduate training program
that is approved or recognized in accordance with the statutory requirements
applicable to the practitioner; and who is participating in patient care under
the direction of licensed practitioners who have clinical privileges in the
hospital and are members of the hospital's medical staff.
Licensed
Practical Nurse – a person with a valid Illinois license to practice as a
practical nurse under the Nurse Practice Act.
Medical Staff
– an organized body composed of the following individuals granted the privilege
by the governing authority of the hospital to practice in the hospital:
persons who are graduates of a college or school approved or recognized by the
Illinois Department of Financial and Professional Regulation, and who are
currently licensed by the Illinois Department of Financial and Professional
Regulation to practice medicine in all its branches; practice dental surgery;
or, practice podiatric medicine in Illinois, regardless of the title of the
degree awarded by the approving college or school.
Medicines –
drugs or chemicals or preparations of drugs or chemicals in suitable form
intended for and having for their main use the prevention, treatment, relief,
or cure of diseases in humans or animals when used either internally or
externally.
Nurse – a
registered nurse or licensed practical nurse as defined in the Nurse Practice
Act.
Nursing
Administrator (or Chief Nursing Officer or Director of Nursing) – a registered
professional nurse who is employed full-time within the hospital as director of
the nursing administration pursuant to Section 250.910.
Nursing Staff
– registered nurses, licensed practical nurses, nursing assistants and others
who render patient care under the supervision of a registered professional
nurse.
Patient Care
Unit or Nursing Care Unit – an organized unit in which nursing services are
provided on a continuous basis. This unit is a clearly defined administrative
and geographic area to which specific nursing staff is assigned.
Pharmacist – a
person who is licensed as a pharmacist under the Pharmacy Practice Act.
"Pharmacy
– a location where pharmacist care is provided by a pharmacist and where drugs
and medicines are dispensed, sold, offered or displayed for sale at retail;
where prescriptions of physicians, dentists, advanced practice registered
nurses, physician assistants, podiatric physicians, or optometrists, within the
limits of their licenses, are compounded, filled or dispensed; and which has a
sign bearing the word or words "Pharmacist", Druggist", "
Pharmacy", Pharmaceutical Care", or similar terms or where the
characteristic prescription sign (Rx) or similar design is exhibited. (Section
3 of the Pharmacy Practice Act). Any room or designated area where drugs and
medicines are dispensed (including repackaging for distribution) shall be
considered to be a pharmacy and shall be required to be licensed by the
Illinois Department of Financial and Professional Regulation.
Pharmacy
practice – includes the following services as defined in the Pharmacy Practice
Act:
the
interpretation and the provision of assistance in the monitoring, evaluation,
and implementation of prescription drug orders;
the
dispensing of prescription drug orders;
participation
in drug in drug and device selection;
drug
administration limited to administration of oral, topical, injectable, and
inhalation as follows:
in the
context of patient education on the proper use or delivery of medications;
pursuant to
a valid prescription or standing order by a physician licensed to practice
medicine in all its branches, upon completion of appropriate training,
including how to address contraindications and adverse reaction pursuant to
Pharmacy Practice Act rules (68 Ill. Adm. Code 1330), with notification to
the patient's physician and appropriate record retention, or pursuant to
hospital pharmacy and therapeutics committee policies and procedure:
vaccination of patients 7 years of age and older;
following
the initial administration of long-acting or extended-release form opioid
antagonists by a physician licensed to practice medicine in all its branches,
administration of injections of long-action or extended-release form opioid
antagonists;
administration
of injections of alpha-hydroxyprogesterone caproate;
administration
of injections of long-term antiphyschotic medications (appropriate training
must be conducted by an Accreditation Counsel of Pharmaceutical Education
accredited provider);
drug regimen review;
drug or drug-related research;
the provision of patient counseling;
the practice of telepharmacy;
the
provision of those acts or services necessary to provide pharmacist care;
medication
therapy management; and
the
responsibility for compounding and labeling of drugs and devices (except
labeling by a manufacturer, repackager, or distributor of non-prescription drugs
and commercially package legend drugs and devices), proper and safe storage of
drugs and devices, and maintenance of required records as defined in the Pharmacy
Practice Act. (Section 3 of the Pharmacy Practice Act)
Physical
Rehabilitation Facility – a licensed specialty hospital or clearly defined
special unit or program of an acute care hospital providing physical
rehabilitation services either through the facility's own staff members or when
appropriate, through the mechanism of formal affiliations and consultations.
Physical
Rehabilitation Services – a complete, intensive multi-disciplinary process of
individualized, time-limited, goal-oriented services, including evaluation,
restoration, personal adjustment, and continuous medical care under the
supervision and direction of a physician qualified by training and experience
in physical rehabilitation. Physical rehabilitation has two major components:
inpatient and outpatient care. Both components involve the patient and,
whenever possible, the family in establishing treatment goals and discharge
plans, and consist of the following scope of services available for inpatient
care: physician, rehabilitation nursing, physical therapy, occupational
therapy, speech therapy, audiology, prosthetic and orthotic services, as well
as rehabilitation counseling, social services, recreational therapy,
psychology, pastoral care, and vocational counseling. Basic scope of services
for outpatient facilities shall include at least a physician, physical therapy,
occupational therapy, speech therapy, vocational services, psychology and
social service. The purpose of multi-faceted services is to reduce the
disability and dependency in activities of daily living while promoting optimal
personal adjustment in dimensions such as psychological, social, economic,
spiritual and vocational.
Physician – a
person licensed to practice medicine in all of its branches as provided in the
Medical Practice Act of 1987.
Physician
Assistant – a person authorized to practice under the Physician Assistant
Practice Act of 1987.
Podiatrist – a
person licensed to practice podiatry under the Podiatric Medical Practice Act
of 1987.
Reference
Materials – a sample in which the chemical composition and physical properties
resemble the specimen to be analyzed on which sufficient analyses have been run
to give a reasonably good approximation of the concentration of the constituent
being assayed. The reference materials are routinely analyzed along with patient
specimens to determine the precision and accuracy of the analytical process
used.
Registered
Nurse – a person with a valid Illinois license to practice as a registered
professional nurse under the Nurse Practice Act.
Rural
Emergency Hospital (REH) – an entity that operates for the purpose of providing
emergency department services, observation care, and other outpatient medical
and health services, in which the annual per patient average length of stay
does not exceed 24 hours. The entity must not provide inpatient services,
except those furnished in a unit that is a distinct part licensed as a skilled
nursing facility to furnish post-REH or post-hospital extended care services
pursuant to 42 CFR 485.502.
Safe Lifting Equipment and
Accessories – mechanical equipment designed to lift, move, reposition,
and transfer patients, including, but not limited to, fixed and portable
ceiling lifts, sit-to-stand lifts, slide sheets and boards, slings, and
repositioning and turning sheets. (Section 6.25(a) of the Act)
Safe
Lifting Team – at least 2 individuals who are trained in the use of both
safe lifting techniques and safe lifting equipment and accessories, including
the responsibility for knowing the location and condition of such equipment and
accessories. (Section 6.25(a) of the Act)
Standard
Solution – a solution used for calibration in which the concentration is
determined solely by dissolving a weighted amount of primary standard material
in an appropriate amount of solvent.
Surgical
smoke plume – the by-product of the use of energy-based devices on tissue
during surgery and containing hazardous materials, including, but not limited
to, bioaerosols, smoke, gases, tissue and cellular fragments and particulates,
and viruses. (Section 6.32(a) of the Act)
Surgical
smoke plume evacuation system – a dedicated device that is designed to capture,
transport, and filter surgical smoke plume at the site of origin and before it
can diffuse and pose a risk to the occupants of the operating or treatment room.
(Section 6.32(a) of the Act)
Tissue bank
– any facility or program operating in Illinois that is certified by the
American Association of Tissue Banks or the Eye Bank Association of America and
is involved in procuring, furnishing, donating, or distributing corneas, bones,
or other human tissue for the purpose of injecting, transfusing or
transplanting any of them into the human body. "Tissue bank" does not
include a licensed blood bank. For the purposes of the Act,
"tissue" does not include organs. (Section 3(G) of the Act)
(Source:
Amended at 48 Ill. Reg. 7321, effective May 3, 2024)
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.105 INCORPORATED AND REFERENCED MATERIALS
Section 250.105 Incorporated and Referenced Materials
a) The following
regulations and standards are incorporated in this Part:
1) Private
and Professional Association Standards
A) American
Society for Testing and Materials (ASTM), Standard No. E90-99 (2009): Standard
Test Method for Laboratory Measurement of Airborne Sound Transmission Loss of
Building Partitions and Elements, which may be obtained from the American
Society for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, PA
19428-2959
B) ASTM E
662 (2012), Standard Test Method for Specific Optical Density of Smoke
Generated by Solid Materials, which may be obtained from the American Society
for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959
C) ASTM E
84 (2010), Standard Test Method for Surface Burning Characteristics of Building
Materials, which may be obtained from the American Society for Testing and
Materials, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959
D) The
following standards of the American Society of Heating, Refrigerating, and Air
Conditioning Engineers (ASHRAE), which may be obtained from the American
Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc., 180
Technology Parkway NW, Peachtree, GA 30092:
i) ASHRAE
Handbook of Fundamentals (2009)
ii) ASHRAE
Handbook for HVAC Systems and Equipment (2004)
iii) ASHRAE
Handbook-HVAC Applications (2007)
iv) ASHRAE
Guideline 12-2020, "Managing the Risk of Legionellosis Associated with
Building Water Systems" (March 30, 2021)
v) ASHRAE
Standard 188-2021, "Legionellosis: Risk Management for Building Water
Systems" (August 2021)
E) The
following standards of the National Fire Protection Association (NFPA), which
may be obtained from the National Fire Protection Association, 1 Batterymarch
Park, Quincy, MA 02169:
i) NFPA
101 (2012): Life Safety Code and all applicable references under Chapter 2,
Referenced Publications
ii) NFPA
101A (2013): Guide on Alternative Approaches to Life Safety
F) American
Academy of Pediatrics and American College of Obstetricians and Gynecologists,
Guidelines for Perinatal Care, Eighth Edition (September 2017), which may be
obtained from the American College of Obstetricians and Gynecologists online at:
https://publications.aap.org/aapbooks/book/522/Guidelines-for-Perinatal-Care?autologincheck=redirected
or by phone at 800-762-2264, 409 12th Street SW, Washington, DC 20024-2188
(See Section 250.1820.)
G) American
College of Obstetricians and Gynecologists, Guidelines for Women's Healthcare,
Fourth Edition (2014), which may be obtained online at: https://www.scribd.com/document/359258258/american-college-of-obstetricians-and-gynecologists-guidelines-for-women-s-health-care-a-resource-manual
(See Section 250.1820.)
H) American
Academy of Pediatrics (AAP), Red Book: Report of the Committee on Infectious
Diseases, 32nd Edition (January 2021), available at:
https://publications.aap.org/redbook or from the American Academy of
Pediatrics, 345 Park Blvd., Itasca, IL 60143 (See Section 250.1820.)
I) American
Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, Part 4: Pediatric and Basics and Advanced Life Support and
Part 5: Neonatal Resuscitation (October 2020), available at:
https://tinyurl.com/38zny85p and https://tinyurl.com/2s3dpb8c,
respectively, or from the American Heart Association, 7272 Greenville Ave.,
Dallas, TX 75231 (See Section 250.1830.)
J) National
Association of Neonatal Nurses, Position Statement #3074 Minimum RN Staffing in
the NICU (September 2021), available at:
http://nann.org/about/position-statements or from the National Association of
Neonatal Nurses, 8735 W. Higgins Road, Suite 300, Chicago, IL 60631 (See
Section 250.1830.)
K) National
Council on Radiation Protection and Measurements (NCRP), Report 49: Structural
Shielding Design and Evaluation for Medical Use of X-rays and Gamma Rays of
Energies up to 10 MeV (1976) and NCRP Report 102: Medical X-Ray, Electron Beam
and Gamma-Ray Protection for Energies Up to 50 MeV (Equipment Design,
Performance and Use) (1989), which may be obtained from the National Council on
Radiation Protection and Measurements, 7910 Woodmont Ave., Suite 400, Bethesda,
Maryland 20814-3095 (See Sections 250.2440 and 250.2450.)
L) DOD
Penetration Test Method MIL STD 282 (2020): Filter Units, Protective Clothing,
Gas-mask Components and Related Products: Performance Test Methods, available
at: https://publishers.standardstech.com/stgnet (See Section 250.2480.)
M) National
Association of Plumbing-Heating-Cooling Contractors (PHCC), National Standard
Plumbing Code (2009), which may be obtained from the National Association of
Plumbing-Heating-Cooling Contractors, 180 S. Washington Street, Suite 100,
Falls Church, VA 22046 (703-237-8100)
N) International
Building Code (2012), which may be obtained from the International Code
Council, 4051 Flossmoor Road, Country Club Hills, IL 60478 (See Section
250.2420.)
O) American
National Standards Institute, ANSI A117.1 (2009), Standard for Accessible and
Usable Buildings, which may be obtained from the American National Standards
Institute, 25 West 43rd Street, 4th Floor, New York, NY 10036
(See Section 250.2420.)
P) ASME
Standard A17.1-2007, Safety Code for Elevators and Escalators, which may be
obtained from the American Society of Mechanical Engineers (ASME)
International, 22 Law Drive, Box 2900, Fairfield, NJ 07007-2900
Q) Accreditation
Council for Graduate Medical Education, Common Program Requirements (Residency)
(2023), available at: https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2023v3.pdf
or from the Accreditation Council for Graduate Medical Education, 401 N.
Michigan Ave., Suite 2000, Chicago, IL 60611 (See Section 250.315.)
R) The
Joint Commission, 2022 Hospital Accreditation Standards (HAS), available at:
https://store.jcrinc.com/2022-accreditation-standards-books/ or from the Joint
Commission, 1515 W. 22nd St. Ste. 1300W, Oakbrook Terrace, IL 60523
(See Section 250.1035.)
S) National
Quality Forum, Safe Practices for Better Health Care (2010), available at: https://cms.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx
or from the National Quality Forum, 10991 14th Street NW, Suite 500,
Washington DC 20005, or from www.qualityforum.org
2) Federal
Government Publications
A) Department
of Health and Human Services, Centers for Disease Control and Prevention,
"2007 Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings" (July 2023) available at: https://www.cdc.gov/infection-control/media/pdfs/guideline-isolation-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf
B) Department
of Health and Human Services, Centers for Disease Control and Prevention,
Infection Control in Healthcare Personnel, available in two parts:
"Infrastructure and Routine Practices for Occupational Infection
Prevention and Control Services" (October 25, 2019) and "Epidemiology
and Control of Selected Infections Transmitted Among Healthcare Personnel and
Patients" (October 22, 2024), both available at: https://www.cdc.gov/infection-control/hcp/healthcare-personnel-infrastructure-routine-practices/index.html
C) Department
of Health and Human Services, Centers for Disease Control and Prevention,
"Guidelines for Environmental Infection Control in Health-Care
Facilities": (April 2024), available at: https://www.cdc.gov/infection-control/about/index.html?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html
D) Department
of Health and Human Services, Centers for Disease Control and Prevention,
Guideline for Hand Hygiene in Health Care Settings (October 25, 2002) available
at: https://www.cdc.gov/infection-control/hcp/hand-hygiene/?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html
E) Department
of Health and Human Services, Centers for Disease Control and Prevention,
"Guideline for Disinfection and Sterilization in Healthcare Facilities,
2008", (June 2024), available at: https://www.cdc.gov/infection-control/media/pdfs/guideline-disinfection-h.pdf
F) Department
of Health and Human Services, Centers for Disease Control and Prevention,
"Core Elements of Hospital Stewardship Programs", (2019), which is
available at:
https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf,
and "Implementation of Antibiotic Stewardship Core Elements at Small and
Critical Access Hospitals", which is available at: https://www.cdc.gov/antibiotic-use/hcp/core-elements/small-and-critical-access-hospitals.html?CDC_AAref_Val=https://www.cdc.gov/antibiotic-use/core-elements/small-critical.html
G) Department
of Health and Human Services, Centers for Disease Control and Prevention,
"Toolkit for Controlling Legionella in Common Sources of Exposure",
which is available at: https://www.cdc.gov/control-legionella/php/toolkit/control-toolkit.html?CDC_AAref_Val=https://www.cdc.gov/legionella/wmp/control-toolkit/index.html
H) National
Center for Health Statistics and World Health Organization, Geneva,
Switzerland, "International Classification of Diseases", 11th
Revision (ICD-11), (2022), available at:
https://www.who.int/standards/classifications/classification-of-diseases
I) U.S.
Department of Labor, Occupational Safety and Health Administration,
"Guidelines for Preventing Workplace Violence for Healthcare and Social
Service Workers" (OSHA 3148-06R 2016), available at:
https://www.osha.gov/Publications/osha3148.pdf
J) Department
of Health and Human Services, United States Public Health Service, Centers for
Disease Control and Prevention, National Center for Injury Prevention and
Control, Division of Violence Prevention, "STOP SV: A Technical Package
to Prevent Sexual Violence" (2016), available at: https://stacks.cdc.gov/view/cdc/39126
K) National
Research Council, Recommended Dietary Allowances 10th Edition
(1989). Washington, DC: The National Academies Press. Available at: https://doi.org/10.17226/1349
L) Department
of Health and Human Services, Centers for Disease Control and Prevention,
National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication
No. 2020-119 (2020), "Infectious diseases and circumstances relevant to
notification of emergency response employees: implementation of Sec. 2695 of
the Ryan White HIV/AIDS Treatment Extension Act of 2009, available at: https://www.cdc.gov/niosh/docs/2020-119/pdfs/2020-119.pdf?id=10.26616/NIOSHPUB2020119
3) Federal
Regulations
A) 45 CFR
46.101, To What Does the Policy Apply? (October 1, 2023)
B) 45 CFR
46.103(b), Assuring Compliance with this Policy − Research Conducted or
Supported by any Federal Department or Agency (October 1, 2023)
C) 42 CFR
482, Conditions of Participation for Hospitals (October 1, 2023)
D) 21
CFR, Food and Drugs (April 1, 2023)
E) 42 CFR
489.20, Basic Commitments (October 1, 2023)
F) 29
CFR 1910.1030, Bloodborne Pathogens (July 1, 2022)
G) 42 CFR
413.65(d) and (e), Requirements for a determination that a facility or an
organization has provider-based status (October 1, 2023)
H) 42 CFR
493, Laboratory Requirements (CLIA regulations) (October 1, 2023)
I) 7 CFR
331, Possession, Use, and Transfer of Select Agents and Toxins (January 1,
2024)
J) 9 CFR
121, Possession, Use, and Transfer of Select Agents and Toxins (January 1,
2024)
K) 42 CFR
73, Select Agents and Toxins (October 1, 2024)
b) All
incorporations by reference of federal regulations and guidelines and the
standards of nationally recognized organizations refer to the regulations,
guidelines and standards on the date specified and do not include any editions
or amendments subsequent to the date specified.
c) The
following statutes and State regulations are referenced in this Part:
1) State
of Illinois Statutes
A) Hospital
Licensing Act [210 ILCS 85]
B) Illinois
Health Facilities Planning Act [20 ILCS 3960]
C) Medical
Practice Act of 1987 [225 ILCS 60]
D) Podiatric
Medical Practice Act of 1987 [225 ILCS 100]
E) Pharmacy
Practice Act [225 ILCS 85]
F) Physician
Assistant Practice Act of 1987 [225 ILCS 95]
G) Illinois
Clinical Laboratory and Blood Bank Act [210 ILCS 25]
H) X-Ray
Retention Act [210 ILCS 90]
I) Safety
Glazing Materials Act [430 ILCS 60]
J) Mental
Health and Developmental Disabilities Code [405 ILCS 5]
K) Nurse
Practice Act [225 ILCS 65]
L) Health
Care Worker Background Check Act [225 ILCS 46]
M) MRSA
Screening and Reporting Act [210 ILCS 83]
N) Hospital
Report Card Act [210 ILCS 86]
O) Illinois
Adverse Health Care Events Reporting Law of 2005 [410 ILCS 522]
P) Smoke
Free Illinois Act [410 ILCS 82]
Q) Health
Care Surrogate Act [755 ILCS 40]
R) Perinatal
HIV Prevention Act [410 ILCS 335]
S) Hospital
Infant Feeding Act [210 ILCS 81]
T) Medical
Patient Rights Act [410 ILCS 50]
U) Hospital
Emergency Service Act [210 ILCS 80]
V) Illinois
Anatomical Gift Act [755 ILCS 50]
W) Illinois
Public Aid Code [305 ILCS 5]
X) Substance
Use Disorder Act [20 ILCS 301]
Y) ID/DD
Community Care Act [210 ILCS 47]
Z) Specialized
Mental Health Rehabilitation Act of 2013 [210 ILCS 49]
AA) Veterinary
Medicine and Surgery Practice Act of 2004 [225 ILCS 115]
BB) Alternative
Health Care Delivery Act [210 ILCS 3]
CC) Gestational
Surrogacy Act [750 ILCS 47]
DD) Code of
Civil Procedure (Medical Studies) [735 ILCS 5/8-2101]
EE) Sexual
Assault Survivors Emergency Treatment Act [410 ILCS 70]
FF) Civil
Administrative Code of Illinois (Department of Public Health Powers and Duties
Law) [20 ILCS 2310]
GG) AIDS
Confidentiality Act [410 ILCS 305]
HH) Nursing
Home Care Act [210 ILCS 45]
II) Illinois
Controlled Substances Act [720 ILCS 570]
JJ) Early
Hearing Detection and Intervention Act [410 ILCS 213]
KK) Home
Health, Home Services, and Home Nursing Agency Licensing Act [210 ILCS 55]
LL) Health
Care Violence Prevention Act [210 ILCS 160]
MM) Illinois
Health Finance Reform Act [20 ILCS 2215]
NN) Fair
Patient Billing Act [210 ILCS 88]
OO) Crime
Victims Compensation Act [740 ILCS 45]
PP) Human
Trafficking Resource Center Notice Act [775 ILCS 50]
QQ) Abandoned
Newborn Infant Protection Act [325 ILCS 2]
RR) Emergency
Medical Services (EMS) Systems Act [210 ILCS 50]
SS) Radiation
Protection Act of 1990 [420 ILCS 40]
TT) Illinois
Dental Practice Act [225 ILCS 25]
UU) Criminal
Identification Act [20 ILCS 2630]
VV) Latex
Glove Ban Act [410 ILCS 180]
2) State
of Illinois Administrative Rules
A) Department
of Public Health, Illinois Plumbing Code (77 Ill. Adm. Code 890)
B) Department
of Public Health, Sexual Assault Survivors Emergency Treatment Code (77 Ill.
Adm. Code 545)
C) Department
of Public Health, Control of Notifiable Diseases and Conditions Code (77 Ill.
Adm. Code 690)
D) Department
of Public Health, Food Code (77 Ill. Adm. Code 750)
E) Department
of Public Health, Public Area Sanitary Practice Code (77 Ill. Adm. Code 895)
F) Department
of Public Health, Maternal Death Review (77 Ill. Adm. Code 657)
G) Department
of Public Health, Control of Sexually Transmissible Infections Code (77 Ill.
Adm. Code 693)
H) Department
of Public Health, Control of Tuberculosis Code (77 Ill. Adm. Code 696)
I) Department
of Public Health, Health Care Worker Background Check Code (77 Ill. Adm. Code
955)
J) Department
of Public Health, Language Assistance Services Code (77 Ill. Adm. Code 940)
K) Department
of Public Health, Regionalized Perinatal Health Care Code (77 Ill. Adm. Code
640)
L) Health
Facilities and Services Review Board, Narrative and Planning Policies (77 Ill.
Adm. Code 1100)
M) Health
Facilities and Services Review Board, Processing, Classification Policies and
Review Criteria (77 Ill. Adm. Code 1110)
N) Department
of Public Health, Private Sewage Disposal Code (77 Ill. Adm. Code 905)
O) Department
of Public Health, Ambulatory Surgical Treatment Center Licensing Requirements
(77 Ill. Adm. Code 205)
P) Department
of Public Health, HIV/AIDS Confidentiality and Testing Code (77 Ill. Adm. Code
697)
Q) Capital
Development Board, Illinois Accessibility Code (71 Ill. Adm. Code 400)
R) State
Fire Marshal, Boiler and Pressure Vessel Safety (41 Ill. Adm. Code 120)
S) State
Fire Marshal, Fire Prevention and Safety (41 Ill. Adm. Code 100)
T) Illinois
Emergency Management Agency, Standards for Protection Against Radiation (32
Ill. Adm. Code 340)
U) Illinois
Emergency Management Agency, Use of X-rays in the Healing Arts Including
Medical, Dental, Podiatry, and Veterinary Medicine (32 Ill. Adm. Code 360)
V) Illinois
Emergency Management Agency, Medical Use of Radioactive Material (32 Ill. Adm.
Code 335)
W) Illinois
Emergency Management Agency, Registration and Operator Requirements for
Radiation Installations (32 Ill. Adm. Code 320)
X) Illinois
Emergency Management Agency, Accrediting Persons in the Practice of Medical
Radiation Technology (32 Ill. Adm. Code 401)
Y) Illinois
Emergency Management Agency, General Provisions for Radiation Protection (32
Ill. Adm. Code 310)
Z) Department
of Public Health, Emergency Medical Services, Trauma Centers, Pediatric
Emergency and Critical Care Centers, Stroke Centers Hospital Code (77 Ill.
Admin Code 515)
3) Federal
Statutes
A) Health
Insurance Portability and Accountability Act of 1996 (110 U.S.C. 1936)
B) Emergency
Medical Treatment & Labor Act (42 U.S.C. 1395dd)
4) Federal
Training Materials
A) Preventing
Workplace Violence in Healthcare, available at:
https://www.oshatrain.org/courses/mods/776e.html
B) Workplace
Violence Prevention for Nurses, available at:
https://www.cdc.gov/niosh/topics/violence/
(Source: Amended at 49 Ill. Reg. 14395,
effective October 27, 2025)
|
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.110 APPLICATION FOR AND ISSUANCE OF PERMIT TO ESTABLISH A HOSPITAL
Section 250.110 Application
for and Issuance of Permit to Establish a Hospital
a) A permit to establish a hospital is required for the
following:
1) Construction of a new hospital;
2) Change of location of a hospital;
3) Change of license of a hospital;
4) Change of license category of a hospital;
5) Whenever a facility that was not formerly required to be
licensed becomes subject to licensure.
b) Application for a permit
1) An application for a permit to establish a hospital shall be
made to the Department in accordance with directions and forms provided by it.
2) The application shall include a Certificate of Need Permit
(CON) or Certificate of Exemption from Certificate of Need (COE) issued by the
Health Facility Planning Board pursuant to the Health Facilities Planning Act
(Ill. Rev. Stat. 1991, ch. 111 1/2, par. 1151 et seq.) [20 ILCS 3960].
3) An application for a permit in the case of construction of a
new hospital shall also include architectural plans and specifications.
c) Issuance of Permit
1) Upon receipt of an application for permit to establish a
hospital, the Director shall issue a permit if he finds:
A) that the application is complete, including the issuance of the
necessary CON or COE, and
B) when a new hospital is being constructed, that the
architectural plans and specifications are in compliance with the design and
construction standards required by this Part.
2) An approved application for a permit to establish a hospital
shall be valid for one year from date issued. The approval of a permit may be
extended provided the applicant submits to the Department an acceptable,
well-documented progress report.
d) Permit not transferable
A permit to establish a hospital shall be valid only for the
premises and person named in the application for such permit and shall not be
transferable or assignable.
(Source: Amended at 18 Ill. Reg. 15390, effective October 10, 1994)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.120 APPLICATION FOR AND ISSUANCE OF A LICENSE TO OPERATE A HOSPITAL
Section 250.120 Application
for and Issuance of a License to Operate a Hospital
a) Applicant and Licensee. The applicant or licensee is the
"person" as defined in Section 3(B) of the Act who establishes,
conducts, operates and maintains a hospital, or proposes to do so, and who is
responsible for meeting licensing requirements.
b) Hospitals to be Licensed. A license is required of all places
that are hospitals as defined in Section 3 of the Act, providing that the place
is not specifically excluded by the Act.
c) Places not to be Licensed. The Act excludes the following:
1) Any person or institution required to be licensed pursuant
to the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act
of 2013, the ID/DD Community Care Act, or the MC/DD Act;
2) Hospitalization or care facilities maintained by the State
or any Department or agency thereof, where the Department or agency has
authority under law to establish and enforce standards for the hospitalization
or care facilities under its management and control;
3) Hospitalization or care facilities maintained by the
federal government or agencies thereof;
4) Hospitalization or care facilities maintained by any
university or college established under the laws of this State and supported
principally by public funds raised by taxation;
5) Any person or facility required to be licensed pursuant to
the Substance Use Disorder Act;
6) Any facility operated solely by and for persons who rely
exclusively upon treatment by spiritual means through prayer, in accordance
with the creed or tenets of any well-recognized church or religious
denomination;
7) An
Alzheimer's disease management center alternative health care model licensed
under the Alternative Health Care Delivery Act; or
8) Any veterinary hospital or clinic operated by a
veterinarian or veterinarians licensed under the Veterinary Medicine and
Surgery Practice Act of 2004 or maintained by a State-supported or publicly
funded university or college. (Section (3)(A) of the Act)
d) Application for License
1) The application for a license shall be made to the Department on
forms provided by the Department and shall contain information as the
Department requires for the administration of the Act. (Section 5(a) of the
Act) The initial application is available at:
http://dph.illinois.gov/content/dam/soi/en/web/idph/forms/topics-services/health-care-regulation/health-care-facilities/hospitals/Hospital-Initial-Licensure-2022.pdf
2) Applications on behalf of a corporation or association or
governmental unit or agency shall be made and verified by any two officers of
the corporation or association or governmental unit or agency.
3) The application shall be accompanied by a license fee of
$55 per bed.
A) The license fee for a critical access hospital, as defined
in Section 5-5e(b)(4) of the Illinois Public Aid Code, shall be $0 per
bed.
B) The license fee for a Safety-Net Hospital, as defined in
Section 5-5e.1 of the Illinois Public Aid Code shall be $0 per bed.
(Section 5(b) of the Act)
e) Issuance and Renewal of License. Licenses issued under the
Act and this Part shall be valid for a period of one year. The Department will
issue renewal licenses to those hospitals meeting licensing requirements as
determined by an ongoing review of reports, surveys, and recommendations on
file with the Department as related to the operation of the hospital and
payment of a license fee as established pursuant to Section 5 of the Act
and subsection (d). (Section 6(b) of the Act) Except for hospitals excluded
under subsections (d)(3)(A) and (B), payment of the annual license fee shall be
made to the Department prior to the expiration of a hospital's license. The
Department will mail an invoice to the hospital 60 days prior the expiration of
the hospital's license.
f) License not Transferable; Notification of Change of Licensee, Location
or Name
1) The license is not transferable. Each license is separate and
distinct and shall be issued to a specific licensee for a specific location.
The Department shall be notified prior to any change in the licensee, the name,
or the location of a hospital.
2) If the hospital's name is changed, a new license certificate
will be issued upon notification to the Department of the change.
3) Prior to changing the location of a hospital, the hospital
shall meet the requirements of Section 250.110 and this Section.
4) A change in the legal identity (e.g., transfer of ownership or
change of hospital license category) of the licensee of a hospital constitutes
the establishment of a new hospital, and the hospital shall meet the requirements
of Section 250.110 and this Section.
g) A change of ownership of a hospital occurs when one of the
following transactions is completed:
1) When ownership and responsibility for the operation of the
assets constituting the licensed entity are transferred from the licensee to
another person or another legal entity (including a corporation, limited
liability company, partnership or sole proprietor) as part of an asset purchase
or similar transaction;
2) A material change in a partnership that is caused by the
removal, addition, or substitution of a partner;
3) In a corporation, when the licensee corporation merges into
another corporation, or with the consolidation of two or more corporations, one
of which is the licensee, resulting in the creation of a new corporation;
4) The leasing of all the hospital's operations to another
corporation or partnership.
h) Prior
to completing the transactions described in subsection (g)(1) or (g)(2), the
new person, legal entity or partnership shall apply for a new license in
compliance with Section (6)(b) of the Act. The transaction shall not be
complete until the Director issues a new license to the new person, legal
entity or partnership.
i) The transactions described in subsection (g) do not constitute
a change in ownership when all of the entities that are parties to the
transaction are under common control or ownership before and after the
transaction is completed. In these transactions, the name of the corporation,
its officers, its independent subsidiaries and any other relevant information
that the Department may require shall be made available to the Department upon
request.
j) Pursuant to subsection (g), the transfer of corporate stock
or the merger of another corporation into the licensee corporation does not
constitute a change of ownership if the licensee corporation remains in
existence.
k) License Category; Approval of Services
1) Each license shall apply only to the categories of service
offered by the hospital at the time the license is issued, and as reflected in
the CON or COE issued by the Health Facilities and Services Review Board. A
hospital shall be licensed as one of the following:
A) General
Acute Care Hospital – a facility that offers an integrated variety of categories
of short-term, general acute care services and performs scheduled surgical
procedures on an inpatient basis. A General Acute Care Hospital may be
licensed as a Critical Access Hospital if the facility meets requirements of
the Centers for Medicare and Medicaid Services rules at 42 CFR 485.608, 485.610
and 485.612; or
B) Specialty
or Specialized Hospital – a facility that offers primarily a special or
particular category of services (e.g. psychiatric, pediatric, rehabilitation,
or long-term acute care, as defined in 42 CFR 412.22(e)).
C) Rural
Emergency Hospital (REH) − a facility that operates for the purpose of
providing emergency department services, observation care, and other outpatient
medical and health services, in which the annual per patient average length of
stay does not exceed 24 hours.
2) The license shall apply only to the number of beds and the
clinical services operating at the time the license is issued. If a new
clinical service is to be initiated, or an existing service expanded or
discontinued, the approval of the Department and the Health Facilities and
Services Review Board shall first be obtained. If a change in clinical service
results in change of license category, then a new application for license shall
be submitted to the Department and the hospital shall meet the requirements of
Section 250.110 and this Section.
l) Provisional License. The Director may issue a provisional
license to any hospital that does not substantially comply with the provisions
of the Act and this Part provided that the hospital has undertaken changes and
corrections that, upon completion, will render the hospital in substantial
compliance with the provisions of the Act and this Part, and provided that the
health and safety of the patients of the hospital will be protected during the
period for which the provisional license is issued. The Director will advise
the licensee of the conditions under which the provisional license is issued,
including the manner in which the hospital fails to comply with the provisions
of the Act and this Part. The Director also will advise the licensee of the
time within which the changes and corrections necessary for the hospital to
substantially comply with the Act and this Part shall be completed.
m) Posting of License. Licenses shall be posted, either by
physical or electronic means, in a conspicuous place on the licensed premises. (Section
6(b) of the Act)
n) Reinstatement
of Hospital Operations. A hospital that has suspended its operations due to
outstanding violations of the Act or this Part or termination by Medicare may
not reinstate operations without Department approval. The following conditions
shall be met before the Department will approve a request to reinstate
operations:
1) A
hospital shall submit a plan of correction to the Department that demonstrates
how all outstanding violations will be corrected to ensure compliance with all
licensing requirements.
2) A
hospital shall submit an updated license application pursuant to the
requirements of this Section.
3) The
Department will conduct a survey to ensure the hospital is in compliance will
all licensing requirements and to confirm the reason for the suspension of
operations no longer exists and the plan of correction has been fully met.
4) If
the Department determines the hospital is in compliance with all licensing
requirements and the plan of correction has been met, the Department will issue
a provisional license to the hospital.
5) The
Department will conduct a second survey within four months after the exit date
of the first survey to determine if the hospital has maintained compliance with
licensing requirements.
6) After
the second survey, the hospital's license will be reissued upon determination
by the Department that the hospital is in compliance with all licensing
requirements and has fully implemented the plan of correction.
7) If
the hospital is not in compliance with the licensing requirements, the
Department may either extend the provisional licensure period or deny the
request to reinstate operations. If the Department denies the request for
reinstatement, it will follow the provisions in Section 250.140, including, but
not limited to, providing notice of the denial and an opportunity for hearing.
o) Suspension
of Hospital Operations due to natural or human-induced disaster. A hospital
that has suspended its operations as the result of unplanned damage from a
natural or human-induced disaster must notify the Department of any such
suspension and may not reinstate operations without Department approval. The
following conditions shall be met upon suspension of operations due to natural
or human-induced disaster:
1) A
hospital shall submit written notification to the Department within 24 hours of
any suspension of hospital operations that extends beyond one day of operation.
2) A
hospital shall submit a description of the event, changes, and modifications to
the facility that occurred that required the suspension of hospital facility
operations or suspension of operations of units within the hospital facility.
At the time of the suspension of operations, the facility shall provide a
projected date for resumption of full services. The projected time frame for
the suspension must be consistent with the repairs or renovation required.
This information shall be provided in the written notification to the
Department required in subsection (o)(1).
3) The
facility shall submit progress reports to the Department regarding any changes
to the projected re-opening date from original submittal as requested by the
Department.
4) Upon
written notification to the Department that the hospital is in compliance with
all licensing requirements and ready to resume operations, and at the earliest
date available for Department surveyors, the Department will conduct an onsite
survey before a hospital reopens after a disaster impacting inpatient
operations. The Department will determine the need for an onsite survey on a
case-by-case basis for other affected operational services to confirm the
hospital is operationally safe and approved to resume those operations.
5) If
the hospital is not in compliance with the licensing requirements of the Act
and this Part, the Department may issue a provisional license pursuant to
subsection (l).
p) Notification of Closure of Hospital. The licensee shall
notify the Department of the impending closure of the hospital at least 90 days
prior to the closure. The hospital shall be responsible for the removal of
patients and their placement in other hospitals. The hospital shall implement
the policies for preservation of patient medical records and medical staff
credentialing files in accordance with Section 250.1510(d)(2) and Section
250.310(b)(16). Notification to the Department shall include the address (i.e.,
physical location) of all medical records and medical staff credentialing files
and a contact name, phone number, and email address for the keeper of the
medical records.
(Source: Amended at 47 Ill.
Reg. 14455, effective September 26, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.130 ADMINISTRATION BY THE DEPARTMENT
Section 250.130
Administration by the Department
a) Interpretation of Regulations
Nothing in this
Part shall be interpreted or used to impose any method of treatment or care
inconsistent with the creed or moral tenets of any religious denomination,
provided that the requirements as to personnel, building, equipment, space,
sanitation, food service, supplies, records, and fire safety are met.
b) Research Programs and/or Experimental Procedures
1) Definitions
A) Experimental procedures − means the use of medical,
surgical, manipulative, or psychiatric procedures, drugs, or devices for
purposes of diagnosis or treatment of human subjects who are inpatients or
outpatients of a hospital and who are subjects at risk.
B) Research program − means any organized activity intended
to establish new medical or scientific information, involving medical,
surgical, manipulative, or psychiatric diagnosis or treatment of human subjects
who are inpatients or outpatients of a hospital and who are subjects at risk.
C) Subject at risk − means any individual who may be exposed
to the possibility of injury, including physical, psychological, or social
injury, as a consequence of participation as a subject in any research,
development, or related activity that significantly departs from the
application of those established and accepted methods necessary to meet the
individual's needs, or that increases the ordinary risks of daily life,
including the recognized risks inherent in a chosen occupation or field of
service. (See 45 CFR 46.103(b).)
2) Entitlement to Conduct Research Programs and/or Experimental
Procedures. A licensed hospital may conduct research programs and/or
experimental procedures if the hospital meets any of the following:
A) The hospital is formally affiliated with, or is part of, a
school whose graduates are eligible for examination for licensing pursuant to
statutes, rules and regulations administered by the Department of Financial and
Professional Regulation and whose graduates, if licensed, are eligible for
admission to the medical staff, provided that the research programs and/or
experimental procedures are conducted on a service or within a department of
the hospital that is within the scope of the formal affiliation. Documentation
of that affiliation shall be available for inspection by the Department upon
reasonable request.
B) The hospital is conducting, or proposing to conduct, programs
subject to the provisions of 45 CFR 46.101, or pursuant to the provisions of
Title 21, Code of Federal Regulations. Documentation of approval of the
Secretary of the Department of Health and Human Services for these research
programs and/or experimental procedures shall be available for inspection by
the Department upon reasonable request.
C) The hospital has an Institutional Review Committee and has
complied with all requirements specified in subsection (b)(4).
3) Approval to Conduct Research Programs and/or Experimental
Procedures
A) Hospitals that meet the requirements of subsection (b)(2)(A) or
(b)(2)(B) may conduct approved research programs.
B) Hospitals that do not meet the requirements of subsection
(b)(2)(A) or (b)(2)(B) shall have an Institutional Review Committee as
described in subsection (b)(4).
4) Use of Institutional Review Committee to Approve Research
Programs and/or Experimental Procedures
A) The Committee shall be composed of not fewer than five persons
with varying backgrounds to assure complete and adequate review of activities
commonly conducted by the institution. The Committee shall be sufficiently qualified
through the maturity, experience, and expertise of its members and the diversity
of its membership to ensure respect for its advice and counsel for safeguarding
the rights and welfare of human subjects.
B) In addition to possessing the professional competence
necessary to review specific activities, the Committee shall be able to
ascertain the acceptability of applications and proposals in terms of
institutional commitments and regulations, applicable law, standards of
professional conduct and practice, and community attitudes. The Committee shall
therefore include persons whose concerns are in these areas. No member of a
Committee shall be involved in either the initial or continuing review of an
activity in which the member has a conflicting interest, except to provide
information requested by the Committee. No Committee shall consist entirely of
persons who are officers, employees, or agents of, or are otherwise associated
with, the institution, apart from their membership on the Committee. No
Committee shall consist entirely of members of a single professional group.
The quorum of the Committee shall be defined, but shall not be less than a
majority of the total membership, duly convened to carry out the Committee's
responsibilities.
C) The Institutional Review Committee shall develop a set of
implementation guidelines, including identification of the Committee and a
written description of its review procedures. At a minimum, the review
procedures shall provide for informed consent, which shall include provision to
the individual of an explanation of any procedures that are experimental, a
description of any discomforts and risks to be expected, alternative procedures
that might be advantageous, answers to any inquiries concerning the procedures,
and the opportunity to withdraw the individuals consent and discontinue in the
project at any time without prejudice.
D) The Institutional Review Committee shall review all
applications for research programs and/or experimental procedures within a
hospital and prepare a written report, following the implementation requirements
in subsection (b)(4)(C), to be given to the applicant on the acceptance or
rejection of the program. A copy of this report shall also be sent to the
Department within 30 days after completion of the written report. In addition,
minutes covering all activities shall be prepared and made available to the
Department. Complete copies of the minutes and reports shall be presented to
the hospital's governing authority. Records shall be retained for three years.
E) If the Department finds that the public interest, safety or
welfare requires emergency action, the Director, after appropriate medical
consultation and guidance, may issue to the applicant a notice not to proceed
with or continue (if initiated) the research program and/or experimental
procedure that is the subject of the application. The Director shall then
obtain further information and clarification regarding the research program
and/or experimental procedure that is the subject of the application and make a
final decision to approve or to disapprove the identified program and/or
procedure.
F) Failure to establish an Institutional Review Committee and/or
failure to utilize the Institutional Review Committee shall be considered a
violation of the Hospital Licensing Act.
c) Inspections
1) All hospitals to which these requirements apply shall be
subject to inspection by the Department, or by such other persons, including
full-time local health officers, as the Department may designate. The licensee
or person representing the licensee in the hospital shall provide the
representative of the Department with any requested hospital records, assist in
inspecting the premises, and secure information required by the Act or this
Part.
2) The Department shall make or cause to be made such inspections
and investigations as it deems necessary, except that, subject to
appropriation, the Department shall investigate every allegation of abuse of a
patient received by the Department. (Section 9 of the Act)
3) Hospitals are authorized to submit a copy of The Joint Commission
on Accreditation of Healthcare Organizations' (TJC), or Accreditation for
Health Care (ACHC), or DNV-Healthcare (DNV) survey report, certification and
accreditation, interim self-evaluation report and Plan of Correction to the
Department.
4) Information contained in reports of surveys made by TJC, ACHC
or DNV and information gained from reports of surveys or transmittals of
information from the various Divisions of the Department or other State agencies
may be used in determining the need for inspections for compliance with
licensing requirements. All reports provided to the Department for this
purpose shall be considered confidential information as provided in Section 9
of the Act.
d) Required Regulations
Hospitals
participating in the Medicare/Medicaid Programs shall comply with the
regulations of the Federal Department of Health and Human Services as set forth
in the Conditions of Participation for Hospitals (42 CFR 482).
(Source: Amended at 46 Ill.
Reg. 15597, effective September 1, 2022)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.140 HEARINGS
Section 250.140 Hearings
a) Denial, suspension or revocation of a permit
An application
for a permit may be denied, or a previously issued permit may be suspended or
revoked, if the Director finds that the applicant for a permit has failed to
comply with Section 6.(a) of the Act and/or the regulations promulgated and
published in Subpart A of these regulations.
b) Denial, suspension or revocation of a license
An application
for a license may be denied, or previously issued license may be suspended or
revoked for the following reasons:
1) The institution, place, building, or agency is determined not
to be a "hospital" within the meaning of the Act.
2) The institution, place, building, or agency is one
specifically excluded from the provisions of the Act.
3) There has been a substantial or continued failure to comply
with regulations.
c) Notice of denial, suspension, or revocation; opportunity for
hearing
1) Prior to any action to deny, suspend, or revoke a permit or a
license, the Department shall offer every reasonable assistance and
consultation. Meetings and discussions between the applicant or licensee and
the Department for this purpose shall be encouraged and shall not constitute
hearings.
2) Whenever an action is proposed to be taken to deny, suspend,
or revoke a permit or a license, the Department shall:
A) Present the matter to the Hospital Licensing Board for review
and recommendations.
B) Serve the applicant or licensee notice by registered mail or
personal service, stating the reasons for the proposed action and providing
opportunity for hearing not less than 15 days from the date of notice. The
date of notice shall be the date mailed or personally served.
C) On the basis of such hearing, or upon default of the applicant
or licensee, a decision regarding the proposed action shall be made. In case of
a denial to an applicant of a permit to establish a hospital, such
determination shall specify the subsection of Section 6 under which the permit
was denied and shall contain findings of fact forming the basis of such denial.
D) A copy of the decision shall be sent by registered mail to or
be served personally on the applicant or licensee and shall become final 35
days thereafter unless there is a petition for administrative review under the
provisions of the Administrative Review Act.
E) The detailed provisions regarding hearings as set forth in
Section 7 of the Act shall be followed.
d) Judicial Review
All final
administrative decisions of the Department regarding the denial, suspension or
revocation of a permit or license shall be subject to review in accordance with
the provisions of the Administrative Review Law (Ill. Rev. Stat. 1983, ch. 110,
pars. 3-101 et seq.).
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.150 DEFINITIONS (RENUMBERED)
Section 250.150 Definitions
(Renumbered)
(Source: Section 250.150 renumbered
to Section 250.100 at 38 Ill. Reg. 13280, effective June 10, 2014)
|
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.160 INCORPORATED AND REFERENCED MATERIALS (RENUMBERED)
Section 250.160 Incorporated
and Referenced Materials (Renumbered)
(Source: Section 250.160 renumbered
to Section 250.105 at 38 Ill. Reg. 13280, effective June 10, 2014)
|
SUBPART B: ADMINISTRATION AND PLANNING
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.210 THE GOVERNING BOARD
Section 250.210 The
Governing Board
a) Each hospital shall have a governing authority, called the
board, responsible for the organization, management, control and operation of
the hospital, including the appointment of the medical staff. For two or more
hospitals within a health care system, the system board may serve as the single
governing authority of each hospital (which shall be referred to as the
"system board"). When this option is exercised, the system board
shall be responsible for compliance with the medical staff requirements in the
Act and its regulations.
b) The board shall be organized in accordance with a written
constitution and bylaws that clearly set forth organization, duties, responsibilities
and relationships. The Department may require a copy for its files.
c) The board shall meet regularly. Monthly meetings are
recommended. Written reports of all meetings shall be maintained.
d) The board shall employ a competent executive officer or
administrator and vest him or her with authority and responsibility to carry
out its policies. A qualified individual shall be responsible to the
administrator in matters of administration and shall represent him or her during
the administrator's absence.
e) The board shall ensure the availability of competent, well
qualified personnel for all hospital departments in order to efficiently carry
out the functions of the hospital and meet patient care needs. The board shall
also provide a mechanism for assisting employees in addressing physical and
mental health problems.
f) The board shall be responsible for the maintenance of
standards of professional work in the hospital and shall require that the
medical staff function competently. Clinical audits shall be performed by the
medical staff and reviewed by a committee of the governing authority and the
medical staff. The board shall consult directly with the individual who is
responsible for the organization and conduct of the hospital's medical staff.
The direct consultation shall occur at least twice per year and shall include
discussion of matters related to the quality of medical care provided to the
patients of the hospital. For a hospital system using a system board, the
system board shall consult directly with the individual responsible for the
organized medical staff (or his or her designee) of each hospital within the
system. Direct consultation occurs when the governing body, or a subcommittee
of the governing body, meets with the leaders of the medical staffs, or their designee,
either face-to-face or via a telecommunications system that permits immediate,
synchronous communication.
g) The board shall establish a policy providing for the
investigation of unusual incidents that may occur. (Refer to Section 250.990.)
h) Two
or more separately licensed hospitals that are part of a hospital system with a
system board may elect to use the option of a unified medical staff,
conditioned upon acceptance by a majority vote of the medical staff members of
the participating hospitals. Members who hold privileges to practice at the
hospital shall vote in accordance with the medical staff bylaws. Nothing in
this Section shall be construed to require a unified medical staff for any
hospital.
1) The
system board shall be responsible for the decisions of the unified medical
staff and may direct the unified medical staff to consider any matter or
reconsider any decision. The system board shall take final action on all
medical staff matters, on behalf of the hospitals within the system that share
a unified medical staff, including, but not limited to:
A) The
appointment, reappointment and delineation of clinical privileges of the
medical staff;
B) The
denial or revocation of a medical staff appointment and the denial, revocation,
suspension, restriction or reduction of clinical privileges;
C) The
approval of bylaws and policies; and
D) The
maintenance of standards for professional work in the hospital and the review
of clinical audits, pursuant to subsection (f).
2) The
unified medical staff shall be considered a committee of a licensed hospital
for purposes of Section 8-2101 of the Code of Civil Procedure.
3) All
of the activities of the system board shall be in compliance with the medical
staff provisions of the Act and this Part.
4) If two or more hospitals within a hospital system designate a
system board, each hospital in the hospital system shall still individually
comply with the Act and this Part.
(Source: Amended at 41 Ill. Reg. 7154, effective June 12, 2017)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.220 ACCOUNTING
Section 250.220 Accounting
Accounting procedures shall be
carried out in accordance with a recognized system of hospital accounting and
should be adequate to permit satisfactory auditing. It is recommended that an
audit be performed at least annually by a qualified auditor independent of the
hospital.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.230 PLANNING
Section 250.230 Planning
a) Occupancy Control
1) Every hospital shall develop occupancy control measures and
participate in inter-hospital and community planning to meet medical and
hospital needs. Such planning shall include a continuing evaluation of the
hospital's facilities and services to make effective use of existing hospital,
nursing home and public health facilities and services, including community
home care services, and of developing new and/or additional services.
2) Every hospital shall enforce its occupancy control measures in
an effort to avoid over utilization of its facilities and services. Hospitals
experiencing a high level occupancy should, if other measures are inadequate,
develop hospital expansion plans in conjunction with recognized health facility
planning organizations within its area or region. Expansion programs must also
comply with Public Act 78-1156, the Illinois Health Facilities Planning Act, as
administered by the Health Facilities Planning Board. (Refer to Section
250.310 (a)(14))
b) Admission – Discharge
The hospital shall control its admission and discharge of
patients so that occupancy does not at any time exceed capacity, except in the
event of unusual emergency and then only as a temporary measure.
c) Admission – Discharge Control Committee
1) The hospital shall, if high-level occupancy is expected or
being experienced on any of its services or nursing units, activate a standing
committee which shall further scrutinize existing activities of utilization
review, admission, discharge, elective surgery and assure that patient census
will not exceed bed capacity.
2) The Medical staff, Hospital administration and the Nursing
service shall be represented on this committee.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.240 ADMISSION AND DISCHARGE
Section 250.240 Admission
and Discharge
a) Principle
The hospital
shall have written policies for the admission, discharge, and referral of all
patients who present themselves for care. Procedures shall assure appropriate
utilization of hospital resources such as preadmission testing, ambulatory care
programs, and short-term procedure units.
b) Referrals
A hospital
licensed under the Hospital Licensing Act may not refer a patient or the family
of a patient, or have an entity on a resource reference list for a patient
or the family of a patient, to a home health, home services, or home
nursing agency unless the agency is licensed under the Home Health, Home
Services, and Home Nursing Agency Licensing Act. (Section 3.8 of the Home
Health, Home Services, and Home Nursing Agency Licensing Act) A hospital shall
verify that an agency is currently on the Department's list of licensed home
health, home services, and home nursing agencies posted on the Department's
website or obtain a copy of an agency's license prior to making a referral to
that agency.
c) Access
1) All persons shall be admitted to the hospital, whether as
inpatients or under observation by a member of the medical staff with admitting
privileges, an advanced practice registered nurse, or a physician assistant
with clinical privileges recommended by the medical staff and granted by the
hospital governing board. All persons admitted to the hospital shall be under
the professional care of a member of the medical staff.
2) Insofar as possible, the hospital shall assign patients to
accommodations with regard to gender, age, and medical requirement.
3) The hospital shall provide basic and effective care to each
patient. No person seeking necessary medical care from the hospital shall be
denied care for reasons not based on sound medical practice or the hospital's
charter, and, particularly, no person shall be denied care on account of race,
creed, color, religion, gender, or sexual orientation.
4) When the hospital does not provide the services required by a
patient or a person seeking necessary medical care, an appropriate referral
shall be made.
d) Required Testing for All Admissions
1) The laboratory examinations required on all admissions shall
be determined by the medical staff and shall be consistent with the scope and
nature of the hospital. The required list or lists of tests shall be in
written form and shall be available to all members of the medical staff. The
required examinations shall be consistent with the requirements of this
subsection (d).
2) Uterine Cytologic Examination for Cancer
A) Every hospital shall offer a uterine cytologic examination
for cancer to every female inpatient 20 years of age or over, unless one of
the following conditions exists:
i) The examination is considered contra-indicated by
the attending physician; or
ii) The patient has had a uterine cytologic examination for
cancer performed within the previous year prior to the admission to the
hospital.
B) Every woman for whom the test is applicable shall have the
right to refuse such test on the counsel of the attending physician or on her
own judgment.
C) Patient records for all female inpatients 20 years of age or
older shall indicate one of the following:
i) The results of the test;
ii) The reasons that the test offer requirement was not
applicable as provided under subsection (d)(2)(A); or
iii) A statement that it was refused by the patient.
(Section 2310-540 of the Civil Administrative Code).
3) Testing for Infection with Human Immunodeficiency Virus (HIV)
A) The hospital shall offer testing for infection with human
immunodeficiency virus (HIV) to patients upon request.
B) The hospital shall ensure that pre-test and post-test
counseling is provided to the patient in accordance with the provisions of
the AIDS Confidentiality Act and the HIV/AIDS Confidentiality and Testing Code.
C) Testing that is performed under the Act and this Part shall
be subject to the provisions of the AIDS Confidentiality Act and the
HIV/AIDS Confidentiality and Testing Code. (Section 6.10 of the Act)
e) Discharge Notification
1) The
hospital shall develop a discharge plan of care for all patients who present
themselves to the hospital for care.
2) The
discharge plan shall be based on an assessment of the patient's needs by
various disciplines responsible for the patient's care.
3) When
a patient is discharged to another level of care, the hospital shall ensure
that the patient is being transferred to a facility that is capable of meeting
the patient's assessed needs.
4) A hospital’s discharge procedures shall include prohibitions
against discharging or referring a patient to any facility for further health
care services that is unlicensed, uncertified, or unregistered.
5) Whenever a patient who qualifies for the federal Medicare
program is hospitalized, the patient shall be notified of discharge at least 24
hours prior to discharge from the hospital. The notification shall be
provided by, or at the direction of, a physician with medical staff
privileges at the hospital or any appropriate medical staff member. The
notification shall include:
A) The anticipated date and time of discharge.
B) Written information concerning the patient's right to appeal
the discharge pursuant to the federal Medicare program, including the steps to
follow to appeal the discharge and the appropriate telephone number to call if
the patient intends to appeal the discharge. This written information does
not need to be included in the notification, if it has already been provided to
the patient. (Section 6.09 of the Act)
6) Every hospital shall develop and implement
policies and procedures to provide the discharge notice required in
subsection (e)(5). The policies and procedures may also include a waiver
of the notification requirement in either or both of the following cases:
A) When a discharge notice is not feasible due to a short
length of stay in the hospital by the patient. The hospital policy shall
specify the length of stay when discharge notification will not be considered
feasible.
B) When the patient voluntarily desires to leave the hospital
before the expiration of the 24 hour period. (Section 6.09 of the Act)
7) When
a facility-provided medication is ordered at least 24 hours in advance for
surgical procedures and is administered to a patient at a hospital, any unused
portion of the facility-provided medication shall be offered to the
patient upon discharge when it is required for continuous treatment.
A) A
facility-provided medication shall be labeled consistent with labeling
requirements under Section 22 of the Pharmacy Practice Act.
B) If
the facility-provided medication is used in an operating room or emergency
department setting, the prescriber is responsible for counseling the patient on
its proper use and administration and the requirement of pharmacist counseling
is waived. (Section 6.28 of the Act)
C) For
the purposes of this Section, “facility-provided medication” means any
topical antibiotic, anti-inflammatory, dilation, or glaucoma drop or ointment
(Section 15.10 of the Pharmacy Practice Act)
f) Patient
Notice of Observation Status. Within 24 hours after a patient's placement into
observation status by a hospital, the hospital shall provide that patient with
an oral and written notice that the patient is not admitted to the hospital and
is under observation status. The written notice shall be signed by the patient
or the patient's legal representative to acknowledge receipt of the written
notice and shall include, but not be limited to, the following information:
1) A
statement that observation status may affect coverage under the federal
Medicare program, the medical assistance program under Article V of the
Illinois Public Aid Code, or the patient's insurance policy for the current
hospital services, including medications and other pharmaceutical supplies, as
well as coverage for any subsequent discharge to a skilled nursing facility or
for home and community based care; and
2) A
statement that the patient should contact his or her insurance provider to
better understand the implications of being placed into observation status.
(Section 6.09b of the Act)
g) The
hospital shall develop a written policy for cases in which a patient in
observation status is incapacitated and attempts to contact the patient's legal
representative within 24 hours pursuant to subsection (f) have been
unsuccessful. The hospital shall document all attempts to contact the patient's
legal representative.
h) Background
Checks for Patients Transferring to a Long-Term Care Facility
1) Before
transfer of a patient to a long term care facility licensed under the Nursing
Home Care Act where elderly persons reside, a hospital shall as soon as
practicable initiate a name-based criminal history background check by
electronic submission to the Department of State Police for all persons between
the ages of 18 and 70 years; provided, however, that a hospital shall be
required to initiate such a background check only with respect to patients who:
A) are
transferring to a long term care facility for the first time;
B) have
been in the hospital more than 5 days;
C) are
reasonably expected to remain at the long term care facility for more than 30
days;
D) have
a known history of serious mental illness or substance abuse; and
E) are
independently ambulatory or mobile for more than a temporary period of time.
2) A
hospital may also request a criminal history background check for a patient who
does not meet any of the criteria set forth in subsections (h)(1)(A)
through (E).
3) A
hospital shall notify a long term care facility if the hospital has initiated a
criminal history background check on a patient being discharged to that
facility. In all circumstances in which the hospital is required by this
subsection (h) to initiate the criminal history background check, the
transfer to the long term care facility may proceed regardless of the
availability of criminal history results.
4) Upon
receipt of the results, the hospital shall promptly forward the results to the
appropriate long term care facility. If the results of the background check
are inconclusive, the hospital shall have no additional duty or obligation to seek
additional information from, or about, the patient. (Section 6.09(d) of the
Act)
(Source: Amended at 47 Ill. Reg. 14455,
effective September 26, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.245 FAILURE TO INITIATE CRIMINAL BACKGROUND CHECKS
Section 250.245 Failure to Initiate Criminal Background
Checks
The Department may impose fines on hospitals, not to
exceed $500 per occurrence, for failing to initiate a criminal background check
on a patient that meets the criteria for hospital-initiated background checks.
In assessing whether to impose such a fine, the Department shall consider
various factors including, but not limited to, whether the hospital has engaged
in a pattern or practice of failing to initiate criminal background checks.
Money from fines will be deposited into the Long Term Care Provider Fund.
(Section 7(a) of the Act)
(Source: Added at 35 Ill.
Reg. 13875, effective August 1, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.250 VISITING RULES
Section 250.250 Visiting
Rules
a) Each hospital shall establish, in the interest of the patient,
policies regarding visitation on the various services and departments of the
hospital. It is recommended that visitors be limited to two per patient at any
one time.
b) In times of increased incidence of communicable disease in the
community, the hospital should consult with the local health officer regarding
further restriction of visitors.
c) Hospitals shall implement and comply with Section 3.2 of the
Medical Patient Rights Act regarding visitation rights, policies, and
procedures. Hospitals shall develop policies and procedures to address
visitation when a disaster exists or in the event of an outbreak or epidemic of
communicable disease.
d) 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.
e) Children
1) Children under 12 years of age should not be admitted as
visitors to the hospital except in the company of a responsible adult.
2) Children under six years of age should be admitted as visitors
only when the hospital has a special family visiting program or when requested
in writing by the attending physician or chief executive officer of the
hospital. Visiting facilities other than the patient's room shall be used for
children under six years of age, unless that room is a private room.
f) No lay visitor shall be given access to the operating rooms
during surgery, except as provided in Section 250.1305 or Section 250.1860(a).
g) See Section 250.1830(k) for visiting regulations applicable to
maternity departments and newborn nurseries.
h) Smoking by visitors shall be prohibited except in specially
designated outside areas.
i) No visitors shall be permitted in the postoperative recovery
room.
j) No birds, turtles, dogs, cats, or other animals (exclusive of
those required for laboratory purposes or for animal-assisted therapy in
accordance with Section 250.890) shall be allowed in a medical facility, except
as provided in this subsection (j). Guide dogs may accompany sightless
persons. When animals are allowed in the hospital, the hospital shall have
policies for infection control, sanitation, care of the animals, and any
necessary patient screening. The policies shall be followed and shall comply
with the requirements concerning animals in the Department's Food Code.
(Source: Amended at 47 Ill.
Reg. 6477, effective April 27, 2023)
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.260 PATIENTS' RIGHTS
Section 250.260 Patients'
Rights
a) Policy on Patients' Rights
1) Hospitals shall adopt a written policy on patients' rights.
2) This policy shall be available to all patients and personnel
upon request.
b) Patient Morale
1) Emotional and Attitudinal Support
Hospitals
shall have a written plan for the provision of those components of total
patient care that relate to the spiritual, emotional and attitudinal health of
the patient, patients' families and hospital personnel.
2) Social Services
Hospitals
shall have a written plan for providing social services. This service may be
provided through:
A) An organized social service within the hospital; or
B) A social worker employed on a part-time basis; or
C) Social work consultant services from a community agency.
c) Patient
Protection from Abuse
1) For purposes of this
subsection (c):
Abuse – means any physical or
mental injury or sexual abuse intentionally inflicted by a hospital or hospital
affiliate employee, agent, or medical staff member on a patient of the hospital
or hospital affiliate and does not include any hospital or hospital affiliate,
medical, health care, or other personal care services done in good faith in the
interest of the patient according to established medical and clinical standards
of care.
Hospital affiliate – means a
corporation, partnership, joint venture, limited liability company, or similar
organization, other than a hospital, that is devoted primarily to the
provision, management, or support of health care services and that directly or
indirectly controls, is controlled by, or is under common control of the
hospital. For the purposes of this definition, "control" means
having at least an equal or a majority ownership or membership interest. A
hospital affiliate shall be 100% owned or controlled by any combination of
hospitals, their parent corporations, or physicians licensed to practice
medicine in all its branches in Illinois. "Hospital affiliate" does
not include a health maintenance organization regulated under the Health
Maintenance Organization Act. (Section 10.8(b) of the Act)
Mental Injury – means
intentionally caused emotional distress in a patient from words or gestures
that would be considered by a reasonable person to be humiliating, harassing,
or threatening and which causes observable and substantial impairment.
Sexual Abuse – means any intentional
act of sexual contact or sexual penetration of a patient in the hospital.
Substantiated – with respect to
a report of abuse, means that a preponderance of the evidence indicates that
abuse occurred.
2) No
administrator, agent, or employee of a hospital or a hospital affiliate or a
member of a hospitals' medical staff may abuse a patient in the hospital or in
a facility operated by a hospital affiliate.
3) Any
hospital administrator, agent, employee, or medical staff member, or an
administrator, employee, or physician employed by a hospital affiliate, who has
reasonable cause to believe that any patient with whom he or she has direct
contact has been subjected to abuse in the hospital or hospital affiliate shall
promptly report or cause a report to be made to a designated hospital
administrator responsible for providing such reports to the Department as
required by this subsection (c).
4) Retaliation
against a person who lawfully and in good faith makes a report under this subsection
(c) is prohibited.
5) Upon
receiving a report under subsection (c)(3), the hospital or hospital
affiliate shall submit the report to the Department within 24 hours after
obtaining such report. In the event that the hospital receives multiple
reports involving a single alleged instance of abuse, the hospital shall submit
one report to the Department.
6) Upon
receiving a report under this subsection (c), the hospital or hospital
affiliate shall promptly conduct an internal review to ensure the alleged
victim's safety. Measures to protect the alleged victim shall be taken as
deemed necessary by the hospital's administrator and shall include, but
are not limited to, removing suspected violators from further patient contact
during the hospital's or hospital affiliate's internal review. If the alleged
victim lacks decision-making capacity under the Health Care Surrogate Act and
no health care surrogate is available, the hospital or hospital affiliate may
contact the Illinois Guardianship and Advocacy Commission to determine the need
for a temporary guardian of that person.
7) All
internal hospital and hospital affiliate reviews shall be conducted by a
designated employee or agent who is qualified to detect abuse and is not
involved in the alleged victim's treatment. All internal review findings shall
be documented and filed according to hospital or hospital affiliate procedures
and shall be made available to the Department upon request.
8) Any
other person may make a report of patient abuse to the Department if that
person has reasonable cause to believe that a patient has been abused in the
hospital or hospital affiliate.
9) The
report required under this subsection (c) shall include:
A) The
name of the patient;
B) The
name and address of the hospital or hospital affiliate treating the patient;
C) The
age of the patient;
D) The
nature of the patient's condition, including any evidence of previous injuries
or disabilities;
E) Any
other information that the reporter believes might be helpful in establishing
the cause of the reported abuse and the identity of the person believed to have
caused the abuse;
F) The
date of the alleged abuse incident and the date the hospital or hospital
affiliate was notified; and
G) A
description of the alleged abuse.
10) Except
for willful or wanton misconduct, any individual, person, institution, or
agency participating in good faith in making a report under this subsection
(c), or in the investigation of such a report or in making a disclosure of
information concerning reports of abuse under this subsection (c), shall
have immunity from any liability, whether civil, professional, or criminal,
that otherwise might result by reason of such actions. For the purpose of any
proceedings, whether civil, professional, or criminal, the good faith of any
persons required to report cases of suspected abuse under this subsection
(c) or who disclose information concerning reports of abuse in compliance
with this subsection (c) shall be presumed.
11) No
administrator, agent, or employee of a hospital or hospital affiliate shall
adopt or employ practices or procedures designed to discourage or having
the effect of discouraging good faith reporting of patient abuse under this subsection
(c).
12) Every
hospital or hospital affiliate shall ensure that all new and existing employees
are trained in the detection and reporting of abuse of patients and retrained
at least every 2 years thereafter.
13) The
Department will investigate each report of patient abuse made under this
subsection (c) according to the procedures of the Department, except
that a report of abuse which indicates that a patient's life or safety is in
imminent danger shall be investigated within 24 hours after such
report. Under no circumstances may a hospital's or hospital affiliate's internal
review of an allegation of abuse replace an investigation of the allegation by
the Department.
14) The
Department will keep a continuing record of all reports made pursuant to
this subsection (c), including indications of the final determination of
any investigation and the final disposition of all reports. The Department will
inform the investigated hospital or hospital affiliate and any other person
making a report under subsection (c)(8) of this Section of its final
determination or disposition in writing.
15) All
patient identifiable information in any report or investigation under this subsection
(c) shall be confidential and shall not be disclosed except as authorized by
the Act or other applicable law.
16) Nothing
in this subsection (c) relieves a hospital or hospital affiliate administrator,
employee, agent, or medical staff member from contacting appropriate law
enforcement authorities as required by law.
17) Nothing
in this subsection (c) shall be construed to mean that a patient is a
victim of abuse because of health care services provided or not provided by
health care professionals.
18) Nothing
in this subsection (c) shall require a hospital or hospital affiliate,
including its employees, agents, and medical staff members, to provide any
services to a patient in contravention of his or her stated or implied
objection thereto upon grounds that such services conflict with his or her
religious beliefs or practices, nor shall such a patient be considered abused
under this Section for the exercise of such beliefs or practices. (Section
9.6 of the Act)
d) Patient Discrimination
1) Discrimination Grievance Procedures. Upon receipt of a
grievance alleging unlawful discrimination on the basis of race, color, or national
origin, the hospital must investigate the claim and work with the patient to
address valid or proven concerns in accordance with the hospital's grievance
process. At the conclusion of the hospital's grievance process, the hospital
shall inform the patient that such grievances may be reported to the Department
if not resolved to the patient's satisfaction at the hospital level.
(Section 5.1 of the Medical Patient Rights Act)
2) Emergency Room Anti-discrimination Notice. Every hospital
shall post, either by physical or electronic means, a sign next to or in close
proximity of its sign required by 42 CFR 489.20(q)(1) stating the
following: "You have the right not to be discriminated against by the
hospital due to your race, color, or national origin if these characteristics
are unrelated to your diagnosis or treatment. If you believe this right has
been violated, please call the Illinois Department of Public Health Central
Complaint Registry, 1-800-252-4343." (Section 5.2 of the Medical Patient
Rights Act)
e) In compliance with Section 3.4 of the Medical Patient Rights
Act, every hospital shall post information about the rights
listed in Section 3.4 of the Medical Patient Rights Act in a prominent place
(physical or electronic) and on their websites. The postings in the
hospital and on the hospital's website shall include the web address of the
Department's posting of this information, http://www.dph.illinois.gov/topics-services/health-care-regulation/facilities/hospitals.
(Section 3.4(b) of the Medical Patient Rights Act)
(Source: Amended at 49 Ill. Reg. 11475,
effective August 26, 2025)
|
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.265 LANGUAGE ASSISTANCE SERVICES
Section 250.265 Language
Assistance Services
The hospital shall comply with the Language Assistance
Services Act [210 ILCS 87] and the Language Assistance Services Code (77 Ill.
Adm. Code 940).
(Source: Amended at 29 Ill. Reg. 12489,
effective July 27, 2005)
|
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.270 MANUALS OF PROCEDURE
Section 250.270 Manuals of
Procedure
a) It is recommended that the hospital administrator, in
cooperation with the medical staff and the respective department heads,
formulate manuals of procedure so that technics and departmental relationships
may be systematized and standardized.
b) Where appropriate these manuals shall contain a statement of
policy and procedure regarding routine laboratory and x-ray examinations.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.280 AGREEMENT WITH DESIGNATED ORGAN PROCUREMENT AGENCIES
Section 250.280 Agreement
with Designated Organ Procurement Agencies
a) Each hospital shall have an agreement with its federally
designated organ procurement agency providing for notification of the organ
procurement agency when potential organ donors become available, as required in
Section 2 of the Organ Donation Request Act [755 ILCS 60]. (Section 6.16
of the Act)
b) Each hospital shall provide its federally designated organ
procurement agency and any tissue bank with which it has an agreement with
access to the medical records of deceased patients for the following purposes:
1) estimating the hospital's organ and tissue donation
potential;
2) identifying the educational needs of the hospital with
respect to organ and tissue donation; and
3) identifying the number of organ and tissue donations and
referrals to potential organ and tissue donors. (Section 6.17(a) of the
Act)
c) All hospital and patient information, interviews, reports,
statements, memoranda, and other data obtained or created by a tissue bank or
federally designated organ procurement agency from the medical records review
in subsection (b) of this Section shall be privileged, strictly
confidential, and used only for the purpose put forth in subsection (b) of
this Section and shall not be admissible as evidence nor discoverable in
an action of any kind of court or before a tribunal, board, agency, or person.
(Section 6.17(b) of the Act)
d) Any person who, in good faith, acts in accordance with the
terms of this Section shall not be subject to any type of civil or criminal
liability or discipline for unprofessional conduct for those actions.
(Section 6.17(c) of the Act)
(Source: Added at 20 Ill. Reg. 10009, effective July 15, 1996)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.285 SMOKING RESTRICTIONS
Section
250.285 Smoking Restrictions
The hospital
shall comply with the Smoke Free Illinois Act [410 ILCS 82].
(Source: Added at 34 Ill.
Reg. 19031, effective November 17, 2010)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.290 SAFETY ALERT NOTIFICATIONS
Section 250.290 Safety Alert
Notifications
a) Each
hospital shall subscribe to the free e-mail notification services of the U.S.
Food and Drug Administration and the U.S. Centers for Disease Control and
Prevention.
1) FDA:
MedWatch E-List , which can be accessed at www.fda.gov/Safety/MedWatch/default.htm;
and
2) CDC:
Clinician Outreach and Communication Activity (COCA), which can be accessed at
http://emergency.cdc.gov/coca/. COCA updates and clinical reminders may be
requested by sending an email to coca@cdc.gov.
b) Actions in response to
these notifications shall be taken promptly.
(Source: Amended at 39 Ill.
Reg. 13041, effective September 3, 2015)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.295 NOTIFICATION AND POSTING REQUIREMENTS
Section 250.295 Notification and Posting Requirements
Hospitals shall comply with all hospital notification and
posting requirements, by physical or electronic means, of the following Acts:
a) Section
6.14(c) of the Hospital Licensing Act, related to the hospital's license,
complaint procedures, Department or court orders, and other materials available
for public inspection under Section 6.14(d) of the Act;
b) Section
4-4 of the Illinois Health Finance Reform Act, related to established charges
for services;
c) Section 15 of the Fair
Patient Billing Act, related to patient financial assistance;
d) Section
3.4 of the Medical Patient Rights Act, related to the rights of women with
regard to pregnancy and childbirth;
e) Section
5.1(a) of the Crime Victims Compensation Act, related to posters, provided by
the Attorney General, regarding the existence of the Crime Victims Compensation
Act and its provisions;
f) Sections
5 and 10 of the Human Trafficking Resource Center Notice Act, related to the
requirements of the Human Trafficking Resource Center Notice Act as provided in
the model notice; and
g) Section
22 of the Abandoned Newborn Infant Protect Act, related to relinquishing a
newborn infant.
(Source: Added at 46 Ill. Reg. 15597,
effective September 1, 2022)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.300 AT-HOME PATIENT CARE WAIVERS
Section 250.300 At-Home
Patient Care Waivers
a) To
adequately respond to COVID-19, a hospital may apply to the Centers for
Medicare and Medicaid Services (CMMS) for an Acute Hospital Care at Home waiver
from the requirements of 42 CFR 482.23(b) and (b)(1) to provide limited
inpatient services directly in a patient’s home. The waiver application may be
found at https://qualitynet.cms.gov/acute-hospital-care-at-home.
b) A
participating hospital with an approved waiver from the Centers for Medicare
and Medicaid Services (CMMS) shall provide the Department with the following:
1) A copy of the
CMMS-approved Medicare waiver;
2) A
copy of the participating hospital’s screening protocol to determine patient
eligibility for the at-home, inpatient services; and
3) A
copy of the participating hospital's policy and procedures for clinical
management of inpatients at home.
c) The
Department will conduct any complaint investigation, survey, or inspection of
the participating hospital, request any documentation, and require corrective
action pursuant to its State licensure authority under the Hospital Licensing
Act and this Part.
d) A
participating hospital also shall meet the following requirements:
1) Provide
safe and quality care to each patient in the patient's home;
2) Prohibit
all abuse of a patient by an administrator, agent, employee, or member of its
medical staff and, in addition, comply with the abuse and neglect reporting
requirements of Section 250.260 for suspected occurrences;
3) Ensure
access to health care information and services for limited English-speaking or
non-English speaking patients, in compliance with Section 250.265;
4) Administer
no medication, treatment, or diagnostic test to a patient except on a written
or verbal order, if necessary, by a licensed medical professional acting within
the professional's scope of practice;
5) Ensure
nursing services are under the direction of a registered nurse who has
qualifications in nursing administration;
6) Maintain
an adequate, timely, and complete medical record for each patient receiving
at-home care in compliance with Section 250.1510;
7) Comply
with incident reporting requirements in Section 250.1520(f);
8) Ensure
all drugs and medicines are stored and dispensed in compliance with Section
250.2110(f) and (g); and
9) Comply
with State law or rule related to COVID-19 diagnosis and treatment from the
Department or other State agencies.
(Source: Added at 48 Ill. Reg. 2516,
effective January 30, 2024)
SUBPART C: THE MEDICAL STAFF
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.310 ORGANIZATION
Section 250.310 Organization
a) For the purposes of this Section only:
1) Adverse Decision − means a decision reducing,
restricting, suspending, revoking, denying, or not renewing medical staff
membership or clinical privileges. (Section 10.4(b) of the Act)
2) A Distant-site Hospital − means an Illinois licensed
hospital or a Medicare participating hospital.
3) A Distant-site Telemedicine Entity – means an entity
consisting of a group of licensed physicians that:
A) Provides telemedicine services;
B) Is not a Medicare-participating hospital; and
C) Provides contracted services in a manner that enables a
hospital using its services to meet all applicable Medicare conditions of
participation, particularly those requirements related to the credentialing and
privileging of practitioners providing telemedicine services to the patients of
a hospital. A distant-site telemedicine entity would include a distant-site
hospital that does not participate in the Medicare program that is providing
telemedicine services to a Medicare-participating hospital.
4) Economic Factor − means any information or reasons
for decisions unrelated to quality of care or professional competency.
(Section 10.4(b) of the Act)
5) Non-simultaneously − means that, while the telemedicine
physician or practitioner still provides clinical services to the patient upon
a formal request from the patient's attending physician, these services may,
for example, involve after-the-fact interpretation of diagnostic tests,
consultations between a physician or practitioner and a person outside the
State of Illinois, or second opinions provided to an Illinois-licensed
physician or practitioner in order to provide an assessment of the patient's
condition and do not necessarily require the telemedicine practitioner to
directly assess the patient in real time or establish a provider-to-patient
relationship or interaction. An example of after-the-fact interpretation of
diagnostic tests would be similar to the services provided by an on-site
radiologist who interprets a patient's x-ray or CT scan and then communicates the
assessment to the patient's attending physician who then bases a diagnosis and
treatment plan on these findings.
6) Privilege − means permission to provide medical or
other patient care services and permission to use hospital resources, including
equipment, facilities and personnel that are necessary to effectively provide
medical or other patient care services. This definition shall not be construed
to require a hospital to acquire additional equipment, facilities, or personnel
to accommodate the granting of privileges. (Section 10.4(b) of the Act)
7) Simultaneously − means that the clinical services (for
example, assessment of the patient with a clinical plan for treatment,
including any medical orders needed) are provided to the patient in real time
by the telemedicine physician or practitioner, similar to the actions of an
on-site physician or practitioner.
8) Telemedicine − means the provision of clinical services
to patients by physicians or practitioners remotely via electronic
communications. The distant-site telemedicine physician or practitioner
provides clinical services to the hospital patient either simultaneously, as is
often the case with teleICU services, for example, or non-simultaneously, as
may be the case with many teleradiology services. Telemedicine may also
include provider-to-provider consultations between Illinois-licensed physicians
or practitioners and physicians or practitioners licensed in the United States.
b) The
medical staff shall be organized in accordance with written bylaws, rules and
regulations approved by the governing board. The bylaws, rules and regulations
shall specifically provide, but are not limited to:
1) establishing
written procedures relating to the acceptance and processing of initial
applications for medical staff membership, granting and denying of medical
staff reappointment, and medical staff membership or clinical privileges
disciplinary matters in accordance with subsection (e) for county hospitals as
defined in Section 15-1(c) of the Illinois Public Aid Code, or subsection (f)
for all other hospitals. The procedures for initial applicants at any
particular hospital may differ from those for current medical staff members. However,
the procedures at any particular hospital shall be applied equally to each
practitioner eligible for medical staff membership as defined in Section 250.100.
The procedures shall provide that, prior to the granting of any medical
staff privileges to an applicant, or renewing a current medical staff member's
privileges, the hospital shall request of the Director of the Department
of Financial and Professional Regulation information concerning the licensure
status, proper credentials, required certificates, and any disciplinary action
taken against the applicant's or medical staff member's license. This
provision shall not apply to medical personnel who enter a hospital to
obtain organs and tissues for transplant from a deceased donor in accordance
with the Illinois Anatomical Gift Act. This provision shall not apply to medical
personnel who have been granted disaster privileges pursuant to the procedures
and requirements established in this Section. (Section 10.4(a) of the
Act);
2) identifying
divisions and departments as are warranted (as a minimum, active and consulting
divisions are required);
3) identifying
officers as are warranted;
4) establishing
committees as are warranted to assure the responsibility for functions such as
pharmacy and therapeutics, infection control, utilization review, patient care
evaluation, and the maintenance of complete medical records;
5) assuring
that active medical staff meetings are held regularly, and that written minutes
of all meetings are kept;
6) reviewing
and analyzing the clinical experience of the hospital at regular intervals −
the medical records of patients to be the basis for review and analysis;
7) identifying
conditions or situations that require consultation, including consultation
between medical staff members in complicated cases;
8) examining
tissue removed during operations by a qualified pathologist and requiring that
the findings are made a part of the patient's medical record;
9) keeping
completed medical records;
10) maintaining
a Utilization Review Plan, which shall be in accordance with the Conditions of
Participation for Hospitals;
11) establishing
Medical Care Evaluation Studies;
12) establishing
policies requiring a physician as first assistant to major or hazardous
surgery, including written criteria to determine when an assistant is
necessary;
13) assuring,
through credentialing by the medical staff, that a qualified surgical
assistant, whether a physician or non-physician, assists the operating surgeon
in the operating room;
14) determining
additional privileges that may be granted a staff member for the use of the
staff member's employed allied health personnel in the hospital in accordance
with policies and procedures recommended by the medical staff and approved by
the governing body. The policies and procedures shall include, at least,
requirements that the staff member requesting this additional privilege shall
submit the following for review and approval by the medical staff and the
governing body of the hospital:
A) a
curriculum vitae of the identified allied health personnel, and
B) a
written protocol with a description of the duties, assignments and functions,
including a description of the manner of performance within the hospital by the
allied health personnel in relationship with other hospital staff;
15) establishing
a mechanism for assisting medical staff members in addressing physical and
mental health problems;
16) implementing
a procedure for preserving medical staff credentialing files in the event of
the closure of the hospital;
17) establishing a procedure for granting telemedicine
privileges, based upon the privileging decisions of a distant-site hospital or
telemedicine entity that has a written agreement that meets Medicare
requirements; and
18) establishing
a procedure for granting disaster privileges.
A) When
the emergency management plan has been activated and the hospital is unable to
handle patients' immediate needs, it shall:
i) identify
in writing the individuals responsible for granting disaster privileges;
ii) describe
in writing the responsibilities of the individuals granting disaster
privileges. The responsible individual is not required to grant privileges to
any individual and is expected to make decisions on a case-by-case basis at his
or her discretion;
iii) describe
in writing a mechanism to manage individuals who receive disaster privileges;
iv) include
a mechanism to allow staff to readily identify individuals who receive disaster
privileges;
v) require
that medical staff address the verification process as a high priority and
begin the verification process of the credentials and privileges of individuals
who receive disaster privileges as soon as the immediate situation is under
control.
B) The
individual responsible for granting disaster privileges may grant disaster
privileges upon presentation of any of the following:
i) a
current picture hospital ID card;
ii) a
current license to practice and a valid picture ID issued by a state, federal
or regulatory agency;
iii) identification
indicating that the individual is a member of a Disaster Medical Assistance
Team (DMAT) or an Illinois Medical Emergency Response Team (IMERT);
iv) identification
indicating that the individual has been granted authority to render patient
care, treatment and services in disaster circumstances (authority having been
granted by a federal, state or municipal entity); or
v) presentation
by current hospital or medical staff members with personal knowledge regarding
practitioner's identity.
C) Any
hospital and any employees of the hospital or others involved in granting
privileges who, in good faith, grant disaster privileges, pursuant to Section
10.4 of the Act, to respond to an emergency shall not, as a result of their
acts or omissions, be liable for civil damages for granting or denying disaster
privileges except in the event of willful and wanton misconduct, as that term
is defined in Section 10.2 of the Act.
D) Individuals
granted privileges who provide care in an emergency situation, in good faith
and without direct compensation, shall not, as a result of their acts or
omissions, except for acts or omissions involving willful and wanton
misconduct, as that term is defined in Section 10.2 of the Act, on the
part of the person, be liable for civil damages. (Section 10.4 of the Act)
c) General
Acute or Critical Access Hospitals without a licensed pediatric unit or board
certified or board eligible pediatrician in the hospital or on call 24 hours a
day, 7 days a week that provide limited inpatient or observation services to
pediatric patients (neonate (less than 28 days of age) to 14 years old):
1) Shall
have a written agreement with a children’s hospital or hospital with a licensed
pediatric unit. The agreement shall include provider-to-patient and/or
provider-to-provider consultations that meet the telemedicine requirements
provided in subsections (a)(2) through (a)(8) remotely via electronic
communications, whether synchronous or asynchronous, and specify other
information including communication frequency, equipment, education, transfers,
case reviews, and critical criteria for emergency transfers;
2) Must
have an agreement with one primary hospital, for the purposes of continuing
education and consultation, but are encouraged to have agreements with multiple
hospitals, in order to ensure options when a transfer is warranted but
restricted from accommodation due to primary hospital census or family
preference;
3) May
have agreements with out-of-state hospitals who have agreements with the
Department under the Regionalized Perinatal Health Care Code (77 Ill. Adm. Code
640) and designated as a trauma center by the Department in accordance with
Section 3.90 of the Emergency Medical Services (EMS) Systems Act;
4) May
include a fee for provider-to-patient and/or provider-to-provider consultations
with the consulting hospital in the written agreement, but the fee may not be
transferred to the patient;
5) Shall
have until June 1, 2024 to enter into an agreement, or amend an existing
agreement, as required in this subsection (c);
6) Shall
consult with the children’s hospital or hospital with licensed pediatric unit
prior to the patient being moved to a medical/surgical unit from either the
emergency department or post-operative procedure unit. In cases where the
consultation cannot occur prior to the move, the consultation must occur within
one hour after the patient has been placed on the medical/surgical unit as an
inpatient or in observation status. The frequency of the consultations during
the pediatric patient’s stay shall be determined by the health care provider
and shall continue until the patient is discharged or transferred;
7) Shall
maintain a record of the consultation in the pediatric patient’s medical file;
8) Shall
report pediatric services provided pursuant to the requirements of this
subsection (c) to the Department quarterly as required by Section 250.1520(i);
and
9) Shall
not require providers who give provider-to-provider consultations to be
privileged at the hospital where the patient is receiving treatment.
d) If a
hospital is part of a hospital system consisting of two or more separately
licensed hospitals, and the system elects to have a unified, integrated medical
staff for its separately licensed member hospitals, each separately licensed
hospital shall permit the medical staff members of each separately licensed hospital
in the system (in other words, all medical staff members who hold specific
privileges to practice at that hospital) to vote, in accordance with medical
staff bylaws, whether to accept a unified, integrated medical staff structure
or to maintain a separate and distinct medical staff for their respective
licensed hospital.
1) If
the medical staffs of the separately licensed hospitals vote to accept an
integrated, unified medical staff structure, they shall meet the following
conditions:
A) Adopt
written bylaws, rules and requirements that describe the processes for
self-governance, appointment, credentialing, privileging and oversight, as well
as peer review policies and due process rights guarantees, including a process
for the members of the medical staff of each separately licensed hospital to be
advised of their rights to opt out of the unified and integrated medical staff
structure after a majority vote by the members to maintain a separate and
distinct medical staff for their hospital;
B) Take
into account each member hospital's unique circumstances and any significant
differences in patient populations and services offered in each hospital; and
C) Establish
and implement written policies and procedures, including meetings that shall occur
at least twice per fiscal or calendar year, to ensure that the needs and
concerns expressed by members of the medical staffs at each separately licensed
hospital, regardless of practice or location, are given due consideration, and
that the unified, integrated medical staff has mechanisms in place to ensure
that issues localized to particular hospitals are considered and addressed.
2) The
unified, integrated medical staff shall be organized in accordance with the
Conditions of Participation for Hospitals related to medical staff.
3) Medical
staffs may vote, no more than every two years, whether to remain or discontinue
as an integrated, unified medical staff.
4) This
subsection (d) shall not apply to hospitals that are required to have a
unified, integrated medical staff under 42 CFR 413.65(d) and (e) as being a
multi-campus hospital under one Medicare certification number.
e) The
medical staff bylaws for county hospitals as defined in Section 15-1(c) of the
Illinois Public Aid Code shall include at least the following:
1) The
procedures relating to evaluating individuals for staff membership, whether the
practitioners are or are not currently members of the medical staff, shall
include procedures for determining qualifications and privileges; criteria for evaluating
qualifications; and procedures requiring information about current health
status, current license status in Illinois, and biennial review of renewed
license.
2) Written procedures that allow the medical staff to rely upon
the credentialing and privileging decisions of a distant-site hospital or
telemedicine entity as an option for recommending the privileging of
telemedicine physicians.
3) The
procedure shall grant to current medical staff members at least: written notice
of an adverse decision by the governing board; an explanation and reasons for
an adverse decision; the right to examine and/or present copies of relevant
information, if any, related to an adverse decision; an opportunity to appeal
an adverse decision; and written notice of the decision resulting from the
appeal. The procedures for providing written notice shall include timeframes
for giving notice.
f) The medical staff bylaws for all hospitals except county hospitals
shall include at least the following provisions for granting,
limiting, renewing, or denying medical staff membership and clinical staff
privileges:
1) Minimum procedures for pre-applicants or applicants for
medical staff membership, including the following:
A) Written procedures relating to the acceptance and processing
of pre-applicants or applicants for medical staff membership.
B) Written procedures to be followed in determining a
pre-applicant's or an applicant's qualifications for being granted medical
staff membership and privileges.
C) Written criteria to be followed in evaluating a
pre-applicant's or an applicant's qualifications.
D) An evaluation of a pre-applicant's or an applicant's current
health status and current license status in Illinois.
E) A written response to each pre-applicant or applicant that
explains the reason or reasons for any adverse decision (including all reasons
based in whole or in part on the applicant's medical qualifications or any
other basis, including economic factors).
F) Written procedures that allow the medical staff to rely upon
the credentialing and privileging decisions of a distant-site hospital or
telemedicine entity as an option for recommending the privileging of
telemedicine physicians.
2) Minimum procedures with respect to medical staff and
clinical privilege determinations concerning current members of the medical
staff shall include the following:
A) A written notice of an adverse decision and explanation
of the reasons for an adverse decision including all reasons based on the
quality of medical care or any other basis, including economic factors.
B) A statement of the medical staff member's right to request a
fair hearing on the adverse decision before a hearing panel whose membership is
mutually agreed upon by the medical staff and the hospital governing board. The
hearing panel shall have independent authority to recommend action to the hospital
governing board. Upon the request of the medical staff member or the hospital
governing board, the hearing panel shall make findings concerning the nature of
each basis for any adverse decision recommended to and accepted by the hospital
governing board.
i) Nothing in this subsection (f)(2)(B) limits a
hospital's or medical staff's right to summarily suspend, without a prior
hearing, a person's medical staff membership or clinical privileges if the
continuation of practice of a medical staff member constitutes an immediate
danger to the public, including patients, visitors, and hospital employees and
staff.
ii) In the event that a hospital or the medical staff imposes
a summary suspension, the Medical Executive Committee, or other comparable
governance committee of the medical staff as specified in the bylaws, must meet
as soon as is reasonably possible to review the suspension and to recommend
whether it should be affirmed, lifted, expunged, or modified if the suspended medical
staff member requests a review.
iii) A summary suspension may not be implemented unless there
is actual documentation or other reliable information that an immediate danger
exists. This documentation or information must be available at the time the
summary suspension decision is made and when the decision is reviewed by the
Medical Executive Committee.
iv) If the Medical Executive Committee recommends that the
summary suspension should be lifted, expunged, or modified, this recommendation
must be reviewed and considered by the hospital governing board, or a committee
of the board, on an expedited basis.
v) Nothing in this subsection (f)(2)(B) shall affect
the requirement that any requested hearing must be commenced within 15 days
after the summary suspension and completed without delay unless otherwise
agreed to by the parties.
vi) A fair hearing shall be commenced within 15 days after the
suspension and completed without delay, except that, when the medical staff
member's license to practice has been suspended or revoked by the Department
of Financial and Professional Regulation, no hearing shall be necessary. (Section
10.4(b)(2)(C)(i) of the Act)
vii) Nothing in this subsection (f)(2)(B) limits a
medical staff's right to permit, in the medical staff bylaws, summary
suspension of membership or clinical privileges in designated administrative
circumstances as specifically approved by the medical staff. This bylaw
provision must specifically describe both the administrative circumstance that
can result in a summary suspension and the length of the summary suspension.
The opportunity for a fair hearing is required for any administrative summary
suspension. Any requested hearing must be commenced within 15 days
after the summary suspension and completed without delay. Adverse decisions
other than suspension or other restrictions on the treatment or admission of
patients may be imposed summarily and without a hearing under designated
administrative circumstances as specifically provided for in the medical staff
bylaws as approved by the medical staff. (Section 10.4(b)(2)(C)(ii) of the
Act)
viii) If a hospital exercises its option to enter into an
exclusive contract and that contract results in the total or partial
termination or reduction of medical staff membership or clinical privileges of
a current medical staff member, the hospital shall provide the affected medical
staff member 60 days prior notice of the effect on his or her medical staff
membership or privileges. An affected medical staff member desiring a hearing
under this subsection (f)(2)(B) must request the hearing within 14 days
after the date he or she is so notified. The requested hearing shall be
commenced and completed (with a report and recommendation to the affected
medical staff member, hospital governing board, and medical staff) within 30
days after the date of the medical staff member's request. If agreed upon by
both the medical staff and the hospital governing board, the medical staff
bylaws may provide for longer time periods. (Section 10.4(b)(2)(C)(iii) of
the Act)
C) A statement of the member's right to inspect all pertinent
information in the hospital's possession with respect to the decision.
D) A statement of the member's right to present witnesses and
other evidence at the hearing on the decision.
E) The right to be represented by a personal attorney.
F) A written notice and written explanation of the decision
resulting from the hearing.
G) A written notice of a final adverse decision by the hospital
governing board.
H) Notice given 15 days before implementation of an adverse
medical staff membership or clinical privileges decision based substantially on
economic factors. This notice shall be given after the medical staff member
exhausts all applicable procedures under subsection (f)(2)(B)(viii), and
under the medical staff bylaws in order to allow sufficient time for the
orderly provision of patient care. (Section 10.4(b)(2)(D) through (G) of
the Act)
3) Nothing in subsection (f)(2) limits a medical staff
member's right to waive, in writing, the rights provided in
subsection (f)(2)(A) through (H) upon being granted privileges to
provide telemedicine services or the written exclusive right to provide
particular services at a hospital, either individually or as a member of a
group. If an exclusive contract is signed by a representative of a group of
physicians, a waiver contained in the contract shall apply to all members of
the group unless stated otherwise in the contract. (Section 10.4(b)(2)(H)
of the Act)
4) All peer review used for the purpose of credentialing,
privileging, disciplinary action, or other recommendations affecting medical
staff membership or exercise of clinical privileges, whether relying in whole
or in part on internal or external reviews, shall be conducted in accordance
with the medical staff bylaws and applicable rules, regulations, or policies of
the medical staff. If external review is obtained, any adverse report utilized
shall be in writing and shall be made part of the internal peer review process
under the bylaws. The report shall also be shared with a medical staff peer
review committee and the individual under review. If the medical staff peer
review committee or the individual under review prepares a written response to
the report of the external peer review within 30 days after receiving the
report, the governing board shall consider the response prior to the
implementation of any final actions by the governing board which may affect the
individual's medical staff membership or clinical privileges. Any peer review
that involves willful or wanton misconduct shall be subject to civil damages as
provided for under Section 10.2 of the Act. (Section 10.4(b)(2)(C-5)
of the Act)
5) Every adverse medical staff membership and clinical
privilege decision based substantially on economic factors shall be reported to
the Hospital Licensing Board before the decision takes effect. The reports
shall not be disclosed in any form that reveals the identity of any hospital or
physician. These reports shall be utilized to study the effects that hospital
medical staff membership and clinical privilege decisions based upon economic
factors have on access to care and the availability of physician services.
(Section 10.4(b)(3) of the Act)
g) If a hospital enters into agreement for telemedicine services
with a distant-site hospital or distant-site entity, the governing body of the
hospital whose patients are receiving the telemedicine services may choose, in
lieu of the hospital performing the credentialing and privileging requirements,
to rely upon the credentialing and privileging decisions made by the
distant-site hospital when making recommendations on privileges for the
individual distant-site physicians and practitioners providing the services.
The hospital's governing body ensures, through its written agreement with the
distant-site hospital, that the distant-site hospital meets the Conditions of
Participation for Hospitals for credentialing and privileging of physicians and
practitioners. The agreement shall be in writing and shall verify:
1) That the distant-site hospital providing the telemedicine
services is an Illinois licensed hospital or a Medicare participating hospital;
2) That the individual distant-site physician or practitioner is
privileged at the distant-site hospital that provides the telemedicine services
and provides to the hospital a current list of the distant-site physician's
privileges;
3) That the individual distant-site physician or practitioner holds
a license issued or recognized by the State of Illinois; and
4) That, if the hospital conducts an internal review of the
distant-site physician's or practitioner's performance, it provides the
distant-site hospital with the performance information for use in the
distant-site hospital's periodic appraisal of the distant-site physician or
practitioner. At a minimum, this information shall include all adverse events
that result from the telemedicine services provided by the distant-site
physician or practitioner to the hospital's patients and all complaints the
hospital has received about the distant-site physician or practitioner.
h) The hospital's governing body shall grant privileges to each
telemedicine physician or practitioner providing services at the hospital under
an agreement with a distant-site hospital or telemedicine entity before the
telemedicine physician or practitioner may provide telemedicine services. The
scope of the privileges granted to the telemedicine physician or practitioner shall
reflect the provision of the services offered via a telecommunications system.
i) When the hospital's governing body exercises the option to
grant privileges based on its medical staff recommendations, which rely upon
the privileging decisions of a distant-site telemedicine hospital or entity,
the governing body may, but is not required to, maintain a separate file on
each telemedicine physician or practitioner. In lieu of maintaining a separate
file on each telemedicine physician or practitioner, the hospital may have a
file on all telemedicine physicians or practitioners providing services at the
hospital under each agreement with a distant-site hospital or telemedicine
entity, indicating which telemedicine services privileges the hospital has
granted to each physician or practitioner on the list. The file or files may be
kept in a format determined by the hospital.
j) Regardless
of any other categories (divisions of the medical staff) having privileges in
the hospital, the hospital shall have an active staff, which shall include
physicians and may also include podiatrists and dentists, properly organized, who
perform all the organizational duties pertaining to the medical staff. These
duties include:
1) Maintaining
the proper quality of all medical care and treatment of inpatients and
outpatients in the hospital. Proper quality of medical care and treatment
includes:
A) availability
and use of accurate diagnostic testing for the types of patients admitted;
B) availability
and use of medical, surgical, and psychiatric treatment for patients admitted;
C) availability
and use of consultation, diagnostic tools and treatment modalities for the care
of patients admitted, including the care needed for complications that may be
expected to occur; and
D) availability
and performance of auxiliary and associate staff with documented training and
experience in diagnostic and treatment modalities in use by the medical staff
and documented training and experience in managing complications that may be
expected to occur.
2) Organizing
the medical staff, including adoption of rules and regulations for its
government (which require the approval of the governing body), election of its
officers or recommendations to the governing body for appointment of the
officers, and recommendations to the governing body upon all appointments to
the staff and grants of hospital privileges.
3) Making
other recommendations to the governing body regarding matters within the
purview of the medical staff.
k) The
medical staff may include one or more divisions in addition to the active
staff, but this in no way modifies the duties and responsibilities of the
active staff.
(Source: Amended at 48 Ill. Reg. 450,
effective December 20, 2023; expedited correction at 48 Ill. Reg. 5807,
effective December 20, 2023)
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| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.315 HOUSE STAFF MEMBERS
Section 250.315 House Staff
Members
a) In hospitals participating in professional graduate training
programs, the policies of the hospital, which shall be approved by the Board,
must specify the duty hour requirements for house staff members and the
mechanisms by which house staff members are supervised by members of the
medical staff in carrying out their patient care responsibilities.
b) These policies shall comply with the Accreditation Council for
Graduate Medical Education, Common Program Requirements (Residency).
(Source: Amended at 47 Ill. Reg. 6477, effective April 27, 2023)
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.320 ADMISSION AND SUPERVISION OF PATIENTS
Section 250.320 Admission
and Supervision of Patients
a) All persons admitted to the hospital shall be under the
professional care of a member of the medical staff. Patients admitted by a
podiatrist or a dentist shall be under the care of both the admitting medical
staff member and a physician who is also a medical staff member. The
podiatrist or the dentist shall be responsible for all care within the limits
of the privileges granted to them; the physician shall be responsible for all
aspects of general medical care. Patients admitted by a dentist or a podiatrist
may have their histories and physical examinations performed by the
admitting dentist or podiatrist, provided that the dentist or podiatrist is a
member of the hospital medical staff, that the dentist or podiatrist has been
approved to perform histories and physical examinations by the hospital
governing board and that the history and physical examination are directly
related or incident to the dental or podiatrist service, operation, or surgery
for which the patient is being admitted.
b) Patients admitted by an advanced practice registered nurse or
physician assistant shall be under the care of both the advanced practice
provider and a physician who also is a medical staff member. The advanced
practice provider shall be responsible for care within the limits of the
privileges granted to him or her.
(Source: Amended at 43 Ill. Reg. 3889,
effective March 18, 2019)
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| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.330 ORDERS FOR MEDICATIONS AND TREATMENTS
Section 250.330 Orders for
Medications and Treatments
a) No medication, treatment, or diagnostic test shall be
administered to a patient except on the written order of a member of the
medical staff, a house staff member under the supervision of a member of the
medical staff, or allied health personnel with clinical privileges recommended
by the hospital medical staff and granted by the hospital governing board, with
the exception of influenza and pneumococcal polysaccharide vaccines, which may
be administered per medical staff-approved hospital policy that includes an
assessment for contraindications, and medications and treatments provided to
patients in a hospital outpatient setting as set forth in a policy approved by
the hospital medical staff and governing board.
1) The
staff-approved influenza and pneumococcal immunization policy shall include,
but not be limited to, the following:
A) Procedures
for identifying patients age 50 or older for influenza immunization and 65 or
older for pneumococcal immunization and, at the discretion of the hospital,
other patients at risk;
B) Procedures
for offering immunization against influenza virus when available between
September 1 and April 1, and against pneumococcal disease upon admission or
discharge, to patients in accordance with the recommendations of the Advisory
Committee on Immunization Practices of the Centers for Disease Control and
Prevention that are most recent to the time of vaccination, unless
contraindicated; and
C) Procedures
for ensuring that patients offered immunization, or their guardians, receive
information regarding the risks and benefits of vaccination.
2) The
hospital shall provide a copy of its influenza and pneumococcal immunization
policy to the Department upon request. (Section 6.26 of the Act)
3) The
outpatient medication and treatment administration policy shall include, but
not be limited to, the following:
A) Procedures
for verifying the credentials and scope of practice of non-medical staff
members providing written orders for medications and treatment for patients
under their care and management.
B) Identifying
what, if any, medications or treatments should not be included in this
exception.
C) A
process for tracking non-medical staff members providing written orders for
medication and treatments and the medications and/or treatments ordered.
4) The
hospital shall provide a copy of its outpatient medication and treatment policy
to the Department upon request.
b) Verbal orders shall be signed before the member of the medical
staff, the house staff member, or allied health personnel with clinical privileges
recommended by the hospital medical staff and granted by the hospital governing
board leaves the area. Telephone orders shall be used sparingly and
countersigned by the ordering practitioner or another practitioner who is
responsible for the care of the patient as soon as practicable pursuant to a
hospital policy approved by the medical staff, but no later than 72 hours after
the order was given.
c) Members of the medical staff, house staff members, or allied
health personnel with clinical privileges recommended by the hospital medical
staff and granted by the hospital governing board shall give orders for
medication and treatment only to the licensed, registered or certified
professional persons who are authorized by law to administer or dispense the
medication or treatment in the course of practicing their identified specific
discipline.
d) The medical directors of the laboratory, radiology, or other
diagnostic services may respectively authorize the performance of diagnostic
tests and procedures at the request of other than members of the medical staff
in accordance with policies approved by the medical staff and governing board.
e) The medical director of the physical therapy or rehabilitation
department may authorize the provision of physical therapy or rehabilitation
services or treatments at the request of other than members of the medical
staff in accordance with policies approved by the medical staff and governing
board.
(Source: Amended at 48 Ill.
Reg. 7321, effective May 3, 2024)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.340 AVAILABILITY FOR EMERGENCIES
Section 250.340 Availability
for Emergencies
The governing board shall
provide that one or more physicians shall be available at all times for
emergencies.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
SUBPART D: PERSONNEL SERVICE
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.410 ORGANIZATION
Section 250.410 Organization
a) Personnel department organization
1) There shall be an organized personnel department or service
designed to meet the needs of the personnel.
2) The chief executive officer shall designate an individual as
department or service chief.
3) The chief executive officer (administrator) shall ensure that
personnel policies and practices that adequately support hospital services and
quality of patient care are established and maintained.
4) There shall be sufficient qualified personnel to properly
operate the various departments and the adjunct services requiring technical
skill, such as laboratory, x-ray, physical therapy, pharmacy, nursing, surgery,
respiratory therapy, etc.
5) There shall be sufficient service personnel to properly
operate service departments.
6) Qualified personnel shall mean those persons who hold
necessary licenses for the activities they perform. If no license is required,
qualified personnel shall mean those persons who are registered or certified by
the Department, the Illinois Department of Financial and Professional
Regulation, the Council on Medical Education of the American Medical
Association or Agencies or Committees established in collaboration with the
Council, other accrediting agencies approved by the Department, or an
acceptable experience equivalent to the above.
b) Personnel policies shall be written and available to all
personnel.
c) Personnel policies shall be reviewed and/or revised
periodically, but no less than once every two years. The date of review or
revision shall be indicated on the personnel policies.
d) The hospital's governing body, through its chief executive
officer, shall identify functions for the management of personnel and place
responsibility for implementation and actions related to established policies
and procedures.
e) Under the direction of the hospital's administration, the
personnel department shall have available organizational charts that identify
all departments and/or services.
f) All positions shall be authorized by the governing authority,
either directly or through delegation to the administrator.
g) There shall be a written job description including minimum
qualifications for each position in the hospital.
h) Prior to employing any individual in a position that requires
a State license, the hospital shall contact the Illinois Department of Financial
and 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.
i) The hospital shall check the status of all applicants with
the Health Care Worker Registry prior to hiring.
j) Hospitals shall ensure that employees of the hospital are
made aware of employee assistance programs or other like programs available for
the physical and mental well-being of the employees. Hospitals shall provide
information on these programs, no less than at the time of employment and
during any benefit open enrollment period. A hospital may provide this
information to employees electronically. (Section 6.33 of the Act)
(Source: Amended at 47 Ill. Reg. 6477,
effective April 27, 2023)
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| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.420 PERSONNEL RECORDS
Section 250.420 Personnel
Records
a) Accurate, current and complete personnel records shall be
maintained for each hospital employee during his term of employment and for the
years thereafter as may be necessary to satisfy other State Agency or Federal
requirements.
b) There shall be an established standard of content for
personnel records, which shall contain at least the following:
1) Application form and/or resume with current and background
information sufficient to justify the initial and continuing employment of the
individual.
2) Verification of license, if the applicants for the positions
require a license. A licensed person should be employed only after obtaining
verification of their license.
3) A record regarding the employee's specialized education,
training, and experience.
4) Verification of identity.
5) Employment health examination and subsequent health services
rendered to the employees as are necessary to ensure that all hospital
employees are physically able to perform their duties.
6) Record of orientation to the job.
7) Continuance of education.
8) Current information relative to periodic work performance
evaluations.
(Source: Added at 4 Ill. Reg. 25, p. 138, effective June 6, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.430 DUTY ASSIGNMENTS
Section 250.430 Duty
Assignments
Employees shall not be assigned
duties which exceed their education training, experience, and qualifications.
(Source: Added at 4 Ill. Reg. 25, p. 138, effective June 6, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.435 HEALTH CARE WORKER BACKGROUND CHECK
Section 250.435 Health Care
Worker Background Check
A hospital 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 31 Ill.
Reg. 4245, effective February 20, 2007)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.440 EDUCATION PROGRAMS
Section 250.440 Education
Programs
Orientation and in-service
training programs shall be provided in order that personnel may maintain their
skills and learn new developments.
(Source: Added at 4 Ill. Reg. 25, p. 138, effective June 6, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.445 WORKPLACE VIOLENCE PREVENTION PROGRAM
Section 250.445 Workplace Violence Prevention Program
a) A
hospital licensed under the Act shall comply with the Health Care Violence
Prevention Act. (Section 9.8 of the Act)
b) Each
hospital shall display, either by physical or electronic means, a notice
stating that verbal aggression will not be tolerated and physical assault will
be reported to law enforcement. (Section 15(c) of the Health Care Violence
Prevention Act)
c) Each
hospital shall create a workplace violence prevention program that complies
with the Occupational Safety and Health Administration (OSHA) Guidelines for Preventing
Workplace Violence for Healthcare and Social Service Workers. In addition, the
workplace violence prevention program shall include:
1) the
following classification of workplace violence as one of 4 possible types:
A) "Type
1 violence" – workplace violence committed by a person who has no
legitimate business at the work site and includes violent acts by anyone who
enters the workplace with the intent to commit a crime;
B) "Type
2 violence" – workplace violence directed at employees by customers,
clients, patients, students, inmates, visitors, or other individuals
accompanying a patient;
C) "Type
3 violence" – workplace violence against an employee by a present or
former employee, supervisor, or manager; or
D) "Type
4 violence" – workplace violence committed in the workplace by someone who
does not work there, but has or is known to have had a personal relationship
with an employee.
2) management
commitment and worker participation, including, but not limited to nurses;
3) worksite analysis
and identification of potential hazards;
4) hazard prevention
and control;
5) safety
and health training that includes annual completion of one of the following
online courses:
A) Preventing
Workplace Violence in Healthcare (OSHA); or
B) Workplace
Violence Prevention for Nurses (CDC); and
6) recordkeeping
and evaluation of the violence prevention program. (Section 20 of the
Health Care Violence Prevention Act)
d) A hospital's workplace
violence prevention program shall also include:
1) An
overview of the incidence and prevalence of sexual assault and sexual violence;
2) Strategies and
approaches to prevent sexual violence;
3) Intervention procedures
to report sexual violence;
4) Contact
information for local programs and services to assist victims of sexual
violence; and
5) Additional
training and education resources regarding the prevention and reporting of
sexual violence, including, but not limited to, the Centers for Disease Control
and Prevention's STOP SV: A Technical Package to Prevent Sexual Violence.
(Source: Amended at 46 Ill. Reg. 15597,
effective September 1, 2022)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.450 PERSONNEL HEALTH REQUIREMENTS
Section 250.450 Personnel
Health Requirements
a) Each hospital 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; and
3) Policies and procedures for the periodic health assessment of
all personnel. These policies shall specify the content of the health
assessment and the interval between assessments, and shall comply with the Control
of Tuberculosis Code).
b) Personnel absent from duty because of any communicable disease
shall not return to duty until examined for freedom from any condition that
might endanger the health of patients or employees.
(Source: Amended at 38 Ill.
Reg. 13280, effective June 10, 2014)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.460 BENEFITS
Section 250.460 Benefits
Policies shall be established
concerning pay days, sick leave, vacations, holidays, overtime,
hospitalization, retirement plan, leaves of absence and other benefits or
related conditions of employment, and a statement of all such policies should
be furnished all personnel upon commencing work.
SUBPART E: LABORATORY
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.510 LABORATORY SERVICES
Section 250.510 Laboratory
Services
The hospital shall have a
clinical laboratory, certified in accordance with 42 CFR 493, to perform
services commensurate with the hospital's needs for its patients. Anatomical
pathology services and blood bank services shall be available either in the
hospital or by arrangement with other facilities.
a) Adequacy of Laboratory Services. Clinical laboratory services
adequate for the individual hospital shall be maintained in the hospital, as
determined by the following:
1) The extent and complexity of services are commensurate with
size, scope and nature of the hospital, and the demands of the medical staff
upon the laboratory.
2) Basic laboratory services, necessary for routine examinations
as defined in subsection (b), are provided in the hospital.
b) Clinical Laboratory Examinations. Provisions shall be made to
carry out basic clinical laboratory examinations including chemistry,
microbiology, hematology, serology, and clinical microscopy in such depth as
required by the medical staff.
1) Other laboratory examinations may be provided under
arrangements by the hospital with another laboratory which is certified under
CLIA regulations.
2) In the case of work performed by an outside laboratory, the
original report from this laboratory shall be contained in the medical record
as specified in subsection (f).
c) Availability of Facilities and Services
1) Facilities and services shall be available at all times.
Adequate provision shall be made for assuring the availability of emergency
laboratory services, either in the hospital or under arrangements with a
laboratory which meets the requirements of subsection (b).
2) Such services shall be available 24 hours a day, 7 days a
week, including holidays. Coverage of the service is permissible by having
arrangements with personnel for "on call duty."
3) Where services are provided by an outside laboratory, the
conditions, procedures, and availability of examinations performed are to be in
writing and available in the hospital.
d) Required Examinations. The laboratory examinations required
on all admissions shall be determined by the medical staff as provided in
Section 250.240(c).
e) Laboratory Report.
Signed or
otherwise authenticated reports shall be filed with the patient's medical
record and duplicate copies are maintained in the laboratory.
1) The laboratory director shall be responsible for the
laboratory reports.
2) There shall be a policy for assuring that all tests and
procedures are ordered by a member of the medical staff or by others in
accordance with approved policies. (See Section 250.330)
f) Pathologist Services. Services of a pathologist shall be
provided as indicated by the needs of the hospital.
1) Services are to be under the supervision of a pathologist
certified by the American Board of Pathology or who possesses training and
experience acceptable to the Department and equivalent to such certification,
and licensed to practice medicine in all its branches in Illinois, on a
full-time, regular part-time or regular consultive basis. If the latter
pertains, the hospital shall provide for, at a minimum, semimonthly consultive
visits by a pathologist.
2) The pathologist shall participate in staff, departmental and
clinicopathologic conferences.
g) Tissue Examination. All tissues removed at operation are to
be submitted for examination. The extent of examination is determined by the
pathologist.
1) All tissues removed from patients at surgery shall be
macroscopically, and if necessary, microscopically examined by the pathologist,
with the exception of the following tissues and materials, which do not need to
be examined by a pathologist:
A) Foreskin, fingernails, toenails, and teeth that are removed
during surgery;
B) Bone, cartilage, normal skin and scar tissue that are
coincidentally removed during the course of cosmetic or corrective surgery;
C) Cataract lenses that are removed during the course of eye
surgery;
D) Foreign substances (e.g., wood, glass, pieces of metal
including previously inserted surgical hardware) that are removed during
surgery; and
E) Placenta and placental tissue, unless requested by the
delivering physician or practitioner.
2) The pathologist is responsible for verifying the receipt of tissues
for examinations.
3) A list of tissues which routinely require microscopic
examination shall be developed in writing by the pathologist with the approval
of the medical staff.
4) A tissue file shall be maintained and include, as a minimum,
reports, slides and cross-index.
5) In the absence of a pathologist, there shall be an established
plan for sending to a pathologist outside the hospital all tissues requiring
examination. The pathologist may refer tissues to another pathologist for
consultation when he deems necessary.
h) Reports of Tissue Examination. Signed reports of tissue
examinations are to be filed with the patient's medical record and duplicate
copies are to be maintained.
1) All reports of macro and microscopic examinations performed
shall be signed by the pathologist.
2) Provisions are to be made for the prompt filing of examination
results in the patient's medical record and notification of the physician
requesting the examination.
3) Duplicate copies of the examination reports are to be
maintained in a manner which permits ready identification and accessibility.
(Source: Amended at 48 Ill. Reg. 450, effective December 20, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.520 BLOOD AND BLOOD COMPONENTS
Section 250.520 Blood and
Blood Components
Facilities for procurement,
safekeeping and necessary pretransfusion procedures for blood and blood
components shall be provided or readily available.
a) The hospital shall maintain, as a minimum, blood storage
facilities under adequate control and supervision of the pathologist or other
authorized physician.
b) For emergency situations the hospital maintains at least a
minimum blood supply in the hospital or can obtain blood quickly from community
blood banks or institutions, or has an up-to-date list of donors and equipment
necessary to bleed them.
c) Where the hospital depends on outside blood banks, there shall
be an agreement governing the procurement, transfer and availability of blood
which is reviewed and approved by the medical staff, administration and
governing body.
d) There shall be provision for prompt blood typing and
cross-matching, and for laboratory investigation of transfusion reactions,
either through the hospital or by arrangements with others on a continuous
basis, under the supervision of a physician licensed to practice medicine in
all its branches in Illinois.
e) A committee of the medical staff or its equivalent shall
review all transfusions of blood or blood components and make recommendations
concerning policies governing such practices.
f) The review committee shall investigate all transfusion
reactions occurring in the hospital and make recommendations to the medical
staff.
(Source: Amended at 18 Ill. Reg. 11945, effective July 22, 1994)
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.525 DESIGNATED BLOOD DONOR PROGRAM
Section 250.525 Designated
Blood Donor Program
a) Each hospital shall establish and operate a designated blood
donor program that allows a recipient of blood to designate a donor of their
choice for purpose of receiving red blood cells. Policies and procedures
which are followed in the operation of the program must be approved and
reviewed at least annually by the medical staff or its designated subcommittee.
The program must be consistent with the requirements of this Section.
b) The program shall allow designated blood donations that meet
the requirements of Section 7-109 of the Illinois Clinical Laboratory and Blood
Bank Act.
c) The hospital shall insure that designated blood donations are
properly labeled, stored, screened, and reserved for the designated recipient as
required by Section 7-109 of the Illinois Clinical Laboratory and Blood Bank
Act.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
|
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.530 PROFICIENCY SURVEY PROGRAM (REPEALED)
Section 250.530 Proficiency
Survey Program (Repealed)
(Source: Repealed at 18 Ill. Reg. 11945, effective July 22, 1994)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.540 LABORATORY PERSONNEL (REPEALED)
Section 250.540 Laboratory
Personnel (Repealed)
(Source: Repealed at 18 Ill. Reg. 11945, effective July 22, 1994)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.550 WESTERN BLOT ASSAY TESTING PROCEDURES (REPEALED)
Section 250.550 Western Blot
Assay Testing Procedures (Repealed)
(Source: Repealed at 18 Ill. Reg. 11945, effective July 22, 1994)
SUBPART F: RADIOLOGICAL SERVICES
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.610 GENERAL DIAGNOSTIC PROCEDURES AND TREATMENTS
Section 250.610 General Diagnostic Procedures and
Treatments
a) The
hospital shall maintain and provide radiological services sufficient to perform
and interpret the radiological examinations necessary for the diagnosis and
treatment of the various types of patients, to the extent that the complexity
of services are commensurate with the size, scope and nature of the hospital.
Additional required services shall be provided by shared services or referral
of patients.
b) The
physician responsible for the direction of a radiological department or service
shall be board certified or eligible for certification by the American Board of
Radiology or equivalent. The physician shall have a written agreement with the
hospital to direct the radiological services on a full-time, part-time or
consulting basis and be an approved member of the medical staff. The
responsibilities of the physician shall be identified in the hospital's Policy
and Procedure Manual or other document.
c) Radiological
facilities shall comply with Sections 250.2440(c)(3) or 250.2630(c)(3).
d) Technicians
employed in the radiological services shall be accredited pursuant to 32 Ill.
Adm. Code 401 as appropriate and have had sufficient training and experience to
carry out the procedures safely and efficiently commensurate with the size,
scope and nature of the service. A procedure and means for evaluating
qualifications shall be established and used. (Refer to Section 250.410 and 32
Ill. Adm. Code 401.)
e) Each
general hospital shall provide for emergency radiological services at all
times. (Refer to Section 250.710.)
f) Complete
signed reports of the radiological examinations shall be made part of the
patient's record and duplicate copies kept in the radiological department for a
period of time established by the hospital.
g) Written
reports of each radiological interpretation, consultation and treatment shall
be signed by the physician responsible for conducting the procedure and shall
be a part of the patient's medical record. Maintenance and filing of records
shall be coordinated with direction and supervision by the medical record
administrator. (Refer to Section 250.1510.)
h) Hospital
X-ray or Roentgen Photographs shall be retained in accordance with the X-Ray
Retention Act, which requires retention for five years and longer when
notification of litigation is received.
i) X-ray
or roentgen photographs or treatments of therapy shall be given only on an
order for treatment in accordance with Section 250.330.
j) Radiological
facilities operated by a hospital constitute a "radiation installation"
within the meaning of the Radiation Protection Act of 1990 and are required to
be registered with the Illinois Emergency Management Agency, Division of
Nuclear Safety.
k) Every
radiation therapy service shall be integrated into a comprehensive program for
total cancer care. Radiation therapy service shall be available in
coordination with other institutions or agencies for the necessary supportive
services.
(Source: Amended at 47 Ill. Reg. 6477,
effective April 27, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.620 RADIOACTIVE MATERIAL
Section 250.620 Radioactive Material
Radioactive material, whether
for diagnostic or therapeutic purposes, shall be received, handled, used, and
disposed of pursuant to the Radiation Protection Act of 1990 and the
regulations promulgated thereunder.
(Source: Amended at 47 Ill. Reg. 6477, effective April 27, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.630 GENERAL POLICIES AND PROCEDURES MANUAL
Section 250.630 General
Policies and Procedures Manual
Each radiological department or
department in charge of an identified distinct radiological service shall
prepare and maintain a policies and procedures manual. It shall be reviewed
and updated annually. It shall include but not be limited to provisions for
the following identified requirements:
a) The hospital shall establish and enforce safety policies that
will protect both patient and radiological worker from excessive or stray
radiation in accordance with the Radiation Protection Act of 1990 and the
regulations promulgated thereunder.
b) Personnel Monitoring shall be performed pursuant to 32 Ill.
Adm. Code 340.210 and 340.520.
1) Procedures for personnel monitoring shall be maintained for
each individual working in the area of radiation where there is a reasonable
possibility an individual will exceed 10% of annual limit.
2) Personnel monitoring records resulting from the use of film
badges or dosimeters must be maintained. Readings must be on at least a
quarterly basis.
3) Upon termination of employment, each worker shall be provided
with a summary of the worker's exposure record.
4) Permanent records of exposure on all monitored personnel shall
be maintained for review by surveyors for licensing.
c) Monthly and yearly reports shall be maintained on the number
of examinations done and kinds of treatment given.
d) The use of all radiological apparatus shall be limited to
personnel designated as qualified by the physician responsible for the
direction and supervision of the department or service. Qualified personnel
shall comply with the Radiation Protection Act of 1990 and the regulations
promulgated thereunder, specifically 32 Ill. Adm. Code 401. The use of
fluoroscopes shall be limited to persons licensed under the Medical Practice Act
of 1987, the Illinois Dental Practice Act, or the Podiatric Medical Practice
Act of 1987, and to personnel who meet the requirements in 32 Ill. Adm. Code
360.50(n)(1) through (4).
e) Radiological personnel accredited pursuant to 32 Ill. Adm.
Code 401 shall participate in continuing education pursuant to 32 Ill. Adm.
Code 401.140. Physicians shall participate in training pursuant to Subpart J
of 32 Ill. Adm. Code 335 as applicable. The continuing education shall be
documented.
f) At all times, there shall be reasonable privacy for the
radiological patient relative to dressing, evacuation, and the study being
performed.
g) The hospital must develop and maintain written safety policies
for the radiological services to protect patients and personnel. These
policies must relate to radiation pursuant to the Radiation Protection Act and
the regulations promulgated thereunder, electrical and mechanical hazards,
prevention and containment of fire and explosion, and prevention and treatment
of any untoward reaction to contrast media.
h) The hospital must enforce written policies and procedures for
the radiological services that relate to the management of critically ill
patients and to the administration of diagnostic agents by nonphysicians.
i) When qualified personnel are permitted to administer
diagnostic agents intravenously for radiological evaluations, the hospital
shall develop and enforce written safety guidelines specifying which
individuals have this authority and whether a physician shall be physically
present or immediately available, in accordance with 32 Ill. Adm. Code
360.50(n)(1) through (4). If radioactive materials are being administered,
accreditation and supervision rules apply. Refer to 32 Ill. Adm. Code
335.1050.
j) There must always be an emergency drug tray in the room or
immediately available where parenteral diagnostic agents for radiologic
evaluations are being administered. The hospital must maintain a system for
maintaining an emergency drug tray with no outdated medications or missing
items, and to ensure that the tray's content is appropriate. Oxygen, airways,
syringes and needles, intravenous administration sets, and appropriate
parenteral solutions shall be available at all times.
k) Policies and procedures for the administration of radiological
drugs shall be coordinated with and approved by the Pharmacy and Therapeutics
Committee. (Refer to Subpart R Section 250.2140).
l) Written safety policies must provide for the steps to be
followed in the event of a spill of radioactive material pursuant to Subpart M
of 32 Ill. Adm. Code 340; for specific authority for any nonphysician qualified
personnel who administer radioactive material intravenously pursuant to 32 Ill.
Adm. Code 335.1050; for the recording of cumulative radiation exposure of all
personnel pursuant to 32 Ill. Adm. Code 340.1160 and 340.520; a requirement for
protective security from all radioactive areas for all unauthorized personnel
pursuant to Subpart G of 32 Ill. Adm. Code 340 and 32 Ill. Adm. Code 340.810;
and the establishment of a radiation protection survey at least once per week
pursuant to 32 Ill. Adm. Code 335.2080 if applicable.
m) Instrument logbooks maintained by radiological services must
include calibration records of equipment and monitors, maintenance and repair
records, and the findings of outside evaluators (if used), with the corrective
action taken pursuant to 32 Ill. Adm. Code 340.1130.
n) Requests by attending members of the medical staff for
radiological examinations must contain a concise statement of the reason for
the examination.
(Source:
Amended at 47 Ill. Reg. 6477, effective April 27, 2023)
SUBPART G: EMERGENCY SERVICES
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.710 CLASSIFICATION OF EMERGENCY SERVICES
Section 250.710
Classification of Emergency Services
a) Each hospital, except long-term acute care hospitals and
rehabilitation hospitals identified in Section 1.3 of the Hospital
Emergency Service Act and in subsection (d) of this Section (Section 1
of the Hospital Emergency Service Act), shall provide emergency services
according to one of the following categories:
1) Comprehensive
Emergency Treatment Services
A) At least one licensed physician shall be in the emergency
department at all times.
B) Physician specialists who represent the major specialties and
sub-specialties, such as plastic surgery, dermatology and ophthalmology, shall
be available within minutes.
C) Ancillary services, including laboratory and x-ray, shall be
staffed at all times. The pharmacy shall be staffed or on call at all times.
2) Basic
Emergency Treatment Services
A) At least one licensed physician shall be in the emergency
department at all times.
B) Physician specialists who represent the specialties of
medicine, surgery, pediatrics and obstetrics shall be available within minutes.
C) Ancillary services, including laboratory, x-ray and pharmacy,
shall be staffed or on call at all times.
3) Standby
Emergency Treatment Services
A) A registered nurse on duty in the hospital shall be available
for emergency services at all times.
B) A licensed physician shall be on call to the emergency
department at all times.
b) All hospitals, irrespective of the category of services
provided, shall provide immediate first aid and emergency care to persons
requiring first aid emergency treatment on arrival at the hospital. A
hospital, in accordance with Section 1395dd(a) and 1395dd(b) of the Social
Security Act, shall not delay provisions of a required appropriate medical
screening examination or further medical examination and treatment for a
patient in order to inquire about the individual's method of payment or
insurance status. (Section 6.34 of the Act)
c) Every hospital, except long-term
acute care hospitals and rehabilitation hospitals identified in Section 1.3
of the Hospital Emergency Service Act, shall furnish hospital emergency
services to any applicant who applies for the same in case of injury or acute
medical condition where the same is liable to cause death or severe injury or
serious illness. (Section 1(a) of the Hospital Emergency Service Act)
1) These services shall be furnished in accordance with the
procedures required by the federal Emergency Medical Treatment and Active Labor
Act (EMTALA), including, but not limited to, medical screening, the provision
of necessary stabilizing treatment, procedures for refusals to consent,
restricting transfers until the individual is stabilized, appropriate transfers
of patients, nondiscrimination, no delay in examination or treatment, and
whistleblower protections. (Section 1(a) of the Hospital Emergency Service
Act)
2) For the purposes of this Section:
A) "Applicant" includes any person who
presents at the hospital or who is brought to a hospital by ambulance or
specialized emergency medical services vehicle as defined in the Emergency
Medical Services (EMS) Systems Act. (Section 1(a) of the Hospital
Emergency Service Act)
B) "Injury or acute medical condition where the same is
liable to cause death or severe injury or serious illness" includes,
but is not limited to, when a pregnant patient is experiencing ectopic
pregnancy, complications of pregnancy loss, risks to future fertility,
previable preterm premature rupture of membranes (PPROM), or emergent
hypertensive disorders, such as preeclampsia. (Section (b-1) of the
Hospital Emergency Service Act)
C) "Stabilizing treatment" includes, but
is not limited to, abortion when abortion is necessary to resolve the
patient's injury or acute medical condition that is liable to cause death or
severe injury or serious illness. (Section (b-2) of the Hospital Emergency
Service Act)
d) General acute care hospitals designated by Medicare as
long-term acute care hospitals and rehabilitation hospitals are not required to
provide hospital emergency services described in this Section or Section
1 of the Hospital Emergency Service Act. Hospitals defined in this
subsection (d) may provide hospital emergency services at their option.
1) Any
hospital defined in this subsection (d) that opts to discontinue or otherwise
not provide emergency services shall:
A) Comply with all provisions of EMTALA and the Hospital
Emergency Service Act;
B) Comply with all provisions required under the Social
Security Act;
C) Provide annual notice to communities in the hospital's
service area about available emergency medical services; and
D) Make educational materials available to individuals who are
present at the hospital concerning the availability of medical services within
the hospital's service area.
2) Long-term acute care hospitals that operate standby
emergency services as of January 1, 2011 may discontinue hospital emergency
services by notifying the Department. Long-term acute care hospitals that
operate basic or comprehensive emergency services must notify the Health
Facilities and Services Review Board and follow the appropriate procedures.
(Section 1.3 of the Hospital Emergency Service Act)
3) Any
rehabilitation hospital that opts to discontinue or otherwise not provide
emergency services shall comply with subsection (d)(1), shall not use
the term "hospital" in its name or on any signage, and shall notify
in writing the Department, the Health Facilities and Services Review Board,
and the Division of Emergency Medical Services and Highway Safety of
the discontinuation. (Section 1.3 of the Hospital Emergency Service Act)
A) "Signage"
means any signs or system of signs affixed to, adjacent to, or directing the
public to the hospital, including but not limited to informational road signs.
B) Signage
does not include materials for advertising, licensure, certification or patient
referral materials.
e) Violations.
The Department will investigate violations of the Hospital
Emergency Service Act, which may include a medical clinical review by a
physician, and may issue a minimum monetary penalty of $50,000 for
violating the Hospital Emergency Service Act. The Department may assess
a fine only if there are no fines assessed for the violation by the federal government.
(Section 2.1 of the Hospital Emergency Service Act) The Department will
consider the following identifying factors in determining whether or not to
issue a fine:
1) The
applicant presented to the hospital requesting examination or treatment of an
injury or acute medical condition liable to cause death or severe injury or
serious illness (Section 1(b-1) of the Hospital Emergency Service Act) and
was denied necessary stabilizing treatment;
2) The
applicant suffered harm that resulted from the failure to provide services as
required by Section 1(a) of the Hospital Emergency Service Act and subsection
(c)(1) of this Section;
3) The
applicant was transferred without documentation by the transferring physician
that the transfer was necessary and that the benefits of the treatment provided
by the receiving hospital would outweigh the risks of the transfer;
4) The
hospital's prior violations of the Hospital Emergency Service Act;
5) The
hospital's failure to take appropriate corrective action to remedy the
violation prior to the Department's investigation;
6) The
hospital's failure to properly train staff and employees regarding their duties
under this Section; and
7) Any misrepresentation
made by hospital staff to the applicant concerning the applicant's condition or
other information, including the hospital's obligations under the Hospital
Emergency Service Act.
f) Aggravating
Factors. In determining whether to issue a fine greater than $50,000, the
Department will consider aggravating factors, including, but not limited to:
1) The hospital's
violation caused serious or permanent physical, mental, or emotional harm;
2) The hospital's
violation proximately caused death;
3) The
hospital's prior violations of the Hospital Emergency Service Act;
4) The
hospital's failure to self-report a violation to the Department; or
5) The
hospital's request for proof of insurance, prior authorization, or a monetary
payment prior to appropriately screening or initiating stabilizing treatment
for an emergency medical condition, or requesting a monetary payment prior to
stabilizing an emergency medical condition.
g) The
presence of any single aggravating circumstance may justify imposing a larger penalty
even when one or more mitigating factors is present.
(Source: Amended at 49 Ill.
Reg. 7975, effective May 21, 2025)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.720 GENERAL REQUIREMENTS
Section 250.720 General
Requirements
a) Each hospital shall provide adequate facilities for the
provision of immediate life saving measures.
b) Policies and procedures governing the acceptance and care of
emergency patients shall be established. These shall be in accordance with the
category of emergency services established in the hospital. Specific policies
shall be adopted and implemented in regard to rendering emergency care in the
hospital's emergency department, in the hospital but away from the emergency
department, and within proximity to the hospital. In developing these
policies, the hospital shall take into consideration any available national or
state guidelines on the standard of practice in this area. These policies
shall be included as a part of any initial employee orientation/training and
shall be reviewed annually with staff.
c) An appropriate record shall be maintained on each patient who
presents for emergency services.
d) Appropriate supplies and equipment shall be available and ready
for use.
e) This Section shall not be construed to affect hospital-patient
arrangements regarding payment for care.
f) Hospitals providing obstetric services shall have a written
policy and conduct continuing education yearly (calendar) for providers
and staff of obstetric medicine, and of the emergency department, and other
staff that may care for pregnant or postpartum women. The written policy and
continuing education shall include management of severe maternal hypertension
and obstetric hemorrhage, addressing airway emergencies experienced during
childbirth, and management of other leading causes of maternal mortality for
units that care for pregnant or postpartum women. Hospitals providing
obstetric services shall demonstrate compliance with these written policy
and education requirements. (Section 2310-222(b) of the Department of
Public Health Powers and Duties Law) (See also Section 250.1830(n) and (o)).
g) A REH shall have an agreement with at least one licensed and
Medicare-certified hospital that is a level I or level II trauma center for the
referral and transfer of patients requiring emergency medical care beyond the
capabilities of the REH.
h) The use of latex gloves by hospital staff is
prohibited. If a crisis exists that interrupts a hospital's ability to
reliably source nonlatex gloves, hospital staff may use latex gloves
upon a patient. However, during the crisis, hospital staff shall
prioritize, to the extent feasible, using nonlatex gloves for the treatment of
any patient with self-identified allergy to latex; and any patient upon whom
the latex gloves are to be used who is unconscious or otherwise physically
unable to communicate and whose medical history lacks sufficient information to
indicate whether or not the patient has a latex allergy. (Sections 10(c)
and 15 of the Latex Glove Ban Act)
(Source:
Amended at 48 Ill. Reg. 7321, effective May 3, 2024)
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.725 NOTIFICATION OF EMERGENCY PERSONNEL
Section 250.725 Notification
of Emergency Personnel
a) For purposes of this Section:
1) "Vehicle Service Provider" means an entity
licensed by the Department to provide emergency or non-emergency medical
services in compliance with requirements in the Emergency Medical Services
(EMS) Systems Act and the Emergency Medical Services, Trauma Centers,
Pediatric Emergency and Critical Care Centers, Stroke Centers Hospital Code, and
an operational plan approved by its EMS System(s), utilizing at least
ambulances or specialized emergency medical service vehicles (SEMSV).
(Section 3.85(a) of the Emergency Medical Services (EMS) Systems Act)
2) "Emergency Medical Services personnel" or
"EMS personnel" means persons licensed as an Emergency Medical
Responder (EMR)(First Responder), Emergency Medical Dispatcher (EMD), Emergency
Medical Technician (EMT), Emergency Medical Technician-Intermediate (EMT-I),
Advanced Emergency Medical Technician (A-EMT), Paramedic (EMT-P), Emergency
Communications Registered Nurse (ECRN), Pre-Hospital Registered Nurse (PHRN),
Pre-Hospital Advanced Practice Registered Nurse (PHAPRN), or Pre-Hospital
Physician Assistant (PHPA) (Section 3.5 of the Emergency Medical Services
(EMS) Systems Act)
3) "Ambulance Personnel" means any person employed by
an emergency services provider agency who is or was involved in the prehospital
or interhospital transportation and care of a patient requiring emergency care
or life support services as an ambulance crew member, including the vehicle
driver.
b) Each hospital shall establish procedures for providing notification
to police officers, firefighters, emergency medical technicians, private
emergency medical services providers, and ambulance personnel who have provided
or about to provide transport services, emergency care, or life support
services to a patient who has been diagnosed as having a dangerous communicable
or infectious disease per NIOSH guidelines listed below. (Section
6.08(a) of the Act) The procedures shall include at a minimum the requirements
of this Section.
c) Notification shall be required for all potentially
life-threatening contagious diseases including but not limited to those listed
in NIOSH Publication No. 2020-119 (see Part III. Guidelines Describing the
Manner in Which Medical Facilities Should Make Determinations for Purposes of
Section 2695B(d) (42 U.S.C. 300ff–133(d))) and for any biological agents and
toxins pursuant to 7 CFR 331, 9 CFR 121, and 42 CFR 73
d) The hospital shall send the letter of notification to
exposed personnel no later than 48 hours after a confirmed diagnosis of any
of the bloodborne or body-fluid borne (including gastrointestinal fluids)
communicable diseases that require notification per subsection (c).
1) The hospital shall attempt to make verbal communication,
followed by written notification only if the police officers, firefighters, emergency
medical technicians, private emergency medical services providers, or ambulance
personnel have indicated both verbally and on the ambulance run sheet that a
reasonable possibility exists that they have had blood or bodily fluid contact
with the patient, or if hospital personnel providing the notification have
reason to know of a possible exposure. (Section 6.08(c) of the Act).
2) The hospital shall send the letter of notification no later
than 48 hours after a confirmed diagnosis of any of the airborne or
droplet-transmitted communicable diseases that require notification per
subsection (c) and the hospital shall attempt to make verbal communication,
followed by written notification. (Section 6.08 (c-5) of the Act)
e) Notification letters shall be sent to the designated
officer at the municipal or private provider agencies listed on the ambulance
run sheet. Except in municipalities with a population over 1,000,000, a list
attached to the ambulance run sheet shall contain all municipal and
private provider agency personnel who have provided any pre-hospital care
immediately prior to transport. In municipalities with a population over
1,000,000, the ambulance run sheet shall contain the company number or
unit designation number for any fire department personnel who have provided any
pre-hospital care immediately prior to transport. The letter shall state the
following:
1) The names of crew members listed on the attachment to the
ambulance run sheet,
2) the name of the communicable disease diagnosed, but shall
not contain the patient's name (Section 6.08(d) of the Act),
3) The date the patient was transported,
4) A statement that this information shall be maintained as a
confidential medical record (See 77 Ill. Adm. Code 697.140),
5) A statement that upon receipt of the notification
letter, the applicable private provider agency or the designated infectious
disease control officer of a municipal fire department or fire protection
district shall contact all personnel involved in the pre-hospital or
inter-hospital care and transport of the patient.
f) Upon discharge of a patient with a communicable disease
listed in subsection (c) or to emergency personnel, the hospital shall
notify the emergency personnel of appropriate precautions against the
communicable disease, but shall not identify the name of the disease. (Section
6.08(e) of the Act)
g) Upon
discharge of a patient with a communicable disease in a contagious state
requiring transmission-based precautions, including gastrointestinal infections
(e.g. shigellosis, Clostridiodes difficile, norovirus), respiratory infections,
and XDRO organisms (e.g. C auris, carbapenemase-producing organisms, etc.) to
emergency personnel, the hospital shall notify the emergency personnel of
appropriate precautions against the communicable disease.
h) The hospital may, in its discretion, take any measures in
addition to those required in Section 6.08 of the Act to notify police
officers, firefighters, emergency medical technicians, and ambulance
personnel of possible exposure to any communicable disease. However, in all
cases this information shall be maintained as a confidential medical record.
(Section 6.08(f) of the Act)
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
|
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.730 EMERGENCY PREPAREDNESS, COMMUNITY, OR AREAWIDE PLANNING
Section 250.730 Emergency
Preparedness, Community, or Areawide Planning
a) Hospitals shall meet the requirements of the Centers for
Medicare and Medicaid Services for Conditions of Participation for Hospital
Emergency Preparedness 42 CFR 482.15 and Section 240 of the Emergency Medical
Services, Trauma Centers, Pediatric Emergency and Critical Care Centers, Stroke
Centers Hospital Code.
b) The primary participating hospital in any emergency
preparedness, community, or areawide plan for hospital emergency services must
meet the requirements of either Comprehensive Emergency Treatment Services or
Basic Emergency Treatment Services (See Section 250.710(a)(1) and (a)(2)).
c) The emergency preparedness, community, or areawide plan for
providing hospital emergency services shall be forwarded to the hospital's
designated resource hospital, as defined in the Emergency Medical Services,
Trauma Centers, Pediatric Emergency and Critical Care Centers, Stroke Centers
Hospital Code.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
|
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.740 DISASTER AND MASS CASUALTY PROGRAM (REPEALED)
Section 250.740 Disaster and
Mass Casualty Program (Repealed)
(Source: Repealed at 49 Ill. Reg. 14395, effective October 27, 2025)
|
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.750 MEDICAL FORENSIC SERVICES FOR SEXUAL ASSAULT SURVIVORS
Section 250.750 Medical
Forensic Services for Sexual Assault Survivors
a) All hospitals providing emergency services shall render care
to victims of sexual assault. The care shall be in accordance with 77 Ill.
Adm. Code 545.55 (Treatment and Transfer of Pediatric Sexual Assault Survivors),
77 Ill. Adm. Code 545.60 (Treatment of Sexual Assault Survivors), 77 Ill. Adm.
Code 545.63 (Treatment Hospital with Pediatric Transfer), and 77 Ill. Adm. Code
545.65 (Transfer of Sexual Assault Survivors).
b) A hospital may fulfill its obligation to provide medical
forensic services to sexual assault victims by participating in an areawide
plan for emergency service in accordance with 77 Ill. Adm. Code 545.50 (Areawide
Sexual Assault Treatment Plans).
c) Pursuant to, but not limited to, Sections 7 and 7.5 of the
Sexual Assault Survivors Emergency Treatment Act, a hospital shall not seek
payment from a sexual assault survivor who presents at a hospital for medical
forensic services. If the Department becomes aware that a sexual assault
survivor has been billed for treatment, the Department will refer the matter to
the Office of the Attorney General for enforcement.
d) The hospital shall provide a sexual assault survivor with a sexual
assault services voucher. For the purposes of this Section, a sexual assault
services voucher is a document generated by a hospital at the time the
sexual assault survivor receives outpatient medical forensic services that may
be used to seek payment for any ambulance services, medical forensic services,
laboratory services, pharmacy services, and follow-up healthcare provided as a
result of the sexual assault. (Section 1a of the Sexual Assault Survivors
Emergency Treatment Act)
(Source: Amended at 44 Ill. Reg. 18379, effective October 29, 2020)
SUBPART H: RESTORATIVE AND REHABILITATION SERVICES
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.810 APPLICABILITY OF OTHER PARTS OF THESE REQUIREMENTS
Section 250.810
Applicability of Other Parts of These Requirements
All other Parts of these
requirements are applicable with the exception of Subparts O, Q and S and as
otherwise amended and modified by this Part.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.820 GENERAL
Section 250.820 General
In setting forth the regulations
for Restorative and Rehabilitation Services, it is recognized that there are
several "levels," or degrees of comprehensiveness, that can be
provided by a facility. Just what level is to be provided should be a function
of such factors as: perceived need; hospital size and location; financial
feasibility; and services available elsewhere within the community. It is
important that each hospital select in writing the level of restorative or
rehabilitation services which it will provide in accord with license. Those
levels not provided directly by the hospital must be made accessible to every
patient through formal referral mechanisms or contractual arrangements.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.830 CLASSIFICATIONS OF RESTORATIVE AND REHABILITATION SERVICES
Section 250.830
Classifications of Restorative and Rehabilitation Services
a) Basic rehabilitation (restorative) services – This level must
be provided by all hospitals and includes at least restorative nursing, medical
management and administrative services;
b) Physical rehabilitation services – In addition to basic
restorative services, this level must include the provision for at least
physical therapy and social services. It is recommended that occupational
therapy and speech therapy be available.
c) Comprehensive physical rehabilitation services – This level of
services must be provided in a distinct, clearly defined, special unit, of an
acute care hospital, or in a special referral hospital. This scope of services
provided must include, but is not limited to, the services of members of the
medical staff, rehabilitation nursing, physical therapy, occupational therapy,
speech therapy, social services, psychology, vocational counseling and
nutritional counseling. It is recommended that correctional therapy be
available.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.840 GENERAL REQUIREMENTS FOR ALL CLASSIFICATIONS
Section 250.840 General
Requirements for all Classifications
Regardless of the selected level
of services to be provided by each hospital, every hospital shall provide an
identifiable, active restorative or rehabilitation program with written goals
of assisting each patient to achieve and maintain their optimal level of
self-care and independence. The program shall include coordinated health
services utilizing the team approach. It shall meet the following
requirements:
a) Effective written policies and procedures relating to the
program organization, function, casefinding, follow-up and appropriate referral
mechanisms. These policies and procedures shall be developed by
representatives of all health professions participating in the program,
particularly as they relate to their specialties.
b) A clear indication of physical, philosophical and economic
support of the program through:
1) An identifiable program of quality assurance involving action
by a patient care and/or utilization review committee to assist in implementing
program services as needed, including provision of the time required to achieve
restorative or rehabilitation goals. The committee shall include physicians and
representatives of allied health professions within the hospital.
2) Access to restorative and rehabilitation services for all patients
requiring such care regardless of the service to which the patient is
assigned. If needed levels of rehabilitation service are not available
in-house, formal referral mechanisms or contractual arrangements to obtain
appropriate services must be in evidence.
3) A budget that is adequate for necessary program personnel,
equipment and facilities.
c) Physician direction of coordinated individual patient care
through written orders and assistance in establishing and attaining treatment
objectives.
d) Involvement of all appropriate health care professionals in
the development and implementation of each patient's care plan. This shall be
accomplished through formal patient-care conferences, or other established
methods of interaction between the physicians and allied health professionals.
e) Documentation of the patient's response to treatment by all
health-care professionals involved in carrying out the patient's care plan.
This shall be part of the ongoing medical record.
f) Restorative nursing provided on a 24-hour, seven-day-a-week
basis.
g) Adequate space and equipment to provide treatment offered
through the program.
h) Regularly scheduled departmental and interdisciplinary
in-service education, embracing program orientation, skill-training and
continuing education regarding the restorative and rehabilitation process.
Representatives of all professions involved in the program should be given the
opportunity of performing the "teaching" function.
i) Establishment of safety policies in the selection, use and
maintenance of patient-care equipment.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.850 SPECIFIC REQUIREMENTS FOR COMPREHENSIVE PHYSICAL REHABILITATION SERVICES
Section 250.850 Specific
Requirements for Comprehensive Physical Rehabilitation Services
a) Treatment shall be multidisciplinary, intensive, time-limited,
goal-oriented, integrated and coordinated.
b) The multidisciplinary treatment team shall function under the
direction of a physiatrist for each patient. The team shall meet on a
scheduled basis to review evaluations, to set treatment plans and objectives,
to review patient response to treatment and to plan discharge and follow-up. A
physician qualified by education and experience in physical rehabilitation may
act as team leader until a physiatrist is available.
c) The patient, and wherever possible, the family or significant
others, should be actively involved in planning and goal-setting. The patient
is actively involved in treatment.
d) Evaluation and treatment planning should be geared to the
"whole person," with the primary objectives of reducing disability
and dependence in activities of daily living, concurrent with the promotion of
optimal personal adjustment in psychological, social, emotional, spiritual and
economic dimensions.
e) Extensive pre-admission screening must be conducted to assess
the patient's need for this level of service.
f) In addition to restorative nursing, rehabilitation nursing
must be provided on a daily basis.
g) Program shall include at least access to vocational
assessment, training and placement. This is often done in conjunction with
state-operated vocational rehabilitation services.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.860 MEDICAL DIRECTION
Section 250.860 Medical
Direction
a) Basic rehabilitation (restorative) services – The attending
medical staff member shall provide written orders for care, including treatment
objectives.
b) Physical Rehabilitation
1) Facilities identifying themselves under this category shall
regularly provide medical participation through:
A) A qualified physiatrist
B) A physician qualified by training and/or experience in physical
rehabilitation; or
C) A formally designated group of physicians from various
specialties usually associated with physical rehabilitation (e.g. orthopedics,
neurology, neurosurgery, etc.).
2) The physician(s) shall meet on a regular basis with
representatives of the professions involved in patient-care to discuss patient
evaluations, set objectives, report patient response to treatment and to plan
discharges and follow-up care where appropriate.
c) Comprehensive Physical Rehabilitation Unit or Hospital –
Facilities identifying themselves under this category shall
provide patient-care under the direction of a physiatrist. A physician fully
qualified by education and experience in physical rehabilitation may provide
patient care direction until a physiatrist is available.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.870 NURSING CARE
Section 250.870 Nursing Care
a) Facilities providing basic rehabilitation (restorative) care
shall include rehabilitation concepts in their orientation program. Basic
restorative care shall be evidenced in the patient care plan. (Refer to
Subpart I.)
b)
1) Facilities providing physical rehabilitation services shall
have available a person who by education or training may provide consulting
services in rehabilitation nursing.
2) The consultant shall meet on a regular basis with
representatives of the nursing staff and document staff participation.
c)
1) Facilities providing comprehensive physical rehabilitation
services shall have clinical specialists available on the staff.
2) It is recommended that all nursing staff receive adequate
training in rehabilitation nursing through initial orientation training,
on-going in-service education and by attending accredited workshops, seminars
and training programs.
3) Patient care plans should include appropriate inputs from
other allied health professionals.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.880 ADDITIONAL ALLIED HEALTH SERVICES
Section 250.880 Additional
Allied Health Services
a) Restorative and physical rehabilitation programs may include,
but are not limited to, any or all of the following specialty services:
1) Diagnostic and/or treatment services of physicians
2) Nursing services
3) Physical Therapy services
4) Occupational Therapy services
5) Speech Therapy Services
6) Social services
7) Psychology services
8) Vocational services
9) Audiology services
10) Prosthetic services (including biomedical engineering
services)
11) Orthotic services (including biomedical engineering services)
12) Religious/spiritual services
13) Recreational Therapy services
14) Podiatric services
15) Nutritional Counseling services
16) Education services
17) Dental services
18) Optometric services
19) Inhalation Therapy services
20) Corrective Therapy
b) These services shall be provided under the supervision of
professionals, fully qualified by education and experience, and holding a state
license, or state or national certification or registration where applicable.
c) Each allied health service shall have documented in the
medical chart patient assessment, care plans, objectives and follow-up plans,
and shall provide evaluative, therapeutic and follow-up programs, working in
coordination with other services, under the overall direction of an
appropriately qualified physician, for the purpose of maximizing patient
self-care and independence.
d) It is recommended that hospitals provide appropriate, current
and accessible reference materials as guides for the specific restoration
services offered.
(Source: Amended at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.890 ANIMAL-ASSISTED THERAPY
Section
250.890 Animal-Assisted Therapy
a) Animal-assisted
therapy programs may be established in hospitals if the boarding and grooming
location of the animals is separate and distinct from patient care units and
the presence of the animals is part of a special program established in
accordance with this Section.
b) The
hospital's Medical Staff and Infection Control Committee shall approve an
animal-assisted therapy program prior to operation of the program.
c) The
Infection Control Committee and Medical Staff shall develop written policies
and procedures for operation of the animal-assisted therapy program, including,
but not limited to, the following. All policies and procedures shall be
developed in accordance with the Guidelines of the Centers for Disease Control
and Prevention titled "Guidelines for Environmental Infection Control in
Health-Care Facilities: Recommendations – Animals in Health Care Facilities"
(see Section 250.160).
1) Designation
of a department within the hospital that will be responsible for operation and
establishment of the animal-assisted therapy program (e.g., Volunteer Services).
2) Development
of written goals and objectives for the program.
3) Policies
governing sanitation, infection control and care and grooming of animals,
including veterinary care.
4) Certification
and training requirements for animals, animal handlers and hospital staff.
5) Policies
for patient screening and assessment for participation in animal-assisted
therapy.
6) Policies
governing areas in the hospital where animals are permitted and prohibited,
including whether therapy will be held in a public area of the hospital or in
the patients' rooms.
7) Policies for determining the
length of therapy sessions.
8) Policies
governing the types of animals that will be permitted to participate in the
program.
9) Policies
governing patient safety and incidents of biting, scratching or other behavior,
and including reporting requirements and patient care.
10) Policies
governing patient consent requirements for participation in the program, for
both adult and child patients.
d) Records
shall be kept for each patient who participates in the program and shall be
available for review by Department staff.
e) All
animal-assisted therapy sessions shall be prescheduled and approved in advance
by the patient's physician and hospital staff who are responsible for the
program.
f) If a
therapy animal is to be boarded overnight in the hospital, the hospital shall
establish, in addition to the infection control requirements of this Section,
policies governing the location in the hospital where the animal will board. A
hospital staff member who has had training for this responsibility shall be
responsible for the care and management of the animal during the time that the
animal is boarding.
g) Therapy
animals shall be accompanied at all times that the animal is in the hospital by
a volunteer or staff member who is familiar with and capable of controlling the
animal's behavior.
h) The
animal-assisted therapy program shall be evaluated annually in a written report
to the Infection Control Committee.
(Source: Added at 32 Ill. Reg. 14336,
effective August 12, 2008)
SUBPART I: NURSING SERVICE AND ADMINISTRATION
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.910 NURSING SERVICES
Section 250.910 Nursing
Services
The hospital shall provide an
organized nursing service.
a) Nursing Services – General Provisions
b) The hospital shall maintain a staff of nursing personnel
organized to provide the nursing care for its patients commensurate with the
size, scope and nature of the hospital.
c) Director of Nursing Administration
1) The nursing service shall be under the direction of a
registered professional nurse who has qualifications in nursing administration
and who has the ability to organize, coordinate, and evaluate the service.
2) The Nursing Administrator (Director of Nursing) shall be a
registered professional nurse who holds a degree in nursing or has documented
experience and relevant continuing education. He/She shall be employed
full-time within the hospital as director of the nursing administration.
3) The Nursing Administrator shall be accountable to the Chief
Executive Officer or designate for developing and implementing policies and
procedures of the service and for the nursing practice.
4) The Nursing Administrator should have authority over the
selection, promotion and retention of nursing personnel based on established
job descriptions.
d) Assistants to the Nursing Administrator.
A qualified registered nurse shall be designated and
authorized to act in the absence of the nursing administrator on a 24 hour
basis.
e) Nursing Staff.
1) A sufficient number of registered professional nurses shall be
on duty at all times to assess, plan, assign, supervise, and evaluate nursing
care and provide patients such nursing care for which the judgement and
specialized skills of a registered nurse is required.
2) Licensed practical nurses and other nursing personnel shall be
qualified through training, education, and experience, and shall have
demonstrated abilities to give nursing care that does not require the skill and
judgement of a registered professional nurse. Auxiliary nursing personnel
shall be assigned and supervised by a professional nurse and shall be given
only those duties for which they are trained.
3) 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.
4) Specific staffing requirements for particular units shall be
followed as stated in other sections of this Part.
f) Staffing Standards.
1) 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.
2) Staffing schedules shall accomplish the following:
A) Identification of the nurse in charge of the patient care unit.
B) Assignment of personnel in a manner which gives consideration
to patient care plans and minimizes the risk of cross-infections.
C) Projection of future time schedules indicating assignment of
personnel by name, status, date and duty tour.
D) Time schedules shall be kept in detail, indicating the
assignment of nursing personnel by name, status, date, patient care unit, and
duty tour. Actual time reports shall be kept verifying personnel attendance by
name date, patient care unit, and time of actual attendance.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.920 ORGANIZATIONAL PLAN
Section 250.920
Organizational Plan
a) A written organizational plan of nursing services shall be an
integral part of the overall hospital organizational plan and shall be
available to all nursing personnel.
b) The nursing service organizational plan shall:
1) be reviewed annually, revised as necessary and dated to
indicate the time of last review;
2) indicate the lines of communication within and between nursing
services;
3) define the relationship of nursing services to other services
and departments of the hospital, both administrative and professional;
4) include a written statement which defines the role and
responsibility of both the nursing service and the education program if the
hospital provides clinical facilities for the education and training of nursing
students.
c) Nursing service goals shall be identified, reviewed annually
and made available to all nursing personnel.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.930 ROLE IN HOSPITAL PLANNING
Section 250.930 Role in
hospital planning
Planning, decision making, and
formulation of policies that affects the operation of the nursing service, the
care of patients, or the environment of patients shall include nursing service
representatives, and their recommendations shall be considered.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.940 JOB DESCRIPTIONS
Section 250.940 Job
descriptions
Job descriptions shall be
written for each position classification in the nursing services and shall
delineate the functions, responsibilities, and qualification for each
classification. Copies of job descriptions shall be available to nursing
personnel.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.950 NURSING COMMITTEES
Section 250.950 Nursing
committees
Nursing committee(s) shall be
formally organized within the nursing department to facilitate the
establishment and attainment of the goals and objectives of the nursing
service. The purpose and function of each standing committee shall be defined
in the nursing service organizational plan.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.960 SPECIALIZED NURSING SERVICES
Section 250.960 Specialized
nursing services
If specialized nursing services
are provided for separate clinical departments or patient care units, those
services shall be subject to the policies and procedures established pursuant
to this Part.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.970 NURSING CARE PLANS
Section 250.970 Nursing Care
Plans
a) There shall be evidence that the nursing service provides
safe, efficient, and therapeutically effective nursing care through the
planning of the care of each inpatient, and patient in observation, and the
effective implementation of nursing care plans.
b) In any case where it is determined that a nursing care plan is
not necessary, that decision shall be documented in the patient's record.
c) The nursing care plan for each patient shall be coordinated
with their medical management plan and the patient's representative.
d) Each nursing care plan shall, at minimum, indicate:
1) The patient’s problems as identified by the nursing staff and
what nursing care is needed;
2) How it can best be accomplished;
3) What methods and approaches are believed likely to be most
successful; and
4) What modifications are necessary to ensure the best results.
e) Each nursing care plan shall be initiated upon the admission
of the patient to the hospital and shall include a discharge plan.
f) The nursing care plans shall be available to all nursing
personnel and shall be reviewed and revised as necessary.
g) Nursing care plans may be considered as a part of and filed
with the patient's record.
(Source:
Amended at 47 Ill. Reg. 14455, effective September 26, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.980 NURSING RECORDS AND REPORTS
Section 250.980 Nursing
Records and Reports
a) Nursing records and reports which reflect the progress of each
patient and the nursing care planned shall be maintained.
b) They shall be pertinent, accurate, and concise so that they
contribute to the continuity of patient care.
c) Nursing records and reports shall become part of each
patient's medical record.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.990 UNUSUAL INCIDENTS
Section 250.990 Unusual
Incidents
a) A procedure shall be established to investigate any unusual
incidents which occur at any time on a patient care unit. (Refer to Subpart B
Section 250.210 (g)).
b) The procedure shall include the making and disposition of
incident reports. Notation of incidents having a direct medical effect on a
specific patient shall be entered in the medical record of that patient.
(Refer to Subpart R, Section 250.2140 (c)(5).)
c) Each report shall be analyzed and summarized, and corrective
action shall be taken if necessary. Summarized reports shall be available to
the Department of Public Health and shall be confidential in accordance with
Section 9 of the Licensing Act.
d) Pursuant to Section 3.2(a) of the Criminal Identification Act,
if a patient is not accompanied by a law enforcement officer, as soon as
treatment allows, a hospital, physician, or nurse shall notify the local law
enforcement agency that serves the hospital when it appears that the patient
has any injury sustained as a victim of an alleged sexual assault or sustained
an injury as a victim of a criminal offense.
1) In instances of alleged sexual assault, the hospital shall
obtain the patient's consent prior to disclosure of the patient's identity to
law enforcement and prior to any interview with law enforcement.
2) A hospital, physician, or nurse shall be forever held
harmless from any civil liability for their reasonable compliance with the
provisions of this Section. (Section 3.2(a)(2) of the Criminal
Identification Act)
(Source: Amended at 47 Ill. Reg. 6477, effective April 27, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1000 MEETINGS
Section 250.1000 Meetings
a) Meetings of the nursing staff shall be held on a regular basis
and proceedings of the meetings shall be recorded.
b) Meetings may be organized consistent with the organizational
plan of the nursing service.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1010 EDUCATION PROGRAMS
Section 250.1010 Education
Programs
a) In an attempt to provide the patient with competent nursing
personnel, there shall be continuing education programs and educational
opportunities for nursing personnel.
b) The Nursing Service Administrator or designee shall design and
implement an educational program to orient new employees and to keep the
nursing staff up-to-date on new and expanding programs, techniques, equipment,
and concepts of care. The program shall be planned, scheduled, documented by a
written outline of its contents, and evaluated at least annually.
c) The scope and duration of the educational program shall be
such as to effectively prepare new and existing personnel. An orientation
program shall be provided for each new nursing service employee.
d) The educational program shall be conducted using resources
internal or external to the hospital. Teaching material and suitable reference
shall be supplied as needed for each patient care unit.
e) There shall be documented evidence of the attendance at each
meeting.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1020 LICENSURE
Section 250.1020 Licensure
a) A procedure shall be maintained to ensure that nursing
personnel for whom licensure is required have valid and current licenses in the
State of Illinois. There shall be a procedure to verify licensure status.
b) The current license and credentials of private duty and agency
nurses shall be verified prior to assignment. The nursing service shall
maintain adequate supervision of private duty and agency nurses and shall
require that they abide by the appropriate policies, procedures and maintain
standards of the hospital and the nursing service.
(Source: Added at 5 Ill. Reg. 507, effective December 29, 1980)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1030 POLICIES AND PROCEDURES
Section 250.1030 Policies
and Procedures
a) For the purposes of this Section:
"Health
care worker" means an individual providing direct patient care services
who may be required to lift, transfer, reposition, or move a patient. A
direct patient care provider is the same as a health care worker.
"Safe lifting
equipment and accessories" means mechanical equipment designed to lift,
move, reposition, and transfer patients, including, but not limited to, fixed
and portable ceiling lifts, sit-to-stand lifts, slide sheets and boards,
slings, and repositioning and turning sheets.
"Safe lifting
team" means at least 2 individuals who are trained in the use of both safe
lifting techniques and safe lifting equipment and accessories, including the
responsibility for knowing the location and condition of such equipment and
accessories. (Section 6.25 of the Act)
b) Nursing policies and procedures shall be developed, reviewed
periodically but at least once a year, and revised as necessary by nursing
representatives in cooperation with appropriate representatives from
administration, the medical staff, and other concerned hospital services or
departments.
c) The nursing policies and procedures shall be dated to indicate
the time of the most recent review or revision.
d) Written policies shall include, but not be limited to, the
following:
1) Criteria pertaining to the performance of special procedures
and the circumstances and supervision under which these may be performed by
nursing personnel;
2) Communication and implementation of diagnostic and therapeutic
orders, including verbal orders, and the responsibility and mechanism for
nursing service to obtain clarification of orders when indicated;
3) Administration of medication;
4) Assignments for providing nursing care to patients;
5) Documentation in patients' records by nursing personnel;
6) Infection control, pursuant to Section 250.1100;
7) A
policy to identify, assess, and develop strategies to control risk of injury to
patients and nurses and other health care workers, associated with the lifting,
transferring, repositioning, or movement of a patient. The policy shall
establish a process that, at a minimum, includes all of the following:
A) Analysis
of the risk of injury to patients and nurses and other health care workers
posted by the patient handling needs of the patient populations served by the
hospital and the physical environment in which the patient handling and
movement occurs;
B) Education
and training of nurses and other direct patient care providers in the
identification, assessment, and control of risks of injury to patients and
nurses and other health care workers during patient handling and on safe
lifting policies and techniques and current lifting equipment;
C) Evaluation
of alternative ways to reduce risks associated with patient handling, including
evaluation of equipment and the environment;
D) Restriction,
to the extent feasible with existing equipment and aids, of manual patient
handling or movement of all or most of a patient's weight except for emergency,
life-threatening, or otherwise exceptional circumstances;
E) Collaboration
with, and an annual report to, the nurse staffing committee;
F) Procedures
for a nurse to refuse to perform or be involved in patient handling or movement
that the nurse in good faith believes will expose a patient or nurse or other
health care worker to an unacceptable risk of injury;
G) Submission
of an annual report to the hospital's governing body or quality assurance
committee on activities related to the identification, assessment, and
development of strategies to control risk of injury to patients and nurses and
other health care workers associated with the lifting, transferring,
repositioning, or movement of a patient;
H) In
developing architectural plans for construction or remodeling of a hospital or
unit of a hospital in which patient handling and movement occurs, consideration
of the feasibility of incorporating patient handling equipment or the physical
space and construction design needed to incorporate that equipment;
I) Fostering and maintaining patient safety, dignity,
self-determination, and choice, including the following policies, strategies,
and procedures:
i) The existence and availability of a trained safe lifting
team;
ii) A policy of advising patients of a range of transfer and
lift options, including adjustable diagnostic and treatment equipment,
mechanical lifts, and provision of a trained safe lifting team;
iii) The right of a competent patient, or guardian of a patient
adjudicated incompetent, to choose among the range of transfer and lift
options, subject to the provisions of subsection (d)(7)(I)(v);
iv) Procedures for documenting, upon admission and as status
changes, a mobility assessment and plan for lifting, transferring,
repositioning, or movement of a patient, including the choice of the patient or
patient's guardian among the range of transfer and lift options; and
v) Incorporation of such safe lifting procedures, techniques,
and equipment as are consistent with applicable federal law; (Section
6.25(b) of the Act)
8) Nursing role in other hospital services, including but not
limited to services such as dietary, pharmacy, and housekeeping; and
9) Emotional and attitudinal support. (Refer to Section 250.260(b)(1).)
e) A nursing procedure manual shall be developed to provide a
ready reference on nursing procedures and a basis for standardization of
procedures and equipment in the hospital.
f) Copies of the nursing procedure manual shall be available on
the patient care units, to the nursing staff, and to other services and
departments of the hospital, including members of the medical staff and
students.
g) The use of latex gloves by hospital staff is
prohibited. If a crisis exists that interrupts a hospital's ability to
reliably source nonlatex gloves, hospital staff may use latex gloves
upon a patient. However, during the crisis, hospital staff shall
prioritize, to the extent feasible, using nonlatex gloves for the treatment of
any patient with self-identified allergy to latex; and any patient upon whom
the latex gloves are to be used who is unconscious or otherwise physically
unable to communicate and whose medical history lacks sufficient information to
indicate whether or not the patient has a latex allergy. (Sections 10(c)
and 15 of the Latex Glove Ban Act)
(Source: Amended at 48 Ill.
Reg. 7321, effective May 3, 2024)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1035 DOMESTIC VIOLENCE STANDARDS
Section 250.1035 Domestic
Violence Standards
A hospital licensed under the
Act shall comply with the following standards relating to
domestic violence (Section 6.01 of the Act) (see Hospital Accreditation
Standards (HAS) of the Joint Commission on Accreditation of Healthcare
Organizations, Section 250.160):
a) Hospitals shall have policies regarding the identification of
possible victims of abuse.
b) Hospital policies regarding possible victims of alleged or
suspected abuse or neglect shall address patients' special needs relative to
the patient assessment process, including consent, evidence collection,
notification and release of information to authorities, and referrals to
community agencies.
c) Nothing in this Section requires hospitals to adopt new
policies regarding domestic violence if their existing hospital policies meet
the requirements of this Section.
(Source: Added at 27 Ill.
Reg. 1547, effective January 15, 2003)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1040 PATIENT CARE UNITS
Section 250.1040 Patient
Care Units
a) Facilities
Patient care units in existence shall comply with patient
care unit requirements and recommendations as stated under Subpart U. When
major remodeling is undertaken on such patient care units the requirements of
Subpart T shall be met.
b) Patient's Rooms
All patient rooms shall be in compliance with Subpart T or U
of this Part.
c) Isolation Room
At least one isolation room shall be provided for each
hospital in compliance with Subparts T or U of this Part.
d) Special Care Room for Disturbed Patients
Every hospital shall provide facilities for emergency
retention of patients with acute mental illness. Emergency retention is a
temporary measure, usually for less than seventy-two hour duration, and is
concerned with the immediate protection of the patient or other persons, or
with the prevention of conduct on the part of disturbed persons that appear to
be dangerous. Emergency retention may be provided in a Special Care Room. The
Special Care Room may be used for multiple purposes and may be located in the
Emergency Department or in a private room on a patient care nursing unit. (See
Subpart S, Section 250.2220 (c).)
e) Room Furnishings
1) Room furnishings shall be arranged to facilitate nursing care
and to avoid the transmission of infection.
2) For spacing see Subparts T or U of this Part.
f) Bed and Bedding
A hospital-type bed with suitable mattress, pillow, and
necessary coverings shall be provided for each patient. Side rails shall be
readily available for each bed. It is recommended that replacement bed
purchases have side rails integral with the bed.
g) Bedside Furniture
There shall be a bedside table and chair for each patient
except infants. Such furnishings may be removed if clinically indicated.
h) Storage Space
There shall be sufficient and satisfactory storage space for
clothing, toilet articles, and other personal belongings of patients.
i) Signals
Audio and/or visual means for signaling nurses shall be
provided within easy reach of patients confined to bed.
j) Patients' Screens
Screens or cubicle curtains shall be available for multibed
rooms to assure privacy for each patient.
(Source: Amended at 11 Ill. Reg. 10642, effective July 1, 1987)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1050 EQUIPMENT FOR BEDSIDE CARE
Section 250.1050 Equipment
for Bedside Care
a) There shall be sufficient equipment for patient care according
to the types of patients accepted by the hospital and for emergency needs.
b) Equipment used near patients and staff shall be adequately
supported or secured and protected to avoid accident and injury.
c) Precautions shall be taken in the use of equipment. Policies
and procedures shall be established accordingly.
d) Specific Equipment
1) Utensils: There shall be a sufficient number of patient care
utensils, wash basins, mouth wash cups, bedpans, emesis basins, urinals, and
soap dishes. Reusable utensils must be sterilized before reissue to another
patient. Disposable equipment shall be used for one patient. There shall be
no resterilization of disposable utensils.
2) Thermometers:
A) There shall be a sufficient number of clinical thermometers to
permit an individual thermometer for each patient. An effective procedure for
cleaning thermometers shall be followed. (A laboratory tested procedure is
recommended.) When electronic thermometers are utilized there shall be a
sufficient supply of probe cots for each patient to have their own. After use,
the probe cot shall be discarded. The probe and cord shall be cleansed at
intervals with an effective agent.
B) A sufficient number of hypothermic or electronic
thermometers capable of aiding in the diagnosis of hypothermia shall be
available. The actual number of these types of thermometers for each
hospital will depend on the numbers and needs of the patients of the hospital.
(Ill. Rev. Stat. 1985, ch. 111½, par. 147.07)
3) Hot Water Bags: When hot water bags are used, they shall be
tested for leakage and covered before being placed in beds. The temperature of
the water should not exceed 110º F (55º C).
4) Electrical Appliances and Equipment: Electrical equipment
shall be inspected before use. It shall be maintained in good repair under the
provisions of a preventive maintenance program of the Engineering and
Maintenance Services. (Refer Subpart O.)
5) Restraints: Restraints shall be available and policies shall
be established for their use. (Policy shall reflect use of cloth and leather
restraints.) (See Section 250.2280(c).)
6) Oxygen Equipment:
A) Oxygen apparatus shall be provided and maintained in good
repair. Definite marked storage space shall be provided for oxygen equipment.
B) Oxygen tanks in use at patient's bedside, or wherever located,
shall be adequately secured to prevent movement or falling.
(Source: Amended at 11 Ill. Reg. 10642, effective July 1, 1987)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1060 DRUG SERVICES ON PATIENT UNIT
Section 250.1060 Drug
Services on Patient Unit
Refer to Subpart R – Pharmacy or
Drug and Medicine Service and Subpart C – Medical Staff Section 250.330(a).
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1070 CARE OF PATIENTS
Section 250.1070 Care of
Patients
a) All persons shall be admitted to the hospital, by a member of
the medical staff with admitting privileges, an advanced practice registered nurse,
or a physician assistant with clinical privileges recommended by the medical
staff and granted by the governing board. All persons admitted to the hospital,
whether as inpatients or outpatients, shall be under the professional care of a
member of the medical staff. (See Section 250.240(b)(1).)
b) The hospital shall provide basic and effective care to each
patient. Insofar as possible, the hospital shall assign patients to
accommodations that will provide for adequate segregation with regard to sex,
age, and medical management. (See Section 250.240(b)(2).)
(Source: Amended at 43 Ill. Reg. 3889,
effective March 18, 2019)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1075 USE OF RESTRAINTS AND SECLUSION
Section 250.1075 Use of
Restraints and Seclusion
a) Each hospital licensed under the Act and this
Part shall have a written policy to address the use of restraints and
seclusion in the hospital. Each hospital policy shall include periodic review
of the use of restraints and seclusion in the hospital. (Section 6.20 of
the Act)
b) The hospital's policy governing the use of restraints and
seclusion shall be consistent with 42 CFR 482.213(e) and (f). (Section
6.20 of the Act)
c) In hospitals, restraints or seclusion may only be ordered
by a physician licensed to practice medicine in all its branches or a
registered nurse with supervisory responsibilities as authorized by the medical
staff. The medical staff of a hospital may adopt a policy specifying the
requirements for the use of restraints or seclusion and identifying whether a
registered nurse with supervisory responsibilities may order restraints or
seclusion in the hospital when the patient's treating physician is not
available. (Section 6.20 of the Act)
d) Registered nurses authorized to order restraints or
seclusion shall have appropriate training and experience as determined by
medical staff policy. The treating physician shall be notified when restraints
or seclusion is ordered by a registered nurse. Nothing in this Section
requires that a medical staff authorize a registered nurse with supervisory
responsibilities to order restraints or seclusion. (Section 6.20 of the
Act)
e) When hard restraints are employed, all nursing and patient care
staff assigned to that unit must have a restraint key in their possession for
the duration of their shift.
(Source: Amended at 27 Ill.
Reg. 13467, effective July 25, 2003)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1080 ADMISSION PROCEDURES AFFECTING CARE
Section 250.1080 Admission
Procedures Affecting Care
a) Written policies and procedures for the routine admission of
patients shall be established.
b) Patients having communicable disease need not be denied
admission. If admitted, proper isolation procedures shall be initiated and
enforced.
c) A policy for the admission and treatment of patients with
communicable disease shall be established by the Infection Control Committee of
the hospital. The policy shall indicate conditions for transfer of those cases
which cannot be properly cared for at the institution.
d) A policy shall be established for the treatment of patients
with infectious or communicable diseases requiring intensive care or other
ancillary service.
e) On admission, the admitting member of the medical staff shall
provide an admission or tentative diagnosis which shall become a part of the
patient's medical record.
f) The admitting member of the medical staff shall provide
initial orders for the care of each patient upon admission.
g) At all times there shall be used as a reliable method of
patient identification affixed to the patient in an acceptable manner.
Particular attention shall be given to the identification of infants and young
children and others unable to identify themselves.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1090 STERILIZATION AND PROCESSING OF SUPPLIES
Section 250.1090
Sterilization and Processing of Supplies
a) All sterilization and processing of all sterile supplies and
equipment shall be under competent, qualified supervision.
1) The director or person responsible for central services shall
be responsible to the chief executive officer either directly or through a
designated department head. The director of the central sterile supply shall
be qualified for the position by education, training, and experience and shall
be a member of the Infection Control Committee. (See Section 250.1100(a).)
2) The number of supervisory and support personnel shall be
related to the scope of the services provided. New employees shall receive
initial orientation and on-the-job training, and all employees shall
participate in a continuing in-service education program, which shall be
documented.
3) Educational efforts, though directed primarily at
sterile-supply processing and handling techniques, shall also include
management concepts, safety, personal hygiene, health requirements, and work
attire.
b) There shall be written policies and procedures for the
decontamination and sterilization activities performed in central services and
elsewhere in the hospital. The hospital shall comply with the Centers for
Disease Control and Prevention Guidelines for Disinfection and Sterilization in
Healthcare Facilities. These policies and procedures shall include, but are
not limited to, the following:
1) The receiving, decontaminating, cleaning, preparing,
disinfecting and sterilizing of reusable items.
2) The assembly, wrapping, storage, distribution, and quality
control of sterile equipment and medical supplies. Load control numbers shall
be used to designate the hospital sterilization equipment used for each item,
including the sterilization date and cycle.
3) The use of sterilization process monitors, including
temperature and pressure recordings, and the use and frequency of appropriate
chemical indicator and bacteriological spore tests for all sterilizers.
4) Designation of the shelf life for each hospital-wrapped and
-sterilized medical item and, to the maximum degree possible, for each
commercially prepared item.
A) Designation of a shelf life may be a specific expiration date,
i.e., 30 days, six months, etc., based on manufacturer's recommendation, a
nationally recognized authority, or other standard approved by the facility's
Infection Control Committee.
B) Designation of shelf life may be event related if policies and
procedures, approved by the Infection Control Committee, address at least the
following:
i) requirements for wrapping, storage and rotation of sterile
supplies;
ii) definition of an event that may cause a sterile item to be or
be suspected of being compromised, such as the package being wet or torn, or
the seal being broken or tampered with;
iii) clear direction that the final inspection of the package and
the ultimate decision to use the contents of the package rest with the
clinician; and
iv) orientation, in-service and other follow-up training to assure
that all necessary staff understand and implement the policies and procedures.
C) A facility may choose to use both a specific expiration date
and event-related shelf life designation specific for certain wrappings, areas
of the hospital, etc., as long as the policies and procedures, as approved by
the Infection Control Committee, and the training of staff define this
practice.
5) Acquisition of supplies after normal working hours or any time
the central service or sterile supply unit is considered "closed" or
unstaffed.
6) Preventive maintenance of all central supply service
equipment, including performance verification records and reports.
7) The recall and disposal or reprocessing of expired or
inadequately sterilized supplies.
8) The emergency collection and disposition of supplies when
special warnings have been issued by the manufacturer. The attending physician
shall be notified when patient exposure is known.
9) Specific aeration requirements for each category of
gas-sterilized items to eliminate the hazard of toxic residues.
10) The cleaning and sanitizing of work surfaces, floors,
utensils, and equipment used in central service functions.
c) Space shall be provided for the efficient operation of all
central service functions. Functional design and work flow patterns shall
provide for the separation of soiled and contaminated supplies from those that
are clean and sterile. Equipment of adequate design, size, and type shall be
provided for the effective decontaminating, disinfecting, cleaning, packaging,
sterilizing, storing, and distributing of medical instruments, supplies, and
equipment used in patient care.
d) Equipment and procedures
1) The facilities, equipment, and procedures for clean-up,
preparation, and sterilization shall be adequate to allow proper cleaning,
processing, and sterilizing of patient care supplies and equipment.
2) When clean-up, preparation, and sterilization functions are
carried out in the same room or unit (as in a central sterilizing department)
the physical facilities and equipment and the policies and procedures for their
use shall be such as to effectively separate soiled or contaminated supplies
and equipment from the clean or sterilized supplies and equipment.
3) Sterilization equipment shall be maintained in good repair and
under the provisions of a preventive maintenance program of the Engineering and
Maintenance Services. (Refer to Subpart P.)
4) All pressure steam autoclaves shall have recording
thermometers, and the sterilization performance shall be otherwise checked.
e) Sterilization of instruments and utensils
1) All surgical instruments not adversely affected by high
temperature shall be sterilized by pressure steam sterilization.
2) The steam method of sterilization is the preferred method for
sterilizing medical and surgical instruments that are not damaged by heat,
steam, pressure, or moisture. Low-temperature sterilization technologies
(e.g., Ethylene Oxide (EtO), hydrogen peroxide gas plasma) may be used for
reprocessing patient care equipment that is heat or moisture sensitive. In
addition, a peracetic acid immersion system of sterilization may be used to
sterilize heat-sensitive immersible medical and surgical items, and dry-heat
sterilization may be used to sterilize items (e.g., powders, oils) that can
sustain high temperatures. Operating parameters and guidelines for each method
or system of sterilization shall be followed for whichever method is used.
3) All instruments shall be thoroughly cleaned before
sterilization.
4) Boiling is not an approved method of sterilization.
f) Water sterilization
1) When non-commercial sterile water is utilized, water
sterilization equipment shall be maintained and operated in a manner that will
protect the sterilized water from contamination.
2) An acceptable method for checking the sterility of the water
shall be utilized. Water may be sterilized either in approved water sterilizers
or autoclaved in approved flasks.
g) Sterilization and storage of supplies and equipment
1) Supplies and equipment shall be properly wrapped and labeled
before sterilization.
2) The effectiveness of hospital sterilization shall be checked.
Mechanical, chemical, and biologic monitors shall be used to ensure the
effectiveness of the sterilization process. Indicators shall be used to show
that the items have been sterilized. A procedure shall be established for the
recall of expired or inadequately sterilized goods for both in-house and
commercially sterilized supplies and equipment. Refer to Section 250.1100(a).
3) Supplies and equipment commercially prepared so as to retain
sterility indefinitely are acceptable. The hospital shall satisfy itself of
the sterility of such materials.
4) Sterile equipment and supplies shall be stored properly in clean
cabinets, cupboards or other suitable enclosed spaces. An orderly system of
rotation of supplies is recommended so that supplies stored first will be used
first.
h) Transmissible spongiform
encephalopathies (TSEs)
1) Records
shall be maintained for at least 20 years regarding quarantine, disposal,
decontamination, and sterilization of surgical instruments used for patients
with a confirmed or suspected TSE.
2) For
the purposes of this Section, TSEs are a group of rapidly progressive, invariably
fatal neurodegenerative diseases that affect both humans and animals. TSEs in
humans include Creutzfeldt-Jakob disease (CJD), kuru,
Gerstmann-Straussler-Scheinker syndrome (GSS), fatal familial insomnia (FFI),
and variant CJD (vCJD).
(Source: Amended at 34 Ill.
Reg. 19031, effective November 17, 2010)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1100 INFECTION CONTROL
Section 250.1100 Infection
Control
a) A
hospital shall designate a person or persons as Infection Prevention and
Control Professionals to develop and implement policies governing control of
infections, communicable diseases, and Antibiotic Stewardship Programs. The
Infection Prevention and Control Professionals shall be qualified through
education, training, experience, or certification. The qualifications shall be
documented.
b) A multidisciplinary Infection Control Committee, composed at
least of members of the medical staff and nursing staff, the Infection
Prevention and Control Professionals, and the supervisor of Central Sterile
Supply and administration, shall be responsible for investigations and
recommendations for the prevention and control of infections within the
hospital. This Committee shall perform an annual facility-wide infection
control risk assessment. (Section 6.23 of the Act)
c) Policies and procedures for reporting cases of communicable
diseases and for the care of patients with communicable diseases shall be in
accordance with the Control of Communicable Diseases Code, the Control of
Sexually Transmissible Infections Code and the Control of Tuberculosis Code.
d) When patients having a communicable disease, or presenting
signs and symptoms suggestive of that diagnosis, are admitted, proper
precautionary measures shall be taken to avoid cross-infection to personnel,
other patients, or the public.
e) The hospital shall provide facilities and equipment for the
isolation of known or suspected cases of infectious disease.
f) Policies and procedures for handling infectious cases shall
include orders for nursing and non-professional staffs providing for proper
isolation technique.
g) A
hospital shall develop a policy for testing its water supply for Legionella pneumophila
bacteria. The policy shall be based on the ASHRAE publications "Managing
the Risk of Legionellosis Associated with Building Water Systems" and
"Legionellosis: Risk Management for Building Water Systems", and the
Centers for Disease Prevention and Control's "Toolkit for Controlling
Legionella in Common Sources of Exposure". The policy shall include
the frequency with which testing is conducted. The policy and the results of
any tests and corrective actions taken shall be made available to the
Department upon request. (Section 6.29 of the Act) The policy shall
include, at a minimum:
1) A
procedure to conduct a facility risk assessment to identify potential
Legionella and other waterborne pathogens in the facility water system;
2) A
water management program that identifies specific testing protocols and
acceptable ranges for control measures; and
3) A system to document
the results of testing and corrective actions taken.
h) All persons who care for patients with, or suspected of having,
a communicable disease, or whose work brings them in contact with materials
that are potential conveyors of communicable disease, shall take appropriate
safeguards to avoid transmission of the disease agent.
i) The
hospital shall develop and implement comprehensive interventions to prevent and
control multidrug-resistant organisms (MDROs), including methicillin-resistant
Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and
certain gram-negative bacilli (GNB), that take into consideration guidelines of
the Centers for Disease Control and Prevention for the management of MDROs in
health care settings, including the "Guidelines for Isolation
Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings" and "Guidelines for Hand Hygiene in Health-Care Settings".
(Section 6.23 of the Act)
j) All
hospitals shall comply with the Centers for Disease Control and Prevention
publication "Guidelines for Infection Control in Health Care Personnel".
k) The multidisciplinary
Infection Control Committee shall be responsible for developing, implementing,
monitoring, and enforcing a hand hygiene program in the hospital. For the
purposes of this Section, "hand hygiene" is a general term that
applies to hand washing with plain soap and water; antiseptic hand wash using
soap containing antiseptic agents and water; antiseptic hand rub using a
waterless antiseptic product, most often alcohol based, rubbed on the surface
of the hands; or surgical hand antiseptic.
1) The
Committee shall assess the current practices and compliance, assess hand
hygiene products that are currently being used, solicit input from clinical
staff, and develop a hand hygiene program for all staff.
2) All
staff (including contractual and medical) shall be educated in the hand hygiene
program during initial orientation and at least annually. This education shall
be documented.
3) The
program shall have clear written goals that require quantitative, time-specific
improvement targets.
4) The
Committee shall develop and implement measurement tools to be used to assure
ongoing compliance with the program.
5) The
program shall incorporate the requirements for hand hygiene in educational
materials presented to all staff on an ongoing basis; engage patients and
families in the hand hygiene efforts; monitor compliance of all staff with
recommended measurement tools for hand hygiene, including immediate feedback to
personnel; and track compliance over time.
6) The
results of the monitoring shall be incorporated in the Quality
Assurance/Quality Improvement Program.
l) Contaminated material shall be handled and disposed of in a
manner designed to prevent the transmission of the infectious agent.
m) Thorough hand hygiene shall be required after touching any
contaminated or infected material.
n) Whenever the Control of Communicable Diseases Code and the
Control of Tuberculosis Code require the submission of laboratory specimens for
the release of a patient from isolation or quarantine and the hospital
laboratory is not approved by the Department for the performance of the
specific tests, the specimens shall be submitted to the laboratories of the
Illinois Department of Public Health or other laboratory licensed by the
Department for the specific tests required.
o) The hospital shall establish a systematic plan of checking and
recording cases of infection, known or suspected, that develop in the
institution; these cases shall be reported to the Infection Control Committee
and hospital administration. The Committee shall be empowered and directed to
investigate health care-associated infections to determine the causative
organism and its possible sources. The findings and recommendations of the Infection
Control Committee shall be reported to the medical staff and administration for
corrective action.
p) Policies and procedures related to this Section and to the
following items shall be developed:
1) The admission and isolation of patients with specific or
suspected infectious diseases, and protective isolation of appropriate
patients.
2) In-service education programs on the control of infectious diseases.
3) Policies and procedures for isolation techniques appropriate
to the working diagnosis of the patient, and protective routines for personnel
and visitors.
4) The recording and reporting of all infections of clean
surgical cases to the Infection Control Committee, and procedures for the
investigation of those cases.
q) In
order to improve the prevention of hospital-associated bloodstream infections
due to methicillin-resistant Staphylococcus aureaus (MRSA), every hospital
shall establish an MRSA control program that requires:
1) Identification
of all MRSA-colonized patients in all intensive care units, and other at-risk
patients identified by the hospital, through active surveillance testing.
2) Isolation
of identified MRSA-colonized or MRSA-infected patients in an appropriate
manner.
3) Monitoring
and strict enforcement of hand hygiene requirements.
4) Maintenance
of records and reporting of cases under Section 10 of the Act.
(Section 5 of the MRSA Screening and Reporting Act)
r) Each
hospital shall adopt, implement, and update no less than every three years
evidence-based protocols for the early recognition and treatment of patients
with sepsis, severe sepsis, or septic shock (sepsis protocols) that are based
on generally accepted standards of care. Sepsis protocols shall include
components specific to the identification, care, and treatment of adults and of
children, and shall clearly identify where and when components will differ for
adults and for children seeking treatment in the emergency department or as an
inpatient. These protocols shall also include the following components:
1) A
process for the screening and early recognition of patients with sepsis, severe
sepsis, or septic shock;
2) A
process to identify and document individuals appropriate for treatment through
sepsis protocols, including explicit criteria defining those patients who
should be excluded from the protocols, such as patients with certain clinical
conditions or who have elected palliative care;
3) Guidelines
for hemodynamic support with explicit physiologic and treatment goals,
methodology for invasive or non-invasive hemodynamic monitoring, and timeframe
goals;
4) For
infants and children, guidelines for fluid resuscitation consistent with
current, evidence-based guidelines for severe sepsis and septic shock with
defined therapeutic goals for children;
5) Identification
of the infectious source and delivery of early broad spectrum antibiotics with
timely re-evaluation to adjust to narrow spectrum antibiotics targeted to
identified infectious sources; and
6) Criteria
for use, based on accepted evidence of vasoactive agents.
s) Each
hospital shall ensure that professional staff with direct patient care
responsibilities and, as appropriate, staff with indirect patient care
responsibilities, including, but not limited to, laboratory and pharmacy staff,
are periodically trained to implement the sepsis protocols required under
subsection (r). The hospital shall ensure updated training of staff if
the hospital initiates substantive changes to the sepsis protocols.
t) Each
hospital shall be responsible for the collection and utilization of quality
measures related to the recognition and treatment of severe sepsis for purposes
of internal quality improvement.
u) The
evidence-based protocols adopted by the hospital under Section 6.23a
of the Act shall be provided to the Department upon the Department's request.
v) Hospitals
submitting sepsis data as required by the Centers for Medicare and Medicaid
Services Hospital Inpatient Quality Reporting Program are presumed to meet the
sepsis protocol requirements outlined in this Section. (Section 6.23a of
the Act)
(Source: Amended at 46 Ill.
Reg. 15597, effective September 1, 2022)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1110 MANDATORY OVERTIME PROHIBITION
Section 250.1110 Mandatory
Overtime Prohibition
a) As
used in this Section, the following definitions apply:
"Agreed-to,
predetermined shift" – nursing hours of work, provided in advance to
staff, in a prospective nurse staffing schedule for each patient care unit.
Any work hours in addition to the predetermined shifts or prospective work
schedule must be agreed to between the nurse employee and the employer. The
agreed-to, predetermined shift may include "on call" but does not
include other overtime staffing mechanisms in which a nurse employee's work, or
availability to work additional hours, is at the sole discretion of the
employer.
"Mandated
overtime" – work that is required by the hospital in excess of an
agreed-to, predetermined work shift. Time spent by nurses required to be
available as a condition of employment in specialized units, such as surgical
nursing services, shall not be counted or considered in calculating the amount
of time worked for the purpose of applying the prohibition against mandated
overtime. (Section 10.9(a) of the Act)
"Nurse"
– any advanced practice registered nurse, registered professional nurse, or
licensed practical nurse, as defined in the Nursing and Advanced Practice
Nursing Act, who receives an hourly wage and has direct responsibility to
oversee or carry out nursing care. For the purposes of this Section,
"advanced practice registered nurse" does not include a certified
registered nurse anesthetist who is primarily engaged in performing the duties
of a nurse anesthetist. (Section 10.9(a) of the Act)
"On-call/available"
– the voluntary agreement by any nurse to be assigned specific agreed-to,
predetermined hours of availability for work as a condition of employment.
Additional hours of on-call in excess of the nurse's predetermined hours of
work shall be strictly voluntary.
"Overtime"
– the hours of work in excess of an agreed-to predetermined regularly scheduled
shift, not to exceed 40 hours of work in a seven-day workweek.
"Retaliation"
– disciplining, discharging, suspending, demoting, harassing, denying
employment or promotion, laying off, or taking any adverse action against a
nurse.
"Specialized
unit" – a unit, such as surgical nursing services.
"Substantially
affect" – affecting a situation, except for deviations that result in
unimportant changes, given the particular situation involved.
"Unforeseen
emergent circumstances" –
Any
declared national, State or municipal disaster or other catastrophic event, or
implementation of a hospital's disaster plan, that will substantially affect or
increase the need for health care services; or
Any
circumstances in which patient care needs require specialized nursing skills
through the completion of a procedure.
An
"unforeseen emergent circumstance" does not include situations in
which the hospital fails to have enough nursing staff to meet the usual and
reasonably predictable nursing needs of its patient. (Section 10.9(a) of
the Act)
b) Mandated overtime is prohibited. No nurse shall
be required to work mandated overtime except in the case of an unforeseen
emergent circumstance when such overtime is required only as a last resort.
1) Such mandated overtime shall not exceed 4 hours beyond an
agreed-to, predetermined work shift. (Section 10.9(b) of the Act)
2) Time spent by nurses required to be available as a
condition of employment in specialized units, such as surgical nursing
services, shall not be counted or considered in calculating the amount of time
worked for the purpose of applying the prohibition against mandating overtime.
(Section 10.9(a) of the Act)
3) For any nurse who does not agree to employment requiring
on-call hours, the refusal of a nurse employee to agree to such on-call
availability shall not constitute grounds for retaliation, discrimination,
dismissal, discharge, or any other penalty, threat of reports for discipline,
or employment decisions adverse to the nurse employee.
4) The hospital's written staffing plan shall include an on-call
policy for those units where on-call is required as a condition of employment.
5) On-call is not to be used to fill vacancies resulting from
chronic or foreseeable staff shortages.
c) When a nurse is mandated to work up to 12 consecutive
hours, the nurse shall be allowed at least 8 consecutive hours of
off-duty time immediately following the completion of a shift. (Section
10.9(c) of the Act)
d) No hospital shall discipline, discharge, or take any
other adverse employment action against a nurse solely because the nurse
refused to work mandated overtime as prohibited under subsection (b).
(Section 10.9(d) of the Act)
e) Violations
1) Any employee of a hospital that is subject to the Act and
this Part may file a complaint with the Department of Public Health regarding
an alleged violation of the Act. (Section 10.9(e) of the Act)
A) A complaint shall be submitted to the Department in writing, by
telephone, or by personal visit.
B) An oral complaint will be reduced to writing by the Department.
2) The complaint shall be filed within 45 days
following the occurrence of the incident giving rise to the alleged violation.
The Department will forward notification of the alleged violation to the
hospital in question within 3 business days after the complaint is filed.
(Section 10.9(e) of the Act)
3) Upon receiving a complaint of a violation of this Section,
the Department may take any action authorized under Section 7 or 9 of the
Act. (Section 10.9(e) of the Act)
f) Any violation of this Section shall be proved by
clear and convincing evidence that a nurse was required to work overtime
against his or her will. The hospital may defeat the claim of a violation by
presenting clear and convincing evidence that an unforeseen emergent
circumstance, which required overtime work, existed at the time the employee
was required or compelled to work. (Section 10.9(f) of the Act) Hearings
shall be conducted in accordance with Section 250.140.
(Source: Amended at 43 Ill. Reg. 3889,
effective March 18, 2019)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1120 STAFFING LEVELS
Section 250.1120 Staffing
Levels
a) As used in this Section, the following
definitions apply:
"Nursing
care" – care that falls within the scope of practice set forth in the
Nursing and Advanced Practice Nursing 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 Hospital Report Card Act [210 ILCS
86])
"Staffing
levels" – the numerical nurse to patient ratio by licensed nurse
classification within a nursing department or unit. (Section 10 of the Hospital Report Card Act)
"Unit"
– a functional division or area of a hospital in which nursing care is
provided. (Section 10 of the
Hospital Report Card Act)
b) 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 of the Hospital Report Card Act)
c) 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. 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.
Upon the roster's expiration, the hospital shall retain the roster for 5 years
from the date of its expiration. (Section 15 of the Hospital Report Card
Act)
d) All records required under this
Section and Section 15 of the Hospital Report Card Act, including
anticipated staffing schedules and the methods to determine and adjust staffing
levels, shall be made available to the public upon request. (Section 15 of
the Hospital Report Card Act)
e) All records required under this
Section and Section 15 of the Hospital Report Card Act shall be maintained
by the facility for no less than 5 years. (Section 15 of the Hospital Report
Card Act)
f) A hospital covered by the Hospital
Report Card Act shall not penalize, discriminate, or retaliate in any manner
against an employee with respect to compensation or the terms, conditions, or
privileges of employment who in good faith, individually or in conjunction with
another person or persons, reports violations of the Hospital Licensing Act
or the Hospital Report Card Act pursuant to Sections 35 and 40 of the Hospital
Report Card Act. (Section 35 of the Hospital Report Card Act)
(Source:
Added at 31 Ill. Reg. 14530, effective October 3, 2007)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1130 NURSE STAFFING BY PATIENT ACUITY
Section 250.1130 Nurse Staffing by Patient Acuity
a) As used in this Section,
the following definitions apply:
"Acuity Model" – means
assessment tool selected and implemented by a hospital, as recommended by a
nursing care committee, that assesses the complexity of patient care needs
requiring professional nursing care and skills and aligns patient care needs
and nursing skills consistent with professional nursing standards.
"Direct Patient Care"
– means care provided by a registered professional nurse with direct
responsibility to oversee or carry out medical regimens or nursing care for one
or more patients.
"Nursing-sensitive Care Performance
Measure" – means data that examine nursing contributions to inpatient
hospital care, including, but not limited to, the data collected and analyzed
under the Hospital Report Card Act, the Illinois Adverse Health Care Events
Reporting Law of 2005, and the National Database for Nursing Quality
Indicators. The National Database for Nursing Quality Indicators may be
accessed at https://www.pressganey.com/products/clinical-excellence/national-database-nursing-quality-indicators.
Hospitals are not required to subscribe to the database.
"Nursing Care Committee"
− means a hospital-wide committee or committees of nurses whose
functions, in part or in whole, contribute to the development, recommendation,
and review of the hospital's nurse staffing plan established pursuant to
subsection (b). (Section 10.10(b) of the Act)
"Patient Acuity"
− means the complexity of patient care needs requiring the skill and care
of a nurse, which is addressed when aligning nursing resources and professional
practice standards as part of the patient's treatment plan.
"Registered Professional Nurse"
– means a person licensed as a Registered Nurse under the
Nurse Practice Act.
"Written Staffing Plan for
Nursing Care Services" – means a written plan for the assignment of
patient care nursing staff based on multiple nurse and patient considerations
that yield minimum staffing levels for inpatient care units and the adopted
acuity model aligning patient care needs with nursing skills required for
quality patient care consistent with professional nursing standards. (Section
10.10(b) of the Act)
b) Written Staffing Plan
1) Every
hospital shall implement a written hospital-wide staffing plan, prepared by a
nursing care committee or committees, that provides for minimum direct care
professional registered nurse-to-patient staffing needs for each inpatient care
unit, including inpatient emergency departments.
2) If
the staffing plan prepared by the nursing care committee is not adopted by the
hospital, or if substantial changes are proposed, the chief nursing officer
shall either provide a written explanation to the committee of the reasons the
plan was not adopted or provide a written explanation of any substantial
changes made to the proposed plan prior to it being adopted by the hospital.
3) The
written hospital-wide staffing plan shall include, but need not be limited to,
the following considerations:
A) The
complexity of complete care, assessment on patient admission, volume of patient
admissions, discharges and transfers, evaluation of the progress of a patient's
problems, ongoing physical assessments, planning for a patient's discharge,
assessment after a change in patient condition, and assessment of the need for
patient referrals;
B) The
complexity of clinical professional nursing judgment needed to design and
implement a patient's nursing care plan, the need for specialized equipment and
technology, the skill mix of other personnel providing or supporting direct
patient care, and involvement in quality improvement activities, professional
preparation (credentials), and experience;
C) Patient
acuity and the number of patients for whom care is being provided;
D) The
ongoing assessments of a unit's patient acuity levels and nursing staff needed,
routinely made by the unit nurse manager or his or her designee; and
E) The
identification of additional registered nurses available for direct patient
care when patients' unexpected needs exceed the planned workload for direct
care staff and the process to add additional staff. (Section
10.10(c) of the Act)
F) The
process for submitting the nursing care committee's recommendations to hospital;
and
G) The
process for providing feedback to the nursing care committee from the hospital
administration regarding unresolved or ongoing issues.
4) A
written staffing plan shall consider the time required for nursing staff documentation
of patient care.
5) In
order to provide staffing flexibility to meet patient needs, every hospital
shall identify an acuity model for adjusting the staffing plan for each
inpatient care unit.
6) Each
hospital shall implement the staffing plan and assign nursing personnel to each
inpatient care unit, including inpatient emergency departments, in accordance
with the staffing plan.
A) A
registered nurse may report to the nursing care committee any variations where
the nurse personnel assignment in an inpatient care unit is not in accordance
with the adopted staffing plan and may make a written report to the nursing
care committee based on the variations.
B) Shift-to-shift
adjustments in staffing levels required by the staffing plan may be made by the
appropriate hospital personnel overseeing inpatient care operations. If a
registered nurse in an inpatient care unit objects to a shift-to-shift
adjustment, the registered nurse may submit a written report to the nursing
care committee.
C) The
nursing care committee shall develop a process to examine and respond to
written reports submitted under subsections (b)(6)(A) and (b)(6)(B), including
the ability to determine if a specific written report is resolved or should be
dismissed. (Section 10.10(c)(2.5) of the Act)
7) The
written staffing plan shall be posted, either by physical or electronic means,
in a conspicuous and accessible location for both patients and direct care
staff, as required under the Hospital Report Card Act. A copy of the written
staffing plan shall be provided to any member of the general public upon
request. (Section 10.10(c)(3) of the Act)
8) In
addition to the hospital providing a copy of the written staffing plan per
subsection (b)(6), the hospital shall allow members of the public to schedule
an appointment with the Chief Nursing Officer or their designee to review the
staffing plan and address any questions.
c) Nursing Care Committee
1) Every
hospital shall have a nursing care committee that meets at least 6 times per
year. A hospital shall appoint members of a committee of which at least
55% of the members are registered professional nurses providing direct inpatient
care, one of whom shall be selected annually by the direct inpatient care
nurses to serve as co-chair of the committee. (Section 10.10(d)(1) of the
Act)
A) The
registered professional nurses on the nursing care committee shall be as
broadly representative of the clinical service areas as practically reasonable;
e.g., surgery, critical care, medical surgical, obstetrics, emergency
department and pediatrics.
B) When
committee or nurse staff volume is not practically reasonable to include
representatives from each clinical service area at any one time, the hospital
may schedule for rotating representation of the hospital's clinical service
areas over a defined timeframe to achieve input from all clinical service areas
every three years.
C) Minutes
for the nursing care committee meetings, summarizing key issues, discussions
and recommendations, shall be recorded and maintained for five years.
2) A
nursing care committee shall prepare and recommend to hospital administration
the hospital's written hospital-wide staffing plan. If the staffing plan is
not adopted by the hospital, the chief nursing officer shall provide a written
statement to the committee prior to a staffing plan being adopted by the
hospital that:
A) Explains
the reasons the committee's proposed staffing plan was not adopted; and
B) Describes
the changes to the committee's proposed staffing or any alternative to the
committee's proposed staffing plan. (Section 10.10(d)(2.5) of the
Act)
3) A
nursing care committee's or committees' written staffing plan for the hospital shall
be based on the principles from the staffing components set forth in subsection
(b). In particular, a committee or committees shall provide input and
feedback on the following:
A) Selection,
implementation, and evaluation of minimum staffing levels for inpatient care
units.
B) Selection,
implementation, and evaluation of an acuity model to provide staffing
flexibility that aligns changing patient acuity with nursing skills required.
C) Selection,
implementation, and evaluation of a written staffing plan incorporating the
items described in subsections (b)(1) through (b)(5). (Section
10.10(d)(3) of the Act)
i) The
process for review and evaluation of the written staffing plan shall take into
consideration nursing-sensitive care performance measures.
ii) The
process for review and evaluation of the written staffing plan shall consider
the National Quality Forum's Safe Practices for Better Healthcare.
4) The
committee or committees shall review the nurse staffing plans for all
inpatient areas and current acuity tools and measures in use. The nursing care
committee's review shall consider:
A) Patient outcomes;
B) Complaints
regarding staffing, including complaints about a delay in direct care nursing
or an absence of direct care nursing;
C) The
number of hours of nursing care provided through an inpatient hospital unit
compared with the number of inpatients served by the hospital unit during a
24-hour period;
D) The aggregate hours
of overtime worked by the nursing staff;
E) The
extent to which actual nurse staffing for each hospital inpatient unit differs
from the staffing specified by the staffing plan; and
F) Any
other matter or change to the staffing plan determined by the committee to
ensure that the hospital is staffed to meet the health care needs of patients.
(Section 10.10(d)(3)(D) of the Act)
5) System-related
or clinical service area nurse staffing or patient issues identified between
meetings shall be shared, reviewed and addressed at the next nurse care
committee meeting.
6) A
nursing care committee must issue a written report addressing the items
described in subsections (c)(3) and (c)(4) semi-annually. A
written copy of this report shall be made available to direct inpatient care
nurses by making available a paper copy of the report, distributing it
electronically, or posting it on the hospital's website. (Section 10.10(d)(4)
of the Act)
7) A
nursing care committee must issue a written report at least annually to the
hospital governing board that addresses items including, but not limited to:
A) The
items described in subsections (b)(1) through (b)(5);
B) Changes
made based on committee recommendations and the impact of these changes;
C) Recommendations
for future changes related to nurse staffing (Section 10.10(d)(5) of the
Act);
D) The
composition of the nursing units represented by members of the nursing care
committee;
E) Goals
and accomplishments of the nursing care committee;
F) Outline
of the current acuity tools in each inpatient and emergency department;
G) Personnel
data including annual registered nurse turnover rate, current registered nurse
vacancy rate, current and posted full-time or full-time equivalent registered
nurse positions, and annual certified nurse aid/tech turnover and vacancy rate;
H) Number
of registered nurse injuries related to patient lifting and handling as per
Section 250.1030(d)(7); and
I) Number
of hospital inpatient acquired pressure injuries.
8) A
Nursing care committee must annually notify the hospital nursing staff of the
staff's rights under Section 10.10 of the Act. The annual notice must
provide a phone number and an email address for staff to report noncompliance
with the nursing staff's rights as described in this Section of the Act.
The notice must be provided by email or by regular mail in a manner that
effectively facilitates receipt of the notice. (Section 10.10(d)(6) of the
Act)
d) Nothing
in this Section shall be construed to limit, alter, or modify any of the terms,
conditions, or provisions of a collective bargaining agreement entered into by
the hospital. (Section 10.10(e) of the Act)
e) No
hospital may discipline, discharge, or take any other adverse employment action
against an employee solely because the employee expresses a concern or
complaint regarding an alleged violation of this Section or concerns
related to nurse staffing. (Section 10.10(f) of the Act)
f) Any
employee of a hospital may file a complaint with the Department regarding an
alleged violation of this Section. The Department will forward
notification of the alleged violation to the hospital in question within 10
business days after the complaint is filed. Upon receiving a complaint of a
violation of this Section, the Department may take any action authorized
under Section 7 or 9 of the Act. (Section 10.10(g) of the Act)
g) If
a hospital demonstrates a pattern or practice of failing to substantially
comply with the requirements of Section 10.10 of the Act or the
hospital's written staffing plan, the hospital shall provide a plan of
correction to the Department within 60 days after receiving notice of noncompliance.
The Department may impose fine as follows:
1) If
a hospital fails to implement a written staffing plan for nursing services, a
fine not to exceed $500 per occurrence may be imposed;
2) If
a hospital demonstrates a pattern or practice of failing to substantially
comply with a plan of correction within 60 days after the plan takes effect, a
fine not to exceed $500 per occurrence may be imposed; and
3) If
a hospital demonstrates for a second or subsequent time a pattern or practice
of failing to substantially comply with a plan of correction with 60 days after
the plan takes effect, a fine not to exceed $1,000 per occurrence may be
imposed. (Section 7(a-5) of the Act)
(Source: Amended at 48 Ill.
Reg. 7321, effective May 3, 2024)
SUBPART J: SURGICAL AND RECOVERY ROOM SERVICES
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1210 SURGERY
Section 250.1210 Surgery
a) Where a hospital provides surgical services, the service shall
be provided in a manner sufficient to meet surgical needs of the patients. The
surgical department/service shall have a defined organization and shall be
integrated with other departments and services of the hospital and shall be
governed by written policies and procedures.
b) The Director of Surgical Services or their designee shall
design and implement an education program to orient new physicians, residents,
physician assistants, advanced practice providers, and other employees and
shall collaborate with the nursing administrator or their designee to establish
orientation and continuing education programs for the nursing staff. The
programs shall be planned, scheduled, documented by a written outline of its
contents, and evaluated at least annually.
c) The education program may be conducted using resources
internal or external to the hospital. Teaching material and suitable reference
shall be supplied as needed for each patient care unit.
d) A member of the hospital's medical staff shall direct the
surgical services and shall be qualified by training and experience, preferably
Board Certified by the American Board of Surgery and approved by the hospital's
medical staff and board.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1220 SURGERY STAFF
Section 250.1220 Surgery
Staff
a) A current roster of physicians, dentists, podiatrists and
allied health personnel shall be maintained in the surgical suite and be available
to the surgical nursing and medical staff.
b) The supervisory nurse in charge of the surgical services over
the direct patient care shall be a registered professional nurse, knowledgeable
in invasive and diagnostic as well as operating room procedures.
c) A
registered nurse licensed under the Nurse Practice Act and qualified by
training and experience in operating room nursing shall be present in the
operating room and function as the circulating nurse during all invasive or
operative procedures. As used in this subsection, "circulating
nurse" means a registered nurse who is responsible for coordinating all
nursing care, patient safety needs, and the needs of the surgical team in the
operating room or surgical suite during an invasive or operative
procedure. (Section 10.7(2.5) of the Act)
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1230 POLICIES & PROCEDURES
Section 250.1230 Policies
& Procedures
a) The department of surgery shall have effective policies and
procedures regarding surgical privileges, maintenance of the operating rooms,
and evaluation of the surgical patient. These shall be available within the
department.
b) The use of latex gloves by hospital staff is
prohibited. If a crisis exists that interrupts a hospital's ability to
reliably source nonlatex gloves, hospital staff may use latex gloves
upon a patient. However, during the crisis, hospital staff shall
prioritize, to the extent feasible, using nonlatex gloves for the treatment of
any patient with self-identified allergy to latex; and any patient upon whom
the latex gloves are to be used who is unconscious or otherwise physically
unable to communicate and whose medical history lacks sufficient information to
indicate whether or not the patient has a latex allergy. (Sections 10(c) and
15 of the Latex Glove Ban Act)
(Source: Amended at 48 Ill. Reg. 7321, effective May 3, 2024)
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1240 SURGICAL PRIVILEGES
Section 250.1240 Surgical
Privileges
a) Surgical privileges shall be delineated for each member of the
medical staff (i.e., a Doctor of Medicine, M.D.; Doctor of Osteopathy, D.O.;
Doctor of Podiatric Medicine, D.P.M.; or Doctor of Dental Surgery, D.D.S.) who
has been granted surgical privileges in accordance with the competence of each
such member of the medical staff. A file specifying the surgical privileges of
each of these members shall be available in the operating room and in the files
of the Hospital's medical staff credentialing and administration Department.
b) Policies and procedures shall identify which surgical
procedures necessitate a second hospital-credentialed physician to assist in
the surgical procedure.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1250 SURGICAL EMERGENCY CARE
Section 250.1250 Surgical
Emergency Care
a) An on-call schedule of physicians shall be established and viewable
at each patient care unit or other area where surgical patients are admitted or
the communications center of the hospital to ensure that there is 24-hour
emergency care.
b) An emergency surgical case is defined as any case in which, in
the opinion of the attending physician or surgeon, the risk of a delay
endangers the patient's life, limb or organs. The declaration of an emergency
shall be appropriately noted in the patient's chart.
c) In the event of the declaration of an emergency case, any of
the requirements regarding the preoperative assessment of the patient and
informed consents may be waived by the attending physician or surgeon and noted
in the medical record.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1260 OPERATING ROOM REGISTER AND RECORDS
Section 250.1260 Operating
Room Register and Records
a) An operating room record, including those created by
electronic means, shall be provided and maintained on a current basis. If the record
is created by electronic means, then safeguards to protect the integrity and
confidentiality of these records must be in place. The operating room record
shall contain the date of the operation, name and number of patient, names of
surgeons and surgical assistants, name of anesthetist, type of anesthesia given
and pre- and post-operative diagnosis, type of surgical procedure, operating
room number and the presence or absence of complications in surgery.
b) The medical staff shall establish procedures to ensure that
preoperative and postoperative medical records are completed in a timely and
accurate manner. A properly executed consent for the proposed surgical or
diagnostic procedure, including a consent for anesthesia services, shall be in
the patient's chart prior to surgery. Except in an emergency, a complete
history and physical work-up shall be recorded in the chart of every patient
prior to surgery.
c) The medical record of the patient shall be available in the
operating suite and post-anesthesia area.
d) An operative report describing techniques and findings shall
be written or dictated immediately following surgery and signed by the surgeon
as soon after transcription as possible.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1270 SURGICAL PATIENTS
Section 250.1270 Surgical
Patients
a) Patients undergoing major surgical procedures shall be
observed both pre-operatively and post-operatively by a competent registered nurse
specifically assigned to the patient. Such observations and assessments shall
be documented in the patient's record.
b) The chart of the patient shall accompany the patient to the
operating suite, to the recovery area and be returned with the patient to the
patient care unit.
c) All tissue/specimens removed at surgery, except those exempted
by Section 250.510(g)(1), shall be placed in a container properly labeled and
submitted for pathological examination.
d) All infections of surgical, procedural, and endoscopy cases (including,
but not limited to those reportable to NHSN) shall be recorded and reported to
administration and to the hospital's Infection Control Committee. The
Infection Control Committee shall determine a procedure for the surveillance of
such cases. The Committee shall report the data to the hospital's board at
least annually.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1280 EQUIPMENT
Section 250.1280 Equipment
a) The operating suite is to be equipped with the appropriate and
necessary equipment and instruments for the surgical or diagnostic procedures
performed.
b) The surgical suite shall have appropriate resuscitation
equipment immediately available at all times.
c) A dedicated emergency call system must be present in each
operating room for the purpose of alerting operating suite personnel to an
emergency or life-saving situation.
(Source: Amended at 23 Ill. Reg. 13913, effective November 15, 1999)
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1290 SAFETY
Section 250.1290 Safety
a) Policies and procedures shall be established concerning the
safety and welfare of patients treated in the surgical suite, and safety
training shall be provided to personnel.
b) Policies and procedures shall be established for the control,
storage, and safe use of anesthetics, oxygen and other medical gases. Refer:
Section 250.1410(e).
c) Suitable facilities must be provided for the safe and
convenient preparation of drugs and medications, including ample light, running
water, sufficient work area, refrigeration and a secure and locked cabinet for
the storage of schedule drugs.
d) Policies and procedures shall be established addressing
principles of sterility and asepsis in the surgical suite.
e) Rigid adherence to accepted standards of sterility and asepsis
is mandatory in the Surgical Department.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1300 OPERATING ROOM
Section 250.1300 Operating
Room
a) The
surgical area shall be a controlled traffic area. A control point shall be
established to monitor the flow of patients, personnel, and materials.
b) The
surgical area is composed of restricted, semi-restricted, monitored
unrestricted, and transition areas.
1) Restricted
area: Traffic shall be restricted to authorized personnel and patients. No
street clothing shall be worn in the restricted area. Health care workers
shall wear hospital laundered scrub attire. Head and facial hair shall be
contained within protective covering. If cloth head coverings are used, they shall
be laundered by the hospital. Additional garments, including personal head
coverings such as scarves, shall be completely contained or covered within the
scrub attire. Masks shall be worn in restricted areas where open sterile
supplies and equipment are present or scrubbed persons are located. Patients
shall wear attire appropriate for their surgical procedure and shall wear hair
covering.
2) Semi-restricted
area: Traffic shall be restricted to authorized personnel and patients. No
street clothing shall be worn in the semi-restricted area. Health care workers
shall wear hospital laundered scrub attire. Head and facial hair shall be
contained within protective covering. If cloth head coverings are used, they shall
be laundered by the hospital. Additional garments, including personal head
coverings such as scarves, shall be completely contained or covered within the
scrub attire. Masks are not required in this area. Patients shall wear attire
appropriate for their surgical procedure and shall wear hair covering.
3) Transition
area: Traffic shall be permitted to allow movement of personnel from
unrestricted to semi-restricted areas or restricted areas. Personnel may enter
in street clothing and shall exit into the semi-restricted or restricted area
in surgical attire.
4) Monitored
unrestricted area: Permitted traffic includes authorized personnel, patients,
and their families. Health care workers in scrub attire may use this area as a
transition area for the purpose of patient management and hospital business.
c) Signage shall clearly
define the traffic flow and surgical attire requirements.
d) Movement
of clean and sterile items shall be separated from contaminated or dirty items
by space, time, or traffic patterns. The handling of clean and soiled linen
shall meet the requirements set forth in Sections 250.1750 and 250.1760.
e) All
jewelry shall be removed prior to the surgical scrub. Jewelry shall not be
worn in the operating room, except that anesthesia personnel may wear a watch.
f) Additional
personal protective equipment shall be worn when exposure to blood or other
potentially infectious material is anticipated.
g) Whenever
scrub attire or personal protective equipment is soiled, it shall be removed
promptly and placed in an appropriately designated container.
h) The
sterile gown and gloves used when participating in surgical procedures shall be
removed and discarded prior to leaving the operating room.
i) The use of single-use
coverall suits shall be determined by hospital policy.
j) Shoe
covers shall be worn when it can reasonably be anticipated that splashes or
spills may occur. If shoe covers are worn, they shall be changed whenever they
become torn, wet, or soiled. They shall be removed and discarded before
leaving the surgical area.
k) The
use of cover gowns for covering the scrub attire when outside of the surgical
area shall be determined by hospital policy. Scrub attire worn into the
institution from outside shall be changed before entering the semi-restricted
or restricted areas. Persons exiting the hospital shall don hospital laundered
scrub attire on return to the surgical area.
l) Personnel suffering from communicable diseases shall be
excluded from the surgical area.
(Source: Amended at 49 Ill.
Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1305 VISITORS IN OPERATING ROOM
Section 250.1305 Visitors in
Operating Room
a) No lay visitor shall be given access to the operating rooms
during surgery.
b) Only individuals in the categories authorized herein and
individuals authorized in accordance with hospital policy shall be allowed
access to the operating rooms during surgery. Individuals authorized herein
shall be members of the medical staff, persons with additional privileges per
Section 250.310(b)(14), persons employed by the hospital and assigned to the
operating room, and persons participating in residency or clinical training
programs.
c) Where hospital policy approved by the Governing Board permits
other persons to be in attendance in the operating room during surgery, the
policy shall provide for the screening of such persons to ensure the necessity
of their presence, such as documentation that they have appropriate licensure,
qualifications or competence and that the person performing the procedure, the
patient's attending physician and the chairman of the department of surgery in
departmentalized hospitals have agreed to allow such access. These individuals
shall follow the requirements set forth in Section 250.1300.
d) The presence of a parent or guardian, or other designated individual
selected by a child's parent or guardian, may be allowed in the operating room
during the induction of anesthesia on an individual who is under 18 years of
age and for an intellectually disabled adult, at the discretion of the hospital
if the hospital has first adopted a policy on the matter, approved by the
Governing Board. The policy shall include, but not be limited to, the following
conditions:
1) Written consent of the parent, guardian or other designated individual,
the anesthesia provider, and the physician performing the surgery;
2) Notation in the patient's medical record of the presence of the
additional person in the operating room during the induction of anesthesia;
3) Application of safeguards against the introduction of
infection or other hazards by the parent, guardian or other designated individual,
including orientation, education and training of the person prior to
performance of the procedure; this shall include, at a minimum, specifics
regarding the procedure and what can be expected, basic infection control
practices expected of the person, and instruction that the person must leave
the operating room after the induction of anesthesia is completed;
4) Requirements
that the parent, guardian, or other designated individual wear a mask, cover
all head and facial hair and don hospital laundered scrub attire or a
single-use coverall suit designed to totally cover outside apparel;
5) Provision of at least one additional staff person in the
operating room assigned to oversee, supervise and assist the parent, guardian
or other designated individual for the period of time the parent, guardian or other
designated individual is present; and
6) If, at any point during the induction of the anesthesia, the
physician performing the surgery or the attending anesthesia provider determines
that the parent, guardian or other designated individual poses a threat to the
safe completion of the induction of the anesthesia, they may require the
parent, guardian or other designated individual to leave the operating room.
(Source: Amended at 49 Ill.
Reg. 14395, effective October 27, 2025)
|
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1310 CLEANING
Section 250.1310 Cleaning
a) Procedures for cleaning the operating rooms after each case
may be more but not less stringent than the following:
1) The operating room and its contents shall be thoroughly
cleaned after each case.
2) Furniture and equipment shall be washed with an approved
disinfecting solution. Instruments shall be soaked in an approved disinfecting
solution.
3) Specimen material for laboratory examination or research shall
be placed in a closed container.
4) Nurses, surgical technicians/assistants, surgeons, and
anesthetists shall remove contaminated gowns and gloves at the door immediately
before leaving the room.
5) All linen shall be bagged in the operating room. There shall
be specific procedures for the identification and handling of surgery linen.
b) The Infection Control Committee, in cooperation with the
surgery service, shall develop guidelines and specific requirements for
cleaning the operating room following a case in which an individual is infected
or colonized with an organism requiring non-routine decontamination and
cleaning materials (e.g. C auris, carbapenemase-producing organisms, C diff).
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1320 POSTANESTHESIA CARE UNITS
Section 250.1320
Postanesthesia Care Units
a) Provision and use of Phase 1 Postanesthesia Care Unit (Phase 1
PACU)
1) For the purposes of this Section, Phase 1 of postanesthesia
care is the phase immediately following surgery, usually in a recovery room,
after which the patient is returned to their room.
2) Postanesthesia care units shall be provided by all hospitals
in which surgery is performed. They shall be in a separate room where patients
who have undergone surgical procedures can be immediately observed and receive
specialized care by selected and trained personnel and where, when necessary,
prompt emergency care can be initiated.
3) The services of the Phase 1 PACU may be used for postpartum care
if the delivery room or place of delivery is in proximity to the Phase 1 PACU.
4) All patients with a contagious condition shall be recovered in
a Phase 1 isolation room or in the operating room if no PACU isolation room is
available per the isolation requirements established by the hospital's Infection
Prevention and Control Professionals (See Section 250.1100).
b) Personnel
1) Anesthesiologist
An anesthesiologist
shall be responsible for the conduct of the Phase 1 PACU, for the training of Phase
1 PACU personnel, and for the establishment of admission, discharge, and
emergency policies and procedures.
2) Nurse
A) A registered nurse who has education and experience in Phase 1
postanesthesia care shall supervise all personnel performing nursing service
functions.
B) A registered nurse shall be in attendance at all times when
patients are in the Phase 1 PACU.
C) There shall be sufficient nursing personnel to provide the
specialized care required for the postsurgical patient. It is recommended that
a ratio of one nursing personnel to two patients be maintained at all times.
D) Nursing personnel shall be assigned permanently to the Phase 1
PACU when patients are present.
c) Practices for operation of the Phase 1 PACU
1) Proper patient placement shall be determined by the surgical
team based on clinical criteria according to the hospital's policy.
2) A member of the medical staff shall provide initial orders for
the care of each patient upon admission.
3) A member of the medical staff shall be responsible for the
patient's discharge from the Phase 1 PACU.
4) Anesthetized patients shall be constantly attended. Side
rails shall be attached to movable carts and beds and raised above mattress
level when occupied by anesthetized patients. Cribs shall be provided for the
anesthetized or postsurgical child.
5) Written policies and procedures, which shall be reviewed
regularly and revised as necessary, shall be established.
6) A complete orientation program and continuing in-service
education program shall be provided for all personnel assigned to the Phase 1
PACU.
7) Personnel with communicable diseases shall be excluded from
the Phase 1 PACU.
8) Visitors shall be permitted in the Phase 1 PACU if a hospital
has adopted a policy, approved through the Governing Board, that allows for
visitation in the Phase 1 PACU while the patient is recovering from a surgical
procedure. Before allowing individuals to be present in the Phase 1 PACU, the
hospital shall have a policy in place that includes at least the following:
A) Written consent of an adult patient; the parent, guardian, or legal
representative of a minor or a mentally disabled adult; or the physician
performing the surgery;
B) Notation in the patient's medical record of the presence of
additional visitors in the Phase 1 PACU during recovery of the patient from a
surgical procedure;
C) Application of safeguards against the introduction of infection
or other hazards by the visitor, including orientation, education and training
of the person, preferably prior to the performance of the procedure but at
least prior to visitation; this shall include, at minimum, specifics regarding recovery,
what can be expected, and basic infection control practices expected of the visitor;
D) Provision of safeguards to ensure the privacy of other patients
who may be recovering from surgical procedures, which may include separate
rooms or some other type of separation for recovery of patients who would have
a visitor present. Privacy safeguards shall allow Phase 1 PACU staff to
provide constant attention to anesthetized patients; and
E) If, at any point during the recovery of the patient, Phase 1
PACU personnel determine that the visitor poses a threat to the safe,
therapeutic recovery of the patient, personnel may require the visitor to leave
the Phase 1 PACU.
d) Drugs, supplies and equipment
Drugs,
supplies and equipment shall be immediately and continually accessible in the Phase
1 PACU, including emergencies. These shall include cardiac-respiratory monitoring
and resuscitation materials.
e) The Phase 1 PACU shall contain and provide for a drug
distribution station, including a secure area, adequate hand-washing
facilities, charting and dictating area, soiled utility area with bedpan
flushing device, and adequate storage space for supplies and equipment.
(Source: Amended at 49 Ill.
Reg. 14395, effective October 27, 2025)
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| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1325 SURGICAL SMOKE PLUME EVACUATION SYSTEM EQUIPMENT AND POLICIES
Section 250.1325 Surgical Smoke Plume Evacuation System
Equipment and Policies
a) To
protect patients and health care workers from the hazards of surgical smoke
plume, hospitals shall adopt policies to ensure the elimination of surgical
smoke plume by use of a surgical smoke plume evacuation system for each
procedure that generates surgical smoke plume from the use of energy-based
devices, including, but not limited to, electrosurgery and lasers. (Section
6.32(b) of the Act)
1) The
facility's surgical department shall perform a risk assessment to identify all
procedures that are performed with energy-based surgical devices (e.g. lasers,
electrosurgical instruments, and ultrasonic devices) that generate a surgical
smoke plume and will require the use of a surgical smoke plume evacuation
system.
2) All
surgical team members shall be trained on the methods for mitigating the
hazards and minimizing exposure to surgical smoke plume, positioning and
operating surgical smoke plume evacuation pursuant to the manufacturer's
instructions, and the requirements in facility policies and procedures for
management of surgical smoke plume.
3) Staff
shall wear appropriate respiratory protection when needed as secondary
protection against residual smoke in accordance with the hospital's respiratory
protection plan.
4) To
protect against potential smoke hazards, the facility’s policy and procedure
shall minimally include:
A) During
utilization of the smoke evacuator, the suction nozzle inlet shall be positioned
as close to the surgical site as possible to maximize capture of airborne
contaminants.
B) The
smoke evacuator shall be “ON” (activated) at all times when airborne particles
are produced during all surgical or other procedures
C) New
tubing shall be used before each procedure and the smoke evacuator filter shall
be replaced as recommended by the manufacturer. Consider all tubing, filters
and absorbers as infectious waste and dispose of appropriately in accordance
with OSHA bloodborne pathogens standards.
D) Inspection
of smoke evacuator systems regularly, including inspection immediately prior to
use, to ensure proper functioning.
b) The
hospital shall report to the Department that policies required under
subsection (a) have been adopted. The hospital shall provide the
Department a letter identifying the date of the adoption of the facility's
policy for utilization of smoke evacuation system. (Section 6.32(c) of the Act)
(Source: Added at 46 Ill. Reg. 15597,
effective September 1, 2022)
SUBPART K: ANESTHESIA SERVICES
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1410 ANESTHESIA SERVICE
Section 250.1410 Anesthesia
Service
a) The Anesthesia Service shall be organized under written
policies and procedures regarding staff privileges, the administration of
anesthetics, and the maintenance of strict safety controls. In hospitals where
there is no organized Anesthesia Service, the Surgery Service shall assume the
responsibility for establishing general policies and supervising the
administration of anesthetics. The Anesthesia Service is responsible for all
anesthetics administered in the hospital.
b) The Anesthesia Service shall be under the direction of a
physician who has had specialized preparation and experience in the area or who
has completed a residency in anesthesiology. An anesthesiologist shall be
Board certified or a candidate for Board certification in the American Board of
Anesthesiology examination system.
c) A physician or certified registered nurse anesthetist shall
supervise the work of all nonmedical personnel working in the Anesthesia
Service. For the purposes of this Section, a certified registered nurse anesthetist
means a registered professional nurse who has been certified as a nurse
anesthetist by the American Association of Nurse Anesthetists.
d) The hospital shall establish procedures for regular
inspection, maintenance, and repair of anesthesia equipment and supplies.
e) The Anesthesia Service, Director of Surgical Services,
Director of Pharmacy, and medical staff shall collaborate to establish policies
and procedures for the control, storage, and safe use of combustible
anesthetics, oxygen, and other medicinal gases; types of anesthesia to be
administered and procedures for each; personnel permitted to administer
anesthesia; infection control, and safety regulations to be followed.
f) The hospital shall recognize the dangers of accidental
ignition of anesthetic gases to patients and others, and shall establish
procedures to minimize this hazard in accordance with NFPA 99.
g) Anesthetic agents and medicinal gases shall be administered
only on the order of a member of the medical staff and shall be administered
only by persons qualified in the management of these materials. See subsection
(e).
h) The use and storage of anesthetic gases shall be in accordance
with NFPA 99. Areas for cleaning, testing, and storing anesthesia equipment
shall be provided.
i) An anesthetic record on special forms shall be made a part of
the patient's chart. Drugs used, vital signs and other relevant information
shall be recorded at regular intervals during anesthesia.
1) There
shall be a history and physical examination by a physician no more than 30 days
prior to nonemergency surgery or a procedure requiring anesthesia services, or
within 24 hours after admission or registration for a surgery or procedure
requiring anesthesia services. Findings must be recorded in the patient's
record prior to surgery or a procedure requiring anesthesia services. For
dental surgery, the history and physical examination may be performed by a
dentist who has been granted privileges by the hospital medical staff.
2) Except
in an emergency, no anesthetic shall be administered until the patient has had
a history and physical examination, and a record made of the findings.
j) Patients under or recovering from anesthesia and those who
have received sedatives or analgesic shall remain under continuous, direct
nursing supervision until vital signs have become stabilized. Any nurse
performing this duty shall have been instructed in the management of
post-anesthetic patients, shall have no other clinical duties while supervising
these patients, and shall have immediate recourse to the attending surgeon,
anesthesiologist, anesthetist, or qualified substitute present in the hospital.
k) Post-anesthetic follow-up visits shall be made within 48 hours
after the operation by the anesthesiologist, nurse anesthetist, or responsible
physician, who shall note and record any postoperative abnormalities or
complications from anesthesia.
(Source: Amended at 49 Ill. Reg. 14395, effective October 27, 2025)
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SUBPART L: RECORDS AND REPORTS
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1510 MEDICAL RECORDS
Section 250.1510 Medical
Records
a) Facilities
1) The hospital shall maintain medical record facilities with
adequate supplies and equipment.
2) Medical records shall be stored safely and handled in a way
that ensures protection from water seepage or fire damage. Medical records
shall be secured in a way that protects the integrity of authentication and
provides safeguards from unauthorized use.
b) Organization
1) Responsible Personnel
A) A qualified health information practitioner (registered health
information administrator or accredited health information technician) shall be
employed or contracted as the director of the medical records department.
B) The director of the medical records department shall
participate in educational programs relative to health information activities,
on-the-job training and orientation of other medical record personnel, and
in-service health information educational programs. Professional consultation
services shall be provided for the health information practitioner.
2) An adequate, accurate, timely, and complete medical record
shall be maintained for each patient. Minimum requirements for medical record
content are:
A) Patient identification and admission information;
B) The history of the patient as to chief complaints, present
illness and pertinent medical history, family history, and social history;
C) A physical examination report;
D) Provisional diagnosis;
E) Diagnostic and therapeutic reports on laboratory test results,
x-ray findings, any surgical procedure performed, any pathological examination,
any consultation, and any other diagnostic or therapeutic procedure performed;
F) Orders and progress notes made by the attending physician and,
when applicable, by other members of the medical staff and allied health
personnel;
G) Observations notes and vital sign charting made by nursing
personnel; and
H) Conclusions as to the primary and any associated diagnoses;
brief clinical resume; disposition at discharge, including instructions and
medications; and any autopsy findings on a hospital death.
3) For record requirements pertaining to obstetric patients and
newborn infants, see Section 250.1830(h).
4) A committee of the organized medical staff shall be
responsible for reviewing medical records to ensure adequate documentation,
completeness, promptness, and clinical pertinence.
5) The hospital shall establish requirements for the completion
of medical records and for the retention period for medical records.
A) Every hospital shall preserve its medical records in a
format and for a duration established by hospital policy and for not
less than 10 years, provided that if the hospital has been notified in writing
by an attorney before the expiration of the 10 year retention period that there
is litigation pending in court involving the record of a particular patient as
possible evidence and that the patient is their client or is the person
who has instituted such litigation against their client, then the
hospital shall retain the record of that patient until notified in writing by
the plaintiff's attorney, with the approval of the defendant's attorney of
record, that the case in court involving such record has been concluded or for
a period of 12 years from the date that the record was produced, whichever
occurs first in time. (Section 6.17(c) of the Act).
B) The hospital shall issue policies and procedures pertaining to
the use of medical records and the release of medical record information.
Discharge diagnoses shall be expressed in terminology of a recognized disease
nomenclature.
6) When a hospital provides a sexual assault survivor with a
voucher in compliance with Section 250.750(d), the hospital shall make a
copy of the voucher and place it in the medical record of the sexual assault
survivor. The hospital shall provide a copy of the voucher to the sexual
assault survivor after discharge upon request. (Section 5(b-5) of the
Sexual Assault Survivors Emergency Treatment Act)
c) Authentication of Medical Record Entries
1) All entries into the medical record shall be authenticated by
the individual who made or authorized the entry. "Authentication,"
for purposes of this Section, means identification of the author of a medical
record entry by that author, and confirmation that the contents are what the
author intended, except that telephone orders may be authenticated by the ordering
practitioner or another practitioner who is responsible for the care of the
patient and who is authorized to write orders pursuant to Section 250.330.
2) Medical record entries shall include all notes, orders or
observations made by direct patient care providers and any other individuals
required to make the entries in the medical record, and written interpretive
reports of diagnostic tests or specific treatments, including, but not limited
to, radiologic or electrocardiographic reports, operative reports, reports of
pathologic examination of tissue and other similar reports. The medical record
may include entries that are transmitted by facsimile machine, provided that
the faxed copies are on non-thermal paper and that the faxed copies are dated
and authenticated pursuant to hospital policy approved by the medical staff.
3) Written signatures or initials and electronic signatures or
computer-generated signature codes are acceptable as authentication. All
signatures or initials, whether written, electronic, or computer-generated,
shall include the initials of the signer's credentials.
4) If a hospital uses electronic signatures or computer-generated
signature codes for authentication purposes, the hospital's medical staff and governing
board shall adopt a policy that permits authentication by electronic or
computer-generated signature. The policy shall identify those categories of
the medical staff, allied health staff or other personnel within the hospital
who are authorized to authenticate patient records using electronic or
computer-generated signatures.
5) At a minimum, the policy shall include adequate safeguards to
ensure confidentiality, including, but not limited to, the following:
A) Each user shall be assigned a unique identifier that is
generated through a confidential access code.
B) The hospital shall certify in writing that each identifier is
kept strictly confidential. This certification shall include a commitment to
terminate a user's use of a particular identifier if it is found that the
identifier has been misused. "Misused" shall mean that the user has
allowed another person or persons to use their personally assigned identifier,
or that the identifier has otherwise been inappropriately used.
C) The user shall certify in writing that they are the only person
with user access to the identifier and the only person authorized to use the
signature code.
D) The hospital shall monitor the use of identifiers periodically
and take corrective action as needed. The process by which the hospital will
conduct the monitoring shall be described in the policy.
6) A system employing the use of electronic signatures or
computer-generated signature codes for authentication shall include a
verification process to ensure that the content of authenticated entries is
accurate. The verification process shall include, at a minimum, the following
provisions:
A) The system shall require completion of certain designated
fields for each type of document before the document may be authenticated, with
no blanks, gaps or obvious contradictory statements appearing within those
designated fields. The system shall also require that previously authenticated
entries are corrected or supplemented by additional entries, separately
authenticated and made after the original entry.
B) The system shall allow the user to verify that the document is
accurate and that the signature has been properly recorded.
C) The hospital shall, as part of its quality assurance
activities, periodically sample records generated by the system to verify the
accuracy and integrity of the system.
7) A user may terminate authorization for use of electronic or
computer-generated signature upon written notice to the Director of Medical
Records or other person designated by the hospital's policy.
8) Each report generated by a user shall be separately
authenticated.
d) Indexing
1) A patient index that serves as a key to the location of the
medical record of each person who is or has been an inpatient shall be
maintained as a perpetual master index. A daily register of patients admitted
to the hospital and babies born in the hospital shall be maintained.
2) Medical records shall be classified and indexed according to
diagnoses, surgical procedures, and physician, and other indices shall be
developed as deemed necessary for the advancement of medical care.
3) The International Classification of Diseases shall be used as
the statistical classification for purposes of uniformity and compatibility of
data between and among hospitals.
e) Preservation
1) All original medical records or photographs of records shall
be preserved in accordance with Section 6.17 of the Act.
2) The hospital shall have a policy for the preservation of
patient medical records if the hospital closes.
3) Prior to completing a change of ownership pursuant to Section
250.120(g) and (h), the buyer and seller shall inform the Department which
party is responsible for record preservation. If one single party is not
responsible for complete record preservation, then the parties shall provide
the Department with a list identifying the records each party is responsible
for preserving. No new license will be issued to the new person, legal entity,
or partnership until the plan for record preservation is submitted to the
Department.
(Source: Amended at 49 Ill.
Reg. 14395, effective October 27, 2025)
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ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1520 REPORTS
Section 250.1520 Reports
a) Each hospital shall submit reports containing such pertinent
data as may reasonably be required by the Department to fulfill its
responsibilities under the Act and this Part.
b) In the reporting of communicable disease cases, the hospital
shall comply with the Control of Communicable Diseases Code.
c) See Sections 250.1830 and 250.1840 regarding reports pertaining
to mothers and infants, and regarding children to be discharged to a person
other than a biological parent.
d) See Section 250.1830 regarding birth, fetal death and death
reports.
e) The death of a pregnant person or the death of a person within
one year following the termination of that person's pregnancy shall be reported
to the Department as required by the Department's rules titled Maternal Death
Review and in Section 250.1830(i)(2). This is required regardless of the type
of hospital or the reason for the patient's admission.
f) Any incident or occurrence in a hospital that could be
considered a catastrophe or creates a potential immediate jeopardy or dangerous
threat that requires the transfer of patients to other parts of the facility or
other facilities, including but not limited to fire, flood, or power failure,
shall be reported to the Department within 24 hours after the occurrence. Reports
shall be made to the Department via email at:
DPH.HospitalReports@illinois.gov.
g) Reporting Opioid Overdoses
1) As used in this Section, the following definitions apply:
"Overdose"
– has the same meaning as provided in Section 414 of the Illinois Controlled
Substances Act.
"Health
care professional" – a physician licensed to practice medicine in all its
branches, a physician assistant, or an advanced practice registered nurse
licensed in Illinois.
2) When treatment is provided in a hospital's emergency
department, a health care professional who treats a drug overdose, hospital
administrator, or the designee of either shall report the case to
the Department of Public Health within 48 hours after providing treatment for
the drug overdose or at such time the drug overdose is confirmed.
3) The hospital shall report to the Department the following
information electronically or on forms provided by the Department:
A) Whether an opioid antagonist was administered and, if
yes, the name of the antagonist;
B) The cause of the overdose, including, but not limited
to, whether the overdose was caused by an opioid or heroin; and
C) The demographic information of the person treated. The
demographic information shall include, but is not limited to, the patient's:
i) Age;
ii) Sex;
iii) Federal Information Process Standards county code;
iv) Zip code;
v) Race, using the Centers for Disease Control and Prevention
(CDC) race category; and
vi) Ethnicity, using the CDC ethnicity group.
4) The person completing the form shall not disclose
the name, address, or any other personal information of the individual
experiencing the overdose.
5) The identity of the person and hospital reporting
under this subsection (g) shall not be disclosed to the subject of the
report. For the purposes of this subsection (g), the health care
professional, hospital administrator, or designee making the report, and
his or her employer, shall not be held criminally, civilly, or
professionally liable for reporting under this subsection (g)(5), except
for willful or wanton misconduct. (Section 6.14g of the Act)
h) Each
hospital shall notify the Department within 24 hours after receiving a notice
of impending strike of staff providing direct care. The hospital shall submit
a strike contingency plan to the Department no later than three calendar days
prior to the impending strike.
i) Hospitals without a licensed pediatric unit that provide
limited inpatient or observation services to pediatric patients (neonate (less
than 28 days of age) to 14 years old) shall report the following information to
the Department quarterly on the form available at:
https://dph.illinois.gov/topics-services/health-care-regulation/hospitals.html:
1) The
number of pediatric patients admitted or under observation;
2) The
number of pediatric mortalities;
3) The
number of pediatric patients admitted and ultimately transferred; and
4) A breakdown of those pediatric patients admitted or under
observation regarding the origin of the patients from the emergency department,
post-procedure, or from direct admission as an in-patient or observation status
setting that were transferred.
j) Consulting hospitals shall report the following information
to the Department quarterly, on the form available at:
https://dph.illinois.gov/topics-services/health-care-regulation/hospitals.html:
1) The number of pediatric consultations provided; and
2) The costs incurred for providing the pediatric consultations.
(Source: Amended at 49 Ill. Reg. 14395,
effective October 27, 2025)
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SUBPART M: FOOD SERVICE
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1610 DIETARY DEPARTMENT ADMINISTRATION
Section 250.1610 Dietary
Department Administration
a) Organization
There shall be
an organized department of dietetics, and a well-defined plan of operation
designed to meet the needs of the patients whether the services are
centralized, decentralized, or provided under contractual agreement.
b) Staffing: Dietetic Service Director
The dietetic
department shall have a full-time dietetic service director, preferably a dietitian,
whose responsibilities shall include, but are not limited to, the following:
1) developing written policies and procedures to include but not
necessarily be limited to:
A) responsibilities and authority for the operation;
B) standards of nutritional care for all regular and therapeutic
diets including supplemental feedings;
C) medically prescribed diet orders and alterations in diets or
diet schedules such as holding trays, late trays, and times for accepting diet
changes;
D) patient tray identification;
E) food preparation, storage and service;
F) personal hygiene;
G) sanitation and safety;
H) ancillary dietetic services including food storage preparation
and service in kitchens and dining areas on patient care units; formula supply;
vending operation; and ice making;
I) conferences--departmental and interdepartmental, clinical,
executive and/or administrative;
J) training programs for personnel; and
K) patient education programs.
2) planning menus for all general and therapeutic diets in
accordance with the current Recommended Dietary Allowances of the Food and
Nutrition Board, National Research Council, and in accordance with the
principles of good dietetic management;
3) planning, organizing, directing, controlling, and evaluating
all management aspects of the dietetic services including such things as budget
and/or interpretations of financial reports, purchasing and/or requisitioning
food, dietetic supplies and equipment, food costs, food storage, food
preparation, food service, safety, sanitation, record keeping, personnel
scheduling, and evaluating;
4) planning, implementing, and/or conducting education programs
for orientation, on-the job training, in-service and continuing education on a
regular, routinely scheduled basis for all dietary and other appropriate
personnel, and staff development sessions for all professional staff;
5) administering all the nutritional aspects of patient care
including, but not necessarily limited to:
A) taking nutrition histories and recording in patients' medical
charts;
B) interviewing patients regarding food habits;
C) giving diet counseling to patients and their families;
encouraging patient participation in planning their own diets;
D) participating in appropriate ward rounds and conferences, or by
other methods; sharing specialized knowledge with medical and nursing staffs
and other appropriate interdisciplinary team members involved in the care of
the patient; and
E) consulting with patient care teams.
c) Consultation
1) When the full-time dietetic service director, for legitimate,
documented reasons, is not a dietitian, the hospital shall employ a dietitian
on a part-time (minimum of 20 hours per week) or on a consulting basis. The
hours of consultation in the hospital shall be dependent upon the size, needs
and complexity of the hospital, and dietetic service but in no case shall there
be less than a minimum of eight hours of consultation per month.
2) If consultant dietetic services are used, the consultant's
visits are to be scheduled at appropriate times of sufficient duration and
frequency to allow for the consultant to liaise with medical, nursing, and
patient care teams, to advise the administrator, to give patient counseling, to
give guidance to the director and staff of the dietetic service, to approve all
menus and administrative nutritional aspects of patient care, to participate in
development and/or revisions of dietetic policies and procedures, and to assist
with planning and conducting orientation, in-service and continuing education
programs for dietary and other appropriate personnel.
d) Staff
1) There shall be a sufficient number of properly trained and
supervised dietary personnel, including one or more clinical dietitians where
warranted, competent to carry out all the functions of the dietetic service in
an efficient, effective manner.
2) Dietary personnel shall be scheduled and on duty to allow for
the dietary department to be open and in service a minimum of 12 hours a day.
e) Health and Hygiene
1) Personnel shall be in good health, free of infections or
communicable disease, and free of boils, infected wounds, sores, or lesions.
Persons suspected of having a communicable, contagious, or infectious disease
shall be subject to the requirements of the Control of Notifiable Diseases and
Conditions Code and the Food Code.
2) The outer clothing of all employees shall be clean and street
clothing shall not be worn as outer clothing by employees while engaged in the
preparation and serving of food.
3) Employees shall wear hair nets, headbands, or other effective
hair restraints to prevent the contamination of food or food-contact surfaces.
4) Employees shall thoroughly wash their hands and exposed
portions of their arms with soap and warm water before starting work, during
work as necessary to keep them clean, and after smoking, eating, drinking, or
using the toilet. Employees shall keep their fingernails clean and trimmed.
5) Except where tasting food is part of the job, employees shall
consume food only in designated dining areas. An area shall not be designated
as a dining area if consuming food there might result in contamination of other
food, equipment, utensils, or other items needing protection.
6) Employees shall not use tobacco in any form while engaged in
food preparation or service, nor while in equipment or utensil washing or food
preparation areas. Employees shall use tobacco in any form only in designated
areas. An area shall not be designated for that purpose if the use of tobacco
there might result in contamination of food, equipment, utensils, or other items
needing protection.
7) Employees shall handle soiled tableware in a way that avoids
contamination of their hands.
8) In the event food service employees are assigned duties
outside the dietetic service, these duties shall not interfere with the
sanitation, safety, or time required for dietetic work assignments.
9) Employees shall maintain a high degree of personal cleanliness
and shall conform to good hygienic practices.
10) Employees shall not use latex gloves in the preparation and
handling of food. If latex gloves must be used in the preparation of food due
to a crisis that interrupts a hospital's ability to source nonlatex
gloves, a sign shall be prominently placed at the point of order or point of
purchase clearly notifying the public of the temporary change. (Section
10(a) of the Latex Glove Ban Act)
(Source:
Amended at 48 Ill. Reg. 7321, effective May 3, 2024)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1620 FACILITIES
Section 250.1620 Facilities
a) Appropriate facilities shall be provided for receiving; food
storage; food preparation; tray make-up; food portioning; dining; utensils and
dishwashing; record keeping and other necessary administrative and clinical
functions of the service.
b) Dietary areas shall be appropriately located, adequate in
size, well lighted, properly ventilated, and equipped with the proper kinds,
sizes and amounts of equipment required to carry out the sanitation and safety
objectives of the dietetic service program. (See the Department's current
rule, "Food Service Sanitation" (77 Ill. Adm. Code 750) for specific
details.)
c) Regulations for the construction and maintenance of the
physical facilities shall be governed by the Department's current rules on
"Food Service Sanitation (77 Ill. Adm. Code 750).
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1630 MENUS AND NUTRITIONAL ADEQUACY
Section 250.1630 Menus and
Nutritional Adequacy
a) Menus shall be prepared at least one week in advance. Menus
for the current week shall be dated and posted. Menus shall be kept on file no
less than 30 days.
b) Menus shall be planned, and followed, to meet the nutritional
needs of patients in accordance with physicians' orders and, to the extent
medically possible, in accordance with the current recommended Dietary
Allowances established by the Food and Nutrition Board, National Research
Council. When changes in the current day's menu are necessary, substitutions
shall provide equal nutritive value and shall be recorded on the original menu.
c) Menus shall be different for the same day of consecutive
weeks.
d) Supplies of staple foods for a minimum of a one week period
and supplies of perishable foods for a minimum of a two day period shall be
maintained on the premises. Supplies shall be appropriate to meet the
requirements of the menu.
e) Records of all food purchased shall be kept on file for less
than 30 days.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1640 DIET ORDERS
Section 250.1640 Diet Orders
a) All diets shall be ordered by the patient's attending
physician and/or a registered dietitian with the attending physician's
confirmation. Diet orders shall be recorded in the patient's medical chart.
b) All diet orders shall be sent to the dietetic service
department in writing. Each diet order shall have sufficient pertinent
information to enable the dietetic service to serve the diet as prescribed by
the physician.
c) Appropriate records for patients shall be maintained in the
dietetic service department. These records shall contain pertinent information
that will be helpful to the patient's nutritional care.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1650 FREQUENCY OF MEALS
Section 250.1650 Frequency
of Meals
a) To the extent medically possible, a minimum of three or their
equivalent, shall be served daily, at regular hours with no more than a 14 hour
span between a substantial evening meal and breakfast.
b) To the extent medically possible, bedtime nourishment shall be
offered to all patients.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250
HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1660 THERAPEUTIC (MODIFIED) DIETS
Section 250.1660 Therapeutic
(Modified) Diets
a) Diets shall be medically prescribed and recorded in the
patient's medical chart.
b) Therapeutic (modified) diet menus shall be planned in writing
and served as ordered with supervision or consultation from the dietitian.
c) A current diet manual approved by the dietitian and medical
staff shall be available for use in the dietetic service department and a copy
shall be conveniently located at each patient care unit for use by physicians,
nurses and other appropriate staff. Nutritional deficiencies for each type of
diet shall be included in the diet manual. Diet manuals should be reviewed and
updated at least every five years or more frequently if necessary.
ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.1670 FOOD PREPARATION AND SERVICE
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