TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1000 DEFINITIONS
Section 518.1000 Definitions
For the purposes of this Part:
Act – the
Emergency Medical Services (EMS) Systems Act.
Advanced
Life Support Services or ALS Services – an advanced level of
pre-hospital and inter-hospital emergency care and non-emergency medical services
that includes basic life support care, cardiac monitoring, cardiac
defibrillation, electrocardiography, intravenous therapy, administration of
medications, drugs and solutions, use of adjunctive medical devices, trauma
care, and other authorized techniques and procedures as outlined in the provisions
of the National EMS Education Standards relating to Advanced Life Support and
any modifications to that curriculum specified in this Part and in the
Emergency Medical Services, Trauma Center, Comprehensive Stroke Center, Primary
Stroke Center and Acute Stroke Ready Hospital Code. (Section 3.10 of the Act)
Advanced
Practice Registered Nurse or APRN – has the meanings ascribed in Section 50-10
of the Nurse Practice Act.
Ambulance –
any publicly or privately owned on-road vehicle that is specifically designed,
constructed or modified and equipped, and is intended to be used for, and is
maintained or operated for the emergency transportation of persons who are
sick, injured, wounded or otherwise incapacitated or helpless, or the
non-emergency medical transportation of persons who require the presence of
medical personnel to monitor the individual's condition or medical apparatus
being used on such individuals. (Section 3.85 of the Act)
Associate
Hospital – a hospital participating in an approved EMS System in accordance
with the EMS System Program Plan; fulfilling the same clinical and
communications requirements as the Resource Hospital; having a basic or
comprehensive emergency department with 24-hour physician coverage; and having
a functioning intensive care unit and/or a cardiac care unit.
Auxiliary
Nursing Personnel – unlicensed direct care staff or unlicensed staff providing
direct patient care or unlicensed staff providing care directly to patients.
Basic Life
Support Services or BLS – a basic level of pre-hospital and
inter-hospital emergency care and non-emergency medical care that includes
medical monitoring, clinical observation, airway management, cardiopulmonary
resuscitation (CPR), control of shock and bleeding and splinting of fractures,
as outlined in the provisions of the National EMS Education Standards relating
to Basic Life Support and any modifications to that curriculum specified in
the Emergency Medical Services and Trauma Center Code. (Section 3.10 of the
Act)
Communicable
Disease – has the meaning set forth in the Control of Communicable Diseases
Code.
Comprehensive
Emergency Treatment Services – emergency treatment services provided in
accordance with Section 518.2020 of this Part.
Contagious
Disease − has the meaning set forth in the Control of Communicable
Diseases Code.
Department –
the Illinois Department of Public Health. (Section 3.5 of the Act)
Diagnostic
Imaging Specialist – a person who possesses the knowledge, training and
experience to apply the principles of radiological physics to diagnostic x-ray
applications. The diagnostic imaging specialist shall be approved and
registered by the Illinois Emergency Management Agency – Division of Nuclear
Safety pursuant to 32 Ill. Adm. Code 410.
Director – the
Director of the Illinois Department of Public Health or the Director's
designee. (Section 3.5 of the Act)
Drugs – the
term "drugs" means and includes:
articles
recognized in the official United States Pharmacopoeia-National Formulary, or
any supplement to it, 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 to affect the structure or any
function of the body of man or other animals, 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 of any articles
specified above, but does not include devices or their components, parts or
accessories.
Emergency –
a medical condition of recent onset and severity that would lead a prudent layperson,
possessing an average knowledge of medicine and health, to believe that urgent
or unscheduled medical care is required. (Section 3.5 of the Act)
Emergency
Medical Services System or EMS System or System – an organization of
hospitals, vehicle service providers and personnel approved by the Department
in a specific geographic area, which coordinates and provides pre-hospital and
inter-hospital emergency care and non-emergency medical transports at a BLS,
ILS and/or ALS level pursuant to a System program plan submitted to and
approved by the Department, and pursuant to the EMS Region Plan adopted for the
EMS Region in which the system is located. (Section 3.20 of the Act)
Emergency
Medical Technician-Basic or EMT-B – a person who has successfully completed a
course of instruction in basic life support as prescribed by the Department, is
currently licensed by the Department in accordance with standards prescribed by
the Act and the Emergency Medical Services, Trauma Center,
Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke Ready
Hospital Code and practices within an EMS System. (Section 3.50 of the
Act)
Emergency
Medical Technician-Intermediate or EMT-I – a person who has successfully
completed a course of instruction in intermediate life support as prescribed by
the Act and the Emergency Medical Services, Trauma Center,
Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke Ready
Hospital Code and practices within an Intermediate or Advanced Life Support
EMS System. (Section 3.50 of the Act)
Emergency
Medical Technician-Paramedic or EMT-P – a person who has successfully completed
a course of instruction in advanced life support care as prescribed by the
Department, is licensed by the Department in accordance with standards
prescribed by the Act and the Emergency Medical Services, Trauma
Center, Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke
Ready Hospital Code and practices within an Advanced Life Support EMS System.
(Section 3.50 of the Act)
EMS System
Program Plan – the document approved by the Department pursuant to 77 Ill. Adm.
Code 515 that describes the EMS System program and directs the program's
operation.
Freestanding
Emergency Center or FEC or Facility – a facility that provides
comprehensive emergency treatment services 24 hours per day, on an outpatient
basis and has been issued a license by the Department as a Freestanding
Emergency Center. (Section 32.5 of the Act)
Hospital – has
the meaning ascribed in Section 3 of the Hospital Licensing Act.
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 FEC's
medical, osteopathic, dental, or podiatric graduate training program, which 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 FEC and
are members of the FEC's medical staff.
Infectious
Disease – has the meaning established in the Control of Communicable Diseases
Code.
Intermediate
Life Support Services or ILS Services – an intermediate level of
pre-hospital and inter-hospital emergency care and non-emergency medical care
that includes basic life support care, plus intravenous cannulation and fluid
therapy, invasive airway management, trauma care, and other authorized
techniques and procedures as outlined in the Intermediate Life Support National
Curriculum of the United States Department of Transportation and any
modifications to that curriculum specified in the Emergency Medical
Services and Trauma Center Code. (Section 3.10 of the Act)
Licensee – the
person or entity licensed to operate the FEC pursuant to the Act.
Medical Staff –
an organized body composed of the following individuals granted the privilege
by the governing authority of the FEC to practice in the FEC: 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 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 thereof in suitable form intended for and having
for their main use the prevention, treatment, relief, or cure of diseases when
used either internally or externally.
Morbidity – a
negative outcome that is the result of the original trauma and/or treatment
rendered or omitted.
Nursing Staff –
registered nurses, licensed practical nurses, and others rendering patient care
under the supervision of a registered professional nurse.
Outpatient – a
person who visits an FEC for diagnosis or treatment. There are no overnight
stays in an FEC.
Owning or
Controlling Hospital – the Associate or Resource Hospital that wholly owns or
controls a freestanding emergency center.
Participating
Hospital – a hospital participating in an approved EMS System in accordance
with the EMS System Program Plan, which is not a Resource Hospital or an
Associate Hospital.
Patient – a
person who visits an FEC and requires medical care on an outpatient basis.
Pharmacist – a
person who holds a certificate of registration as a registered 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 the
repackaging for distribution) shall be considered to be a pharmacy and shall be
required to be licensed by the 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 and device selection;
drug administration limited to
the 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 procedures:
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 antipsychotic medications (appropriate training must be conducted
by an Accreditation Council 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 packaged 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)
Physician – any
person licensed to practice medicine in all of its branches under the Medical
Practice Act of 1987.
Physician
Assistant – has the meaning ascribed in Section 4 of the Physician Assistant
Practice Act of 1987.
Plan of
Correction or POC – the response the facility must develop to address/answer
deficiencies identified during a survey.
Program
Narrative – a written description of the services provided at the FEC.
Radiation
hazard – the danger to the health of an individual arising from exposure to
ionizing radiation that exceeds public dose limits as defined in 32 Ill. Adm.
Code 340.
Registered
Nurse or Registered Professional Nurse or RN – a person who is licensed as a registered
professional nurse under the Nurse Practice Act.
Resource
Hospital – the hospital with the authority and the responsibility for an EMS
System as outlined in the Department-approved EMS System Program Plan.
Social Worker –
a person who is a licensed social worker or a licensed clinical social worker
under the Clinical Social Work and Social Work Practice Act.
Survey – a
detailed critical inspection or investigation by the Department.
Therapeutic radiological physicist – an individual who has
the knowledge, training and experience to measure ionizing radiation, evaluate
safety techniques, advise regarding radiation protection needs and apply the
principles of radiological physics to clinical radiation therapy. The
therapeutic radiological physicist shall be approved and registered by the
Illinois Emergency Management Agency – Division of Nuclear Safety pursuant to
32 Ill. Adm. Code 410.
Unit – a
specific distinctly separated area within the FEC.
Working Days –
Monday through Friday, except State holidays.
(Source: Amended at 47 Ill.
Reg. 12120, effective July 28, 2023)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1050 INCORPORATED AND REFERENCED MATERIALS
Section 518.1050
Incorporated and Referenced Materials
a) The following regulations, standards and guidelines are
incorporated in this Part:
1) Private and professional association standards:
A) ASHRAE Handbook − Fundamentals (2009), which may be
obtained from the National Association of American Society of Heating,
Refrigerating, and Air Conditioning Engineers, Inc., 180 Technology Parkway NW,
Peachtree Corners, GA 30092.
B) The following NFPA standards, 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
C) National Council on Radiation Protection and Measurements
(NCRP), Report No. 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
No. 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 (NCRP), 7910
Woodmont Ave., Suite 905, Bethesda, MD 20814-3046.
D) The International Code Council, 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.)
E) American National Standards Institute (ANSI) Standard No.
A17.1-2007, Safety Code for Elevators and Escalators, which may be obtained
from the American Society of Mechanical Engineers, Two Park Avenue, New York, NY,
10016-5990.
F) Facilities Guidelines Institute Guidelines (2010 edition),
Guidelines for Design and Construction of Health Care Facilities, which may be
obtained from www.fgiguidelines.org.
2) Federal Regulations
A) 14 CFR 157 (January 1, 2021) − Notice of Construction,
Alteration, Activation, and Deactivation of Airports
B) 14 CFR 77, Subpart D (January 1, 2021) − Aeronautical
Studies and Determinations
C) 42 CFR 493, Laboratory Requirements (October 1, 2020)
3) Federal
Guidelines
Center for
Infectious Diseases, Centers for Disease Control and Prevention, United States
Public Health Service, Department of Health and Human Services.
A) Guideline for Hand Hygiene in Health-Care Settings, available
at: https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html (October
25, 2002)
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 3, 2022), both available at https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html
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 amendments or editions subsequent to the date specified.
c) The following statutes and State regulations are referenced in
this Part:
1) Federal statutes:
A) Federal Aviation Act of 1958, Sections 307 and 308 (P.L.
85-726, 72 U.S.C. 731)
B) Emergency Medical Treatment and Active Labor Act (42 U.S.C.
1395dd)
C) Clinical Laboratory Improvement Amendments of 1988 (42 U.S.C.
263a)
D) Title XVIII and Title XIX of the Social Security Act (42 U.S.C.
301 et seq., 1395 et seq., and 1396 et seq.)
2) State of Illinois statutes:
A) Emergency Medical Services (EMS) Systems Act [210 ILCS 50]
B) Hospital Emergency Service Act [210 ILCS 80]
C) Hospital Licensing Act [210 ILCS 85]
D) Medical Practice Act of 1987 [225 ILCS 60]
E) Nurse Practice Act [225 ILCS 65]
F) Illinois Health Facilities Planning Act [20 ILCS 3960]
G) Emergency Medical Treatment Act [210 ILCS 70]
H) X-ray Retention Act [210 ILCS 90]
I) Radiation Protection Act of 1990 [420 ILCS 40]
J) Pharmacy Practice Act [225 ILCS 85]
K) Illinois Clinical Laboratory and Blood Bank Act [210 ILCS 25]
L) Language Assistance Services Act [210 ILCS 87]
M) Criminal Identification Act [20 ILCS 2630]
N) Civil Administrative Code of Illinois (Department of Public Health Powers and Duties Law) [20
ILCS 2310]
O) Physician Assistant Practice Act of 1987 [225 ILCS 95]
P) Mental Health and Developmental Disabilities Code [405 ILCS 5]
Q) Health Care Worker Background Check Act [225 ILCS 46]
3) State of Illinois regulations:
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 Communicable Diseases
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, HIV/AIDS Confidentiality and
Testing Code (77 Ill. Adm. Code 697)
G) Department of Public Health, Control of Sexually Transmissible Infections
Code (77 Ill. Adm. Code 693)
H) Department of Public Health, Emergency Medical Services, Trauma
Center, Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke
Ready Hospital Code (77 Ill. Adm. Code 515)
I) Department of Public Health, Hospital Licensing Requirements
(77 Ill. Adm. Code 250)
J) Capital Development Board, Illinois Accessibility Code (71
Ill. Adm. Code 400)
K) Department of Transportation, Aviation Safety (92 Ill. Adm.
Code 14)
L) Pollution Control Board, Special Waste Hauling (35 Ill. Adm.
Code 809)
M) Pollution Control Board, Interim Status Standards for Owners and
Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities (35
Ill. Adm. Code 725)
N) Department of Public Health, Health Care Worker Background
Check Code (77 Ill. Adm. Code 955)
O) Department of Public Health, Rules of Practice and Procedure in
Administrative Hearings (77 Ill. Adm. Code 100)
P) Department of Public Health, Violent Injury Reporting Code (77
Ill. Adm. Code 560)
Q) Department of Public Health, Language Assistance Services Code
(77 Ill. Adm. Code 940)
R) Department of Financial and Professional Regulation, Pharmacy
Practice Act (68 Ill. Adm. Code 1330)
S) Illinois Emergency Management Agency, Use of X-Rays in the Healing
Arts, Including Medical, Dental, Podiatry, and Veterinary Medicine (32 Ill.
Adm. Code 360)
T) Illinois Emergency Management Agency, Standards For Protection
Against Radiation (32 Ill. Adm. Code 340)
U) Illinois Emergency Management Agency, Medical Use of
Radioactive Material (32 Ill. Adm. Code 335)
V) Illinois Emergency Management Agency, Registration and Operator
Requirements for Radiation Installations (32 Ill. Adm. Code 320)
W) Illinois Emergency Management Agency, Accrediting Persons in the
Practice of Medical Radiation Technology (32 Ill. Adm. Code 401)
X) Illinois Emergency Management Agency, General Provisions for
Radiation Protection (32 Ill. Adm. Code 310)
Y) Illinois Emergency Management Agency, Registration Requirements
for Diagnostic Imaging Specialists and Therapeutic Radiological Physicists (32
Ill. Adm. Code 410)
(Source: Amended at 47 Ill.
Reg. 12120, effective July 28, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1100 FREESTANDING EMERGENCY CENTER LICENSURE
Section 518.1100 Freestanding
Emergency Center Licensure
a) The Department will license freestanding emergency centers
pursuant to the Act and this Part.
b) A freestanding emergency center shall meet the following
requirements:
1) has received a permit from the Health Facilities and
Services Review Board to establish a Freestanding Emergency Center by January
1, 2015;
2) is located:
A) in a municipality with a population of 50,000 or fewer
inhabitants;
B) within 50 miles of the hospital that owns or controls the
freestanding emergency center; and
C) within 50 miles of the Resource Hospital affiliated with the
freestanding emergency center as part of the EMS system;
3) is wholly owned or controlled by an Associate or Resource
Hospital, but is not a part of the hospital's physical plant;
4) meets the standards for licensed FECs, adopted in this
Part, including, but not limited to:
A) facility design, specification, operation, and maintenance
standards;
B) equipment standards; and
C) the number and qualifications of emergency medical personnel
and other staff, which must include at least one board certified emergency
physician present at the FEC 24 hours per day;
5) limits its participation in the EMS System strictly to
receiving a limited number of patients by ambulance:
A) According to the FEC's 24-hour capabilities;
B) According to protocols developed by the Resource Hospital
within the FEC's designated EMS System; and
C) As pre-approved by both the EMS Medical Director and the
Department;
6) provides comprehensive emergency treatment services, as
defined in Hospital Licensing Requirements, 24 hours per day, on an
outpatient basis;
7) provides an ambulance and maintains on site ambulance
services staffed with paramedics 24 hours per day;
8) complies with all State and federal patient rights
provisions, including, but not limited to, the Emergency Medical Treatment Act
and the federal Emergency Medical Treatment and Active Labor Act;
9) maintains a communications system that is fully integrated
with its Resource Hospital within the FEC's designated EMS System;
10) reports to the Department any patient transfers from the
FEC to a hospital within 48 hours after the transfer plus any other data
determined to be relevant by the Department;
11) submits to the Department, on a quarterly basis, the FEC's
morbidity and mortality rates for patients treated at the FEC and other data
determined to be relevant by the Department;
12) does not describe itself or hold itself out to the general
public as a full service hospital or hospital emergency department in its
advertising or marketing activities;
13) complies with any other rules adopted by the Department
under the Act that relate to FECs;
14) passes the Department's site inspection for compliance
with the FEC requirements of the Act;
15) submits a copy of the permit issued by the Illinois Health
Facilities and Services Review Board indicating that the facility has complied
with the Illinois Health Facilities Planning Act with respect to the health
services to be provided at the facility;
16) submits an application for designation as an FEC in a
manner and form prescribed by the Department in this Part; and
17) pays the annual license fee as determined by the
Department. (Section 32.5(a) of the Act)
(Source: Amended at 42 Ill.
Reg. 7701, effective April 10, 2018)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1150 INITIAL LICENSURE APPLICATION
Section 518.1150 Initial Licensure
Application
a) Any person acting individually, or jointly with other
persons, who proposes to build, own, establish or operate a freestanding
emergency center shall submit application information in writing on forms
provided by the Department.
b) An application for a new facility shall be accompanied by a
permit as required by the Illinois Health Facilities Planning Act.
c) Each application shall be accompanied by a non-refundable
license application fee of $2000.
d) The application shall contain the following information:
1) The name, address and telephone number of the applicant if the
applicant is an individual; if the applicant is a firm, partnership or
association, the name, address and telephone number of every member of the
firm, partnership or association; if the applicant is a unit of local
government, the name, address and telephone number of its chief executive
officer.
2) If the applicant is a corporation, it shall submit:
A) A list of the title, name and address of each of its
corporation officers; and
B) A list of the name and address of each of its shareholders
holding more than 7.5% of the shares.
3) The name of the person or persons under whose management or
supervision the facility will be conducted.
4) The location of the facility, including the facility name,
telephone number, exact address, and proof that the freestanding emergency
center is not a part of a Resource or Associate Hospital's physical plant.
5) Information regarding any conviction of the applicant, or, if
the applicant is a firm, partnership or association, of any if its members, or,
if the applicant is a corporation, of any of its officers or directors, or of
the person designated to manage or supervise the facility, of a felony or of
two or more misdemeanors involving moral turpitude in the last five years.
6) Proof of ownership or control by an Associate or Resource
Hospital.
7) The number of procedure rooms and observation/treatment rooms.
8) A statement assuring compliance with all State and federal
patient rights provisions, including, but not limited to, the Emergency Medical
Treatment Act and the federal Emergency Medical Treatment and Active
Labor Act (Section 32.5(a)(8) of the Act).
9) The name, address, telephone number, education, experience,
credentials and any professional licensure or certification of the following
persons:
A) Administrator;
B) Medical
Director; and
C) Nurse
Manager.
10) A list of the medical staff, including name and license number.
11) A list of all staff personnel, including name, position and
any professional licensure or certification.
12) A detailed description of the services to be provided by the
facility.
13) Schematic architectural plans.
e) Each application shall document that at least one board
certified emergency physician is present at the FEC 24 hours per day.
f) The Department will review the application form and other
information required by this Section to determine whether the application meets
the requirements of this Section prior to reviewing building plans and
specifications and conducting a survey of the physical plant.
g) The Department will issue a license if, after application and
survey, it finds the applicant meets the requirements of the Act and this Part.
h) The FEC license shall be prominently displayed in an area
accessible to the public.
i) Ownership Change or Discontinuation
1) The license is not transferable. The license is issued to a
specific licensee and for a specific location. The license and the valid
current renewal certificate immediately become void and shall be returned to
the Department when the facility is sold or leased; when operation is
discontinued; when operation is moved to a new location; when the licensee (if
an individual) dies; when the licensee (if a corporation or partnership)
dissolves or terminates; or when the licensee (whatever the entity) ceases to
exist.
2) A license issued to a corporation shall be null, void and of
no further effect upon the dissolution of the corporation. If the corporation
is subsequently reinstated, a new license shall be obtained.
3) Before any change of ownership, dissolution or closure, the
facility shall follow the notification and process requirements of the Health
Facilities Planning Board.
j) Each FEC shall notify the Department, in writing, of any
changes in:
1) Facility
name;
2) Business
telephone contact information; and
3) Administrator
and/or Nurse Manager.
k) Any freestanding emergency center may voluntarily relinquish
its license prior to the expiration date by notifying the Department in
writing. The notification shall include the anticipated date of termination,
which shall not be less than 30 days nor more than 90 days from the date of
notification. The notification shall describe the procedures taken by the
freestanding emergency center to advise pre-hospital providers, hospitals and
the EMS Medical Director.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1155 APPLICATION FOR ANNUAL LICENSE RENEWAL
Section 518.1155 Application
for Annual License Renewal
a) Application for annual license renewal shall be submitted at
least 90 days prior to licensure expiration on forms prescribed by the
Department. The application shall include, at a minimum, the following
information:
1) The names, addresses and telephone numbers of all persons who
own the facility, any name under which any of these persons does business, and
the type of ownership of the facility (for example, individual, partnership,
corporation, or association). In addition, a corporation shall submit:
A) A list of the title, name and address of each of its
corporation officers; and
B) A list of the name and address of each of its shareholders
holding more than 7.5% of the shares;
2) For other than individual ownership, the name and address of
the Illinois Registered Agent or persons legally authorized to receive service
of process for the facility;
3) The names and addresses of all persons under contract to
manage or operate the facility;
4) The name and exact address of the facility;
5) The names and addresses of the Administrator, Medical Director
and Nurse Manager. In addition, the education, experience, credentials and any
professional licensure or certification of these individuals shall also be
submitted if this information was not submitted with the initial application or
a prior renewal application, or if this information has changed since the prior
submission. The facility shall inform the Department of any change in this
information at the time that the change occurs;
6) A list of medical staff, including names and license numbers;
7) A copy of the organizational plan and description of services
if changes have occurred since the last submission; and
8) Identification of any plans of correction currently in effect
as a result of State and federal surveys.
b) Each renewal application shall be accompanied by a
non-refundable license renewal fee of $2000 and proof of compliance with all
reports required by the Department.
(Source: Added at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1160 SURVEYS
Section 518.1160 Surveys
a) The Department will conduct a survey of an FEC at any time to
determine compliance with the Act and this Part or with a plan of correction
submitted as a result of deficiencies cited by the Department.
b) Surveys (except for initial licenses) will be unannounced.
c) Upon completion of each survey, the Department will submit a
copy of the report to the licensee within 15 working days after exit. The
report will identify deficiencies in compliance with the requirements of the
Act or this Part. The report will include any recommendation for action by the
Department under the Act and of correction from the facility. The licensee may
provide related comments or documentation to refute findings in the report,
explain extenuating circumstances that the facility could not reasonably have
prevented, or indicate methods and timetables for correction of deficiencies
described in the report. A licensee has 15 days after receipt of the survey
report to submit a plan of correction.
d) The Department will determine whether a facility is in
violation of this Section no later than 90 days after completion of each
survey.
e) The Department will maintain all survey reports for at least
seven years in a manner accessible to the public.
f) Any licensee, applicant for a license, or person operating an
FEC shall be deemed to have given consent to any authorized officer, employee
or agent of the Department to enter and inspect the FEC, conduct interviews and
photocopy materials as necessary to determine compliance in the facility in
accordance with the Act and this Part. Refusal to permit such entry or survey
shall constitute grounds for denial, nonrenewal or revocation of a license.
(Source: Added at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1165 COMPLAINTS
Section 518.1165 Complaints
a) The Department shall investigate an applicant or licensee
whenever the Department receives a complaint alleging a violation of the Act or
this Part that, if valid, would constitute violations or other sanctions under Section
518.1200 or 518.1250 of this Part.
b) A person who believes that the Act or this Part has been
violated may submit a complaint in writing, by mail, by telephone, by fax or in
person to the Department.
c) The complaint shall include the following:
1) Complainant's name, address and telephone number (unless the
complainant requests anonymity);
2) Facility's
name and address; and
3) A detailed description of the problem, including the date and
the patient's name.
d) The Department will not disclose the name of the complainant
unless the complainant consents in writing to the disclosure.
e) The Department will acknowledge receipt of the complaint to
the complainant in writing within 10 working days after receiving the
complaint.
f) The Department will investigate each complaint as quickly as
possible based on available personnel and resources. If the complaint involves
an immediate and serious threat to patient health and safety, the Department
shall investigate within two days after receipt of the complaint.
g) Complaint investigations will be unannounced.
h) Based on the information provided by the complainant and the
results of the investigation conducted in accordance with subsection (f) of
this Section, the Department will determine whether the Act or this Part has
been or is being violated. The Department will review and consider any
information submitted by the applicant or licensee in response to an
investigation. Based on the results of the investigation and information
provided by the complainant and/or the applicant or licensee, complaints shall
be classified as "valid", "invalid", or "undetermined".
i) The Department will inform the complainant and the licensee
of the results (i.e., whether the complaint was found to be valid, invalid or
undetermined) of the complaint within 45 days after the conclusion of its
investigation.
j) A complainant or licensee who is dissatisfied with the
results of a complaint investigation may request a hearing in accordance with
Section 518.1250 of this Part.
(Source: Added at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1200 EMERGENCY SUSPENSION ORDERS
Section 518.1200 Emergency
Suspension Orders
The Department shall issue an
emergency suspension order, in accordance with Section 3.40 of the Act and
Section 515.160 of the Emergency Medical Services and Trauma Center Code (77
Ill. Adm. Code 515), for any freestanding emergency center when the
Director or his or her designee has determined that the continued operation of
the freestanding emergency center poses an immediate and serious danger
to the public health, safety and welfare. An opportunity for a hearing shall
be promptly initiated after an emergency suspension order has been issued.
(Section 32.5(b)(3) of the Act)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1250 VIOLATIONS AND HEARINGS
Section 518.1250 Violations
and Hearings
a) The Department shall suspend, revoke, refuse to issue, or
refuse to renew the license of any FEC, after notice and an opportunity for a
hearing, when the Department finds that the FEC has failed to comply with the
standards and requirements of the Act or this Part. (Section 32.5(b)(2) of
the Act)
b) Administrative hearings shall be conducted by the Director
or his/her designee. On the basis of any such hearing, or upon default
of the respondent, the Director shall issue a final order specifying his findings,
conclusions and decision. A copy of the final order shall be sent to the
respondent by certified mail or served personally upon the respondent.
(Section 3.135 of the Act)
c) The procedure governing hearings authorized by the Act
shall be in accordance with the Department's rules governing administrative
hearings (77 Ill. Adm. Code 100). (Section 3.135 of the Act)
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1300 GOVERNING BOARD
Section 518.1300 Governing
Board
a) A governing authority or Governing Board, hereinafter called
the Board, shall be responsible for the organization, management, control and
operation of the FEC, including appointment of the medical staff.
b) The organization, duties, responsibilities, and relationships
of the Board shall be established by the owning or controlling hospital.
Copies shall be maintained by the facility for inspection and/or copying by the
Department.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1350 PROVISION OF EMERGENCY SERVICES
Section 518.1350 Provision
of Emergency Services
The freestanding emergency
center shall provide the following services:
a) Comprehensive emergency treatment services (see Section
518.2020 of this Part) 24 hours a day, on an outpatient basis (Section
32.5(a)(5) of the Act);
b) An ambulance and maintenance of on site ambulance
services staffed with paramedics or one EMT-P and one other EMT or Field RN
24 hours per day (Section 32.5(a)(6) of the Act);
c) A communications system that is fully integrated with its
Resource Hospital within the FEC's designated EMS system (Section
32.5(a)(9) of the Act);
d) Helicopter landing capabilities approved by appropriate
State and federal authorities. (Section 32.5(a)(7) of the Act) The
helicopter landing capabilities shall:
1) Comply with the rules of the Illinois Department of
Transportation entitled "Aviation Safety" (92 Ill. Adm. Code 14.790,
14.792, 14.795);
2) Be covered by a favorable airspace determination letter issued
by the Federal Aeronautics Administration pursuant to Sections 307 and 309 of
the Federal Aviation Act of 1958, and 14 CFR 157 and 14 CFR 77, Subpart D; and
3) Be provided on the campus of the freestanding emergency
center.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1400 EMS SYSTEM PARTICIPATION
Section 518.1400 EMS System
Participation
a) The freestanding emergency center shall limit its
participation in the EMS System strictly to receiving a limited number of BLS
runs by emergency medical vehicles according to protocols developed by the Resource
Hospital within the FEC's designated EMS System and approved by the EMS Medical
Director and the Department. (Section 32.5(a)(4) of the Act)
b) These protocols shall include but not be limited to:
1) Patient status or freestanding emergency center resource
limitations that would result in diversion of a patient to another facility.
2) A commitment by the freestanding emergency center to comply
with applicable standardized procedures that apply to hospital emergency
departments in the EMS System.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1450 PATIENTS' RIGHTS
Section 518.1450 Patients'
Rights
a) The freestanding emergency center shall adopt a written policy
on patients' rights. This policy shall be available to all patients and
personnel.
b) The FEC shall comply with all State and federal patient
rights provisions, including, but not limited to, the Emergency Medical
Treatment Act and the federal Emergency Medical Treatment and Active Labor Act.
(Section 32.5(a)(8) of the Act)
c) The FEC shall have a written plan for providing social
services to those patients with social problems. This service may be provided
through:
1) An organized social service within the FEC, or
2) A social worker employed on a part-time basis, or
3) Social work consultant services from a community agency or the
Resource Hospital, or
4) Social Services provided by the owning or controlling
hospital's social services department.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1500 LANGUAGE ASSISTANCE SERVICES
Section 518.1500 Language
Assistance Services
The freestanding emergency
center may provide language assistance services in accordance with the Language
Assistance Services Act and the Language Assistance Services Code (77 Ill. Adm.
Code 940).
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1550 PERSONNEL SERVICES
Section 518.1550 Personnel
Services
a) An organized personnel department or service shall be
established and designed to meet the needs of the personnel.
b) Personnel policies and practices that adequately support
freestanding emergency center services and quality of patient care shall be established
and maintained.
c) Sufficient, qualified personnel shall be employed to properly
operate the various departments and the adjunct services requiring technical
skill, such as laboratory, x-ray, pharmacy, nursing, etc.
d) Sufficient service personnel shall be employed to properly
operate service departments.
e) 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 equivalent experience.
f) Personnel policies shall be written and available to all
personnel.
g) Personnel policies shall be reviewed and/or revised
periodically, but no less frequently than once every two years. The date of
review or revision shall be indicated on the personnel policies.
h) The personnel service shall have available organizational
charts that identify all departments and/or services.
i) All positions shall be authorized by the Board, either
directly or through delegation to the administrator.
j) A job description shall be written for each position in the
freestanding emergency center, including minimum qualifications.
k) Personnel records
1) Accurate, current and complete personnel records shall be
maintained for each employee during his/her term of employment and for the
years thereafter as may be necessary to satisfy other State or federal
requirements.
2) A standard of content shall be established for personnel
records, which shall contain at least the following:
A) Application form and/or resume with current and background
information sufficient to justify the initial and continuing employment of the
individual;
B) Verification of license, if the position requires a license. A
licensed person shall be employed only after verification of the license is
obtained;
C) A record regarding the employee's specialized education,
training, and experience;
D) Verification of identity;
E) Employment health examination and subsequent health services
rendered to the employees as are necessary to ensure that all employees are
physically able to perform their duties;
F) Record of orientation to the job;
G) Continuance of education; and
H) Current information relative to periodic work performance
evaluations.
l) Employees shall not be assigned duties that exceed their
education, training, experience, and qualifications.
m) Orientation and in-service training programs shall be provided
so that personnel may maintain skills and learn new developments.
n) Personnel health requirements
1) Each FEC shall establish an employee health program that
includes the following:
A) An assessment of the employee's health and immunization status
at the time of employment;
B) Policies regarding required immunizations; and
C) 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 (77 Ill. Adm. Code 696).
2) 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.
o) Personnel services may be provided by the owning or controlling
hospital, provided that standards are specific to the FEC and are established
in accordance with this Section.
p) Prior to employing any individual in a position that requires
a State license, the facility shall contact the Illinois Department of Financial
and Professional Regulation to verify that the individual's license is active.
A copy of the verification shall be placed in the individual's personnel file.
q) The facility shall check the status of all applicants with the
Health Care Worker Registry prior to hiring.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1600 PERSONNEL REQUIREMENTS
Section 518.1600 Personnel
Requirements
a) At least one board certified emergency physician shall
be present at the freestanding emergency center 24 hours per day.
(Section 32.5(a)(3)(C) of the Act)
b) Additional physicians shall be present at the freestanding
emergency center or available within 30 minutes to meet the needs of patients
brought to the freestanding emergency center.
c) Nursing Staff
1) At least two registered nurses shall be available at the
freestanding emergency center from 7:00 a.m. to 11:00 p.m.
2) At least one registered nurse and one other health care
provider (e.g., licensed practical nurse or physician assistant) shall be
available at the freestanding emergency center from 11:00 p.m. to 7:00 a.m.,
with additional registered nurses on call to arrive at the freestanding
emergency center within 15 minutes after notification that their services are
needed.
d) Medical, administrative and support personnel shall be
available to meet the needs of patients brought to the freestanding emergency
center and to meet the requirements of this Part.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1610 HEALTH CARE WORKER BACKGROUND CHECK
Section 518.1610 Health Care
Worker Background Check
The freestanding emergency
center shall comply with the Health Care Worker Background Check Act and the
Health Care Worker Background Check Code.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1650 MEDICAL STAFF ORGANIZATION
Section 518.1650 Medical
Staff Organization
The medical staff shall be
organized in accordance with written bylaws, rules and regulations of, or
developed in cooperation with, the owning or controlling hospital and approved
by the Governing Board.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1700 NURSING SERVICES
Section 518.1700 Nursing
Services
The FEC shall provide an
organized nursing service and shall maintain a staff of nursing personnel
organized to provide the nursing care for its patients commensurate with size,
scope and nature of services.
a) Director of Nursing Administration or Nursing Service Manager
1) The nursing service shall be under the direction of a
registered professional nurse who has qualifications in nursing administration
and/or nursing management and who has the ability to organize, coordinate, and
evaluate the service.
2) The nursing administrator (director of nursing) shall hold a
degree in nursing or have documented experience and relevant continuing
education. He/she shall be employed full-time within the FEC as director of the
nursing administration or nursing service manager.
3) The nursing administrator shall be accountable to the chief
executive officer or designee for developing and implementing policies and
procedures of the service and for the nursing practice.
4) The nursing administrator shall have authority over the
selection, promotion and retention of nursing personnel based on established
job descriptions.
5) A qualified registered nurse shall be designated and
authorized to act in the absence of the nursing administrator on a 24-hour
basis.
b) 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 nursing care for which the judgment and specialized
skills of a registered nurse are 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
judgment of a registered professional nurse. Auxiliary nursing personnel shall
be assigned and supervised by a registered 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 shall be consistent with
the types of nursing care needed by the patients and the capabilities of the
staff. Patients shall be evaluated near the end of each change of shift by
criteria developed by the nursing service.
c) Staffing Standards
1) Staffing schedules shall reflect actual nursing personnel
required for the FEC. 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.
B) Assignment of personnel in a manner that gives consideration to
patient care 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, and patient care
assignment. Actual time reports shall be kept verifying personnel attendance
by name, date, patient care assignment, and time of actual attendance.
d) Planning, decision making, and formulation of policies that
affect 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.
e) Job descriptions shall be written for each position
classification in the nursing service and shall delineate the functions,
responsibilities, and qualifications for each classification. Copies of job
descriptions shall be available to nursing personnel.
f) Procedures shall be maintained to ensure that nursing
personnel for whom licensure is required have valid and current licenses in the
State of Illinois and to verify licensure status.
g) 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 and procedures and maintain
the standards of the FEC and the nursing service.
h) Nursing policies and procedures shall be developed, reviewed
periodically 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 FEC services or
departments. The policies and procedures shall be dated to indicate the time
of the most recent review or revision.
i) 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. The responsibility and mechanism for nursing
service to obtain clarification of an order 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.
7) Patient safety.
8) Nursing role in other FEC services, including, but not limited
to, such services as pharmacy and housekeeping.
9) Emotional and attitudinal support.
j) A nursing procedure manual shall be developed, and copies
shall be available to the nursing staff and to other services and departments,
including members of the medical staff and students.
k) The procedure manual shall provide a ready reference on nursing
procedures and a basis for standardization of procedures and equipment in the
FEC.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1750 ACCOUNTING
Section 518.1750 Accounting
Accounting procedures shall be
carried out in accordance with a recognized system of health care accounting,
shall be adequate to permit satisfactory auditing, and shall allow separation
of expenses and income from the hospital that owns or controls the FEC. An
audit shall be performed at least annually by a qualified auditor independent
of the freestanding emergency center.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1800 QUALITY ASSURANCE AND REPORTING
Section 518.1800 Quality
Assurance and Reporting
a) The freestanding emergency center shall develop and implement
a quality assessment and improvement program designed to meet at least the
following:
1) Ongoing monitoring and evaluation of the quality and
accessibility of care and services provided, including, but not limited to:
A) Infection control,
B) Patient satisfaction,
C) Compliance with EMS System protocols, and
D) Timely patient transfers to hospitals;
2) Identification and analysis of problems; and
3) Identification and implementation of corrective action or
changes in response to problems.
b) The freestanding emergency center shall report the following
to the Department:
1) Reports of any patient transfers from the FEC to a hospital
shall be faxed to the Chief, Division of Health Care Facilities and Programs at
(217)782-0382 within 48 hours after the transfer. (Section
32.5(a)(10) of the Act) Reports shall list the patient's name, diagnosis, date
and time of arrival at the FEC, and date, time, destination and mechanism of
transfer from the FEC.
2) Reports of morbidity and mortality rates for patients
treated at the FEC shall be submitted on a quarterly basis.
(Section 32.5(a)(11) of the Act)
3) Reports of all patients transferred to trauma centers shall be
submitted on a quarterly basis.
4) Reports of injuries allegedly caused by a violent act shall be
reported in accordance with Section 55.80 of the Civil Administrative Code of
Illinois and the Violent Injury Reporting Code.
c) Each freestanding emergency center shall submit a data report,
completed by each vehicle service provider for every emergency pre-hospital or
inter-hospital transport, to the Department's Division of Emergency Medical
Services and Highway Safety on March 1, June 1, September 1 and December 1 of
each year, covering run report data from the preceding quarter. The report
shall be in one of the following formats:
1) Copies of the Department-issued scannable run report form, or
2) A data diskette containing the prescribed data elements.
A) The data elements shall be in a format compatible with the
Department's database input specifications, and
B) Department review and approval of data format compatibility is
required prior to submission.
d) Each FEC shall develop and implement a mechanism for linking
run reports with emergency department, trauma center and admission records from
the hospitals that receive emergency patients within the System. This
mechanism shall facilitate tracking of case outcomes for purposes of internal
quality control, medical study and improvement of both adult and pediatric
patients.
e) The FEC shall use the single form designated or approved by
the Resource Hospital.
f) The FEC shall report any injury resulting from the
discharge of a firearm or any injury sustained in the commission of or as a
victim of a criminal offense. (Section 3.2 of the Criminal Identification
Act)
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1850 ORDERS FOR MEDICATIONS AND TREATMENTS
Section 518.1850 Orders for
Medications and Treatments
a) No medication or treatment or diagnostic test shall be
administered to a patient except on the written order of a member of the
medical staff or a house staff member under the supervision of a member of the
medical staff. Verbal orders shall be signed before the member of the medical
staff or the house staff member leaves the area. Telephone orders shall be used
sparingly and countersigned within 24 hours.
b) Members of the medical staff and house staff members 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.
c) 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 Board.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1900 INFECTION CONTROL
Section 518.1900 Infection
Control
a) The freestanding emergency center shall develop policies and
procedures for the prevention and control of infections within the facility,
which shall be approved by the owning or controlling hospital. The person
responsible for infection control in the FEC shall be a part of the hospital's
Infection Control Committee.
b) Policies and procedures for the reporting and care of individuals
with communicable diseases shall be in accordance with the Control of
Communicable Diseases Code.
c) When patients are diagnosed with or present signs and symptoms
of a communicable disease, precautionary measures shall be taken to avoid
cross-infection to personnel, other patients or the public, in accordance with
the Control of Communicable Diseases Code.
d) Policies and procedures for the care of persons diagnosed with
an infectious disease shall include orders to the medical, nursing and
non-professional staffs providing for isolation technique in accordance with
the Control of Communicable Diseases Code.
e) 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 pursuant to
Centers for Disease Control and Prevention Guideline for Hand Hygiene in
Health-Care Settings and Guidelines for Infection Control in Health Care
Personnel.
f) Thorough hand scrubbing shall be required after touching any
contaminated or infected material.
g) Policies and procedures shall be established related to subsections
(a) through (f) and including, but not limited to, the following items:
1) The admission and isolation of patients with specific and/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.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.1950 STERILIZATION AND PROCESSING OF SUPPLIES
Section 518.1950
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 sterile supplies and
equipment shall be responsible to the chief executive officer. This person
shall be qualified for the position by education, training and experience.
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 hand-washing,
and work attire.
b) Written policies and procedures shall be established for the
decontamination and sterilization activities performed in the freestanding
emergency center and shall relate, but are not limited, to the following:
1) Receiving, decontaminating, cleaning, preparing, disinfecting
and sterilizing reusable items.
2) Assembly, wrapping, storage, distribution, and quality control
of sterile equipment and medical supplies. Load control numbers shall be used
to designate the sterilization equipment used for each item, including the
sterilization date and cycle.
3) 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 FEC-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 owning or
controlling hospital's Infection Control Committee.
B) Designation of shelf life may be event related if policies and
procedures, approved by the owning or controlling hospital's Infection Control
Committee, address at least the following:
i) Requirements for wrapping, storing and rotating 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 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 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 FEC, etc., as long as the policies and procedures, as approved by the
Infection Control Committee, and training of staff define this practice.
5) Acquisition of supplies after normal working hours or any time
the central supply 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 outdated sterile
supplies.
8) The emergency collection and disposition of supplies when
special warnings have been issued by the manufacturer. The attending physician
shall be notified if 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 supply service functions.
c) Space shall be provided for the efficient operation of all
central supply service functions. Functional design and work-flow patterns
shall separate soiled and contaminated supplies from supplies that are clean
and sterile. Equipment of adequate design, size and type shall be provided for
decontaminating, disinfecting, cleaning, packaging, sterilizing, storing and
distributing medical instruments, supplies and equipment used in patient care.
d) Equipment and Procedures
1) The facilities, equipment, and procedures for cleanup,
preparation, and sterilization shall be adequate to allow proper cleaning,
processing, and sterilizing of patient care supplies and equipment.
2) When cleanup, 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 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
be under a preventive maintenance program.
4) All pressure steam autoclaves shall have recording
thermometers, and the sterilization performance shall be otherwise monitored.
e) Sterilization of Instruments and Utensils
1) All surgical instruments not adversely affected by high
temperature shall be sterilized by pressure steam sterilization.
2) Whenever possible, throughout the FEC, sterilization shall be
accomplished by pressure steam sterilization. Hot air sterilization or gas
sterilization may be used. When gas sterilization is used, there shall be
policies and tested procedures for proper aeration to permit safe use. Pressure
steam sterilization of reusable syringes and needles is required.
3) All instruments, whether used on infected cases or clean
cases, shall be cleaned before sterilization. Instruments used on infected
cases shall be disinfected before transport to central supply.
4) Boiling is not an approved method of sterilization.
f) Water Sterilization
1) When non-commercial sterile water is used, 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 used. Water may be sterilized either in water sterilizers or
autoclaved in appropriate 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 sterilization shall be checked. This shall
include bacteriological testing of all sterilization units throughout the
facility. Indicators shall be used to show that a wrapped package has 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.
3) Supplies and equipment commercially prepared so as to retain
sterility indefinitely are acceptable. The FEC shall verify the sterility of these
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.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2000 LABORATORY SERVICES
Section 518.2000 Laboratory
Services
The freestanding emergency
center shall have a clinical laboratory to perform services commensurate with
the FEC's needs for its patients, which is certified under the Clinical
Laboratory Improvement Amendments of 1988 (CLIA 88) and 42 CFR 493. Anatomical
pathology services shall be available either in the FEC or by arrangement with
other facilities.
a) Adequacy of Laboratory Services. Clinical laboratory services
adequate for the individual FEC shall be maintained in the FEC, as determined
by the following:
1) The extent and complexity of services are commensurate with
the size, scope and nature of the FEC and the demands of the medical staff upon
the laboratory.
2) Basic laboratory services, necessary for routine examinations
as defined in subsection (b) of this Section, are provided in the FEC.
b) Clinical Laboratory Examinations. Basic clinical laboratory
examinations, including chemistry, microbiology, hematology, serology and
clinical microscopy, shall be carried out as required by the medical staff.
1) Other laboratory examinations may be provided under
arrangements by the FEC with another laboratory that is certified under CLIA
88.
2) In the case of work performed by an outside laboratory, the
original report from this laboratory shall be contained in the medical record.
c) Availability of Facilities and Services
1) Facilities and services shall be available at all times.
2) 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 FEC.
d) Laboratory Report
Signed or
otherwise authenticated reports shall be filed with the patient's medical
record and duplicate copies maintained in the laboratory.
1) The laboratory director shall be responsible for the
laboratory reports.
2) All tests and procedures shall be ordered by a member of the
medical staff or by others in accordance with approved policies.
e) Pathologist Services. Services of a pathologist shall be
provided as indicated by the needs of the FEC.
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 who is licensed to practice medicine in all of its branches in Illinois, on
a full-time, regular part-time or regular consultive basis. If the latter
pertains, the FEC shall provide for, at a minimum, semimonthly consultive
visits by a pathologist.
2) The pathologist shall participate in staff, departmental and
clinicopathologic conferences.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2010 RADIOLOGICAL SERVICES
Section 518.2010
Radiological Services
a) The freestanding emergency center shall maintain and provide
radiological services sufficient to perform and interpret the radiological
examinations necessary for the diagnosis and treatment of patients, to the
extent that the complexity of services is commensurate with the size and scope
of the FEC. 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 FEC 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 a
policy and procedures manual or other document.
c) Technicians employed in the radiological services shall be
accredited pursuant to 32 Ill. Adm. Code 401 as appropriate and have sufficient
training and experience to carry out the procedures safely and efficiently
commensurate with the size and scope of the service. A procedure and means for
evaluating qualifications shall be established and used by the FEC.
d) Radiological services shall be available at all times.
e) Complete, signed reports of the radiological examinations
shall be made part of the patient's record, and duplicate copies shall be kept
in the department for a period of time established by the FEC.
f) 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.
g) 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.
h) Radiological facilities operated by an FEC 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.
i) Each radiological department or identified distinct
radiological service shall prepare and maintain a policies and procedures
manual, which shall be reviewed and updated annually and shall include, but not
be limited to, the following requirements:
1) The FEC shall establish and enforce safety regulations that
will protect both patient and radiological worker from excessive or stray
radiation pursuant to the Radiation Protection Act of 1990 and the federal regulations
promulgated thereunder.
2) When a radiation hazard exists, the FEC shall periodically
obtain a survey and report by a diagnostic imaging specialist or therapeutic
radiological physicist that indicates whether satisfactory conditions exist.
3) Personnel Monitoring shall be performed pursuant to 32 Ill.
Adm. Code 340.210 and 340.520.
A) 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.
B) Personnel monitoring records resulting from the use of film
badges or dosimeters shall be maintained. Readings shall be on at least a
quarterly basis.
C) Upon termination of employment, each worker shall be provided
with a summary of the worker's exposure record.
D) Permanent records of exposure on all monitored personnel shall
be maintained for review by the Department.
4) Monthly and yearly reports shall be maintained on the number
of examinations done and kinds of treatment given.
5) 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).
6) 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 physician is responsible for the
direction and supervision of radiological services. The continuing education
shall be documented.
7) At all times, reasonable privacy shall be provided for the
radiological patient relative to dressing, evacuation, and the study being
performed.
8) Safety policies shall be written for the radiological services
to protect patients and personnel. These policies shall relate to radiation
pursuant to 32 Ill. Adm. Code 310, 335, 340, and 360, electrical and mechanical
hazards, prevention and containment of fire and explosion, and prevention and
treatment of any untoward reaction to contrast media.
9) Written policies and procedures shall be enforced for the
radiological services that relate to the management of critically ill patients
and to the administration of diagnostic agents by nonphysicians.
10) When nonphysicians are permitted to administer diagnostic
agents intravenously for radiological evaluations, written safety guidelines
shall specify which individuals have this authority and require that a
physician be immediately available. If radioactive materials are being
administered, accreditation and supervision rules apply. Refer to 32 Ill. Adm.
Code 335.1050.
11) An emergency drug tray shall always be present in the room or
immediately available where parenteral diagnostic agents for radiologic
evaluations are being administered. A system shall be established for
maintaining an emergency drug tray with appropriate content and no outdated
medications or missing items. Oxygen, airways, syringes and needles,
intravenous administration sets, and appropriate parenteral solutions shall be
available at all times.
12) Written safety policies shall 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 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.
13) Instrument logbooks maintained by Radiological Services shall
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.
(Source: Amended at 47 Ill. Reg. 12120,
effective July 28, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2020 COMPREHENSIVE EMERGENCY TREATMENT SERVICES
Section 518.2020
Comprehensive Emergency Treatment Services
Each freestanding emergency
center shall provide Comprehensive Emergency Treatment Services, as defined in
this Section and in the Hospital Licensing Requirements, 24 hours per day,
on an outpatient basis, as follows:
a) At least one board certified emergency physician shall
be present at the FEC 24 hours per day. (Section 32.5(a)(2)(C) of the Act)
b) Physician specialists representing the major specialties, and
sub-specialties such as plastic surgery, dermatology, ophthalmology, etc.,
shall be available immediately for consultation and onsite, if necessary, within
30 minutes.
c) Ancillary services, including laboratory and x-ray, shall be
staffed at all times. Pharmacy shall be staffed or "on call" at all
times.
d) Each FEC shall provide facilities for immediate life-saving
measures.
e) Policies and procedures governing the acceptance and care of
emergency patients shall be established.
f) A record shall be maintained on each patient who presents himself/herself
for emergency services.
g) Supplies and equipment shall be available and ready for use.
h) This Section shall not be construed to affect facility-patient
arrangements regarding payment for care.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2030 NOTIFICATION OF EMERGENCY PERSONNEL
Section 518.2030
Notification of Emergency Personnel
a) For purposes of this Section:
1) "Emergency Services Provider Agency" means any
entity that uses vehicles, personnel and equipment for the pre-hospital or
inter-hospital transportation and care of patients requiring emergency care or
life support services in accordance with the Act.
2) "Ambulance Personnel" means any person employed by
an emergency services provider agency who is or was involved in the
pre-hospital or inter-hospital transportation and care of a patient requiring
emergency care or life support services as an ambulance crew member, including
the vehicle driver.
b) Each freestanding emergency center shall provide
notification to police officers, emergency medical technicians and ambulance
personnel who have provided or are about to provide emergency care or life
support services to a patient who has been diagnosed as having a dangerous
communicable or infectious disease. (Section 6.08(a) of the Hospital
Licensing Act) The notification shall include at a minimum the requirements of
this Section.
c) In reporting communicable disease cases, the freestanding
emergency center shall comply with the Control of Communicable Diseases Code.
d) The freestanding emergency center shall send the
letter of notification to the emergency services provider agency within
72 hours after the FEC receives actual knowledge of a confirmed
diagnosis of any of the communicable diseases (see subsection (c)) in
regard to any patient who has been transported to the FEC by police officers, emergency
medical technicians or ambulance personnel. (Section 6.08(c) of the Hospital
Licensing Act)
e) If there is a confirmed diagnosis of AIDS, the FEC
shall send the letter of notification to the emergency services provider
agency within 72 hours only if one or both of the following conditions
exist:
1) The police officers, emergency medical technicians or
ambulance personnel have indicated on the ambulance run sheet that a reasonable
possibility exists that they have had blood or body fluid contact with the
patient.
2) The FEC has reason to know of a possible exposure of
the police officers, emergency medical technicians or ambulance personnel to
the blood or body fluids of the patient. (Section 6.08(c) of the Hospital
Licensing Act)
f) Notification letters shall be sent to the designated
contact at the emergency services provider agency listed on the
ambulance run sheet and shall include at least the following information.
Such notification letters shall not contain the patient's name or any
patient-identifying information. (Section 6.08(d) of the Hospital Licensing
Act)
1) The names of the police officers, emergency medical
technicians, ambulance personnel, and other crew members listed on the
ambulance run sheet,
2) The name of the communicable disease diagnosed,
3) The date the patient was transported,
4) A statement that this information shall be maintained
as a confidential medical record, and
5) A statement that upon receipt of the notification letter,
the provider agency shall contact all personnel involved in the pre-hospital or
inter-hospital care and transport of the patient. (Section 6.08(d) of the
Hospital Licensing Act)
g) Upon discharge of a patient with a communicable disease
to emergency transport personnel, the FEC shall notify the
emergency transport personnel of appropriate precautions against the
communicable disease, but shall not identify the name of the patient.
(Section 6.08(e) of the Hospital Licensing Act)
h) The FEC may take any measures in addition to those required
in this Section to notify police officers, emergency medical technicians
or ambulance personnel of possible exposure to any communicable disease.
(Section 6.08 of the Hospital Licensing Act) However, such measures shall not
violate the confidentiality of the medical record of the patient, or conflict
with the provisions of this Section.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2040 COMMUNITY OR AREAWIDE PLANNING
Section 518.2040 Community
or Areawide Planning
Freestanding emergency centers
may participate in a community or areawide plan that provides for emergency
services, as described in Section 250.730 of the Hospital Licensing
Requirements.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2050 DISASTER AND MASS CASUALTY PROGRAM
Section 518.2050 Disaster
and Mass Casualty Program
a) Each freestanding emergency center shall have and maintain a
disaster and mass casualty program. Such program shall be developed in
cooperation with the hospitals of the area and with official and nonofficial
agencies concerned. This program shall include the possibility of disaster
involving loss of the FEC or serious impairment of its facilities.
b) In instances where FECs are participating in an areawide plan
for emergency services, the plan shall include responsibilities to be shared
for a disaster and mass casualty program.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2060 EMERGENCY SERVICES FOR SEXUAL ASSAULT SURVIVORS
Section 518.2060 Emergency
Services for Sexual Assault Survivors
a) All freestanding emergency centers are required to render care
to sexual assault survivors. Care shall be in accordance with Section 545.60
of the Sexual Assault Survivors Emergency Treatment Code. The FEC shall submit
a sexual assault treatment plan in accordance with the Sexual Assault Survivors
Treatment Code even if the plan is to participate in the plan submitted by the
Associate or Resource Hospital.
b) An FEC may fulfill its obligation to provide emergency service
to sexual assault survivors by participating in an areawide plan for emergency
service in accordance with 77 Ill. Adm. Code 545.50.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2070 PHARMACY SERVICE
Section 518.2070 Pharmacy
Service
a) The freestanding emergency center shall provide a pharmacy or
drug and medicine service (service) for the care and treatment of patients.
b) A pharmacy or drug and medicine service policy and procedure
manual shall identify the service and manner of operation.
c) The service shall be under the direction of a pharmacist
employed by the FEC on a full-time, part-time or consulting basis.
Responsibilities of the pharmacist shall be identified in the policy and
procedure manual or other document.
d) A pharmacist shall staff the pharmacy during all hours when
the pharmacy is open. At all other times, the pharmacy shall be locked. A
pharmacist or pharmaceutical service shall be on call when the pharmacy is not
open.
e) When a pharmacist is absent from the FEC, a registered
professional nurse may have access to the pharmacy. The nurse, after
contacting the on call pharmacist, may obtain a single dose, manufacturer's
original package, or container of a drug or medication prepackaged under the
supervision of a pharmacist necessary to administer to a patient in carrying
out treatment and medication orders of a prescriber. A signed receipt for the
drugs and medicines removed shall be left for the pharmacist.
f) Vending machines for the storage and supply of drugs used in
the facility shall be stocked only under the supervision of a pharmacist. They
shall be securely locked, and shall provide a record of what was supplied and
to whom. The drugs contained in the vending machines may be released only by a
registered professional nurse, licensed practical nurse if the FEC's policy
allows, physician or pharmacist.
g) All drugs and medicines shall be stored and dispensed in
accordance with applicable State laws and rules and federal laws.
h) Pharmacy Personnel
1) A pharmacist shall be available or on call at all times.
2) The number of registered pharmacists and other supportive
personnel provided shall be consistent with the size and activity of the
service.
3) Pharmacy apprentices, if employed, shall be under the direct
and personal supervision of a pharmacist.
i) A pharmacy shall be in an identified area or room that
complies with the requirements of the Pharmacy Practice Act.
j) Drugs and medicines shall be plainly labeled with the name of
the manufacturer, lot and control number, and stored in specifically identified
and well-illuminated medicine cabinets, closets, refrigerators, or other
locations provided with lighting, ventilation and temperature control and fully
protected from access by unauthorized persons.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2080 HOUSEKEEPING SERVICE
Section 518.2080
Housekeeping Service
a) The FEC shall have an organized housekeeping department or
service, under competent supervision.
b) The director of housekeeping services shall be qualified for
the position by education, training, and experience.
1) The number of supervisory and support personnel shall be
related to the size and complexity of the facility and to the scope of the
services provided.
2) To guide personnel in providing a hygienic environment for
patients and staff, specific housekeeping procedures shall be developed and
available for all departments and services. Procedures shall identify
techniques and products used and shall include, but not be limited to, the
following:
A) the use, cleaning, and care of equipment;
B) the selection, measurement, and proper use of housekeeping and
cleaning supplies, their storage, and transportation;
C) the maintenance of cleaning schedules, including frequency of
cleaning of observation/treatment and major procedure rooms;
D) techniques for evaluation of cleaning effectiveness;
E) personal hygiene and handwashing.
c) Participation by housekeeping personnel in a relevant
continuing education program shall be documented.
d) The entire facility, including but not limited to the floors,
walls, windows, doors, ceilings, fixtures, equipment, and furnishings, shall be
maintained in good repair, clean and free of insects, rodents and trash.
1) Dusting, mopping, and vacuum cleaning shall be done in a
manner that will not spread dust or other particulate matter.
2) Adequate supplies and equipment for housekeeping functions shall
be provided, with cleaning compounds and hazardous substances properly labeled
and stored.
3) Venetian blinds, decorative curtains and draperies shall be of
fire resistant materials and shall be kept clean at all times. Venetian blinds,
decorative curtains and draperies shall be prohibited in treatment rooms. When
control of excessive sunlight is necessary, washable pull shades (to be damp
dusted daily) may be used.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2090 INSECT AND RODENT CONTROL
Section 518.2090 Insect and
Rodent Control
Any condition on the
freestanding emergency center site conducive to harboring or breeding insects,
rodents or other vermin shall be prohibited.
a) All outside doors, windows and other openings shall be
effectively screened, except in air-conditioned buildings where doors and
windows are normally kept closed and are opened for minimal use, automatically
operated doors or infrequently used fire exits. Screens shall be kept in good
repair and shall have no fewer than 16 meshes per inch. All screen doors shall
open outward where building design permits and be equipped with self-closing
devices. Fire and panic laws shall be considered in screen installation and
maintenance.
b) Other methods of preventing the entrance of insects, such as
blast-fans, electrocution screens, fly traps, sprays, etc., may be used only as
a supplement to the use of screens. Fly strips, paper, swatters, insecticide
sprays and powders, fly traps, etc., shall be used only in such a manner and
place that dead, injured, or affected insects, or the spray or powder itself,
cannot fall on or otherwise come in contact with any food or food product,
sterile/clean equipment and supplies or patient treatment areas.
c) All rooms shall be free from insects, rodents or other vermin.
d) Any chemical substance of a poisonous nature used to control
or eliminate various types of vermin shall be properly colored or labeled to
identify it as a poison. Identification, storage and use shall be in accordance
with local, State and federal laws.
e) If pest control services are contracted with an outside firm,
that firm shall be a Pest Control Business that is licensed by the Department.
If services are provided by FEC personnel, and restricted-use pesticides are
applied, the person responsible for the application shall be an institutional
multi-housing pest control operator who is certified by the Department.
f) The FEC shall maintain an up-to-date list of all pest control
products used, areas where they are used, and areas where specific formulations
shall not be used. This document shall be readily available, in case of
accidental poisoning.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2100 LAUNDRY SERVICE
Section 518.2100 Laundry
Service
a) Laundry service shall be provided by an organized laundry
service under competent supervision or by contract with another entity.
1) If laundry services are provided by an outside entity, a
written contract shall be available and shall specify that the laundry meets
the same standards required in this Section. The linens shall be transported
in sanitary vehicles. Clean and soiled linens shall not be transported in the
same vehicle at the same time.
2) Equipment and construction shall be as required in Section
518.2180.
b) The freestanding emergency center laundry shall be:
1) Located so that steam, odors, lint and objectionable noises do
not reach patient or personnel areas;
2) Well-lighted, ventilated and adequate in size for the needs of
the FEC and for the protection of employees;
3) Maintained in a safe, sanitary, lint-free condition and kept
in good repair; and
4) Not part of a storage area.
c) A supply of clean linen shall be provided that is adequate for
the capacity and use of the facility.
d) Written procedures shall be developed and maintained
pertaining to the handling, storage, transportation and processing of linens to
prevent the spread of infection and assure the maintenance of clean linen.
e) All linens shall be mechanically washed using soap or
detergent and warm or hot water. Linens shall be disinfected by using one of
the following procedures:
1) Thermal Disinfection: Linen shall be exposed to hot water of
at least 160°F for a cumulative time of at least 25 minutes.
2) Chemical and Thermal Disinfection: Linen shall be exposed to
wash and bleach bath water of at least 140°F. The bleach bath shall be at
least 10 minutes long and have a starting bleach concentration of 100 ppm. This
bleach concentration shall be measured by titration on a periodic basis.
3) Other: A step-wise wash process that has been previously
documented by microbiological study published in a scientific journal. The
results shall indicate no surviving pathogenic microorganisms and a low level
of other organisms. Low level is defined as nine out of 10 samples with fewer
than two colonies per 10 square centimeters of test surface.
f) All washed linens shall be thoroughly rinsed. A neutralizing
rinse is recommended.
g) Separate areas shall be maintained for storage of clean linen
and soiled linen. Linen storage areas shall be adequate in size for the needs
of the facility and shall not be used for any other purpose. Storage shall not
be permitted in areas or rooms where plenums of air conditioning or ventilating
systems are located.
h) Hand-washing and toilet facilities for laundry personnel shall
be provided at locations convenient to the laundry.
i) Soiled and clean linen carts shall be so labeled and shall be
provided with covers made of washable materials that shall be laundered or
suitably cleaned daily.
j) Soiled Linen
1) Radioactive contaminated linen and linen from pathology shall
be separately transported, stored and washed.
2) Isolation and other potentially infectious linens shall be
bagged at the location where they are used in durable, leak-proof bags
resistant to puncture and tears and shall be labeled or identified as
infectious at the site of use.
3) Soiled linen shall not be sorted or pre-rinsed in patient care
areas. Soiled linen may be sorted in a separate enclosed room by a person
instructed in methods of infection control. These personnel shall not have
responsibility for immediately handling clean linen.
4) Soiled linen shall be stored and transported in a manner that
does not permit contamination of clean linen, corridors and areas occupied by
patients.
5) All carts and other containers used to store or to transport
clean or soiled linen shall be identified for soiled linen only or for clean
linen only and shall be kept covered when not in use.
6) If laundry chutes are used for transporting soiled linen, all
soiled linen shall be bagged. The chutes shall be designed to maintain a
negative air pressure within the chute and shall be kept in a clean and
sanitary condition. If chutes are used, they shall meet all of the requirements
of NFPA 101, Section 9.5.
k) Clean Linen
1) Clean linen shall be sorted, handled and transported in such a
manner as to prevent cross-contamination.
2) Clean linen carts shall be used only for the purpose of
transportation or storage of clean linen.
3) Persons processing clean linen shall be dressed in clean
garments at all times while on duty. They shall not handle soiled linen.
4) Clean linen received from a commercial laundry shall be completely
wrapped in convenient-size bundles or otherwise protected and shall be
delivered to a designated clean area of the FEC.
5) Clean linens shall be adequately protected from
contamination. Clean linen in patient care areas shall be stored in clean,
ventilated closets, rooms or alcoves, used only for that purpose. Corridors
shall not be used for storage of linen.
6) If clean linen is stored in the laundry area, it shall be
stored in a room separate from the sorting room, laundry room or soiled linen
room.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2110 FOOD SERVICE
Section 518.2110 Food
Service
Food service, if provided by the
freestanding emergency center, shall be provided in compliance with the Food
Service Sanitation Code and local ordinances.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2120 MAINTENANCE
Section 518.2120 Maintenance
The freestanding emergency
center shall have an organized engineering and/or maintenance department under
competent supervision. The requirements of NFPA 99 shall apply in addition to
the following:
a) Maintenance services shall be under the supervision of a
qualified engineer or persons who have had commensurate experience in the
maintenance of public or private plants, preferably health care facilities.
b) Personnel engaged in maintenance activities shall receive
orientation and follow-up training, including training in principles of
asepsis, cross-infection control, and safe practices.
c) The FEC shall have an effective, organized, detailed
preventive maintenance program. Written instructions for operating and
maintaining equipment and the various mechanical, electrical, and other systems
contained in the FEC shall be available to maintenance personnel.
d) Maintenance and repairs shall be carried out in accordance
with applicable codes and requirements of local jurisdictions, and applicable
rules of the State Fire Marshal and the Department.
e) Space and equipment shall be provided for the managerial
activities of the supervisor of maintenance for repair work and for storage of
maintenance materials. Paints and oils shall not be stored in patient areas.
f) The FEC structure and its component parts shall be kept in
good repair and shall be maintained with consideration for the safety and
comfort of the occupants of the building. Mechanical and electrical equipment
shall be maintained in good repair and operating condition at all times.
g) Roads, walks, and parking areas shall be properly maintained.
h) Grounds and buildings shall be maintained as follows:
1) In a clean condition free of safety hazards;
2) In a manner that will prevent standing water, flooding or
leakage; and
3) Free of excessive noise, odors, pollens, dusts, or other
environmental pollutants and such nuisances as may adversely affect the health
or welfare of patients.
i) Ventilation, heating, air conditioning, and air changing
systems shall:
1) Be maintained in good repair and shall be operated in a manner
that will prevent the spread of infection and provide for patient comfort;
2) Be maintained and operated so that air shall not be circulated
from laboratories, toilet rooms, janitors' closets, storage rooms, shop areas,
soiled linen and soiled utility to any other part of the facility; and
3) Be provided, as needed, with acceptable air filtration
equipment that is cleaned and serviced at adequate intervals.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2130 FIRE SAFETY
Section 518.2130 Fire Safety
a) Buildings and equipment shall be maintained so as to prevent
fire and other hazards to personal safety.
b) Exits, stairways, doors, and corridors shall be kept free of
obstructions.
c) Flammable and combustible liquids shall be labeled, stored,
handled and used in compliance with NFPA 30 .
d) Flammable and non-flammable gases shall be labeled, handled,
and used in compliance with NFPA 99. Separate storage for flammable and
oxidizing gases shall be provided.
e) A master fire plan, developed to suit the needs of the
facility, and acceptable to the Department, shall be maintained.
f) Fire regulations listing the fire stations, procedures and
staff emergency duties by title or position shall be posted conspicuously on
each floor at appropriate locations, and shall be available in each unit,
section and department.
g) Employees shall be trained in procedures to be followed in the
master fire plan.
h) Fire drills shall be conducted at irregular intervals at least
l2 times per year. A record shall be kept of the staff performance and
results, and indicated corrective measures shall be made.
i) Portable fire extinguishers, provided in accordance with NFPA
l0, shall be inspected at least annually, recharged or repaired as needed and
labeled with the dates of the last inspection.
j) Sprinkler systems, fire hoses, fire detection and alarm
devices, and other equipment for use in the fire safety program shall be
connected and maintained in a fully functional condition at all times.
k) Fire detection and protection systems shall be inspected no
less frequently than twice a year by a recognized, competent authority. A
written report of the inspection shall be kept on file at the FEC for at least
three years following the date of inspection.
l) The FEC shall maintain a procedure for reporting to a
designated administrative officer, on a standard form adopted for the purpose,
all accidents to patients, employees or visitors. The report shall include all
pertinent information and shall be kept on file for no fewer than six years
after the occurrence is reported.
m) The FEC shall maintain a procedure to investigate fires. The
FEC shall notify the Department of all fires within 24 hours after the
occurrence. A written report of the investigation containing all pertinent
information shall be made and a copy forwarded to the Department. The report
shall remain on file for no fewer than six years.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2140 WATER SUPPLY
Section 518.2140 Water
Supply
The Department's rules titled
Public Area Sanitary Practice Code shall apply, except when they differ from
this Part.
a) Water supplies of FECs shall be operated in conformance with
the following requirements:
1) All water used in operation of the FEC facility shall be
provided from a public water supply or from an alternative source. The source
of water supply shall be approved by the Department.
2) The construction, maintenance, and operation of any treatment
process that might change the physical, chemical, or bacterial characteristics
of the water shall be approved by the Department.
3) Hot water shall be available at sinks and lavatories at all
times. Water shall be adequate in volume and pressure for all medical
purposes.
4) The water system shall be operated with a hot water system
adequate for all medical purposes.
5) The hot water supply shall be regulated by thermostatic or other
control devices, which shall be either locked or located in places not
accessible to patients or the general public so that the hot water used by
patients and by the public is maintained at an even temperature that cannot
cause personal injury.
b) As part of the disaster and mass casualty program, a plan for
the emergency supply of water shall be available. This plan shall be approved
by the Department, and shall include at least written contracts with any
outside firms, a listing of procedures to be followed, the amounts of water
needed by different departments, the means of dispensing water within the FEC,
and procedures for sanitizing in the case of contamination. Plans using
existing piping are recommended.
c) All plumbing shall be designed, installed, and maintained in
accordance with the requirements of the Illinois Plumbing Code, except when
that Code and this Part differ.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2150 GARBAGE, WASTE AND SEWAGE HANDLING AND DISPOSAL
Section 518.2150 Garbage,
Waste and Sewage Handling and Disposal
a) All garbage and refuse shall be collected, stored, and
disposed of in a manner that will not permit the transmission of a contagious
disease, create a nuisance or fire hazard, or provide a breeding place for
vermin or rodents.
b) Solid waste shall be handled in a safe and sanitary manner
within the facility. Garbage and refuse receptacles within the facility shall
be made of metal or other appropriate material provided with disposable liners
or shall be cleaned and disinfected after each emptying. Receptacles in areas
where wet or hazardous wastes are generated shall have tight-fitting lids and
shall be kept closed except during use. Carts used for transport shall be of
easily cleanable construction, and shall be kept in a sanitary condition. Trash
chutes shall be kept clean and sanitary. Pulping-transport systems, where
installed, shall be operated and maintained in a safe and sanitary manner. All
refuse shall be in impervious bags during transport within the facility.
Potentially hazardous waste shall be identified and bagged in durable bags
resistant to puncture and tears. Waste may be single bagged if it can be put in
the bag without contaminating the outside; otherwise, double bagging is
required. Wastes capable of producing injury, such as needles and scalpel
blades, shall be stored and transported in rigid containers. Blood specimens
may be carefully poured down the drain.
c) Collected garbage and refuse shall be stored in stable,
durable, watertight, vermin- and rodent-proof containers, with tight-fitting
lids. Lids shall be kept closed except during use. Containers shall be emptied
at frequent intervals, and shall be kept clean and sanitary. Garbage storage
areas shall be kept in a clean and nuisance-free condition.
d) Final disposal of general solid waste shall be by incineration
or grinding and flushing to the municipal sewerage system, or removal to a
sanitary landfill that is approved by the Illinois Environmental Protection
Agency. Incinerators shall be those approved by the Illinois Environmental
Protection Agency for the types of wastes being generated. Surgical,
obstetrical and other tissue wastes shall be disposed of by grinding and
flushing, incineration or burial. Other potentially infectious wastes shall be
rendered safe by grinding and flushing, incineration or steam autoclaving.
e) Any blood or blood components, organs, semen, or other human
tissue showing exposure to HIV or to any other identified causative agent of
AIDS, or originating from a patient diagnosed with AIDS, as defined in 77 Ill.
Adm. Code 697.20 shall be disposed of by the FEC in accordance with subsection
(f) of this Section, or delivered in accordance with subsection (g) of this
Section to a research facility to use such blood, blood components, organs,
semen or other human tissue for AIDS research.
f) Any such blood, blood components, organs, semen, or other
human tissue, and any other materials or paraphernalia exposed to, or
contaminated by, such blood, blood components, organs, semen, or other human
tissue shall be completely incinerated, sterilized, or sealed to render the
materials innocuous before disposal or removal from the premises.
1) Materials shall be incinerated in accordance with the
requirements of the Pollution Control Board concerning the operation of an
incinerator (35 Ill. Adm. Code 724).
2) Materials shall be sterilized by autoclaving in accordance
with the recommendations of the manufacturer of the autoclave. The
effectiveness of the autoclave shall be verified and documented at least weekly
with a biological spore assay containing B. stearothermophilus.
3) Incinerated or sterilized materials shall be disposed of
through routine waste disposal methods without precautions against possible
contamination.
4) Materials that have not been incinerated or sterilized shall
be disposed of by a waste hauler with a permit from the Illinois Environmental
Protection Agency under rules of the Pollution Control Board (35 Ill. Adm. Code
809). These materials shall be sealed, transported, and stored in biohazard
containers. These containers shall be marked "Biohazard", shall bear
the universal biohazard symbol, and shall be orange, orange and black, or red.
The containers shall be rigid and puncture resistant, such as a secondary metal
or plastic can with a lid that can be opened by a step-on pedal. These
containers shall be lined with one or two high-density polyethylene or
polypropylene plastic bags with a total thickness of at least 2.5 mil or
equivalent material. The containers that are marked "Biohazard" shall
be sealed before being removed from the FEC.
g) When an FEC delivers such blood, blood components, organs,
semen or other human tissue to any research facility, the FEC shall file a
report with the Department (Division of Laboratories), which shall include at
least the following information:
1) A copy of the request from the research facility for blood or
human tissue;
2) The quantity of blood or human tissue delivered;
3) The name and location of the research facility to which the
blood or human tissue was delivered; and
4) The date and time of delivery.
h) A research facility, for the purposes of this Section, shall
mean any clinical laboratory licensed under the Clinical Laboratory and Blood
Bank Act, or any hospital licensed under the Hospital Licensing Act.
i) All sewage and liquid wastes shall be disposed of in a
municipal sewerage system where such facilities are available. When a
municipal sewerage system is not available, sewage and liquid wastes shall be
collected, treated, and disposed of in an independent plant, the construction,
maintenance, and operation of which are approved by the Department or by the
Illinois Environmental Protection Agency.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2160 SUBMISSION OF ARCHITECTURAL PLANS
Section 518.2160 Submission
of Architectural Plans
a) New Construction, Addition, or Major Alteration
1) When construction is contemplated, either for new buildings or
additions or alterations to existing buildings coming within the scope of this
Part, design development drawings and outline specifications shall be submitted
to the Department for review. Approval of design development drawings and
specifications shall be obtained from the Department prior to starting final
working drawings and specifications. The Department will provide comments or
approval within 30 working days after receipt of the drawings and
specifications and the submission being deemed complete.
2) Final Drawings
A) The final working drawings and specifications shall be
submitted to the Department for review and approval prior to beginning of
construction. For final approval to remain valid, contracts shall be signed
within one year after the approval date. Alternate methods of design
development and construction may be acceptable subject to the approval of the
Department. The Department will provide comments or approval within 30 working days
after receipt of the final drawings and the submission being deemed complete.
B) The Department shall be notified upon the award of construction
contracts.
3) Any contract modifications that affect or change the function,
design, or purpose of a facility shall be submitted to the Department for
approval prior to authorizing the modifications. The Department will provide
comments or approval within 60 working days after receipt of the drawings and
specifications.
4) Upon 90% of completion, the pre-occupancy certification
package shall be submitted to the Department.
5) As-built drawings shall be maintained by the freestanding
emergency center.
b) Minor Alterations and Remodeling. Minor alterations or
remodeling changes that do not affect the structural integrity of the building,
that do not change functional operation, that do not affect fire safety, and
that do not increase capacity over that for which the FEC is licensed need not
be submitted for approval.
c) Alterations of Water Supply, Plumbing and Drainage. No system
of water supply, plumbing, sewage, garbage or refuse disposal shall be
installed, nor any such existing system materially altered or extended, until
complete plans and specifications for the installation, alteration or extension
have been submitted to the Department and have been reviewed and approved.
d) Codes and Standards
1) Nothing stated in this Part shall relieve the licensee from
compliance with building codes, ordinances and regulations that are enforced by
city, county or local jurisdictions.
2) The recommendations of the International Building Code shall
apply insofar as those recommendations are not in conflict with the standards
set forth in this Part or with NFPA 101.
A) The portions of the International Building Code requiring smoke
detectors in all patient rooms and automatic door closers on all patient room
doors are hereby specifically excluded from these requirements.
B) The International Building Code is intended as a model code for
municipalities with no building code of their own.
C) NFPA 101-A shall apply only if the Department determines that
the proposed equivalent system is safe and does not constitute a hazard to the
life and safety of the staff and patients.
(Source: Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2170 PREPARATION OF DRAWINGS AND SPECIFICATIONS SUBMISSION REQUIREMENTS
Section 518.2170 Preparation
of Drawings and Specifications – Submission Requirements
Drawings and specifications
shall be prepared by or under the immediate supervision of an architect
registered in the State of Illinois. The requirements contained in this
Section have been established for the guidance of the FEC and the architect to
provide a standard method of preparation of drawings and specifications.
a) First Stage Submission – Design Development Drawings and
Outline Specifications
1) The preliminary sketch plans shall indicate in detail the
assignment of all spaces and the size of areas and rooms, and shall indicate in
outline the fixed and movable equipment and furniture.
A) The plans shall be drawn at a scale sufficiently large to
clearly present the proposed design and not exceed 30 x 42 inches.
B) The drawings shall include:
i) A plan of each floor, including the basement or ground floor;
ii) Roof plan;
iii) Plan showing roads, parking areas, sidewalks, etc., and elevations
of all facades;
iv) Sections through the building;
v) All adjacent areas clearly labeled if addition or alteration;
and
vi) Fire and smoke separation diagrams.
2) Outline specifications shall provide a general description of
the construction, including finishes; acoustical material, its extent and type;
extent of the conductive floor covering; heating and ventilating systems; and
the type of elevators.
3) The total gross floor area and bed count shall be shown on the
drawings.
4) A brief narrative of the proposed program shall be provided.
b) Second Stage Submission – Working Drawings and Specifications
All working
drawings shall be well prepared so that clean and distinct prints may be
obtained; drawings shall be accurately dimensioned and include all necessary
explanatory notes, schedules and legends. Working drawings shall be complete
and adequate for contract purposes. Separate drawings, not to exceed 30 x 42
inches, shall be prepared for each of the following branches of work:
architectural, structural, mechanical and electrical, and shall include or
contain the following:
1) Architectural Drawings
A) Site plan showing all new topography, newly established levels
and grades, existing structures on the site (if any), new buildings and
structures, roadways, walks, and the extent of the areas to be landscaped. All
structures and improvements that are to be removed under the construction
contract shall be shown;
B) Plan of each floor and roof;
C) Elevations of each facade;
D) Sections through building;
E) Elevators and dumbwaiters. Drawings delineating shaft details
and dimensions, sizes of cab platforms and doors, travel distances, including
elevation height of landings, pit sizes and machine rooms;
F) Laundry, laboratories, and similar areas shall be detailed at
a scale to show the location, type, size and connection of all fixed and
movable equipment;
G) Scale details as necessary; scale details to 1½ inch to the
foot may be necessary to properly indicate portions of the work; and
H) Schedule of finishes.
2) Structural Drawings
A) Plans of foundations, floors, roofs and all intermediate levels
shall show a complete design with sizes, sections, the relative location of the
various members, and a schedule of beams, girders and columns.
B) Floor levels, column centers, and offsets shall be dimensioned.
C) Special openings and pipe sleeves shall be dimensioned or
otherwise noted for easy reference.
D) Details of all special connections, assemblies and expansion
joints shall be given.
E) Notes on design data shall include the name of the governing
building code, values of allowable unit stresses, assumed live loads, wind
loads, earthquake load, and soil-bearing pressures.
F) For special structures, a stress sheet shall be incorporated
in the drawings showing:
i) Outline of structure;
ii) All load assumptions used;
iii) Stresses and bending moments separately for each kind of
loading;
iv) Maximum stress and/or bending moment for which each member is
designed, when not readily apparent from subsection (b)(3); and
v) Horizontal and vertical reactions at column bases.
3) Mechanical Drawings. These drawings with specifications shall
show the complete heating, cooling and ventilation systems, plumbing, drainage,
stand pipe and sprinkler systems.
A) Heating, Cooling and Ventilation
i) Radiators, coils and steam-heated equipment such as
sterilizers, warmers and steam tables;
ii) Heating and steam mains and branches with pipe sizes;
iii) Diagram of heating and steam risers with pipe sizes;
iv) Sizes, types and heating surfaces of boilers, furnaces with
stokers and oil burners, if any;
v) Pumps, tanks, boiler breeching and piping and boiler room
accessories;
vi) Air conditioning systems with required equipment, water and
refrigerant piping and ducts;
vii) Supply and exhaust ventilating systems with connections and
piping; and
viii) Air quantities for all room supply and exhaust ventilating
duct openings.
B) Plumbing, Drainage and Stand Pipe Systems
i) Size and elevation of street sewer, house sewer, house
drains, street water main and water service into the building;
ii) Location and size of soil, waste, and vent stacks with
connections to house drains, cleanouts, fixtures and equipment;
iii) Size and location of hot, cold and circulating mains,
branches, and risers from the service entrance, and tanks;
iv) Riser diagram of all plumbing stacks with vents, water risers
and fixture connections;
v) Gas, oxygen and similar piped systems;
vi) Standpipe and sprinkler systems; and
vii) All fixtures and equipment that require water and drain
connections.
4) Electrical Drawings. Drawings shall show all electrical
wiring, outlets and equipment that require electrical connections.
A) Electrical service entrance with switches and feeders to the
public service feeders, characteristics of the light and power current,
transformers and their connections if located in the building.
B) Location of main switchboard, power panels, light panels and
equipment. Feeder and conduit sizes shall be shown with schedule of feeder
breakers or switches.
C) Light outlets, receptacles, switches, power outlets and
circuits.
D) Telephone layout showing service entrance, telephone
switchboard, strip boxes, telephone outlets and branch conduits as approved by
the telephone company. Where public telephones are used for inter-communication,
a separate room and conduits for racks and automatic switching equipment shall
be provided as required by the telephone company.
E) Nurse call systems with outlets for treatment rooms, duty
stations, corridor signal lights, annunciators and wiring diagrams.
F) Doctors' call and doctors' in-and-out systems with all
equipment wiring, if provided.
G) Fire alarm system with stations, signal devices, control board
and wiring diagrams.
H) Emergency electrical system with outlets, transfer switch,
source of supply, feeders and circuits.
I) All other electrically operated systems and equipment.
5) Additions to Existing Structures
A) Procedures and requirements for working drawings and
specifications are to be followed, and the following information shall be
submitted:
i) Type of activities within the existing building and
distribution of existing treatment rooms, etc.;
ii) Type of construction of existing building and number of
stories in height;
iii) Plans and details showing attachment of new construction to
the existing structure; and
iv) Mechanical and electrical systems tying into existing system.
B) The Department may require submission of architectural drawings
of all or any part of the existing structure if necessary for the Department's
review.
6) Specifications. Specifications shall supplement the drawings
and shall comply with the following:
A) The specifications shall fully describe, except where fully
indicated and described on the drawings, the materials, workmanship, kind,
sizes, capacities, finishes, and other characteristics of all materials,
products, articles and devices.
B) The specifications shall include:
i) Cover or title sheet;
ii) Index;
iii) Invitation for bids;
iv) General conditions;
v) General requirements;
vi) Sections describing material and workmanship in detail for
each class of work; and
vii) Bid form.
(Source:
Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2180 CONSTRUCTION DETAILS
Section 518.2180
Construction Details
a) Compartmentation, exits, automatic extinguishing systems and
other details relating to fire prevention and fire protection shall comply with
requirements listed in the appropriate sections of NFPA 101.
b) Items such as drinking fountains, telephone booths, vending
machines and portable equipment shall be located so as not to restrict corridor
traffic or reduce the corridor width below the required minimum.
c) Doors
1) Doors to observation/treatment rooms shall not be lockable
from inside the room.
2) Special Locking Arrangements: Electronic locking devices may
be installed at specific locations to restrict egress or ingress for
patient/staff safety or security, provided that each of the following is
complied with and after receiving approval from the Department:
A) The facility shall submit a narrative to the Department
providing a rationale for having a locked door in a required means of egress.
The rationale shall relate to security issues.
B) The building shall be fully sprinklered.
C) All locking system components shall be U.L. listed.
D) Cross corridor, smoke or control doors that are located in a
required means of egress shall be secured only with electronic locks and
automatic release devices. The use of only manual keys or tools to unlock the
door is not permitted.
E) Locked doors shall have continuous staff supervision (direct or
electronic remote).
F) No other type of locking arrangement shall be used in a
required means of egress.
G) All locked doors shall release automatically with actuation of
the fire alarm system.
H) All doors shall release automatically with loss of electrical
power to the locking device.
I) All locks shall initiate an irreversible process that will
release the lock within 15 seconds whenever a force of not more than 15 pounds
is continuously applied to the release device (lever type handle or panic bar)
for a period of not more than three seconds. Relocking of such doors shall be
by manual means only. Operation of the release device shall activate a sign in
the vicinity of the door to assure those attempting to exit that the system is
functional. Delays of up to 30 seconds may be acceptable, based on the program
narrative.
J) Permanent signs shall be posted on locked doors that state:
"Push until alarm sounds. Door will be opened in 15 seconds." Sign
letters must be at least 1 inch high with ⅛ inch stroke. Signs may be
omitted for security reasons, based on review and approval by the Department of
the written rationale.
K) Emergency lighting shall be provided at all locked door
locations.
L) The FEC shall fully apprise the local fire department of locked
doors or units and all related details of the system.
M) Any discharge exit door may be locked against entry.
N) Additional electronic release of locked doors initiated from a
staff duty station is to be provided.
O) No more than one such device may be installed in any path of
travel to exit discharge.
d) The minimum width of all doors to rooms needing access for
beds or stretchers shall be 3'8". Doors to rooms needing access for
wheelchairs shall have a minimum width of 2'10".
e) Doors on all openings between corridors and rooms or spaces
subject to occupancy, except elevator doors, shall be swing type. Openings to
patient toilets and other small wet-type areas not subject to fire hazard are
exempt from this requirement. Sliding doors with a break and swing feature are
acceptable.
f) Doors, except those to spaces such as small closets that are
not subject to occupancy, shall not swing into corridors in a manner that might
obstruct traffic flow or reduce the required corridor width. (Large walk-in
type closets are considered as occupiable spaces.)
g) Windows shall be designed so that persons cannot accidentally
fall out of them when they are open, or shall be provided with guards.
h) Glazing. Doors, sidelights, borrowed lights, and windows in
which the glazing extends down to within 18 inches of the floor (thereby
creating possibility of accidental breakage by pedestrian traffic) shall be
glazed with safety glass or plastic glazing material that will resist breaking
and will not create dangerous cutting edges when broken. Fire-rated glass
shall be used where required for fire safety.
i) Where labeled fire doors are required, these shall be
certified by an independent testing laboratory as meeting the construction
requirements equal to those for fire doors in NFPA 80. Reference to a labeled
door includes labeled frame and hardware.
j) Elevator shaft openings shall be class B 1½ hour labeled fire
doors.
k) Linen and refuse chutes shall meet or exceed the requirements
of NFPA 82.
l) Thresholds and expansion joint covers shall be made flush
with the floor surface to facilitate use of wheelchairs and carts.
m) Grab bars shall be provided at all patients' toilets. The bars
shall have 1½ inch clearance to walls and shall have sufficient strength and
anchorage to sustain a concentrated load of 250 pounds.
n) An accessible shower shall be provided. Safety glass or
plastic glazing materials shall be used for shower doors. A grab bar shall be
provided as specified in subsection (m). A recessed soap dish shall be
provided. The shower base shall have a nonslip service.
o) Hand-washing facilities shall be located and arranged to
permit their proper use and operation. Particular care shall be given to the
clearances required for blade-type operating handles.
p) Paper towel dispensers and waste receptacles (or electric hand
dryers) shall be provided at all hand-washing facilities except scrub sinks.
q) Lavatories and hand-washing facilities shall be securely
anchored to withstand an applied vertical load of not less than 250 pounds on
the front of the fixture.
r) X-ray and gamma ray installations shall comply with NCRP
Report No. 147 and Report No. 102. The completed installation shall be tested,
and all defects shall be corrected before use.
s) Ceiling heights shall be as follows:
1) Radiographic, major procedure rooms, and other rooms
containing ceiling-mounted equipment or ceiling-mounted surgical light fixtures
shall have height required to accommodate the equipment or fixtures.
2) All other rooms shall have not less than 8'0" ceilings,
except that ceiling heights in corridors, storage rooms, toilet rooms and other
minor rooms shall be not less than 7'8". Suspended tracks, rails, and
pipes located in the path of normal traffic shall be not less than 6'8"
above the floor.
t) Rooms containing heat-producing equipment (such as boiler or
heater rooms and laundries) shall be insulated and ventilated to prevent any
floor surface above from exceeding a temperature of 10°F (6°C) above the
ambient room temperature.
u) The FEC shall be located on the same level as the ambulance
and walk-in entrance.
v) Response to Natural Disasters
1) General Requirements. An emergency radio communication system
is desirable in each facility. If installed, this system shall be
self-sufficient in time of emergency and shall also be linked with the
available community system and State emergency medical network system,
including connections with police, fire, and civil defense system.
2) Earthquakes. In areas where local experience shows that
earthquakes have caused loss of life or extensive property damage, buildings
and structures shall be designed to withstand the force assumptions specified
in the International Building Code.
3) Tornadoes and Floods. Special provisions shall be made in the
design of buildings in regions where local experience shows loss of life or
damage to buildings resulting from tornadoes or floods.
(Source:
Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2190 FINISHES
Section 518.2190 Finishes
a) Cubicle and window curtains and draperies shall be
noncombustible or flame retardant and shall pass both the large- and small-scale
tests of NFPA 701.
b) Flame spread and smoke developed ratings of finishes shall be
in accordance with NFPA 101.
c) Floor materials shall be easily cleanable and have wear
resistance appropriate for the location involved. Floors in toilets, janitor's
closets and similar areas shall be water resistant. In all areas frequently
subject to wet cleaning methods, floor materials shall not be physically
affected by germicidal and cleaning solutions.
d) Wall bases in soiled workrooms and other areas that are
frequently subject to wet cleaning methods shall be made integral and coved
with the floor, tightly sealed to the wall, and constructed without surface
voids that can harbor vermin.
e) All wall finishes shall be washable and, in the immediate area
of plumbing fixtures, shall be smooth and moisture resistant. Walls in spaces
subject to frequent cleaning shall be of suitable materials.
f) Floor and wall penetrations by pipes, ducts, and conduits
shall be tightly sealed to minimize entry of vermin, smoke and fire. Joints of
structural elements shall be similarly sealed.
g) Ceilings shall be cleanable and shall have a finished surface
that covers all overhead duct work and piping. Finished ceilings may be
omitted in mechanical and equipment spaces, shops, general storage areas, and
similar spaces, unless required for fire-resistive purposes.
h) The following areas shall have acoustical ceilings:
1) Corridors in patient areas,
2) Nurses' stations, and
3) Waiting areas.
(Source:
Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2200 STRUCTURAL REQUIREMENTS
Section 518.2200 Structural
Requirements
a) In addition to compliance with this Part, all applicable local
or State building codes and regulations shall be observed.
b) The buildings and all parts thereof shall be of sufficient
strength to support all dead, live, and lateral loads without exceeding the
working stresses permitted for the materials of their construction in generally
accepted good engineering practice.
c) Special provision shall be made for machines or apparatus
loads that would cause a greater load than the specified minimum live load.
d) Consideration shall be given to structural members and
connections of structures that may be subject to earthquakes or tornadoes.
Floor areas where partition locations are subject to change shall be designed
to support for the partition, a uniformly distributed load of 25 p.s.f.
e) Construction shall be in accordance with NFPA 101 and the
minimum requirements contained in this Part.
1) Foundations shall rest on natural solid ground and shall be
carried to a depth of not less than one foot below the estimated frost line or
shall rest on leveled rock or load-bearing piles or caissons when solid ground
is not encountered. Footings, piers and foundation walls shall be adequately
protected against deterioration from the action of ground water. Test borings
shall be taken to establish proper soil-bearing values for the soil at the
building site.
2) Assumed live load shall be in accordance with the International
Building Code.
f) Chapter 18, New Health Care Occupancies, of NFPA 101 shall
apply in its entirety.
(Source:
Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2210 MECHANICAL REQUIREMENTS
Section 518.2210 Mechanical
Requirements
a) General Requirements
1) Mechanical systems shall be tested, balanced and operated to
demonstrate that these systems are installed and will perform according to the
plans and specifications.
2) Upon completion of the mechanical systems, the owner shall
obtain a complete set of manufacturers' installation, operating, maintenance
and preventive maintenance instructions, and a parts list with numbers and a
description for each piece of equipment. The owner shall also obtain
instruction in the operational use of the systems and equipment as required.
b) Thermal and Acoustical Insulation
1) Insulation shall be provided for the following when located
within the building:
A) Boilers, smoke breeching and stacks;
B) Steam supply and condensate return piping;
C) Hot water piping above 120°F and all water heaters, generators,
and converters. Exposed hot water supplies to fixtures need not be insulated
except where exposed to contact by physically handicapped persons;
D) Chilled water, refrigerant, other process piping and equipment
operating with fluid temperatures below ambient dew point;
E) Water supply, storm and drainage piping on which condensation
may occur;
F) Air ducts and casings with outside surface temperature below
ambient dew point; and
G) Other piping, ducts and equipment as necessary to maintain the
efficiency of the system.
2) Insulation on cold surfaces shall include an exterior vapor
barrier.
3) Insulation, including finishes and adhesives on exterior
surfaces of ducts and equipment, shall have a flame spread rating of 25 or less
and a smoke developed rating of 50 or less as determined by an independent
testing laboratory in accordance with NFPA 255.
4) Pipe insulation shall have a flame spread rating of 25 or less
and a smoke developed rating of 150 or less.
5) No duct linings shall be permitted.
c) Steam and Hot Water Systems
1) Boilers shall have the capacity to supply the normal
requirements of all systems and equipment. The number and arrangement of
boilers shall be such that when one boiler breaks down or is temporarily taken
out of service, the capacity of the remaining boilers shall be sufficient to
provide hot water service, steam for sterilization, and heating for all
treatment rooms.
2) Boiler feed pumps, heating circulating pumps, condensate
return pumps and fuel oil pumps shall be connected and installed to provide
normal and standby service.
3) Supply and return mains and risers of cooling, heating and
process steam systems shall be valved to isolate the various sections of each
system. Each piece of equipment shall be valved at supply and return ends.
4) Humidifiers used in conjunction with air handling systems
shall be of the direct steam injection type.
d) Air Conditioning, Heating and Ventilating Systems
1) The FEC shall employ the most economical and energy-efficient
systems, in accordance with this subsection (d), to provide a comfortable,
clean and controlled environment.
A) The requirements of this subsection (d) do not relieve the
designer from providing system capacities and components as required to
maintain control of air quality, odor, ventilation rates, space temperatures
and space humidity as set forth in this subsection (d).
B) The design of air conditioning, heating and ventilation systems
shall be based on no less than the recommended outdoor design conditions listed
in the ASHRAE Handbook – Fundamentals for 99% occurrence (winter) and 1%
occurrence (summer).
2) Ventilation Systems
A) Air handling systems shall conform to NFPA 90A.
B) Fire dampers, smoke dampers and smoke control systems shall be
constructed, located and installed in accordance with the requirements of NFPA
90A.
C) Ducts that penetrate construction intended for x-ray or other
ray protection shall preserve the effectiveness of the protection.
D) Outdoor air intakes shall be located at least 15 feet from
exhaust outlets of ventilation systems, combustion equipment stacks,
medical/surgical vacuum systems, plumbing vents, or areas that may collect
vehicular exhaust or other noxious fumes, unless other provisions are made to
minimize recirculation of exhaust into outdoor air intakes. Plumbing and vacuum
vents that terminate above the level of the top of the air intake may be
located as close as 10 feet. The bottom of outdoor air intakes serving central
systems shall be located as high as practical but at least 6 feet above ground
level, or, if installed above the roof, 3 feet above the roof level.
E) Exhaust outlets from areas that may be contaminated by
dangerous or noxious dust, fumes, mists, gases, odors, infectious material or
other contaminants harmful to people shall be above the roof level. The
discharge to the atmosphere shall be located as far as possible but not less
than 25 feet from any operable window, door and/or outdoor intake for a fan
that discharges air to an occupied space.
F) The ventilation systems shall be designed and balanced to
provide the ventilation and pressure relationships specified in this Section.
G) If the ventilation rates required in this Section do not
provide sufficient make-up air for use by hoods, safety cabinets and exhaust
fans, the additional make-up air shall be provided to maintain required
pressure balance.
H) An all outdoor air system may be used where required by local
codes, provided that some form of air-to-air or air-to-water heat recovery
system is included to reclaim the energy otherwise discharged with the air
exhausted to the outside.
I) To provide maximum energy conservation, air supplied to
patient care areas not required as make-up air for 100% exhaust systems shall
be recirculated. Any air within the FEC that is circulated between patient
rooms, or patient rooms and other areas of the FEC, shall pass through filters
having a minimum efficiency reporting value (MERV) 14 rating (see subsection
(d)(3) on filters).
J) To provide maximum energy conservation, air supplied to
housekeeping, administration and other nonsensitive areas not required as
make-up air for 100% exhaust systems shall be recirculated. These areas
require filters having a MERV 8 rating on the inlet side of the air handling
unit.
K) When a central system serves areas with different filtration
requirements, the most stringent filtration requirement will be provided for
the complete system.
L) All outside air supplied to patient care areas shall pass
through 90% filters (see subsection (d)(3) on filters).
M) Minimum air circulation requirements indicated in this Section
are applicable to occupied spaces. During unoccupied periods, minimum air
circulation may be provided as required to maintain space design temperature
conditions.
N) Where fan coil or terminal room unit systems are provided in
areas to be occupied by patients, through-the-wall outside air ventilation is
not acceptable. A separate central ventilation system, with final filters
having a MERV 14 rating, shall supply the required outdoor air ventilation.
O) Only fully ducted systems are acceptable. Interstitial spaces
shall not be used as plenums for supply/return/exhaust.
3) Filters
A) All central ventilation or air conditioning systems shall be
equipped with filters having efficiencies no less than those specified in the
area requirements (see subsection (e)).
B) Where two filter beds are required, filter bed No. 1 shall be
located upstream of the air conditioning equipment and filter bed No. 2 shall
be located downstream of the supply fan and air conditioning equipment.
C) Where only one filter bed is required, it shall be located
upstream of the air conditioning equipment.
D) All filter efficiencies shall be average atmospheric dust spot
efficiencies tested in accordance with ASHRAE Handbook – Fundamentals.
E) Filter frames shall be durable and shall provide an air-tight
fit with the enclosing ductwork. All joints between filter segments and
enclosing ductwork shall be gasketed or sealed to provide a positive seal
against air leakage.
F) A local indicating device shall be installed across each
filter bed serving central air systems to measure the static pressure drop
across the bed.
e) Area Requirements
1) Administration, Public Area, Medical Records and Housekeeping
Offices
A) Filters
i) Central ventilation systems shall be provided with prefilters
having a MERV 8 rating.
ii) Units that recirculate air within a room shall be provided
with filters having a MERV 4 rating.
B) Space Design Conditions
i) Temperature,
measured via a dry bulb, shall be 75°F.
ii) The
minimum relative humidity in winter shall be 30%.
iii) The
maximum relative humidity in summer shall be 60%.
C) Air Circulation
i) Total air supplied to each space shall be as required to
maintain space design conditions.
ii) Outdoor air supplied shall be not less than 20% of the total
air supplied.
D) Space Pressurization. The ventilation system shall be designed
and balanced so that space pressure, in relation to surrounding areas of the
building, is neutral.
E) Recirculation
of air within a room is permitted.
2) Laboratories
A) Filters
i) Central ventilation systems shall be provided with prefilters
having a MERV 8 rating and final filters having a MERV 14 rating.
ii) Units that recirculate air within a room shall be provided
with filters having a MERV 8 rating.
B) Space Design Conditions
i) Temperature,
measured via a dry bulb, shall be 75°F.
ii) The minimum relative humidity, in winter, shall be 30%.
iii) The maximum relative humidity, in summer, shall be 60%.
C) Space Pressurization
The
ventilation system shall be designed and balanced so that space pressure, in
relation to surrounding areas of the building, is negative.
D) Recirculation of air within a room is permitted, except in
areas listed in subsection (e)(2)(E), where all air must be exhausted directly
to the outdoors.
E) Air from the following areas shall be exhausted directly to the
outdoors:
i) All fume hoods;
ii) Histology;
iii) Bacteriology; and
iv) Glass-washing areas.
F) All air exhausted from fume hoods shall be made up with
outside air.
G) Laboratory hoods shall meet the following general requirements:
i) Have an average face velocity of not less than 75 feet per
minute;
ii) Be connected to an exhaust system that is separate from the
building exhaust system;
iii) Have an exhaust duct system of noncombustible,
corrosion-resistant material consistent with the usage of the hood; and
iv) Have an exhaust fan located at the discharge end of the duct
system unless provided with a welded stainless steel duct from fan outlet to
termination.
H) Laboratory hoods shall meet the following special requirements:
i) Each hood that processes infectious or radioactive materials
shall have a minimum face velocity of 100 feet per minute, shall be connected
to an independent exhaust system, shall be provided with filters with 99.97%
efficiency (based on the dioctylphthalate test method as described in DOD
Penetration Test Method MIL STD No. 282) in the exhaust system, and shall be
designed and equipped to permit the safe removal, disposal and replacement of contaminated
filters.
ii) Duct systems serving hoods in which radioactive and/or strong
oxidizing agents such as prechloric or nitric acid are used shall be
constructed of stainless steel and shall be equipped with wash-down facilities.
3) Radiology Suite; X-Ray Diagnostic, Fluoroscopy and Special
Procedures
A) Filters
i) Central ventilation systems shall be provided with prefilters
having a MERV 8 rating and final filters having a MERV 14 rating.
ii) Units that recirculate air within a room shall be provided
with filters having a MERV 8 rating.
iii) The exhaust from isotope storage shall be provided with
filters with 99.97% efficiency (based on the dioctylphthalate test methods as
described in DOD Penetration Test Method MIL STD No. 282).
B) Space Design Conditions
i) Temperature,
measured via a dry bulb, shall be 75°F.
ii) The minimum relative humidity, in winter, shall be 30%.
iii) The maximum relative humidity, in summer, shall be 60%.
C) Air Circulation
i) Total air supplied to each space shall be as required to
maintain space design conditions.
ii) Outdoor air supplied shall be not less than 20% of the total
air supplied.
D) Space Pressurization
The
ventilation system shall be designed and balanced so that space pressure, in
relation to surrounding areas of the building, is neutral.
E) The recirculation of air within a room is permitted.
4) Pharmacy Suite
A) Filters
i) Central ventilation systems shall be provided with prefilters
having a minimum MERV 8 rating and final filters having a MERV 14 rating.
ii) Units that recirculate air within a room shall be provided
with filters having a MERV 8 rating.
B) Space Design Conditions
i) Temperature,
measured via a dry bulb, shall be 75°F.
ii) The minimum relative humidity, in winter, shall be 30%.
iii) The maximum relative humidity, in summer, shall be 60%.
C) Air Circulation
i) Total air supplied to each space shall be as required to
maintain space design conditions.
ii) Outdoor air supplied shall be not less than 20% of the total
air supplied.
D) Space Pressurization
The
ventilation system shall be designed and balanced so that space pressure, in
relation to surrounding areas of the building, is neutral.
E) The recirculation of air within a room is permitted.
5) Observation/Treatment Rooms
A) Filters
i) Central ventilation systems shall be provided with prefilters
having a MERV 8 rating and final filters having a MERV 14 rating.
ii) Units that recirculate air within a room shall be provided
with filters having a MERV 8 rating.
B) Space Design Conditions
i) Temperature,
measured via a dry bulb, shall be 75°F.
ii) The
minimum relative humidity, in winter, shall be 30%.
iii) The
maximum relative humidity, in summer, shall be 60%.
C) Air Circulation (Patient Rooms)
i) The total air supplied per bed shall be 15 cubic feet per
minute (cfm).
ii) The
outdoor air supplied per bed shall be 10 cfm.
D) Air Circulation
i) Total air supplied to each space shall be as required to
maintain space design conditions.
ii) Outdoor air supplied shall be not less than 20% of the total
air supplied.
E) Space Pressurization
The
ventilation system shall be designed and balanced so that space pressure, in
relation to surrounding areas of the building, is neutral.
F) Recirculation of air within a room is permitted.
G) Isolation Rooms
These rooms
may be used two ways: to protect the patient from the facility environment or
to protect the facility environment from the patient. Isolation rooms shall
have the same conditions as other treatment rooms, except that the air flow
shall be capable of being either into the room or out of the room. When
isolation procedures are in place (pursuant to the Control of Communicable
Diseases Code), all air shall be exhausted directly to the outdoors.
6) Central Sterile Supply
A) Filters
Central
ventilation systems shall be provided with prefilters having a MERV 8 rating
and final filters having a MERV 14 rating.
B) Space Design Conditions
i) The temperature, measured via a dry bulb, shall be 75°F.
ii) The
minimum relative humidity, in winter, shall be 30%.
iii) The
maximum relative humidity, in summer, shall be 60%.
C) Air Circulation
i) Total air supplied to each space shall be as required to
maintain space design conditions.
ii) Outdoor air supplied shall be not less than 20% of the total
air supplied.
D) Air flow shall be from the clean area toward the soiled or
decontamination area.
E) Sterilization Room
i) Where only steam autoclaves are installed, the air exhausted
from the sterilizer area for heat control may be recirculated through a central
system that is provided with filters having a MERV 14 rating.
ii) Where ethylene oxide sterilizers are used, all air
contaminated with ethylene oxide above 1 part per million (PPM) shall be
exhausted directly outdoors. No air shall be recirculated that has more than 1
PPM of ethylene oxide present.
7) Linen Services; Laundry
A) Filters
Central
ventilation systems shall be provided with prefilters having a MERV 8 rating
and final filters having a MERV 13 rating.
B) Space Design Conditions: The temperature, measured via a dry
bulb in winter, shall be 70°F.
C) All air from the soiled storage and sorting area shall be
exhausted directly to outdoors.
D) Air flow shall be from the clean area to the soiled area. Air
from the clean area may be used to make up air exhausted from the soiled area.
E) Air from the clean area may be recirculated within the laundry
complex, but shall pass through a lint screen or trap before returning to the
air handling unit.
F) The entire laundry ventilation system shall be controlled so
that air flow is into the laundry from the FEC.
G) Circulation and ventilation rates may be variable, but
sufficient outside air shall be supplied to make up for exhaust. Minimum
circulation of unconditioned air at summer design conditions shall be 2 cfm
(cubic feet per minute) per square foot or 12 air changes per hour, whichever
is larger.
8) Miscellaneous Supporting Areas
Space
temperatures in these areas shall be maintained for occupant comfort.
Ventilation systems shall be designed and balanced so that air flows into these
spaces from adjacent areas.
A) Anesthesia Storage Rooms
i) All
air shall be exhausted directly to the outdoors.
ii) Minimum exhaust ventilation rates shall be six air changes
per hour.
iii) The ventilation system shall comply with NFPA 99, including
the option to provide a gravity (non-mechanical) ventilation system.
iv) Supply air makeup for exhaust requirements may be provided
from a mechanical ventilation system or by transfer from adjacent areas.
B) Soiled Holding and Work Rooms
i) All
air shall be exhausted directly to the outdoors.
ii) Minimum exhaust ventilation rates shall be 10 air changes per
hour.
iii) Supply air makeup for exhaust requirements may be provided
from a mechanical ventilation system or by transfer from adjacent areas.
C) Toilet Rooms
i) Exhaust air may be recirculated through a central ventilation
system that is provided with final filters having a MERV 14 rating. Otherwise,
all air shall be exhausted directly to the outdoors.
ii) Minimum exhaust ventilation rate shall be 1.5 cfm per square
foot of floor area, but no less than 50 cfm.
iii) Supply air makeup for exhaust requirements may be provided
from a mechanical ventilation system or by transfer from adjacent areas.
D) Janitor Closets, Linen and Trash Chute Rooms
i) All
air shall be exhausted directly to the outdoors.
ii) Minimum exhaust ventilation rate shall be 1.5 cfm per square
foot of floor area, but not less than 50 cfm.
iii) Supply air makeup for exhaust requirements may be provided
from a mechanical ventilation system or by transfer from adjacent areas.
E) Boiler rooms shall be provided with sufficient outdoor air to
maintain combustion rates of equipment and limit temperatures in working
stations to 97°F effective temperature (97°F and 50% relative humidity or its
equivalent) as defined by ASHRAE Handbook – Fundamentals.
F) Rooms containing heat-producing equipment, such as boiler
rooms, heater rooms, food preparation centers, laundries or sterilizer or
mechanical equipment rooms, shall be insulated and ventilated to prevent any
floor surface above from exceeding a temperature of 100°F.
(Source:
Amended at 33 Ill. Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2220 PLUMBING AND OTHER PIPING SYSTEMS
Section 518.2220 Plumbing
and Other Piping Systems
a) General Requirements
All plumbing
systems shall be designed and installed in accordance with the Illinois
Plumbing Code, except that the number of waterclosets, urinals, lavatories,
drinking fountains and other fixtures shall be as required by this Part.
b) Plumbing Fixtures
1) Plumbing fixtures shall be of nonabsorptive, acid-resistant
materials.
2) The water supply spout for lavatories and sinks required for
filling pitchers and for medical and nursing staff hand washing shall be
mounted so that its discharge point is a minimum perpendicular distance of 5
inches above the rim of the fixture.
3) Hand-washing lavatories used by medical and nursing staff
shall be trimmed with valves that can be operated without the use of hands
where specifically required in this Part.
A) When blade handles are used for this purpose the blade handles
shall not exceed 4½ inches in length, except that the handles on clinical sinks
shall not be less than 6 inches in length.
B) The hand-washing and/or scrub sinks for major procedure rooms
shall be trimmed with valves that are asceptically operated (i.e., knee or foot
controls) without the use of hands. Wrist blades are not acceptable.
4) Clinical rim flush sinks shall have an integral trap in which
the upper portion of a visible trap seal provides a water surface.
c) Water Supply Systems
1) Systems shall be designed to supply water at sufficient
pressure to operate all fixtures and equipment during maximum demand periods.
2) Each water service main, branch main, riser and branch to a
group of fixtures shall be valved. Stop valves shall be provided at each
fixture.
3) Flush valves installed on plumbing fixtures shall be of a
quiet operating type, equipped with silencers.
4) Water distribution systems shall be arranged to provide hot
water at each hot water outlet at all times. Hot water at shower and hand-washing
facilities shall not exceed 110°F (43°C).
d) Water Heaters and Tanks
1) The water-heating equipment shall have sufficient capacity to
supply water at the temperatures and quantities in the following areas:
|
|
Clinical
|
|
gallons/hour/bed
|
6½
|
|
liters/second/bed
|
.007
|
|
temperature °F
|
100
|
|
temperature °C
|
43
|
Water
temperatures are to be taken at hot water point of use or inlet to processing
equipment.
2) Storage tanks shall be fabricated of corrosion-resistant metal
or lined with non-corrosive material.
e) Drainage Systems
1) Drain lines from sinks in which acid wastes may be poured
shall be fabricated from acid-resistant material.
2) Insofar as possible, drain piping shall not be installed over
major procedure rooms and similar critical areas. Special precautions shall be
taken to protect these areas from possible leakage or condensation from such
overhead piping systems.
3) Building sewers shall discharge into a public sewerage system.
4) Where a public sewerage system is not available, plans for any
private sewage disposal system shall be submitted to the Illinois Environmental
Protection Agency for review for approval before construction is started.
f) Nonflammable medical gas systems shall be installed in
accordance with NFPA 99.
g) Clinical vacuum (suction) systems shall be installed in
accordance with NFPA 99.
h) Medical compressed air systems shall be installed in accordance
with NFPA 99.
i) Oxygen, vacuum and medical compressed air shall be piped to
the locations indicated in TABLE A with the required station outlets.
j) Service outlets for central housekeeping vacuum systems, if
used, shall not be located within major procedure rooms.
k) Fire Extinguishing Systems
All fire extinguishing systems
shall be designed, installed and maintained in accordance with NFPA 101, NFPA
13, and NFPA 25.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2230 ELECTRICAL REQUIREMENTS
Section 518.2230 Electrical
Requirements
a) General Requirements
1) All materials including equipment, conductors, controls, and
signaling devices shall be installed in compliance with applicable sections of
the NFPA 70, including Article 517, and as necessary to provide a complete
electrical system.
2) All electrical installations, including alarm, nurses' call
and communication systems, shall be tested to demonstrate that the equipment
installation and operation conforms to this Part.
b) Switchboards and Power Panels
These items
shall comply with NFPA 70. The main switchboard shall be located in an area
separate from plumbing and mechanical equipment and be accessible only to
authorized persons.
c) Panelboards. Panelboards serving lighting and appliance
circuits shall be located on the same floor as the circuits they serve. This
requirement does not apply to the life safety system.
d) Lighting
1) All spaces occupied by people, machinery, and equipment within
buildings, approaches to and through exits from buildings, and parking lots
shall have lighting.
2) Treatment rooms shall have general lighting in addition to
local lighting provided by special lighting units at the treatment tables. The
general lighting shall provide a minimum of 100 footcandles at the treatment
tables. Each fixed special lighting unit at the tables shall be connected to
an independent circuit.
e) Receptacles (Convenience Outlets)
1) Each treatment room shall have at least two receptacles
installed on each wall or eight receptacles in diversified locations per room.
2) Each observation/treatment room shall have duplex grounding
type receptacles as specified in Article 517-18 and Article 517-19 of NFPA 70.
The mounting height of these receptacles shall be 22 to 42 inches above the
finished floor.
3) Duplex receptacles for general use shall be installed
approximately 50'0" apart in all corridors and within 25'0" of the
ends of corridors. These receptacles shall be circuited to the emergency
system.
f) At least two x-ray film illuminators shall be installed in
each treatment room and in the x-ray viewing room of the radiology department.
More than two units shall be installed as needed.
g) Nurses' Calling System
1) Each observation/treatment room shall be served by at least
one calling station. Calls shall register with nursing staff and shall
activate a visible signal in the corridor at the observation/treatment room
door. In multicorridor nursing units, additional visible signals shall be
installed at corridor intersections. In rooms containing two or more calling
stations, indicating lights shall be provided at each station. Nurses' calling
systems that provide two-way voice communications shall be equipped with an
indicating light at each calling station, which will remain lighted as long as
the voice circuit is operating.
2) Nurse call duty stations shall be installed in the clean work
room, soiled work room, medicine preparation room, nourishment station and
nurses' lounge of the unit.
3) A nurses' call emergency station shall be provided for
patients' use at each patient's toilet and at the shower. These stations are
to be the pull-cord type with the cord reaching within 6 inches of the floor.
The cords are to be located within reach of a patient.
4) In areas where patients are under constant surveillance, the
nurses' calling system may be limited to a bedside station that will actuate a
signal that can be readily seen by the other nurses.
5) A communications system that may be used by nurses to summon
assistance shall be provided in each treatment room.
h) Communication System
1) A loud speaker-type sound system shall be provided throughout
the facility to allow for announcements, such as paging of personnel and other
necessary audio functions.
2) Speakers shall be located in all areas to allow personnel to
adequately hear all audio outputs from the system.
3) The system shall be used as the communication link for
emergency announcements, i.e., code blue, impending disasters and others. The
audio line at the last speaker in the audio circuits shall be electrically
supervised against opens and grounds. The supervision shall be indicated at a
building location that is staffed 24 hours a day.
i) Emergency Electric Service
1) To provide electricity during an interruption of the normal
electric supply, an emergency source of electricity shall be provided and
connected to the life safety branch, the critical branch, and the equipment
branch for lighting and power as established in NFPA 70-517.
2) The source of this emergency electric service shall be as
follows:
A) An emergency generating set when the normal service is supplied
by one or more central station transmission lines.
B) An emergency generating set or a central station transmission
line when the normal electric supply is generated on the premises.
3) Emergency Generating Set
A) The required emergency generating set, including the prime
mover and generator, shall be located on the premises. Where stored fuel is
required for the emergency generator operations, the storage capacity shall be
sufficient for not less than 24 hours continuous operation.
B) The emergency generator set may be used during periods of high
energy demands on local utilities. In the event of an outage of the normal
power source, the normal loads shall immediately be removed from the emergency
generator set, and the life safety branch, the critical branch, and the
equipment branch shall be connected to the generator.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.2240 BUILDING REQUIREMENTS
Section 518.2240 Building
Requirements
a) Location
The
freestanding emergency center shall be conveniently accessible to the
population served. In selecting location, consideration shall be given to
factors affecting source and quantity of patient load, including highway
systems, public transportation, industrial plants, and recreational areas.
b) Parking
One parking
space for each staff member on duty at any one time and no fewer than two
spaces for each major procedure room and each observation/treatment room shall
be provided. Handicapped parking spaces shall be provided as required in the
Illinois Accessibility Code. Additional spaces shall be provided for emergency
vehicles. Street, public, and shared lot spaces shall be exclusive for the use
of the emergency facility. All required parking spaces shall be conveniently
located to the emergency entrance.
c) Administration and Public Areas
1) The ambulance and walk-in entrance shall be located at grade
level and be able to accommodate wheelchairs.
A) All entrances shall be covered to permit protected transfer of
patients from ambulances, and a ramp for wheelchairs and stretchers shall be
provided in addition to steps. Doors to emergency services shall be not less
than 4 feet wide.
B) The emergency entrance shall have vision panels to minimize conflict
between incoming and outgoing traffic and to allow for observation of the
unloading area from the control station.
2) A lobby and waiting area shall be provided and shall provide:
A) Convenient access to wheelchairs and stretchers;
B) A control station that may be used for triage functions, is in
direct communication with medical staff and has direct visual control of the
emergency entrance, observation of arriving vehicles, and access to treatment
and lobby areas;
C) Waiting areas convenient to the reception and interview areas;
D) Public toilet facilities for males, females and/or families. Unisex
toilet facilities are prohibited.
3) Facilities for conducting interviews with patients and others
shall be provided and shall include provisions for acoustical and visual privacy.
4) General and individual offices shall be provided.
5) Clerical spaces shall be provided.
6) Multipurpose rooms for staff conferences and consultation
shall be provided.
7) Equipment and general storage areas shall be provided.
d) Clinical Facilities
1) At least one major procedure room shall be provided and shall
meet the following requirements:
A) A minimum clear area of 360 square feet exclusive of cabinets,
shelves, door swings and fixed obstructions;
B) A minimum clear dimension of 16 feet;
C) Emergency communication equipment connected to the nurses' control
station;
D) X-ray film illuminator (as necessary);
E) Mechanical and electrical systems and devices that meet
requirements for hospital surgical rooms in the Hospital Licensing Requirements
(77 Ill. Adm. Code 250).
2) Where additional procedure rooms are set up for multi-patient
use, these rooms shall meet the following requirements:
A) A minimum clear area of not less than 180 square feet per
patient stretcher or bed;
B) A minimum clear dimension of 10 feet per space;
C) Emergency communication equipment connected to the nurses' control
station;
D) X-ray film illuminator (as necessary);
E) Mechanical and electrical devices that meet requirements for
hospital surgical rooms in 77 Ill. Adm. Code 250.
3) A holding area for stretchers and wheelchairs within the
clinical area shall be provided and under staff control and located so as not
to block means of egress.
4) A poison control service shall be provided that contains the
following services:
A) Immediately accessible antidotes;
B) A file of information concerning common poisons; and
C) Communications links with regional and national poison centers
and regional EMS centers.
5) A nurses' work and control station shall be located to permit
visual control and access to clinical areas and shall contain space and
equipment to allow the following services to be provided:
A) Charting;
B) Storage of files;
C) Staff consultation; and
D) Communication link with examination/treatment, lobby and
waiting area control, laboratory, radiology and on-call staff.
6) A cardiopulmonary resuscitation (CPR) emergency cart shall be
located away from traffic and available to all areas.
7) Scrub stations shall be provided at each trauma/cardiac room
with water and soap controls operable without the use of hands.
e) Radiology
1) Facilities for basic diagnostic radiological procedures shall
be provided and shall include the following:
A) Space adequate to accommodate needed equipment with a minimum
clearance of 3 feet on all four sides of the table;
B) A shielded control alcove with windows providing a full view of
the examination table and the patient; and
C) A patient toilet accessible from the radiology room.
2) Film processing facilities shall be provided (if required).
3) Viewing and administrative areas shall be provided.
4) Storage facilities for exposed film shall be provided (if
required).
5) Dressing rooms or booths with convenient toilet access shall
be provided.
f) Laboratory
1) Laboratory facilities shall be provided for the performance of
tests in hematology, clinical chemistry, urinalysis, microbiology, anatomic
pathology and cytology to meet the work load.
2) Laboratory facilities shall provide for the following
procedures to be performed on-site: blood counts, urinalysis, blood glucose,
electrolytes, blood urea and nitrogen (BUN), coagulation, and transfusions
(type capability). If transport time by an ambulance to the nearest hospital is
10 minutes or less, plasma expanders may be used. If transport time by
ambulance to the nearest hospital is greater than 10 minutes, then type O
negative blood shall be available for transfusion. Facilities shall also be
included for specimen collection and processing.
3) The following shall be provided in the laboratory suite:
A) Work counters with space for items such as microscopes,
chemical analyzers, incubators and centrifuges; work counters shall include
sinks and provisions for fluid disposal, eye washes, vacuum, gases, electrical
services and piped-in air;
B) Hand-washing lavatories operable without the use of hands at
strategic locations for convenience of use;
C) Storage facilities;
D) Chemical safety provisions, including emergency showers,
eye-flushing devices and blankets; floor drains at the emergency shower
locations;
E) Flammable liquid storage in the form of vented cabinets
designed for use with flammable liquids;
F) Specimen collection facilities including: blood collection
area with work counter; space for patient seating and hand washing; a urine and
feces collection room equipped with water and lavatory;
G) A terminal sterilization facility for contaminated specimens
(autoclave or electric oven), unless contaminated waste is disposed of through
a licensed waste management service in accordance with Section 518.2150(f)(4);
and
H) If radioactive materials are employed, facilities for long-term
storage and disposal of these materials, appropriately shielded to prevent
exposure.
g) Staff locker rooms and toilets shall be provided.
h) At least one housekeeping room per floor shall be provided. The
housekeeping room shall contain a service sink and storage for housekeeping
supplies and equipment and shall be located within the FEC.
i) Utility Rooms
1) A clean utility room shall be provided and contain the
following:
A) Storage for clean and sterile supplies and equipment;
B) Work counters;
C) Hand-washing sinks operable without the use of hands;
D) Ice maker;
E) Under-counter refrigerator; and
F) Communications equipment.
2) A soiled utility room shall be provided and contain the
following:
A) Storage for soiled supplies and equipment;
B) Work counters;
C) Hands-free hand-washing sinks;
D) Communications equipment; and
E) Clinical service sink.
j) Sterile supply and processing rooms shall be provided and may
be combined with the clean and soiled utility rooms if the program narrative is
approved.
1) One-way flow shall be maintained between the soiled supplies,
clean-up, sterilizing, and storage functions.
2) Storage spaces for clean and sterile supplies and equipment
shall be provided.
3) Storage spaces for soiled supplies and equipment shall be
provided.
4) There shall be no direct access between the soiled and clean
sides of sterile supply and processing.
5) Work counters and hand-washing sinks operable without the use
of hands shall be provided.
6) A clinical service sink shall be provided on the soiled side.
7) The soiled side shall have equipment for cleaning, such as
ultrasound, washers, and deep three-compartment sink and tray assembly.
8) A pass-through sterilizer shall be provided.
9) Space shall be provided in the soiled side for processing
equipment and tray assembly, such as steris machines, dryers, tube racks,
wrapping and labelling counters. The steris machine shall be located in a clean
utility room. Only tray loading is permitted in the soiled side.
k) A nourishment room for the use of patients, conveniently
located to the clinical area, shall contain the following:
1) Work counter;
2) Refrigerator;
3) Ice maker;
4) Hands-free hand-washing sink; and
5) Storage for supplies.
l) Facilities shall be provided for observing patients until
they can be transferred to an appropriate hospital. The size and type of
equipment shall be what is required for anticipated patient load and lengths of
stay. Each observation bed shall provide for:
1) Direct visual observation of each patient from the nurses'
station;
2) Patient privacy;
3) Access to patient toilets;
4) Secure storage of patients' belongings;
5) Medication dispensing;
6) Bedpan storage and cleaning;
7) Hand-washing facilities without the use of hands;
8) Communications system with nurses station; and
9) Monitoring capabilities.
m) A consultation/communications room shall be located within
access of the diagnostic and treatment facilities and shall provide sound
isolated for privacy and confidentiality of consultation for the use of the
staff during the tele-medicine consultation. The room shall contain the
following:
1) Computer support and telecommunications support equipment
necessary for the consultation task;
2) View screens;
3) Work counters;
4) Storage areas; and
5) Additional refrigeration units as required by equipment.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
Section 518.ILLUSTRATION A Seismic Zone Map
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.ILLUSTRATION A SEISMIC ZONE MAP
Section 518.ILLUSTRATION A Seismic
Zone Map
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.TABLE A PIPING LOCATIONS FOR OXYGEN, VACUUM AND MEDICAL COMPRESSED AIR
Section 518.TABLE A Piping
Locations for Oxygen, Vacuum and Medical Compressed Air
|
Location
|
Oxygen
|
Vacuum
|
Compressed
Air
|
|
|
|
|
|
|
Patient Treatment Room
|
A
|
A
|
|
|
Examination and Treatment
Rooms
|
D
|
D
|
|
|
|
|
|
|
A = One outlet accessible to each bed. One outlet may serve 2 beds.
D = One outlet.
(Source: Amended at 33 Ill.
Reg. 8317, effective June 4, 2009)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.TABLE B INSULATION/BUILDING PERIMETER
Section 518.TABLE B Insulation/Building
Perimeter
1) Zones for insulation/building perimeter requirements shall
consist of the counties listed here.
Zone 1
includes the following counties:
|
Boone
|
Ford
|
Kane
|
Lee
|
Ogle
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Tazewell
|
|
Bureau
|
Grundy
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Kankakee
|
Livingston
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Peoria
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Warren
|
|
Carroll
|
Henderson
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Kendall
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Marshall
|
Putnam
|
Whiteside
|
|
Cook
|
Henry
|
Knox
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McHenry
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Rock Island
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Will
|
|
DeKalb
|
Iroquois
|
Lake
|
McLean
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Stark
|
Winnebago
|
|
DuPage
|
JoDaviess
|
LaSalle
|
Mercer
|
Stephenson
|
Woodford
|
Zone 2 includes the following
counties:
|
Adams
|
Clark
|
Effingham
|
Jersey
|
McDonough
|
Pike
|
|
Bond
|
Coles
|
Fayette
|
Logan
|
Menard
|
Sangamon
|
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Brown
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Crawford
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Fulton
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Macon
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Montgomery
|
Schuyler
|
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Calhoun
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Cumberland
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Greene
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Macoupin
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Morgan
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Scott
|
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Cass
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DeWitt
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Hancock
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Madison
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Moultrie
|
Shelby
|
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Champaign
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Douglas
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Jasper
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Mason
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Piatt
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Vermilion
|
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Christian
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Edgar
|
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Zone 3 includes the following
counties:
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Alexander
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Gallatin
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Johnson
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Perry
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St. Clair
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Washington
|
|
Clay
|
Hamilton
|
Lawrence
|
Pope
|
Saline
|
Wayne
|
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Clinton
|
Hardin
|
Marion
|
Pulaski
|
Union
|
White
|
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Edwards
|
Jackson
|
Massac
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Randolph
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Wabash
|
Williamson
|
|
Franklin
|
Jefferson
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Monroe
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Richland
|
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|
2) The following minimum building perimeter
insulation R values shall be provided:
|
|
Roof
|
Walls
|
Floors
|
|
|
|
|
|
|
Zone 1
|
R-38
|
R-17
|
R-19
|
|
Zone 2
|
R-30
|
R-17
|
R-19
|
|
Zone 3
|
R-30
|
R-12
|
R-11
|
3) All windows shall be glazed with double glazed insulating
glass. All exterior windows and door frames shall be constructed of non-cold
conducting materials such as wood or metal with at thermal break.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER g: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 518
FREESTANDING EMERGENCY CENTER CODE
SECTION 518.TABLE C MINIMUM EFFICIENCY REPORTING VALUES
Section 518.TABLE C Minimum
Efficiency Reporting Values
|
Minimum Efficiency Reporting Values
(MERV)
ASHRAE Standard 52.2
|
|
Group Number
|
MERV Rating
|
E1
Average Particle Size Efficiency (PSE)
0.3-1.0 Microns
|
E2
Average Particle Size Efficiency (PSE) 1.0-3.0
Microns
|
E3
Average Particle Size Efficiency (PSE) 3.0-10.0
Microns
|
Average Arrestance (ASHRAE 52.1)
|
Minimum Final Resistance (in Water Gauge)
|
|
|
|
|
|
|
|
|
|
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MERV 1
|
-
|
-
|
< 20%
|
<65%
|
0.3m
|
|
|
|
|
|
|
|
|
|
|
MERV 2
|
-
|
-
|
< 20%
|
65-69.9%
|
0.3m
|
|
1
|
MERV 3
|
-
|
-
|
< 20%
|
70-74.9%
|
0.3m
|
|
|
MERV 4
|
-
|
-
|
< 20%
|
75% or >
|
0.3m
|
|
|
|
|
|
|
|
|
|
|
MERV 5
|
-
|
-
|
20-34.9%
|
-
|
0.6m
|
|
2
|
MERV 6
|
-
|
-
|
35-49.9%
|
-
|
0.6m
|
|
|
MERV 7
|
-
|
-
|
50-69.9%
|
-
|
0.6m
|
|
|
MERV 8
|
-
|
-
|
70-84.9%
|
-
|
0.6m
|
|
|
|
|
|
|
|
|
|
|
MERV
9
|
-
|
<50%
|
85% or >
|
-
|
1.0m
|
|
3
|
MERV
10
|
-
|
50-64.9%
|
85% or >
|
-
|
1.0m
|
|
|
MERV
11
|
-
|
65-79.9%
|
85% or >
|
-
|
1.0m
|
|
|
MERV
12
|
-
|
80-89.9%
|
90% or >
|
-
|
1.0m
|
|
|
|
|
|
|
|
|
|
|
MERV
13
|
< 75%
|
90% or >
|
90% or >
|
-
|
1.4m
|
|
4
|
MERV
14
|
75-84.9%
|
90% or >
|
90% or >
|
-
|
1.4m
|
|
|
MERV
15
|
85-94.9%
|
90% or >
|
90% or >
|
-
|
1.4m
|
|
|
MERV
16
|
95% or >
|
95% or >
|
95% or >
|
-
|
1.4m
|
Notes:
1. ASHRAE Standard 52.2
tests are to be conducted at one of seven air flow rates.
|
118 FPM (.60 m/s)
|
492 FPM (2.50 m/s)
|
|
246 FPM (1.25 m/s)
|
630 FPM (3.20 m/s)
|
|
295 FPM (1.50 m/s)
|
748 FPM (3.80 m/s)
|
|
374 FPM (1.90 m/s)
|
|
2. The
air flow rate at which the filter was tested is included in the MERV rating (MERV
10 @ 2.5m/s).
3. Filters
with an E3 efficiency of less than 20%
(MERV 1 through MERV 4) must also be tested for arrestance per ASHRAE Standard
52.1.
4. Final resistance must be at least
twice the initial resistance at the test air flow rate, or the values shown in
the table above, whichever is greater.
(Source: Added at 33 Ill.
Reg. 8317, effective June 4, 2009)
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