TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.105 INCORPORATED AND REFERENCED MATERIALS


 

Section 250.105  Incorporated and Referenced Materials

 

a)         The following regulations and standards are incorporated in this Part:

 

1)         Private and Professional Association Standards

 

A)        American Society for Testing and Materials (ASTM), Standard No. E90-99 (2009):  Standard Test Method for Laboratory Measurement of Airborne Sound Transmission Loss of Building Partitions and Elements, which may be obtained from the American Society for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, Pennsylvania 19428-2959  

 

B)        ASTM E 662 (2012), Standard Test Method for Specific Optical Density of Smoke Generated by Solid Materials, which may be obtained from the American Society for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, Pennsylvania 19428-2959

 

C)        ASTM E 84 (2010), Standard Test Method for Surface Burning Characteristics of Building Materials, which may be obtained from the American Society for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, Pennsylvania 19428-2959

 

D)        The following standards of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE), which may be obtained from the American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc., 1791 Tullie Circle, N.E., Atlanta, Georgia 30329:  

 

i)          ASHRAE Handbook of Fundamentals (2009)

 

ii)         ASHRAE Handbook for HVAC Systems and Equipment (2004)

 

iii)        ASHRAE Handbook-HVAC Applications (2007)

 

E)        The following standards of the National Fire Protection Association (NFPA), which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02169:

 

i)          NFPA 101 (2012):  Life Safety Code and all applicable references under Chapter 2, Referenced Publications.

 

ii)         NFPA 101A (2013):  Guide on Alternative Approaches to Life Safety

 

F)         American Academy of Pediatrics and American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, Seventh Edition (2012), which may be obtained from the American College of Obstetricians and Gynecologists Distribution Center, P.O. Box 933104, Atlanta, Georgia 31193-3104 (800-762-2264) (See Section 250.1820.)

 

G)        American College of Obstetricians and Gynecologists, Guidelines for Women's Healthcare, Fourth Edition (2014), which may be obtained from the American College of Obstetricians and Gynecologists Distribution Center, P.O. Box 933104, Atlanta, Georgia 31193-3104 (800-762-2264) (See Section 250.1820.)

 

H)        American Academy of Pediatrics (AAP), Red Book: Report of the Committee on Infectious Diseases, 28th Edition (2009), which may be obtained from the American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, Illinois 60007 (See Section 250.1820.)

 

I)         American Academy of Pediatrics and the American Heart Association, 2011 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines, which may be obtained from the American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, Illinois 60007, or at pediatrics.aappublications .org/cgi/reprint/117/5/e1029.pdf (See Section 250.1830.)

 

J)         National Association of Neonatal Nurses, Position Statement #3009 Minimum RN Staffing in NICUs, which may be obtained from the National Association of Neonatal Nurses, 4700 W. Lake Ave., Glenview, Illinois 60025 or at nann.org/pdf/08_3009_rev.pdf  (See Section 250.1830.)

 

K)        National Council on Radiation Protection and Measurements (NCRP), Report 49:  Structural Shielding Design and Evaluation for Medical Use of X-rays and Gamma Rays of Energies up to 10 MeV (1976) and NCRP Report 102: Medical X-Ray, Electron Beam and Gamma-Ray Protection for Energies Up to 50 MeV (Equipment Design, Performance and Use) (1989), which may be obtained from the National Council on Radiation Protection and Measurements, 7910 Woodmont Ave., Suite 800, Bethesda, Maryland 20814-3095 (See Sections 250.2440 and 250.2450.)

 

L)        DOD Penetration Test Method MIL STD 282 (2012):  Filter Units, Protective Clothing, Gas-mask Components and Related Products:  Performance Test Methods, which may be obtained from Naval Publications and Form Center, 5801 Tabor Avenue, Philadelphia, Pennsylvania 19120 (See Section 250.2480.)

 

M)       National Association of Plumbing-Heating-Cooling Contractors (PHCC), National Standard Plumbing Code (2009), which may be obtained from the National Association of Plumbing-Heating-Cooling Contractors, 180 S. Washington Street, P.O. Box 6808, Falls Church, Virginia 22046 (703-237-8100)

 

N)        International Building Code (2012), which may be obtained from the International Code Council, 4051 Flossmoor Road, Country Club Hills, Illinois 60477-5795 (See Section 250.2420.)

 

O)        American National Standards Institute, ANSI A117.1 (2009), Standard for Accessible and Usable Buildings, which may be obtained from the American National Standards Institute, 25 West 433rd Street, 4th Floor, New York, New York 10036 (See Section 250.2420.)

 

P)         ASME Standard A17.1-2007, Safety Code for Elevators and Escalators, which may be obtained from the American Society of Mechanical Engineers (ASME) International, 22 Law Drive, Box 2900, Fairfield, New Jersey 07007-2900

 

Q)        Accreditation Council for Graduate Medical Education, Essentials of Accredited Residencies in Graduate Medical Education (1997), which may be obtained from the Accreditation Council for Graduate Medical Education, 515 North State Street, Suite 2000, Chicago, Illinois 60610 (See Section 250.315.)

 

R)        The Joint Commission, 2006 Hospital Accreditation Standards (HAS), Standard PC.3.10, which may be obtained from the Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181 (See Section 250.1035.)

 

S)         National Quality Forum, Safe Practices for Better Health Care (2009), which may be obtained from the National Quality Forum, 601 13th Street, NW, Suite 500 North, Washington DC 20005, or from www.qualityforum.org

 

2)         Federal Government Publications

 

A)        Department of Health and Human Services, Centers for Disease Control and Prevention, "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007", updated October 2017, available at https://www.cdc.gov/anthrax/pdf/infection-control-guidelines-for-healthcare-setting-2007.pfd

 

B)        Department of Health and Human Services, Centers for Disease Control and Prevention, "Guidelines for Infection Control in Health Care Personnel, 1998", available at https://www.cdc.gov/ infectioncontrol/guidelines/healthcare-personnel/index.html

 

C)        Department of Health and Human Services, Centers for Disease Control and Prevention, "Guidelines for Environmental Infection Control in Health-Care Facilities:  Recommendations − Animals in Health Care Facilities", "Morbidity and Mortality Weekly Report", June 6, 2003/Vol. 52/No. RR-10, available at https://www.cdc.gov /mmwr/preview/mmwrhtml/rr5210a1.htm

 

D)        Department of Health and Human Services, Centers for Disease Control and Prevention, "Guidelines for Hand Hygiene in Health-Care Settings", "Morbidity and Mortality Weekly Report", October 25, 2002/Vol. 51/No. RR-16, available at https://www.cdc.gov/mmwr/preview/

mmwrhtml/rr5116a1.htm

 

E)        Department of Health and Human Services, Centers for Disease Control and Prevention, "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008", updated February 15, 2017, available at https://www.cdc.gov/infectioncontrol/ guidelines/disinfection/

 

F)         Department of Health and Human Services, Centers for Disease Control and Prevention, "Core Elements of Hospital Stewardship Programs", 2014, which is available at http://www.cdc.gov/ getsmart/healthcare/implementation/core-elements.html, and "Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals", which is available at https://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements-small-critical.pdf

 

G)        National Center for Health Statistics and World Health Organization, Geneva, Switzerland, "International Classification of Diseases", 10th Revision, Clinical Modification (ICD-10-CM) (1990), Version for 2015, which can be accessed at http://www.who.int/classifications/icd/en/

 

H)        U.S. Department of Labor, Occupational Safety and Health Administration, "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers" (OSHA 3148-06R 2016), available at:  https://www.osha.gov/Publications/

osha3148.pdf

 

I)         Department of Health and Human Services, United States Public Health Service, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, "STOP SV: A Technical Package to Prevent Sexual Violence", available at:  https://www.cdc.gov/

violenceprevention/pdf/sv-prevention-technical-package.pdf

 

3)         Federal Regulations

 

A)        45 CFR 46.101, To What Does the Policy Apply? (October 1, 2019)

 

B)        45 CFR 46.103(b), Assuring Compliance with this Policy − Research Conducted or Supported by any Federal Department or Agency (October 1, 2019)

 

C)        42 CFR 482, Conditions of Participation for Hospitals (October 1, 2019)

 

D)        21 CFR, Food and Drugs (April 1, 2019)

 

E)        42 CFR 489.20, Basic Commitments (October 1, 2019)

 

F)         29 CFR 1910.1030, Bloodborne Pathogens (July 1, 2019)

 

G)        42 CFR 413.65(d) and (e), Requirements for a determination that a facility or an organization has provider-based status (October 1, 2019)

 

b)         All incorporations by reference of federal regulations and guidelines and the standards of nationally recognized organizations refer to the regulations, guidelines and standards on the date specified and do not include any editions or amendments subsequent to the date specified.

 

c)         The following statutes and State regulations are referenced in this Part:

 

1)         State of Illinois Statutes

 

A)        Hospital Licensing Act [210 ILCS 85]

 

B)        Illinois Health Facilities Planning Act [20 ILCS 3960]

 

C)        Medical Practice Act of 1987 [225 ILCS 60]

 

D)        Podiatric Medical Practice Act of 1987 [225 ILCS 100]

 

E)        Pharmacy Practice Act [225 ILCS 85]

 

F)         Physician Assistant Practice Act of 1987 [225 ILCS 95]

 

G)        Illinois Clinical Laboratory and Blood Bank Act [210 ILCS 25]

 

H)        X-ray Retention Act [210 ILCS 90]

 

I)         Safety Glazing Materials Act [430 ILCS 60]

 

J)         Mental Health and Developmental Disabilities Code [405 ILCS 5]

 

K)        Nurse Practice Act [225 ILCS 65]

 

L)        Health Care Worker Background Check Act [225 ILCS 46]

 

M)       MRSA Screening and Reporting Act [210 ILCS 83]

 

N)        Hospital Report Card Act [210 ILCS 86]

 

O)        Illinois Adverse Health Care Events Reporting Law of 2005 [410 ILCS 522]

 

P)         Smoke Free Illinois Act [410 ILCS 82]

 

Q)        Health Care Surrogate Act [755 ILCS 40]

 

R)        Perinatal HIV Prevention Act [410 ILCS 335]

 

S)         Hospital Infant Feeding Act [210 ILCS 81]

 

T)         Medical Patient Rights Act [410 ILCS 50]

 

U)        Hospital Emergency Service Act [210 ILCS 80]

 

V)        Illinois Anatomical Gift Act [755 ILCS 50]

 

W)       Illinois Public Aid Code [305 ILCS 5]

 

X)        Substance Use Disorder Act [20 ILCS 301]

 

Y)        ID/DD Community Care Act [210 ILCS 47]

 

Z)        Specialized Mental Health Rehabilitation Act of 2013 [210 ILCS 49]

 

AA)     Veterinary Medicine and Surgery Practice Act of 2004 [225 ILCS 115]

 

BB)     Alternative Health Care Delivery Act [210 ILCS 3] 

 

CC)     Gestational Surrogacy Act [750 ILCS 47]

 

DD)     Code of Civil Procedure (Medical Studies) [735 ILCS 5/8-2101]

 

EE)      Sexual Assault Survivors Emergency Treatment Act [410 ILCS 70]

 

FF)      Civil Administrative Code of Illinois (Department of Public Health Powers and Duties Law) [20 ILCS 2310]

 

GG)     AIDS Confidentiality Act [410 ILCS 305]

 

HH)     Nursing Home Care Act [210 ILCS 45]

 

II)        Illinois Controlled Substances Act [720 ILCS 570]

 

JJ)        Early Hearing Detection and Intervention Act [410 ILCS 213]

 

KK)     Home Health, Home Services, and Home Nursing Agency Licensing Act [210 ILCS 55]

 

LL)      Health Care Violence Prevention Act [210 ILCS 160]

 

2)         State of Illinois Administrative Rules

 

A)        Department of Public Health, Illinois Plumbing Code (77 Ill. Adm. Code 890)

 

B)        Department of Public Health, Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545)

 

C)        Department of Public Health, Control of 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, Maternal Death Review (77 Ill. Adm. Code 657)

 

G)        Department of Public Health, Control of Sexually Transmissible Infections Code (77 Ill. Adm. Code 693)

 

H)        Department of Public Health, Control of Tuberculosis Code (77 Ill. Adm. Code 696)

 

I)         Department of Public Health, Health Care Worker Background Check Code (77 Ill. Adm. Code 955)

 

J)         Department of Public Health, Language Assistance Services Code (77 Ill. Adm. Code 940)

 

K)        Department of Public Health, Regionalized Perinatal Health Care Code (77 Ill. Adm. Code 640)

 

L)        Health Facilities and Services Review Board, Narrative and Planning Policies (77 Ill. Adm. Code 1100)

 

M)       Health Facilities and Services Review Board, Processing, Classification Policies and Review Criteria (77 Ill. Adm. Code 1110)

 

N)        Department of Public Health, Private Sewage Disposal Code (77 Ill. Adm. Code 905)

 

O)        Department of Public Health, Ambulatory Surgical Treatment Center Licensing Requirements (77 Ill. Adm. Code 205)

 

P)         Department of Public Health, HIV/AIDS Confidentiality  and Testing Code (77 Ill. Adm. Code 697)

 

Q)        Capital Development Board, Illinois Accessibility Code (71 Ill. Adm. Code 400)

 

R)        State Fire Marshal, Boiler and Pressure Vessel Safety (41 Ill. Adm. Code 120)

 

S)         State Fire Marshal, Fire Prevention and Safety (41 Ill. Adm. Code 100)

 

T)         Illinois Emergency Management Agency, Standards for Protection Against Radiation (32 Ill. Adm. Code 340)

 

U)        Illinois Emergency Management Agency, Use of X-rays in the Healing Arts Including Medical, Dental, Podiatry, and Veterinary Medicine (32 Ill. Adm. Code 360)

 

3)         Federal Statutes

 

A)        Health Insurance Portability and Accountability Act of 1996 (110 USC 1936)

 

B)        Emergency Medical Treatment & Labor Act (42 USC 1395dd)

 

4)         Federal Training Materials

 

A)        Preventing Workplace Violence in Healthcare, available at:  https://www.oshatrain.org/courses/mods/776e.html 

 

B)        Workplace Violence Prevention for Nurses, available at:  https://www.cdc.gov/niosh/topics/violence/

 

(Source:  Amended at 44 Ill. Reg. 18379, effective October 29, 2020)