Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart K - COMPREHENSIVE STROKE CENTERS, PRIMARY STROKE CENTERS AND ACUTE STROKE-READY HOSPITALS › Appendix N - Pediatric Critical Care Center (PCCC)/Emergency Department Approved for Pediatrics (EDAP) Recognition Application

Current through Register Vol. 48, No. 28, July 12, 2024
Application Instructions
Follow these instructions to initiate the process to request
				  recognition as a Pediatric Critical Care Center (PCCC) and Emergency Department
				  Approved for Pediatrics (EDAP). The Pediatric Plan shall be developed through
				  interaction and collaboration with all appropriate disciplines:
1. Complete the Request for Recognition of Pediatric Critical
				  Care Center and Emergency Department Approved for Pediatrics Status Application
				  Form and obtain the appropriate signatures.
2. Using the Pediatric Critical Care Center Plan Application
				  Guideline and the PCCC/EDAP requirements, complete a PCCC and EDAP Pediatric
				  Plan. The Pediatric Plan should follow the Pediatric Critical Care Center Plan
				  Application Guideline checklist format provided in this application and include
				  all requested supporting documentation, including, but not limited to, scope of
				  services/care, credentialing forms, policies (both administrative and
				  department specific), procedures, protocols, guidelines, flow charts, rosters,
				  calendars, schedules, etc.
3. Complete and obtain signatures on the Department-approved
				  physician, nurse practitioner, clinical nurse specialist, physician assistant,
				  and nursing credentialing forms.
4. Complete the EDAP, PICU and Pediatric Unit Equipment
				  Checklists.
5. Submit four copies of the hospital's Pediatric Plan (an
				  original signed copy plus three additional copies) that each contain the
				  following:
a. Signed Request for Recognition of Pediatric
				  Critical Care Center and Emergency Department Approved for Pediatrics Status
				  Application Form;
b. Completed PCCC Plan and EDAP Plan (including
				  supporting documentation);
c. Completed physician, nurse practitioner,
				  clinical nurse specialist, physician assistant, and nursing credentialing
				  forms;
d. Completed EDAP, PICU and Pediatric Inpatient
				  Unit Equipment Checklists.
6. Submit these documents (including all supporting
				  documentation) in the order listed in this application to: Division of EMS
				  & Highway Safety, Illinois Department of Public Health, 422 S.
				  5th Street, Springfield IL 62701.
7. The Pediatric Plan shall be submitted in a single-sided
				  format and unstapled.
8. Any submitted requests to waive any of the EDAP or PCCC
				  equipment requirements shall include the criteria by which compliance is
				  considered to be a hardship and shall demonstrate that there will be no
				  reduction in the provision of medical care.
Site Survey Procedure
1. Within four to six weeks following the Department's
				  receipt of the PCCC Pediatric Plan and supporting documents, the hospital will
				  be informed as to the status of the application. If all documentation is in
				  order, a site visit will be scheduled.
2. In preparation for the site visit, hospital personnel
				  shall prepare evidence to verify adherence to the facility recognition
				  requirements.
3. The site visit will include a survey of the Emergency
				  Department, Pediatric Intensive Care Unit, Pediatric Units and a meeting with
				  the following individuals:
a. chief administrative/executive officer or
				  designee
b. chief of pediatrics
c. medical director of the pediatric intensive
				  care services
d. medical directors of the pediatric units
e. medical director of pediatric ambulatory
				  care
f. nursing director or nurse manager of the
				  pediatric intensive care services
g. nursing director or nurse manager of the
				  pediatric units
h. administrator of pediatric services
i. administrator of emergency services
j. pediatric quality coordinator
k. hospital quality improvement department
				  director or designee
l. emergency department medical director and the
				  pediatric emergency department medical director
m. emergency department nurse manager and the
				  pediatric emergency department nurse manager
n. hospital emergency management/disaster
				  preparedness coordinator
o. transport team medical director
p. transport team nurse coordinator
q. Clinical nurse specialist, nurse practitioner
				  or physician assistant for those facilities that use these clinicians
r. For EMS Resource or Associate Hospitals: The
				  EMS MD and EMS coordinator
Site Survey Team
The EMSC program within the Division of EMS & Highway
				  Safety will appoint the site survey team. Site survey teams will be composed of
				  a physician/nurse team along with a representative from the Illinois Department
				  of Public Health. All team members will attend formal training in the site
				  survey responsibilities, expectations and process.
Following the Site Survey
1. Within four to six weeks following the site visit, the
				  hospital shall receive the results of the survey from the Department. Those
				  hospitals meeting all requirements will receive a formal recognition of their
				  Pediatric Critical Care capabilities.
2. Hospitals that do not meet the requirements will receive a
				  letter from the Illinois Department of Public Health outlining the areas of
				  non-compliance. The Department shall deny a request for recognition if findings
				  show failure to substantially comply with the EDAP and PCCC requirements.
				  Hospitals may appeal the denial by submitting a written request to the Illinois
				  Department of Public Health, Division of EMS & Highway Safety.
3. Re-recognition shall occur every three years, with site
				  visits scheduled as necessary.
ILLINOIS EMSC
FACILITY RECOGNITION
Request for Recognition of Pediatric Critical
				  Care Center (PCCC) and Emergency Department Approved for Pediatrics (EDAP)
				  Status
Application Form
Name of hospital and address (typed)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
The above-named hospital is requesting PCCC and EDAP
				  recognition. In addition, the above-named hospital certifies that each
				  requirement in this Request for Recognition is met.
______________________________________________________________________
Typed name - CEO/Administrator
______________________________________________________________________
Signature -
				  CEO/AdministratorDate
______________________________________________________________________
Typed name - Chairman of the Department of Pediatrics
______________________________________________________________________
Signature - Chairman of the Department of
				  PediatricsDate
______________________________________________________________________
Typed name - Medical Director of Emergency Services
______________________________________________________________________
Signature - Medical Director of Emergency
				  ServicesDate
______________________________________________________________________
Contact Person - Typed name, credentials and title
______________________________________________________________________
Contact Person - Phone number, fax number and
				  email