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 H - TRAUMA CENTERS › Section 515.2020 - Inspection and Revocation of Designation

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department shall have the authority to
				inspect designated trauma centers to assure compliance with the provisions of
				the Act and this Part. Information received by the Department through filed
				reports, inspection or as otherwise authorized under the Act shall not be
				disclosed publicly in such a manner as to identify individuals or hospitals,
				except in a proceeding involving the denial, suspension or revocation of a
				trauma center designation or imposition of a fine on a trauma center. (Section
				3.90(b)(6)
				of the Act)
b) The Department shall
				have the authority to take the following action, as appropriate, after
				determining that a trauma center is in violation of the Act or this Part:
1) If the Director determines that the
				violation presents a substantial probability that death or serious physical
				harm will result and if the trauma center fails to eliminate the violation
				immediately or within a fixed period of time, not exceeding 10 days, as
				determined by the Director, the Director may immediately revoke the trauma
				center designation. The trauma center may appeal the revocation within 15 days
				after receiving the Director's revocation order, by requesting a hearing as
				provided by Section 3.135 of the Act. The Director shall notify the chair of
				the Region's Trauma Center Medical Directors Committee and EMS Medical
				Directors for the appropriate EMS Systems of such a trauma center designation
				revocation.
2) If the Director
				determines that the violation does not present a substantial probability that
				death or serious physical harm will result, the Director shall issue a notice
				of violation and request a plan of correction which shall be subject to the
				Department's approval. The trauma center shall have 10 days after the receipt
				of the notice of violation in which to submit a plan of correction. The
				Department may extend this period for up to 30 days. (Section
				3.90(b)(10)(B)
				of the Act)
A) The Department will consider
				the following factors in determining whether or not to extend the period for
				submission of the plan of correction to a maximum of 30 days: whether a
				substantial probability that death or serious physical harm will result still
				exists, and whether the delay could lead to physical harm.
B) The plan shall include a fixed time period
				not in excess of 90 days within which violations are to be corrected. The plan
				of correction and the status of its implementation by the trauma center shall
				be provided, as appropriate, to the EMS Medical Directors for the appropriate
				EMS Systems. If the Department rejects a plan of correction, it shall send
				notice of the rejection and the reason for the rejection to the trauma center.
				The trauma center shall have 10 days after receipt of the notice of rejection
				in which to submit a modified plan. If the modified plan is not timely
				submitted, or if the modified plan is rejected, the trauma center shall follow
				an approved plan of correction imposed by the Department. If, after notice and
				opportunity for hearing, the Director determines that a trauma center has
				failed to comply with an approved plan of correction, the Director may revoke
				the trauma center designation. The trauma center shall have 15 days after
				receiving the Director's notice in which to request a hearing. Such hearing
				shall conform to the provisions of Section 3.135 of the Act. (Section
				3.90(b)(10)(B)
				of the Act)
C) Each plan of
				correction shall be based on an assessment by the facility of the conditions or
				occurrences which are the basis of the violation and an evaluation of the
				practices, policies, and procedures which have caused or contributed to the
				conditions or occurrences. Evidence of such assessment and evaluation shall be
				maintained by the facility. Each plan shall include:
i) A description of the specific corrective
				action the facility is taking, or plans to take, to abate, eliminate, or
				correct the violation cited in the notice;
ii) A description of the steps that will be
				taken to avoid future occurrences of the same or similar violations.
D) The Department shall review
				each plan of correction to ensure that it provides for the abatement,
				elimination, or correction of the violation. The Department shall reject a
				submitted plan if it finds any of the following deficiencies:
i) The plan does not address the conditions
				or occurrences that are the basis of the violation and an evaluation of the
				practices, policies, and procedures that have caused or contributed to the
				conditions or occurrences.
ii) The
				plan is not specific or does not provide measures to indicate the actual
				actions the facility will be taking to abate, eliminate, or correct the
				violation(s).
iii) The plan does
				not provide steps that will avoid future occurrences of the same and similar
				violations.
iv) The plan does not
				provide for timely completion of the corrective action, considering the
				seriousness of the violation, any possible harm to patients, and the extent and
				complexity of the corrective action.
E) The Department shall verify the completion
				of the corrective action:
i) By requiring the
				trauma center to submit monthly reports to the Department for up to one year,
				which consists of current hospital trauma plan (first month only); trauma
				quality monitoring plan and indicators (first month only); minutes of all
				meetings pertaining to trauma, including but not limited to Trauma Service
				Committee, Department of Surgery, and Morbidity and Mortality Review Committee;
				a list of all Category I and II trauma patients treated in the previous month,
				which includes but is not limited to medical record number, date and time of
				arrival at the trauma center, sex, mechanism of injury, trauma category
				classification and time; trauma surgeon and surgical specialty; time of
				notification and arrival time; and
ii) Through subsequent investigations,
				surveys and evaluations of the trauma center.