reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart A - GENERAL PROVISIONS › Section 205.130 - Approval of Surgical Procedures

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				The list of surgical procedures performed by a center shall be included in the
				application as provided in Section
				205.120
				and in the renewal application as provided in Section
				205.125. All surgical
				procedures to be performed in a facility must be approved by the facility's
				Consulting Committee prior to their performance, and annually reviewed and
				reapproved. Documentation of the approval must be submitted with the initial
				and renewal applications.
b) If,
				after reviewing the quarterly data submission required by Section
				205.620 of this
				Part, the Department questions the safety of a procedure being performed
				because of the complications or postoperative hospitalizations reported as
				being associated with the procedure, the Department shall request that the
				facility's Consulting Committee review the reported cases and submit the
				findings of that review within 30 days after the request.
c) The Department may disapprove a procedure
				based upon the following:
1) The Department's
				review of the statistical information submitted in accordance with Section
				205.620 of this
				Part and the Consulting Committee's review required in subsection (b) above
				indicate that the procedure cannot be safely performed in the surgery center as
				indicated by life threatening or repeated complications, or repeated
				postoperative hospitalizations; or
2) The results of a complaint investigation
				indicate that the procedure is potentially life threatening or results in
				repeated complications or postoperative hospitalizations; or
3) Evidence becomes available from other
				sources, such as a national study or a warning from the Food and Drug
				Administration or other regulatory body, that the procedure cannot be safely
				performed in an ambulatory setting.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart A - GENERAL PROVISIONS › Section 205.135 - Diagnostic Cardiac Catheterization Procedures

Current through Register Vol. 48, No. 28, July 12, 2024
Diagnostic cardiac catheterization procedures may be
				  performed in an ambulatory surgical treatment center in accordance with the
				  following requirements:
a) The
				procedure shall be approved by the facility's consulting committee in
				accordance with Section
				205.130
				of this Part.
b) The procedure
				shall meet the general exclusion criteria for invasive cardiac procedures in
				settings without cardiac surgery in Table 2 of the Clinical Expert Consensus
				Document on Cardiac Catheterization Laboratory Standards (see Section
				205.115(a)(1)(E)
				 ).
c) The facility shall meet Criteria C:
				Cardiac Catheterization and Diagnostic Procedures in the Freestanding
				Laboratory and Criteria D: Candidates for Same-Day or Ambulatory Cardiac
				Catheterization of the Clinical Expert Consensus Document on Cardiac
				Catheterization Laboratory Standards.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart B - OWNERSHIP AND MANAGEMENT › Section 205.210 - Ownership, Control and Management

Current through Register Vol. 48, No. 28, July 12, 2024
a) The ASTC shall have a governing body that
				assumes full responsibility for determining, implementing and monitoring
				policies governing the facility's operation:
1) The governing body shall review and
				approve the facility's organizational plan.
2) The governing body shall ensure that ASTC
				policies and programs provide quality health care in a safe
				environment.
3) The governing body
				shall have oversight and accountability for the facility's Quality Assessment
				and Performance Improvement Program; shall allocate sufficient resources for
				the Program; and shall, at least annually, evaluate the Program's
				effectiveness.
4) The governing
				body shall approve an infection control program designed to prevent, identify
				and manage infections and communicable diseases. The governing body shall
				appoint a qualified infection control professional who will direct the
				infection control program. The governing body shall, at least annually,
				evaluate the effectiveness of the infection control program.
5) The governing body shall establish,
				protect and promote patient rights, including respect for patients' property
				and privacy, patient safety, the confidentiality of clinical records, and the
				exercise of patient rights. The governing body shall designate a grievance
				officer and shall establish, subject to approval by the governing body, a
				documented system by which allegations will be reported, investigated and
				responded to. Allegations will include allegations of violations/grievances
				relating to, but not limited to, mistreatment, neglect, or verbal, mental,
				sexual or physical abuse.
6) The
				governing body shall have oversight and accountability for developing and
				maintaining a written Disaster Preparedness Plan pursuant to Section
				205.510
				and shall review reports and recommendations at least annually.
7) The governing body shall review and
				approve the facility's organizational plan (see Section
				205.220
				).
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart B - OWNERSHIP AND MANAGEMENT › Section 205.220 - Organizational Plan

Current through Register Vol. 48, No. 28, July 12, 2024
a) An
				organizational plan shall be known to the staff and available for public
				information in the facility. The document shall clearly set forth the
				organization, duties, responsibility, accountability and relationships of
				professional staff, including a designated qualified infection control
				professional, a designated grievance officer, and other personnel.
b) The plan shall include details of a
				quality assessment and performance improvement program, an infection control
				program, a patient rights plan, and a disaster preparedness plan.
c) The organizational plan shall be submitted
				to the governing body for review and approval and shall be submitted to the
				Department with the initial licensure application.
d) All owners, administrators, professional
				staff and ancillary personnel shall act in accordance with the organizational
				plan.
e) The Department will review
				the organizational plan at regular inspections.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart B - OWNERSHIP AND MANAGEMENT › Section 205.240 - Policies and Procedures Manual

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				In cooperation with the medical and professional staff, the management/owner of
				the ambulatory surgical treatment center shall formulate a written policies and
				procedures manual, which shall be submitted to the qualified consulting
				committee and the governing body for review and approval.
b) The procedures shall provide for the
				acceptance, care, treatment, anesthesia services, discharge, referral, and
				follow-up of all patients and all incidental operations of the
				facility.
c) The policies and
				procedures manual shall include an ongoing data-driven quality assessment and
				improvement program that addresses measurable improvements in patient health
				outcomes and improves patient safety by addressing quality of care indicators
				or performance measures, adverse events, the reduction of medical errors, and
				infection control. Components of the quality assessment and improvement program
				shall include:
1) The use of quality
				indicators or performance measures and data to document improvements in
				outcomes and to effect improvements in patient care, patient health outcomes,
				and patient safety;
2) Measurement,
				identification and analysis of incidence, prevalence, severity and causes of
				the problems and tracking and implementing improvements that are sustained over
				time to reduce medical errors and to improve health outcomes;
3) The facility-wide infection control
				program (Section
				205.550 );
				and
4) A focus on performance
				improvement activities and preventive strategies that address high risk, high
				volume, and problem-prone areas that affect health outcomes, patient safety,
				and quality of care, and that address adverse patient events and ensure that
				improvements are sustained over time.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart C - PERSONNEL › Section 205.310 - Personnel Policies

Current through Register Vol. 48, No. 28, July 12, 2024
a) Each
				ambulatory surgical treatment center shall have written personnel policies
				including job descriptions for each staff position, which shall include minimum
				qualifications required for the position. There shall be a documented procedure
				for orientation of new employees to the facility's policies and procedures as
				well as the personnel policies including a copy of the appropriate job
				description.
b) Prior to employing
				any individual in a position that requires a State license, the ambulatory
				surgical treatment center shall contact the Illinois Department of Professional
				Regulation to verify that the individual's license is active. A copy of the
				license shall be placed in the individual's personnel file.
c) The ambulatory surgical treatment center
				shall check the status of all applicants with the Nurse Aide Registry prior to
				hiring.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart C - PERSONNEL › Section 205.320 - Presence of Qualified Physician

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				A qualified physician shall be present at the facility until all patients are
				medically discharged, unless the facility possesses a written transfer
				agreement with a hospital and a qualified physician certifies that all
				remaining patients in the facility meet the criteria in this Section at the
				time the last remaining qualified physician departs the facility. The following
				criteria shall be met if a qualified physician will not be physically present
				at a facility:
1) The patient is awake,
				physiologically stable, has experienced no intraoperative or postoperative
				complications;
2) The patient does
				not require the administration of whole blood or any blood products;
3) The patient is three years of age or
				older;
4) The patient does not have
				an active, acute or chronic infectious condition;
5) The patient falls within anesthesia class
				I, II or III, if he or she is medically stable (anesthesia class I indicates a
				normal, healthy patient, anesthesia class II is a patient with mild systemic
				disease, and anesthesia class III is a patient with severe systemic
				disease);
6) The level of care
				needed by the patient is consistent with recovery care for generally healthy
				patients undergoing surgical procedures that require nursing care, pain control
				or observation;
7) Hospitalization
				is not required; and
8) The
				facility has met all other level of care criteria established by the qualified
				consulting committee.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart C - PERSONNEL › Section 205.330 - Nursing Personnel

Current through Register Vol. 48, No. 28, July 12, 2024
a) At
				least one registered professional nurse with postgraduate education or
				experience in surgical nursing shall direct and supervise the nursing personnel
				and the nursing care of patients and shall be on duty at all times on the
				premises when patients are present.
b) Nursing care may be provided by student
				nurses and licensed practical nurses who have been trained in observation and
				emergency techniques for preoperative and postoperative care of surgical
				patients and who are under the direct personal supervision of a registered
				nurse at all times.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart C - PERSONNEL › Section 205.340 - Basic Life Support

Current through Register Vol. 48, No. 28, July 12, 2024
At least one person who is certified in "Basic Life Support"
				  by the American Heart Association shall be on the premises while patients are
				  present.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart C - PERSONNEL › Section 205.350 - Laboratory Services

Current through Register Vol. 48, No. 28, July 12, 2024
Each ambulatory surgical treatment center shall:
a) Possess a valid Clinical Laboratory
				Improvement Amendments (CLIA) certificate or waiver for those tests performed
				by the facility ( 42 CFR 493; Regulations Implementing the Clinical Laboratory
				Improvement Amendments of 1988 (CLIA)).
b) Have a written agreement with a laboratory
				that possesses a valid CLIA certificate or waiver to perform any required
				laboratory procedures that are not performed in the ASTC.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart D - EQUIPMENT, SUPPLIES, AND FACILITY MAINTENANCE › Section 205.410 - Equipment and Related Policies

Current through Register Vol. 48, No. 28, July 12, 2024
Equipment shall be in good working order and shall be
				  available in numbers sufficient to provide quality patient care based on the
				  types of procedures to be performed in the facility.
a) Monitoring equipment, suction apparatus,
				oxygen and related items shall be available within the surgical and
				postoperative recovery areas. Cardiac and pulmonary resuscitation equipment
				shall be available in all facilities.
b) The facility shall have written policies
				and procedures and shall maintain documentation governing the care, use,
				decontamination, sterilization, storage and disposal of all materials to ensure
				that an adequate supply of sterile equipment, instruments and supplies is
				available for each procedure. Written policies and procedures shall include
				documentation that the facility has considered, selected and implemented
				nationally recognized guidelines, including the Centers for Disease Control and
				Prevention publication, "Guidelines for Disinfection and Sterilization in
				Healthcare Facilities" or "Guide to Infection Prevention in Outpatient
				Settings"; or the Association of periOperative Registered Nurses (AORN)
				publication "Perioperative Standards and Recommended Practices for Inpatient
				and Ambulatory Centers". The policies, procedures and documentation shall
				include and address:
1) Staff orientation and
				in-service training to understand and implement facility policies and
				procedures for infection control, and to adhere to manufacturer's instructions
				for receiving, decontaminating, cleaning, preparing, sterilizing and high-level
				disinfection, handling, storage and quality control of equipment, supplies and
				instruments;
2) Preventive
				maintenance of all central supply service equipment pursuant to manufacturer's
				instructions or infection control guidelines; and
3) The Infection Control Program (Section
				205.550) ,
				which shall be under the direction of a designated qualified health care
				professional with training in infection control.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart E - GENERAL PATIENT CARE › Section 205.510 - Disaster Preparedness

Current through Register Vol. 48, No. 28, July 12, 2024
a) Each
				facility shall develop and maintain a disaster preparedness plan that includes
				patients, staff and others in the facility. The plan shall cover fire, natural
				disasters, functional failure of equipment, explosion, and non-patient medical
				emergencies or other unexpected events or circumstances. The plan shall be
				tested bi-annually for effectiveness with drills and written evaluations. Any
				corrections to the plan shall be promptly implemented. This plan shall specify
				persons to be notified and actions to be taken and shall be known by all staff
				of the facility.
b) Each facility
				shall be prepared to manage those medical emergencies that may be associated
				with procedures performed there.
c)
				For the purposes of this Section, "emergency" means a situation, physical
				condition or one or more practices, methods or operations that present imminent
				danger of death or serious physical or mental harm to patients of an
				ASTC.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart E - GENERAL PATIENT CARE › Section 205.520 - Preoperative Care

Current through Register Vol. 48, No. 28, July 12, 2024
a) The ASTC
				shall develop and maintain a policy that:
1)
				Identifies patients who require a medical history and physical examination
				prior to surgery and the timeframe in which the examination is to be completed
				prior to the surgery;
2) Considers
				the type of surgical procedure, age of the patient, and planned levels of
				anesthesia;
3) Addresses common
				diagnoses and known comorbidities; and
4) Is based on applicable nationally
				recognized standards of practice.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart E - GENERAL PATIENT CARE › Section 205.540 - Postoperative Care

Current through Register Vol. 48, No. 28, July 12, 2024
a) All
				patients' postoperative conditions shall be observed and assessed in the
				facility for a period of time sufficient to ensure that the patient is awake,
				physiologically stable, manifests no immediate postoperative complications, and
				is ready to return to home or to a similar environment. Overnight stays are not
				permissible. Before discharge from the facility, each patient shall be
				evaluated by a qualified practitioner for proper anesthesia recovery. No
				patient shall be required to leave the facility in less than one hour following
				the procedure or procedures. Each post-surgical patient's overall condition
				shall be assessed and documented in the medical record by a qualified
				practitioner, showing that the patient is ready for discharge or in need of
				further treatment or monitoring.
b)
				Rh factor sensitization prophylaxis shall be provided to all Rh negative
				patients following procedures performed to terminate pregnancy, in accordance
				with standard medical procedures.
c) Patients in whom a complication is known
				or suspected to have occurred during or after the performance of a surgical
				procedure shall be informed of the complication, and arrangements shall be made
				for treatment of the complication. If the patient is admitted to a hospital, a
				summary of care given in the ambulatory surgical treatment center concerning
				the suspected complication or complications shall accompany the
				patient.
d) To ensure availability
				of follow-up care at a hospital, the ambulatory surgical treatment center shall
				document an effective procedure for the immediate transfer of patients
				requiring emergency care beyond the capabilities of the ASTC, to a hospital
				within 15 to 30 minutes travel time of the ASTC.
e) Written instructions shall be issued to
				all patients in accordance with the standards approved by the consulting
				committee and shall include the following:
1)
				Symptoms of complications associated with procedures performed;
2) Limitations and restrictions of activities
				of the patient;
3) Specific
				telephone number to be used by the patient, at any time, if any complication or
				question arises; and
4) A date for
				a follow-up or return visit after the performance of the surgical procedure,
				which shall be scheduled within six weeks.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart E - GENERAL PATIENT CARE › Section 205.550 - Infection Control

Current through Register Vol. 48, No. 28, July 12, 2024
a) Each ASTC
				shall provide a safe and healthful environment that minimizes infection
				exposure and risk to patients, health care workers and visitors.
b) Each ASTC shall maintain a written, active
				and effective facility-wide infection control program. A system designed for
				the identification, surveillance, investigation, control, and prevention of
				infectious and communicable diseases in patients and health care workers shall
				be included in this program.
c) The
				ASTC shall designate a person as a Qualified Infection Control Professional to
				develop and implement policies governing the control of infectious and
				communicable diseases. The means of qualification (i.e., education, training
				and experience; or certification) shall be documented.
d) Policies and procedures for the reporting
				and care of cases of communicable diseases shall comply with the Control of
				Communicable Diseases Code, the Control of Sexually Transmissible Infections
				Code, and the Control of Tuberculosis Code.
e) The ASTC shall consider, select and
				implement nationally recognized infection control guidelines in developing its
				infection control program, including the Centers for Disease Control and
				Prevention publication "Guidelines for Isolation Precautions: Preventing
				Transmission of Infectious Agents in Healthcare Settings", "Guidelines for
				Disinfection and Sterilization in Healthcare Facilities" or "Guide to Infection
				Prevention in Outpatient Settings: Minimum Expectations for Safe Care"; or the
				Association of periOperative Registered Nurses (AORN) publication
				"Perioperative Standards and Recommended Practices for Inpatient and Ambulatory
				Centers".
1) When patients have a
				communicable disease, or present signs and symptoms suggestive of communicable
				disease, precautionary measures shall be taken to avoid cross-infection to
				personnel, other patients and the public.
2) If an ASTC treats a patient who has a
				communicable disease, the ASTC shall provide appropriate facilities and
				equipment for isolation.
3)
				Policies and procedures for handling infectious cases shall include orders to
				the medical, nursing and non-professional staff concerning isolation
				technique.
4) The ASTC shall
				require that 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, comply with the ASTC's
				infection control program to avoid transmission of the disease agent.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart F - RECORDS AND REPORTS › Section 205.610 - Clinical Records and Reports

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				The ASTC shall maintain accurate and complete clinical records for each
				patient, and all entries in the clinical record shall be made at the time the
				surgical procedure is performed and when care, treatment, medications, or other
				medical services are given. The record shall include, but not be limited to,
				the following:
1) Patient
				identification;
2) Admitting
				information, including any patient medical history and physical examination
				findings as applicable, diagnosis or need for medical services, and all
				consultation reports;
3)
				Pre-counseling notes;
4) Signed
				informed consent;
5) Confirmation
				of a pregnancy (when an abortion is performed);
6) Signed physician orders;
7) Laboratory test reports, pathologist's
				report of tissue or other specimens including foreign bodies, and physician's,
				podiatrist's, dentist's or radiologist's report of imaging studies;
8) An anesthesia record;
9) The operative record, describing
				techniques, findings and tissues or other items removed or altered, shall be
				written or dictated immediately following surgery and signed by the surgeon.
				The operative record shall include, but not be limited to:
A) The name and ASTC identification number of
				the patient;
B) The date and time
				of the surgery;
C) The names of the
				surgeon or surgeons and assistants or other practitioners who performed
				surgical tasks, including practitioners who performed those tasks under
				supervision;
D) The pre-operative
				and post-operative diagnosis;
E)
				The name of the specific surgical procedure or procedures performed;
F) The type of anesthesia
				administered;
G) Complications, if
				any;
H) A description of
				techniques, findings, and tissues or other items (such as foreign bodies)
				removed or altered;
I) A
				description of the specific significant surgical tasks that were conducted by
				practitioners other than the primary surgeon or practitioner, including, but
				not limited to, opening and closing, harvesting grafts, dissecting tissue,
				removing tissue, implanting devices, altering tissues, or monitoring;
				and
J) Prosthetic devices, grafts,
				tissues, transplants or devices, if any, that were implanted in, or removed
				from, the patient;
10)
				Medication administration and medical treatments that were performed;
11) Recovery room progress notes;
12) Physician and nurse progress
				notes;
13) The patient's condition
				at time of discharge;
14) Patient
				instructions; and
15)
				Post-counseling notes.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart F - RECORDS AND REPORTS › Section 205.620 - Statistical Data

Current through Register Vol. 48, No. 28, July 12, 2024
a) Each
				ambulatory surgical treatment center shall collect, compile and maintain the
				following clinical statistical data at the facility to be made available to the
				Department during a survey or inspection, or upon the Department's request:
1) The total number of surgical cases treated
				by the ASTC;
2) The number of each
				specific surgical procedure performed;
3) The number and type of complications
				reported, including the specific procedure associated with each
				complication;
4) The number of
				patients requiring transfer to a hospital for treatment of complications. The
				procedure performed and the complication that prompted each transfer shall be
				listed;
5) The number of deaths,
				including the specific procedure that was performed; and
6) The results of the monitoring of the
				ASTC's hand hygiene program in Section
				205.550(h).
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart H - LICENSURE PROCEDURES › Section 205.810 - Complaints

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department
				shall investigate all complaints received regarding any ambulatory surgical
				treatment center or any physician practicing in an ambulatory surgical
				treatment center (except as provided in subsection (d) of this Section).
				Complaints should preferably be in writing and contain sufficient facts to
				facilitate the investigation. Complaints by telephone will be
				accepted.
b) Each ambulatory
				surgical treatment center shall post a notice provided by the Department which
				reads: "If you have concerns about the care being provided in this licensed
				ambulatory surgical treatment center you may file a complaint with the
				Department of Public Health by writing to the following address: [address], or
				by calling [telephone number] during regular business hours. You may also wish
				to discuss your concerns with the personnel available at this facility. This
				notice is posted as required by regulation of the Department of Public Health."
				The notice shall be posted in each center in a location visible to staff,
				patients, visitors, and the general public.
c) Upon receipt of each complaint the
				Department will, within seven days, acknowledge by letter receipt of the
				complaint.
d) If the complaint
				contains allegations that would constitute a prima facie violation of the Act
				or this Part, an investigation will be conducted. Whenever the complaint
				concerns matters outside the jurisdiction of the Department or may concern
				matters that are within the jurisdiction of another agency, the complaint also
				will be referred to the appropriate agency whenever so doing does not violate
				patient confidentiality.
e) The
				Department will investigate each complaint as quickly as possible based on
				available personnel and resources. Complaints that constitute a threat to the
				public health will be investigated within ten days of receipt of the
				complaint.
f) The Department will
				utilize the most efficient and effective methods to investigate each complaint.
				This may include inspections pursuant to Section 9 of the Act and the issuance
				of subpoenas and subpoenas duce tecum pursuant to Section 10g(c) of the Act,
				when appropriate.
g) Upon the
				conclusion of the investigation the complainant will be notified of the results
				of the investigation and any action taken by the Department.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart H - LICENSURE PROCEDURES › Section 205.820 - Notice of Violation

Current through Register Vol. 48, No. 28, July 12, 2024
a) When
				the Department determines through inspection, review of records, or other means
				of investigation that a facility is in violation of the Act or this Part, a
				notice of violation shall be served upon the licensee. The notice shall be
				served in the manner provided in Section 10g(a) of the Act. (Section 10b of the
				Act)
b) Each notice of violation
				shall be in writing and shall include:
1) A
				description of the nature of the violation.
2) A citation of the statutory provision or
				rule alleged to have been violated.
3) A description of any action the Department
				may take under the Act, including the assessment of a penalty under Section 10d
				of the Act and Section
				205.850 of
				this Part, or adverse licensure action under Section 10f of the Act and Section
				205.840
				of this Part.
4) A statement that
				the facility must submit a plan of correction under Section 10c of the Act and
				Section
				205.830 of
				this Part.
5) A description of the
				manner in which the facility may contest the notice of violation and the right
				to a hearing to contest the violation under Section 10g of the Act and Section
				205.860 of this Part.
				(Section 10b of the Act)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart H - LICENSURE PROCEDURES › Section 205.830 - Plan of Correction

Current through Register Vol. 48, No. 28, July 12, 2024
a) Each
				facility served with a notice of violation under Section 10b of the Act and
				Section
				205.820 of
				this Part shall submit to the Department a written plan of correction within
				ten days of receipt of the notice of violation. Such plan of correction shall
				include:
1) A statement of the specific
				actions the facility intends to take to correct each violation.
2) The specific date by which each violation
				will be corrected. (Section 10c of the Act)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart H - LICENSURE PROCEDURES › Section 205.840 - Adverse Licensure Action

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Adverse licensure actions include the denial of an initial license application,
				denial of an application for license renewal, revocation of a license,
				imposition of a penalty or fine, service suspension, and emergency
				suspension.
b) Adverse licensure
				actions will be considered by the Department under the following conditions:
1) Substantial or continued failure of the
				licensee, facility, or applicant to comply with the Act or this Part. (Section
				10f(a) of the Act)
2) Failure of
				the licensee, facility, or applicant to demonstrate the capacity to safely
				provide one or more of its services to patients. (Section 10f(b) of the
				Act)
3) Violation of any provision
				of the Act or this Part by conduct which is detrimental to the health, safety,
				or welfare of a patient or patients.
4) Refusal of the licensee to make payment of
				a penalty or fine which has been added to the facility's license renewal fee
				under Section 10e of the Act and Section
				205.850(e)(2)
				of this Part. (Section 10e of the Act)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart H - LICENSURE PROCEDURES › Section 205.850 - Fines and Penalties

Current through Register Vol. 48, No. 28, July 12, 2024
a) When
				the Department determines to impose a penalty or fine under Section 10d of the
				Act and Section
				205.840
				of this Part, the Department shall issue a notice of fine assessment. The
				notice shall be served in the manner provided in Section 10g(a) of the Act.
				(Section 10d of the Act)
b) Each
				notice of fine assessment shall include:
1) A
				description of the violation or violations for which the fine is assessed.
				(Section 10d of the Act)
2) The
				amount of the fine as determined under Section
				205.840
				of this Part, which may be up to $500 per violation per day commencing on the
				date the violation was identified and ending on the date the violation is
				corrected, or action is taken to suspend, revoke or deny renewal of the
				license, whichever comes first. (Section 10d of the Act)
3) A description of the manner in which the
				facility may contest the fine assessment and the right to a hearing under
				Section 10g of the Act and Section
				205.860 of this
				Part.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart H - LICENSURE PROCEDURES › Section 205.860 - Hearings

Current through Register Vol. 48, No. 28, July 12, 2024
a) Applicants and
				licensees may appeal certain actions of the Department under the Act and this
				Part. If a facility desires to contest any Department action, it shall send a
				written request for a hearing to the Department within 10 days after receipt of
				the notice of the contested action. Following receipt of a request for a
				hearing, the Department shall conduct a hearing to review the contested action.
				(Section 10c(c) of the Act)
b)
				Hearings conducted pursuant to the Act and this Part shall be conducted in
				accordance with the following:
1) Sections
				10c, 10f, and 10g of the Act.
2)
				Article 10 of the Illinois Administrative Procedure Act.
3) The Department's rules titled" Practice
				and Procedure in Administrative Hearings".
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1310 - Plant and Service Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
All ambulatory surgical treatment centers are required to
				  meet the following physical plant and service requirements.
a) All proposed facilities shall meet these
				requirements before licensure will be granted.
b) All existing facilities that are not in
				compliance with this Section, and subsequent Sections, shall come into
				compliance no later than May 17, 1984.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1320 - General Considerations

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Location
1) An ambulatory surgical treatment
				center shall be identifiably separate from other facilities and
				functions.
2) An ambulatory
				surgical treatment center may be located within an institution or building
				which is not primarily devoted to ambulatory surgery and may share facilities
				and functions with other portions of the institution or building as provided in
				Sections
				205.1350(a)
				and
				205.1390(e).
				Such centers shall be separated from other portions of the institution or
				building by at least a one-hour fire separation. Such centers may be located in
				a physician's office, group practice clinic, or other type of office building,
				unless routine traffic flow and operation of the other facilities located in
				the institution or building would interfere with the operation of the
				center.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1330 - New Construction, Additions and Major Alterations

Current through Register Vol. 48, No. 28, July 12, 2024
Requirements and procedures for new construction, additions,
				  and major alterations are as follows:
a) Preliminary drawings and outline
				specifications, whether for new construction or for substantial alterations,
				shall be submitted to the Department with a program narrative description for
				review and approval prior to starting final working drawings and
				specifications.
b) The final
				working drawings and specifications shall be submitted to the Department for
				review and approval prior to release of contract documents for bidding. Change
				orders that affect scope and/or function shall be submitted for approval prior
				to execution.
c) The Department
				shall be notified of the award of contracts, and when construction has been
				completed. Approval by the Department prior to occupancy is required.
d) The preparation and submission of drawings
				and specifications shall be executed by or be under the immediate supervision
				of an architect registered in the State of Illinois. Structural drawings and
				specifications for these systems may be executed by or be under the immediate
				supervision of a structural engineer licensed in the State of Illinois.
				Mechanical and electrical drawings and specifications for these systems may be
				executed by or be under the immediate supervision of a professional engineer
				licensed in the State of Illinois.
e) First stage submission. Design Development
				Drawings and Outline Specifications.
f) The preliminary sketch plans shall
				indicate in detail the assignment of all spaces, size of areas and rooms,
				indicating in outline the fixed and movable equipment and furniture.
1) The plans shall be drawn at a scale
				sufficiently large to clearly present the proposed design.
2) The drawings shall include:
A) a plan of each floor including the
				basement or ground floor,
B) a plan
				showing roads, parking areas, sidewalks, etc.,
C) elevations of all facades,
D) sections through the building,
				and
E) all adjacent areas clearly
				labeled if addition or alteration.
3) The total gross floor area shall be shown
				on the drawings.
4) Outline
				specifications shall provide a general description of the construction
				including finishes; acoustical material, its extent and type; heating and
				ventilating systems; and the type of elevators.
5) A brief narrative of the proposed program
				shall be included.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1340 - Minor Alterations and Remodeling Changes

Current through Register Vol. 48, No. 28, July 12, 2024
Minor alterations and remodeling changes which do not affect
				  the structural integrity of the building, or change functional operation, or
				  which do not affect safety, need not be submitted for prior
				  approval.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1350 - Administration Department and Public Areas

Current through Register Vol. 48, No. 28, July 12, 2024
a) Administration Department and Public Areas
				are facilities to be provided when indicated by the approved program. The
				facilities required in subsections (c), (e), (f), (g)(1), and (g)(4) of this
				Section may be shared with other offices or functions when the center is
				located in an institution or building not primarily devoted to ambulatory
				surgery.
b) The entrance to the
				center, or the entrance to the building in which the center is located, shall
				be sheltered from the weather, located by grade level and must be able to
				accommodate wheelchairs and stretchers, if applicable.
c) The lobby shall include, if indicated by
				the approved program for the facility, the following:
1) wheelchair and cart storage
2) reception and information
				counter
3) waiting area
4) public toilets
5) public telephone
6) drinking fountain
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1360 - Clinical Facilities

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Examination rooms
1) Each examination room
				shall have a minimum clear floor area of 80 square feet, and a minimum
				dimension of 8 feet, exclusive of vestibule, toilet, closet, and work counter
				(whether fixed or movable). A minimum clear dimension of 2'6" on each side and
				at both ends of the examination table shall be provided.
2) A lavatory or sink equipped for
				handwashing with electronic or knee or foot control shall be
				provided.
3) A counter or shelf
				space for writing shall be provided.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1380 - Diagnostic Facilities

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Radiographic Suite: if radiographic studies are conducted, the following apply:
1) Radiographic rooms shall have a minimum
				clear area of 120 square feet and a minimum clear dimension of 10', exclusive
				of vestibule, toilet, closet, cabinet, and work counter (whether fixed or
				movable). There shall be a minimum of 2'6" clearance at each side and both ends
				of the radiographic table;
2) A
				handwashing sink with a plaster trap within the room;
3) A communication system connected to the
				control station;
4) Film processing
				area with work counters, triple sink, storage cabinets, exhaust venting for
				chemicals, open drains, and safety lighting;
5) Viewing and administration area;
6) Film storage facilities;
7) Toliet room with handwashing facilities,
				directly accessible from each radiographic room without entering the general
				corridor area; and
8) Dressing area
				with convenient access to toilets and a lockable closet unit for patient's
				belongings.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1390 - Other Building Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Engineering service and equipment areas shall have sufficient space for
				equipment rooms for boilers, furnaces, mechanical equipment, and electrical
				equipment.
b) Waste processing
				services shall be provided for the sanitary storage and disposal of waste by
				incineration, mechanical destruction, compaction, containerization, removal, or
				by a combination of these techniques.
c) Storage rooms for building maintenance
				supplies and yard equipment shall be provided.
d) Janitor's closets shall be provided with a
				floor receptor or service sink.
e)
				The facilities required in subsections (a), (b), and (c) of this Section may be
				shared with other offices or functions when the center is located in an
				institution or building not primarily devoted to ambulatory surgery.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1400 - Details and Finishes

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Corridors and Exits
1) Minimum public
				corridor width shall be 5'-0", except those corridors/aisles where patients are
				transported in stretchers or carts shall be 8'-0".
2) The facility or section shall have at
				least two exits that are remote from each other.
3) 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.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart I - BUILDING DESIGN, CONSTRUCTION STANDARDS, AND PHYSICAL REQUIREMENTS › Section 205.1410 - Construction, Including Fire-Resistive Requirements, and Life Safety

Current through Register Vol. 48, No. 28, July 12, 2024
Buildings shall meet the construction requirements and life
				  safety requirements established in Chapters 20 and 21 of NFPA 101 (see Section
				  205.115(a)(1)(B)
				   ).
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart J - MECHANICAL › Section 205.1510 - General

Current through Register Vol. 48, No. 28, July 12, 2024
a) Mechanical
				systems shall be tested, balanced, and operated to demonstrate that the
				installation and performance of these systems conform to the requirements of
				these Standards.
b) Upon completion
				of the contract, the owner shall be provided with a complete set of
				manufacturer's operating, maintenance and preventive maintenance instructions,
				and parts list with numbers and description for each piece of equipment. The
				owner shall also be provided with instruction in the operational use of the
				systems and equipment as required.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS › Subpart J - MECHANICAL › Section 205.1520 - Thermal and Acoustical Insulation

Current through Register Vol. 48, No. 28, July 12, 2024
a) Insulation shall be provided for the
				following within the building:
1) Boilers,
				smoke breeching and stacks.
2)
				Steam supply and condensate return piping.
3) Hot water piping above 180°F and all
				hot water heaters.
4) Hot water
				piping above 125°F that is exposed to contact by patients.
5) Chilled water, refrigerant, other process
				piping and equipment operating with fluid temperatures below ambient dew
				point.
6) Water supply and drainage
				piping with fluid temperatures below ambient dew point.
7) Air ducts and casings with outside surface
				temperature below ambient dew point.
8) Other piping, ducts, and equipment
				necessary to maintain the efficiency of the system.