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
Universal Citation: 77 IL Admin Code ยง 205.210
Current through Register Vol. 48, No. 12, March 22, 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
).
b) Ownership, control and management shall be disclosed at the time of application and upon renewal. The names and addresses of each person with financial interest in the facility shall be submitted to the Department.
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