Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 235 - ADVERSE HEALTH CARE EVENTS REPORTING CODE
Section 235.150 - Root Cause Analysis Findings and Corrective Action Plan
Current through Register Vol. 48, No. 12, March 22, 2024
a) Following the occurrence of an adverse health care event, the health care facility must conduct a root cause analysis of the event. Following the analysis, the health care facility must:
b) A copy of the findings of the root cause analysis and a copy of the corrective action plan must be filed with the Department within 90 days after the submission of the report to the Department. (Section 10-20 of the Act)
c) The root cause analysis findings shall:
d) The corrective action shall include:
e) The Department will determine whether the root cause analysis and corrective action plan are acceptable, based on the requirements of this Section. If the root cause analysis and corrective action plan are acceptable, the Department will instruct the facility to begin follow-up activity to measure the success of the corrective action plan.
f) If the Department determines that the root cause analysis and corrective action plan are unacceptable, based on the requirements of this Section, the Department will provide consultation on the criteria that have not been met and will allow an additional time period (up to 30 calendar days) for resubmission.
g) A health care facility shall report to the Department regarding the outcome of the corrective action plans at eight and 18 months following the initiation of the plan.