Section 250.210  The Governing Board

a)         For each hospital there shall be a governing authority, hereinafter called the board, responsible for its organization, management, control and operation, including appointment of the medical staff.

b)         The board shall be formally organized in accordance with a written constitution and bylaws.  This must clearly set forth organization, duties, responsibilities, and relationships.  The Department may require a copy for its files.

c)         The board shall meet regularly.  Monthly meetings are recommended.  Written reports of all meetings shall be kept.

d)         The board shall employ a competent executive officer or administrator and vest him with authority and responsibility for carrying out its policies.  There shall be a qualified individual responsible to the administrator in matters of administration who shall represent him during his absence.

e)         The board shall insure employment of competent, well qualified personnel in adequate numbers to carry out the functions of the hospital. The board shall also provide a mechanism for assisting employees in addressing physical and mental health problems.

f)          The board shall be responsible for the maintenance of standards of professional work in the hospital and shall require that the medical staff function competently.  Clinical audits shall be performed by the medical staff and reviewed by a committee of the governing authority and the medical staff.

g)         The Board shall be responsible for the establishment of a policy providing for the investigation of unusual incidents which may occur.  (Refer to Section 250.990)

(Source:  Amended at 15 Ill. Reg. 5328, effective May 1, 1991)