Section 545.67  Compliance Review

a)         The Department shall conduct on-site reviews of approved plans with hospital personnel at least once during each three-year approval period to ensure that the established procedures are being followed.  (Section 2 of the Act)

b)         If the Department determines that the hospital is not in compliance with its approved plan, the Department shall provide the hospital with a written list of the specific items of noncompliance within 2 weeks after the conclusion of the site review. The hospital shall have 14 working days to submit to the Department a plan of correction that contains the hospital's specific proposals for correcting the items of noncompliance.  The Department shall review the plan of correction and notify the hospital in writing as to whether the plan is acceptable or unacceptable.  (Section 2.1 of the Act)

c)         Specific proposals for correcting items of noncompliance shall include:

1)         A time frame for implementing corrections;

2)         A description of the activity that will be undertaken to correct the items of noncompliance;

3)         Identification of the person or persons responsible for implementing the corrections; and

4)         A description of how the requirements of this Part will be met.

d)         If the Department finds the plan of correction unacceptable, the hospital shall have 7 working days to resubmit an acceptable plan of correction.  Upon notification that its plan of correction is acceptable, a hospital shall implement the plan of correction within 60 days.  (Section 2.1 of the Act)

e)         The failure to submit an acceptable plan of correction or to implement the plan of correction, within the time frames required in this Section, will subject a hospital to the imposition of a fine by the Department.  The Department shall impose a fine of up to $100 per day until a hospital complies with the requirements of this Section.  (Section 2.1 of the Act)

f)          Before imposing a fine pursuant to this Section, the Department shall provide the hospital via certified mail with written notice and an opportunity for an administrative hearing.  Such hearings must be requested within 10 working days after receipt of the Department's notice.  All hearings shall be conducted in accordance with the Department's Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100).  (Section 2.1 of the Act)

g)           The Department shall maintain the confidentiality of all patient identities and medical information provided during a site survey or otherwise received by the Department pursuant to this Part.  

(Source:  Added at 27 Ill. Reg. 1567, effective January 15, 2003)