Section 518.1000  Definitions

 

For the purposes of this Part:

 

Act – the Emergency Medical Services (EMS) Systems Act.

 

Advanced Life Support Services or ALS Services – an advanced level of pre-hospital and inter-hospital emergency care and non-emergency medical services that includes basic life support care, cardiac monitoring, cardiac defibrillation, electrocardiography, intravenous therapy, administration of medications, drugs and solutions, use of adjunctive medical devices, trauma care, and other authorized techniques and procedures as outlined in the provisions of the National EMS Education Standards relating to Advanced Life Support and any modifications to that curriculum specified in this Part and in the Emergency Medical Services, Trauma Center, Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke Ready Hospital Code.  (Section 3.10 of the Act)

 

Advanced Practice Registered Nurse or APRN – has the meanings ascribed in Section 50-10 of the Nurse Practice Act.

 

Ambulance – any publicly or privately owned on-road vehicle that is specifically designed, constructed or modified and equipped, and is intended to be used for, and is maintained or operated for the emergency transportation of persons who are sick, injured, wounded or otherwise incapacitated or helpless, or the non-emergency medical transportation of persons who require the presence of medical personnel to monitor the individual's condition or medical apparatus being used on such individuals.  (Section 3.85 of the Act)

 

Associate Hospital – a hospital participating in an approved EMS System in accordance with the EMS System Program Plan; fulfilling the same clinical and communications requirements as the Resource Hospital; having a basic or comprehensive emergency department with 24-hour physician coverage; and having a functioning intensive care unit and/or a cardiac care unit.

 

Auxiliary Nursing Personnel – unlicensed direct care staff or unlicensed staff providing direct patient care or unlicensed staff providing care directly to patients.

 

Basic Life Support Services or BLS – a basic level of pre-hospital and inter-hospital emergency care and non-emergency medical care that includes medical monitoring, clinical observation, airway management, cardiopulmonary resuscitation (CPR), control of shock and bleeding and splinting of fractures, as outlined in the provisions of the National EMS Education Standards relating to Basic Life Support and any modifications to that curriculum specified in the Emergency Medical Services and Trauma Center Code.  (Section 3.10 of the Act)

 

Communicable Disease – has the meaning set forth in the Control of Communicable Diseases Code.

 

Comprehensive Emergency Treatment Services – emergency treatment services provided in accordance with Section 518.2020 of this Part.

 

Contagious Disease − has the meaning set forth in the Control of Communicable Diseases Code.

 

Department – the Illinois Department of Public Health.  (Section 3.5 of the Act)

 

Diagnostic Imaging Specialist – a person who possesses the knowledge, training and experience to apply the principles of radiological physics to diagnostic x-ray applications. The diagnostic imaging specialist shall be approved and registered by the Illinois Emergency Management Agency – Division of Nuclear Safety pursuant to 32 Ill. Adm. Code 410.

 

Director – the Director of the Illinois Department of Public Health or the Director's designee.  (Section 3.5 of the Act)

 

Drugs – the term "drugs" means and includes:

 

articles recognized in the official United States Pharmacopoeia-National Formulary, or any supplement to it, and being intended for and having for their main use the diagnosis, cure, mitigation, treatment or prevention of disease in man or other animals;

 

all other articles intended for and having for their main use the diagnosis, cure, mitigation, treatment or prevention of disease in man or other animals;

 

articles (other than food) having for their main use to affect the structure or any function of the body of man or other animals, and intended to affect the structure or any function of the body of man or other animals; and

 

articles having for their main use and intended for use as a component of any articles specified above, but does not include devices or their components, parts or accessories.

 

Emergency – a medical condition of recent onset and severity that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that urgent or unscheduled medical care is required.  (Section 3.5 of the Act)

 

Emergency Medical Services System or EMS System or System – an organization of hospitals, vehicle service providers and personnel approved by the Department in a specific geographic area, which coordinates and provides pre-hospital and inter-hospital emergency care and non-emergency medical transports at a BLS, ILS and/or ALS level pursuant to a System program plan submitted to and approved by the Department, and pursuant to the EMS Region Plan adopted for the EMS Region in which the system is located.  (Section 3.20 of the Act)

 

Emergency Medical Technician-Basic or EMT-B – a person who has successfully completed a course of instruction in basic life support as prescribed by the Department, is currently licensed by the Department in accordance with standards prescribed by the Act and the Emergency Medical Services, Trauma Center, Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke Ready Hospital Code and practices within an EMS System.  (Section 3.50 of the Act)

 

Emergency Medical Technician-Intermediate or EMT-I – a person who has successfully completed a course of instruction in intermediate life support as prescribed by the Act and the Emergency Medical Services, Trauma Center, Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke Ready Hospital Code and practices within an Intermediate or Advanced Life Support EMS System.  (Section 3.50 of the Act)

 

Emergency Medical Technician-Paramedic or EMT-P – a person who has successfully completed a course of instruction in advanced life support care as prescribed by the Department, is licensed by the Department in accordance with standards prescribed by the Act and the Emergency Medical Services, Trauma Center, Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke Ready Hospital Code and practices within an Advanced Life Support EMS System.  (Section 3.50 of the Act)

 

EMS System Program Plan – the document approved by the Department pursuant to 77 Ill. Adm. Code 515 that describes the EMS System program and directs the program's operation.

 

Freestanding Emergency Center or FEC or Facility – a facility that provides comprehensive emergency treatment services 24 hours per day, on an outpatient basis and has been issued a license by the Department as a Freestanding Emergency Center.  (Section 32.5 of the Act)

 

Hospital – has the meaning ascribed in Section 3 of the Hospital Licensing Act.

 

House Staff Member – an individual who is a graduate of a medical, dental, osteopathic or podiatric school; who is licensed as appropriate; who is appointed to the FEC's medical, osteopathic, dental, or podiatric graduate training program, which is approved or recognized in accordance with the statutory requirements applicable to the practitioner; and who is participating in patient care under the direction of licensed practitioners who have clinical privileges in the FEC and are members of the FEC's medical staff.

 

Infectious Disease – has the meaning established in the Control of Communicable Diseases Code.

 

Intermediate Life Support Services or ILS Services – an intermediate level of pre-hospital and inter-hospital emergency care and non-emergency medical care that includes basic life support care, plus intravenous cannulation and fluid therapy, invasive airway management, trauma care, and other authorized techniques and procedures as outlined in the Intermediate Life Support National Curriculum of the United States Department of Transportation and any modifications to that curriculum specified in the Emergency Medical Services and Trauma Center Code.  (Section 3.10 of the Act)

 

Licensee – the person or entity licensed to operate the FEC pursuant to the Act.

 

Medical Staff – an organized body composed of the following individuals granted the privilege by the governing authority of the FEC to practice in the FEC:  persons who are graduates of a college or school approved or recognized by the Illinois Department of Financial and Professional Regulation, and who are currently licensed by the Department of Financial and Professional Regulation to practice medicine in all its branches; practice dental surgery; or practice podiatric medicine in Illinois, regardless of the title of the degree awarded by the approving college or school.

 

Medicines – drugs or chemicals or preparations thereof in suitable form intended for and having for their main use the prevention, treatment, relief, or cure of diseases when used either internally or externally.

 

Morbidity – a negative outcome that is the result of the original trauma and/or treatment rendered or omitted.

 

Nursing Staff – registered nurses, licensed practical nurses, and others rendering patient care under the supervision of a registered professional nurse.

 

Outpatient – a person who visits an FEC for diagnosis or treatment.  There are no overnight stays in an FEC.

 

Owning or Controlling Hospital – the Associate or Resource Hospital that wholly owns or controls a freestanding emergency center.

 

Participating Hospital – a hospital participating in an approved EMS System in accordance with the EMS System Program Plan, which is not a Resource Hospital or an Associate Hospital.

 

Patient – a person who visits an FEC and requires medical care on an outpatient basis.

 

Pharmacist – a person who holds a certificate of registration as a registered pharmacist under the Pharmacy Practice Act.

 

"Pharmacy" − a location where pharmacist care is provided by a pharmacist and where drugs and medicines are dispensed, sold, offered or displayed for sale at retail; where prescriptions of physicians, dentists, advanced practice registered nurses, physician assistants, podiatric physicians, or optometrists, within the limits of their licenses, are compounded, filled or dispensed; and which has a sign bearing the word or words "Pharmacist", Druggist", "Pharmacy", "Pharmaceutical Care", or similar terms or where the characteristic prescription sign (Rx) or similar design is exhibited. (Section 3 of the Pharmacy Practice Act).  Any room or designated area where drugs and medicines are dispensed (including the repackaging for distribution) shall be considered to be a pharmacy and shall be required to be licensed by the Department of Financial and Professional Regulation.

 

Pharmacy practice – includes the following services as defined in the Pharmacy Practice Act:

 

the interpretation and the provision of assistance in the monitoring, evaluation, and implementation of prescription drug orders;

 

the dispensing of prescription drug orders;

 

participation in drug and device selection;

 

drug administration limited to the administration of oral, topical, injectable, and inhalation as follows:

 

in the context of patient education on the proper use or delivery of medications;

 

pursuant to a valid prescription or standing order by a physician licensed to practice medicine in all its branches, upon completion of appropriate training, including how to address contraindications and adverse reaction pursuant to Pharmacy Practice Act rules (68 Ill. Adm. Code 1330), with notification to the patient's physician and appropriate record retention, or pursuant to hospital pharmacy and therapeutics committee policies and procedures:

 

vaccination of patients 7 years of age and older;

 

following the initial administration of long-acting or extended-release form opioid antagonists by a physician licensed to practice medicine in all its branches, administration of injections of long-action or extended-release form opioid antagonists.

 

administration of injections of alpha-hydroxyprogesterone caproate;

 

administration of injections of long-term antipsychotic medications (appropriate training must be conducted by an Accreditation Council of Pharmaceutical Education accredited provider);

 

drug regimen review;

 

drug or drug-related research;

 

the provision of patient counseling;

 

the practice of telepharmacy;

 

the provision of those acts or services necessary to provide pharmacist care;

 

medication therapy management; and

 

the responsibility for compounding and labeling of drugs and devices (except labeling by a manufacturer, repackager, or distributor of non‑prescription drugs and commercially packaged legend drugs and devices), proper and safe storage of drugs and devices, and maintenance of required records as defined in the Pharmacy Practice Act. (Section 3 of the Pharmacy Practice Act)

 

Physician – any person licensed to practice medicine in all of its branches under the Medical Practice Act of 1987.

 

Physician Assistant – has the meaning ascribed in Section 4 of the Physician Assistant Practice Act of 1987.

 

Plan of Correction or POC – the response the facility must develop to address/answer deficiencies identified during a survey.

 

Program Narrative – a written description of the services provided at the FEC.

 

Radiation hazard – the danger to the health of an individual arising from exposure to ionizing radiation that exceeds public dose limits as defined in 32 Ill. Adm. Code 340.

 

Registered Nurse or Registered Professional Nurse or RN – a person who is licensed as a registered professional nurse under the Nurse Practice Act.

 

Resource Hospital – the hospital with the authority and the responsibility for an EMS System as outlined in the Department-approved EMS System Program Plan.

 

Social Worker – a person who is a licensed social worker or a licensed clinical social worker under the Clinical Social Work and Social Work Practice Act.

 

Survey – a detailed critical inspection or investigation by the Department.

 

Therapeutic radiological physicist – an individual who has the knowledge, training and experience to measure ionizing radiation, evaluate safety techniques, advise regarding radiation protection needs and apply the principles of radiological physics to clinical radiation therapy. The therapeutic radiological physicist shall be approved and registered by the Illinois Emergency Management Agency – Division of Nuclear Safety pursuant to 32 Ill. Adm. Code 410.

 

Unit – a specific distinctly separated area within the FEC.

 

Working Days – Monday through Friday, except State holidays.

 

(Source:  Amended at 47 Ill. Reg. 12120, effective July 28, 2023)

 

Section 518.1050  Incorporated and Referenced Materials

 

a)         The following regulations, standards and guidelines are incorporated in this Part:

 

1)         Private and professional association standards:

 

A)        ASHRAE Handbook − Fundamentals (2009), which may be obtained from the National Association of American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc., 180 Technology Parkway NW, Peachtree Corners, GA  30092.

 

B)        The following NFPA standards, which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  02169:

 

i)          NFPA 101 (2012):  Life Safety Code and all applicable references under Chapter 2, Referenced Publications.

 

ii)         NFPA 101A (2013):  Guide on Alternative Approaches to Life Safety

 

C)        National Council on Radiation Protection and Measurements (NCRP), Report No. 49: Structural Shielding Design and Evaluation for Medical Use of X-rays and Gamma Rays of Energies up to 10 MeV (1976) and NCRP Report No. 102: Medical X-Ray, Electron Beam and Gamma-Ray Protection for Energies Up to 50 MeV (Equipment Design, Performance and Use) (1989), which may be obtained from the National Council on Radiation Protection and Measurements (NCRP), 7910 Woodmont Ave., Suite 905, Bethesda, MD  20814-3046.

 

D)        The International Code Council, International Building Code (2012) which may be obtained from the International Code Council, 4051 Flossmoor Road, Country Club Hills, IL  60478. (See Section 250.2420.)

 

E)        American National Standards Institute (ANSI) Standard No. A17.1-2007, Safety Code for Elevators and Escalators, which may be obtained from the American Society of Mechanical Engineers, Two Park Avenue, New York, NY, 10016-5990.

 

F)         Facilities Guidelines Institute Guidelines (2010 edition), Guidelines for Design and Construction of Health Care Facilities, which may be obtained from www.fgiguidelines.org.

 

2)         Federal Regulations

 

A)        14 CFR 157 (January 1, 2021) − Notice of Construction, Alteration, Activation, and Deactivation of Airports

 

B)        14 CFR 77, Subpart D (January 1, 2021) − Aeronautical Studies and Determinations

 

C)        42 CFR 493, Laboratory Requirements (October 1, 2020)

 

3)         Federal Guidelines

Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services.

 

A)        Guideline for Hand Hygiene in Health-Care Settings, available at:  https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html (October 25, 2002)

 

B)        Department of Health and Human Services, Centers for Disease Control and Prevention, Infection Control in Healthcare Personnel, available in two parts: "Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services" (October 25, 2019) and "Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients" (October 3, 2022), both available at https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html

 

b)         All incorporations by reference of federal regulations and guidelines and the standards of nationally recognized organizations refer to the regulations, guidelines and standards on the date specified and do not include any amendments or editions subsequent to the date specified.

 

c)         The following statutes and State regulations are referenced in this Part:

 

1)         Federal statutes:

 

A)        Federal Aviation Act of 1958, Sections 307 and 308 (P.L. 85-726, 72 U.S.C. 731)

 

B)        Emergency Medical Treatment and Active Labor Act (42 U.S.C. 1395dd)

 

C)        Clinical Laboratory Improvement Amendments of 1988 (42 U.S.C. 263a)

 

D)        Title XVIII and Title XIX of the Social Security Act (42 U.S.C. 301 et seq., 1395 et seq., and 1396 et seq.)

 

2)         State of Illinois statutes:

 

A)        Emergency Medical Services (EMS) Systems Act [210 ILCS 50]

 

B)        Hospital Emergency Service Act [210 ILCS 80]

 

C)        Hospital Licensing Act [210 ILCS 85]

 

D)        Medical Practice Act of 1987 [225 ILCS 60]

 

E)        Nurse Practice Act [225 ILCS 65]

 

F)         Illinois Health Facilities Planning Act [20 ILCS 3960]

 

G)        Emergency Medical Treatment Act [210 ILCS 70]

 

H)        X-ray Retention Act [210 ILCS 90]

 

I)         Radiation Protection Act of 1990 [420 ILCS 40]

 

J)         Pharmacy Practice Act [225 ILCS 85]

 

K)        Illinois Clinical Laboratory and Blood Bank Act [210 ILCS 25]

 

L)        Language Assistance Services Act [210 ILCS 87]

 

M)       Criminal Identification Act [20 ILCS 2630]

 

N)        Civil Administrative Code of Illinois (Department of Public Health Powers and Duties Law) [20 ILCS 2310]

 

O)        Physician Assistant Practice Act of 1987 [225 ILCS 95]

 

P)         Mental Health and Developmental Disabilities Code [405 ILCS 5]

 

Q)        Health Care Worker Background Check Act [225 ILCS 46]

 

3)         State of Illinois regulations:

 

A)        Department of Public Health, Illinois Plumbing Code (77 Ill. Adm. Code 890)

 

B)        Department of Public Health, Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545)

 

C)        Department of Public Health, Control of Communicable Diseases Code (77 Ill. Adm. Code 690)

 

D)        Department of Public Health, Food Code (77 Ill. Adm. Code 750)

 

E)        Department of Public Health, Public Area Sanitary Practice Code (77 Ill. Adm. Code 895)

 

F)         Department of Public Health, HIV/AIDS Confidentiality and Testing Code (77 Ill. Adm. Code 697)

 

G)        Department of Public Health, Control of Sexually Transmissible Infections Code (77 Ill. Adm. Code 693)

 

H)        Department of Public Health, Emergency Medical Services, Trauma Center, Comprehensive Stroke Center, Primary Stroke Center and Acute Stroke Ready Hospital Code (77 Ill. Adm. Code 515)

 

I)         Department of Public Health, Hospital Licensing Requirements (77 Ill. Adm. Code 250)

 

J)         Capital Development Board, Illinois Accessibility Code (71 Ill. Adm. Code 400)

 

K)        Department of Transportation, Aviation Safety (92 Ill. Adm. Code 14)

 

L)        Pollution Control Board, Special Waste Hauling (35 Ill. Adm. Code 809)

 

M)       Pollution Control Board, Interim Status Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities (35 Ill. Adm. Code 725)

 

N)        Department of Public Health, Health Care Worker Background Check Code (77 Ill. Adm. Code 955)

 

O)        Department of Public Health, Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100)

 

P)         Department of Public Health, Violent Injury Reporting Code (77 Ill. Adm. Code 560)

 

Q)        Department of Public Health, Language Assistance Services Code (77 Ill. Adm. Code 940)

 

R)        Department of Financial and Professional Regulation, Pharmacy Practice Act (68 Ill. Adm. Code 1330)

 

S)         Illinois Emergency Management Agency, Use of X-Rays in the Healing Arts, Including Medical, Dental, Podiatry, and Veterinary Medicine (32 Ill. Adm. Code 360)

 

T)         Illinois Emergency Management Agency, Standards For Protection Against Radiation (32 Ill. Adm. Code 340)

 

U)        Illinois Emergency Management Agency, Medical Use of Radioactive Material (32 Ill. Adm. Code 335)

 

V)        Illinois Emergency Management Agency, Registration and Operator Requirements for Radiation Installations (32 Ill. Adm. Code 320)

 

W)       Illinois Emergency Management Agency, Accrediting Persons in the Practice of Medical Radiation Technology (32 Ill. Adm. Code 401)

 

X)        Illinois Emergency Management Agency, General Provisions for Radiation Protection (32 Ill. Adm. Code 310)

 

Y)        Illinois Emergency Management Agency, Registration Requirements for Diagnostic Imaging Specialists and Therapeutic Radiological Physicists (32 Ill. Adm. Code 410)

 

(Source:  Amended at 47 Ill. Reg. 12120, effective July 28, 2023)

 

Section 518.1100  Freestanding Emergency Center Licensure

 

a)         The Department will license freestanding emergency centers pursuant to the Act and this Part.

 

b)         A freestanding emergency center shall meet the following requirements:

 

1)         has received a permit from the Health Facilities and Services Review Board to establish a Freestanding Emergency Center by January 1, 2015;

 

2)         is located:

 

A)        in a municipality with a population of 50,000 or fewer inhabitants;

 

B)        within 50 miles of the hospital that owns or controls the freestanding emergency center; and

 

C)        within 50 miles of the Resource Hospital affiliated with the freestanding emergency center as part of the EMS system; 

 

3)         is wholly owned or controlled by an Associate or Resource Hospital, but is not a part of the hospital's physical plant;

 

4)         meets the standards for licensed FECs, adopted in this Part, including, but not limited to:

 

A)        facility design, specification, operation, and maintenance standards;

 

B)        equipment standards; and

 

C)        the number and qualifications of emergency medical personnel and other staff, which must include at least one board certified emergency physician present at the FEC 24 hours per day;

 

5)         limits its participation in the EMS System strictly to receiving a limited number of patients by ambulance:

 

A)        According to the FEC's 24-hour capabilities;

 

B)        According to protocols developed by the Resource Hospital within the FEC's designated EMS System; and

 

C)        As pre-approved by both the EMS Medical Director and the Department;

 

6)         provides comprehensive emergency treatment services, as defined in Hospital Licensing Requirements, 24 hours per day, on an outpatient basis;

 

7)         provides an ambulance and maintains on site ambulance services staffed with paramedics 24 hours per day;

 

8)         complies with all State and federal patient rights provisions, including, but not limited to, the Emergency Medical Treatment Act and the federal Emergency Medical Treatment and Active Labor Act;

 

9)         maintains a communications system that is fully integrated with its Resource Hospital within the FEC's designated EMS System;

 

10)         reports to the Department any patient transfers from the FEC to a hospital within 48 hours after the transfer plus any other data determined to be relevant by the Department;

 

11)         submits to the Department, on a quarterly basis, the FEC's morbidity and mortality rates for patients treated at the FEC and other data determined to be relevant by the Department;

 

12)         does not describe itself or hold itself out to the general public as a full service hospital or hospital emergency department in its advertising or marketing activities;

 

13)         complies with any other rules adopted by the Department under the Act that relate to FECs;

 

14)         passes the Department's site inspection for compliance with the FEC requirements of the Act;

 

15)         submits a copy of the permit issued by the Illinois Health Facilities and Services Review Board indicating that the facility has complied with the Illinois Health Facilities Planning Act with respect to the health services to be provided at the facility;

 

16)         submits an application for designation as an FEC in a manner and form prescribed by the Department in this Part; and

 

17)         pays the annual license fee as determined by the Department. (Section 32.5(a) of the Act)

 

(Source:  Amended at 42 Ill. Reg. 7701, effective April 10, 2018)

 

Section 518.1150  Initial Licensure Application

 

a)          Any person acting individually, or jointly with other persons, who proposes to build, own, establish or operate a freestanding emergency center shall submit application information in writing on forms provided by the Department.

 

b)          An application for a new facility shall be accompanied by a permit as required by the Illinois Health Facilities Planning Act.

 

c)          Each application shall be accompanied by a non-refundable license application fee of $2000.

 

d)          The application shall contain the following information:

 

1)         The name, address and telephone number of the applicant if the applicant is an individual; if the applicant is a firm, partnership or association, the name, address and telephone number of every member of the firm, partnership or association; if the applicant is a unit of local government, the name, address and telephone number of its chief executive officer.

 

2)         If the applicant is a corporation, it shall submit:

 

A)        A list of the title, name and address of each of its corporation officers; and

 

B)        A list of the name and address of each of its shareholders holding more than 7.5% of the shares.

 

3)         The name of the person or persons under whose management or supervision the facility will be conducted.

 

4)         The location of the facility, including the facility name, telephone number, exact address, and proof that the freestanding emergency center is not a part of a Resource or Associate Hospital's physical plant.

 

5)         Information regarding any conviction of the applicant, or, if the applicant is a firm, partnership or association, of any if its members, or, if the applicant is a corporation, of any of its officers or directors, or of the person designated to manage or supervise the facility, of a felony or of two or more misdemeanors involving moral turpitude in the last five years.

 

6)         Proof of ownership or control by an Associate or Resource Hospital.

 

7)         The number of procedure rooms and observation/treatment rooms.

 

8)         A statement assuring compliance with all State and federal patient rights provisions, including, but not limited to, the Emergency Medical Treatment Act and the federal Emergency Medical Treatment and Active Labor Act  (Section 32.5(a)(8) of the Act).

 

9)         The name, address, telephone number, education, experience, credentials and any professional licensure or certification of the following persons:

 

A)        Administrator;

 

B)        Medical Director; and

 

C)        Nurse Manager.

 

10)         A list of the medical staff, including name and license number.

 

11)         A list of all staff personnel, including name, position and any professional licensure or certification.

 

12)         A detailed description of the services to be provided by the facility.

 

13)         Schematic architectural plans.

 

e)         Each application shall document that at least one board certified emergency physician is present at the FEC 24 hours per day.

 

f)         The Department will review the application form and other information required by this Section to determine whether the application meets the requirements of this Section prior to reviewing building plans and specifications and conducting a survey of the physical plant.

 

g)         The Department will issue a license if, after application and survey, it finds the applicant meets the requirements of the Act and this Part.

 

h)         The FEC license shall be prominently displayed in an area accessible to the public.

 

i)          Ownership Change or Discontinuation

 

1)         The license is not transferable.  The license is issued to a specific licensee and for a specific location.  The license and the valid current renewal certificate immediately become void and shall be returned to the Department when the facility is sold or leased; when operation is discontinued; when operation is moved to a new location; when the licensee (if an individual) dies; when the licensee (if a corporation or partnership) dissolves or terminates; or when the licensee (whatever the entity) ceases to exist.

 

2)         A license issued to a corporation shall be null, void and of no further effect upon the dissolution of the corporation.  If the corporation is subsequently reinstated, a new license shall be obtained.

 

3)         Before any change of ownership, dissolution or closure, the facility shall follow the notification and process requirements of the Health Facilities Planning Board.

 

j)          Each FEC shall notify the Department, in writing, of any changes in:

 

1)         Facility name;

 

2)         Business telephone contact information; and

 

3)         Administrator and/or Nurse Manager.

 

k)         Any freestanding emergency center may voluntarily relinquish its license prior to the expiration date by notifying the Department in writing.  The notification shall include the anticipated date of termination, which shall not be less than 30 days nor more than 90 days from the date of notification.  The notification shall describe the procedures taken by the freestanding emergency center to advise pre-hospital providers, hospitals and the EMS Medical Director.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1155  Application for Annual License Renewal

 

a)         Application for annual license renewal shall be submitted at least 90 days prior to licensure expiration on forms prescribed by the Department.  The application shall include, at a minimum, the following information:

 

1)         The names, addresses and telephone numbers of all persons who own the facility, any name under which any of these persons does business, and the type of ownership of the facility (for example, individual, partnership, corporation, or association).  In addition, a corporation shall submit:

 

A)        A list of the title, name and address of each of its corporation officers; and

 

B)        A list of the name and address of each of its shareholders holding more than 7.5% of the shares;

 

2)         For other than individual ownership, the name and address of the Illinois Registered Agent or persons legally authorized to receive service of process for the facility;

 

3)         The names and addresses of all persons under contract to manage or operate the facility;

 

4)         The name and exact address of the facility;

 

5)         The names and addresses of the Administrator, Medical Director and Nurse Manager.  In addition, the education, experience, credentials and any professional licensure or certification of these individuals shall also be submitted if this information was not submitted with the initial application or a prior renewal application, or if this information has changed since the prior submission.  The facility shall inform the Department of any change in this information at the time that the change occurs;

 

6)         A list of medical staff, including names and license numbers;

 

7)         A copy of the organizational plan and description of services if changes have occurred since the last submission; and

 

8)         Identification of any plans of correction currently in effect as a result of State and federal surveys.

 

b)         Each renewal application shall be accompanied by a non-refundable license renewal fee of $2000 and proof of compliance with all reports required by the Department.

 

(Source:  Added at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1160  Surveys

 

a)         The Department will conduct a survey of an FEC at any time to determine compliance with the Act and this Part or with a plan of correction submitted as a result of deficiencies cited by the Department.

 

b)         Surveys (except for initial licenses) will be unannounced.

 

c)         Upon completion of each survey, the Department will submit a copy of the report to the licensee within 15 working days after exit.  The report will identify deficiencies in compliance with the requirements of the Act or this Part.  The report will include any recommendation for action by the Department under the Act and of correction from the facility.  The licensee may provide related comments or documentation to refute findings in the report, explain extenuating circumstances that the facility could not reasonably have prevented, or indicate methods and timetables for correction of deficiencies described in the report.  A licensee has 15 days after receipt of the survey report to submit a plan of correction.

 

d)         The Department will determine whether a facility is in violation of this Section no later than 90 days after completion of each survey.

 

e)         The Department will maintain all survey reports for at least seven years in a manner accessible to the public.

 

f)         Any licensee, applicant for a license, or person operating an FEC shall be deemed to have given consent to any authorized officer, employee or agent of the Department to enter and inspect the FEC, conduct interviews and photocopy materials as necessary to determine compliance in the facility in accordance with the Act and this Part.  Refusal to permit such entry or survey shall constitute grounds for denial, nonrenewal or revocation of a license.

 

(Source:  Added at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1165  Complaints

 

a)         The Department shall investigate an applicant or licensee whenever the Department receives a complaint alleging a violation of the Act or this Part that, if valid, would constitute violations or other sanctions under Section 518.1200 or 518.1250 of this Part.

 

b)         A person who believes that the Act or this Part has been violated may submit a complaint in writing, by mail, by telephone, by fax or in person to the Department.

 

c)         The complaint shall include the following:

 

1)         Complainant's name, address and telephone number (unless the complainant requests anonymity);

 

2)         Facility's name and address; and

 

3)         A detailed description of the problem, including the date and the patient's name.

 

d)         The Department will not disclose the name of the complainant unless the complainant consents in writing to the disclosure.

 

e)         The Department will acknowledge receipt of the complaint to the complainant in writing within 10 working days after receiving the complaint.

 

f)         The Department will investigate each complaint as quickly as possible based on available personnel and resources.  If the complaint involves an immediate and serious threat to patient health and safety, the Department shall investigate within two days after receipt of the complaint.

 

g)         Complaint investigations will be unannounced.

 

h)         Based on the information provided by the complainant and the results of the investigation conducted in accordance with subsection (f) of this Section, the Department will determine whether the Act or this Part has been or is being violated.  The Department will review and consider any information submitted by the applicant or licensee in response to an investigation.  Based on the results of the investigation and information provided by the complainant and/or the applicant or licensee, complaints shall be classified as "valid", "invalid", or "undetermined".

 

i)          The Department will inform the complainant and the licensee of the results (i.e., whether the complaint was found to be valid, invalid or undetermined) of the complaint within 45 days after the conclusion of its investigation.

 

j)          A complainant or licensee who is dissatisfied with the results of a complaint investigation may request a hearing in accordance with Section 518.1250 of this Part.

 

(Source:  Added at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1200  Emergency Suspension Orders

 

The Department shall issue an emergency suspension order, in accordance with Section 3.40 of the Act and Section 515.160 of the Emergency Medical Services and Trauma Center Code (77 Ill. Adm. Code 515), for any freestanding emergency center when the Director or his or her designee has determined that the continued operation of the freestanding emergency center poses an immediate and serious danger to the public health, safety and welfare.  An opportunity for a hearing shall be promptly initiated after an emergency suspension order has been issued.  (Section 32.5(b)(3) of the Act)

 

Section 518.1250  Violations and Hearings

 

a)          The Department shall suspend, revoke, refuse to issue, or refuse to renew the license of any FEC, after notice and an opportunity for a hearing, when the Department finds that the FEC has failed to comply with the standards and requirements of the Act or this Part. (Section 32.5(b)(2) of the Act)

 

b)         Administrative hearings shall be conducted by the Director or his/her designee.  On the basis of any such hearing, or upon default of the respondent, the Director shall issue a final order specifying his findings, conclusions and decision.  A copy of the final order shall be sent to the respondent by certified mail or served personally upon the respondent.  (Section 3.135 of the Act)

 

c)         The procedure governing hearings authorized by the Act shall be in accordance with the Department's rules governing administrative hearings (77 Ill. Adm. Code 100).  (Section 3.135 of the Act)

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1300  Governing Board

 

a)         A governing authority or Governing Board, hereinafter called the Board, shall be responsible for the  organization, management, control and operation of the FEC, including appointment of the medical staff.

 

b)         The organization, duties, responsibilities, and relationships of the Board shall be established by the owning or controlling hospital.  Copies shall be maintained by the facility for inspection and/or copying by the Department.

 

Section 518.1350  Provision of Emergency Services

 

The freestanding emergency center shall provide the following services:

 

a)         Comprehensive emergency treatment services (see Section 518.2020 of this Part) 24 hours a day, on an outpatient basis (Section 32.5(a)(5) of the  Act);

 

b)         An ambulance and maintenance of on site ambulance services staffed with paramedics or one EMT-P and one other EMT or Field RN 24 hours per day (Section 32.5(a)(6) of the Act);

 

c)         A communications system that is fully integrated with its Resource Hospital within the FEC's designated EMS system (Section 32.5(a)(9) of the Act);

 

d)         Helicopter landing capabilities approved by appropriate State and federal authorities.  (Section 32.5(a)(7) of the Act) The helicopter landing capabilities shall:

 

1)         Comply with the rules of the Illinois Department of Transportation entitled "Aviation Safety" (92 Ill. Adm. Code 14.790, 14.792, 14.795);

 

2)         Be covered by a favorable airspace determination letter issued by the Federal Aeronautics Administration pursuant to Sections 307 and 309 of the Federal Aviation Act of 1958, and 14 CFR 157 and 14 CFR 77, Subpart D; and

 

3)         Be provided on the campus of the freestanding emergency center.

 

Section 518.1400  EMS System Participation

 

a)         The freestanding emergency center shall limit its participation in the EMS System strictly to receiving a limited number of BLS runs by emergency medical vehicles according to protocols developed by the Resource Hospital within the FEC's designated EMS System and approved by the EMS Medical Director and the Department. (Section 32.5(a)(4) of the Act)

 

b)         These protocols shall include but not be limited to:

 

1)         Patient status or freestanding emergency center resource limitations that would result in diversion of a patient to another facility.

 

2)         A commitment by the freestanding emergency center to comply with applicable standardized procedures that apply to hospital emergency departments in the EMS System.

 

Section 518.1450  Patients' Rights

 

a)         The freestanding emergency center shall adopt a written policy on patients' rights.  This policy shall be available to all patients and personnel.

 

b)         The FEC shall comply with all State and federal patient rights provisions, including, but not limited to, the Emergency Medical Treatment Act and the federal Emergency Medical Treatment and Active Labor Act.  (Section 32.5(a)(8) of the Act)

 

c)         The FEC shall have a written plan for providing social services to those patients with social problems.  This service may be provided through:

 

1)         An organized social service within the FEC, or

 

2)         A social worker employed on a part-time basis, or

 

3)         Social work consultant services from a community agency or the Resource Hospital, or

 

4)         Social Services provided by the owning or controlling hospital's social services department.

 

Section 518.1500  Language Assistance Services

 

The freestanding emergency center may provide language assistance services in accordance with the Language Assistance Services Act and the Language Assistance Services Code (77 Ill. Adm. Code 940).

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1550  Personnel Services

 

a)         An organized personnel department or service shall be established and designed to meet the needs of the personnel.

 

b)         Personnel policies and practices that adequately support freestanding emergency center services and quality of patient care shall be established and maintained.

 

c)         Sufficient, qualified personnel shall be employed to properly operate the various departments and the adjunct services requiring technical skill, such as laboratory, x-ray, pharmacy, nursing, etc.

 

d)         Sufficient service personnel shall be employed to properly operate service departments.

 

e)         Qualified personnel shall mean those persons who hold necessary licenses for the activities they perform.  If no license is required, qualified personnel shall mean those persons who are registered or certified by the Department, the Illinois Department of Financial and Professional Regulation, the Council on Medical Education of the American Medical Association or Agencies or Committees established in collaboration with the Council, other accrediting agencies approved by the Department, or an acceptable equivalent experience.

 

f)         Personnel policies shall be written and available to all personnel.

 

g)         Personnel policies shall be reviewed and/or revised periodically, but no less frequently than once every two years.  The date of review or revision shall be indicated on the personnel policies.

 

h)         The personnel service shall have available organizational charts that identify all departments and/or services.

 

i)          All positions shall be authorized by the Board, either directly or through delegation to the administrator.

 

j)          A job description shall be written for each position in the freestanding emergency center, including minimum qualifications.

 

k)         Personnel records

 

1)         Accurate, current and complete personnel records shall be maintained for each employee during his/her term of employment and for the years thereafter as may be necessary to satisfy other State or federal requirements.

 

2)         A standard of content shall be established for personnel records, which shall contain at least the following:

 

A)        Application form and/or resume with current and background information sufficient to justify the initial and continuing employment of the individual;

 

B)        Verification of license, if the position requires a license.  A licensed person shall be employed only after verification of the license is obtained;

 

C)        A record regarding the employee's specialized education, training, and experience;

 

D)        Verification of identity;

 

E)        Employment health examination and subsequent health services rendered to the employees as are necessary to ensure that all employees are physically able to perform their duties;

 

F)         Record of orientation to the job;

 

G)        Continuance of education; and

 

H)        Current information relative to periodic work performance evaluations.

 

l)          Employees shall not be assigned duties that exceed their education, training, experience, and qualifications.

 

m)        Orientation and in-service training programs shall be provided so that personnel may maintain skills and learn new developments.

 

n)         Personnel health requirements

 

1)         Each FEC shall establish an employee health program that includes the following:

 

A)        An assessment of the employee's health and immunization status at the time of employment;

 

B)        Policies regarding required immunizations; and

 

C)        Policies and procedures for the periodic health assessment of all personnel. These policies shall specify the content of the health assessment and the interval between assessments and shall comply with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).

 

2)         Personnel absent from duty because of any communicable disease shall not return to duty until examined for freedom from any condition that might endanger the health of patients or employees.

 

o)         Personnel services may be provided by the owning or controlling hospital, provided that standards are specific to the FEC and are established in accordance with this Section.

 

p)         Prior to employing any individual in a position that requires a State license, the facility shall contact the Illinois Department of Financial and Professional Regulation to verify that the individual's license is active.  A copy of the verification shall be placed in the individual's personnel file.

 

q)         The facility shall check the status of all applicants with the Health Care Worker Registry prior to hiring.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1600  Personnel Requirements

 

a)         At least one board certified emergency physician shall be present at the freestanding emergency center 24 hours per day.  (Section 32.5(a)(3)(C) of the Act)

 

b)         Additional physicians shall be present at the freestanding emergency center or available within 30 minutes to meet the needs of patients brought to the freestanding emergency center.

 

c)         Nursing Staff

 

1)         At least two registered nurses shall be available at the freestanding emergency center from 7:00 a.m. to 11:00 p.m.

 

2)         At least one registered nurse and one other health care provider (e.g., licensed practical nurse or physician assistant) shall be available at the freestanding emergency center from 11:00 p.m. to 7:00 a.m., with additional registered nurses on call to arrive at the freestanding emergency center within 15 minutes after notification that their services are needed.

 

d)         Medical, administrative and support personnel shall be available to meet the needs of patients brought to the freestanding emergency center and to meet the requirements of this Part.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1610  Health Care Worker Background Check

 

The freestanding emergency center shall comply with the Health Care Worker Background Check Act and the Health Care Worker Background Check Code.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1650  Medical Staff Organization

 

The medical staff shall be organized in accordance with written bylaws, rules and regulations of, or developed in cooperation with, the owning or controlling hospital and approved by the Governing Board.

 

Section 518.1700  Nursing Services

 

The FEC shall provide an organized nursing service and shall maintain a staff of nursing personnel organized to provide the nursing care for its patients commensurate with size, scope and nature of services.

 

a)         Director of Nursing Administration or Nursing Service Manager

 

1)         The nursing service shall be under the direction of a registered professional nurse who has qualifications in nursing administration and/or nursing management and who has the ability to organize, coordinate, and evaluate the service.

 

2)         The nursing administrator (director of nursing) shall hold a degree in nursing or have documented experience and relevant continuing education. He/she shall be employed full-time within the FEC as director of the nursing administration or nursing service manager.

 

3)         The nursing administrator shall be accountable to the chief executive officer or designee for developing and implementing policies and procedures of the service and for the nursing practice.

 

4)         The nursing administrator shall have authority over the selection, promotion and retention of nursing personnel based on established job descriptions.

 

5)         A qualified registered nurse shall be designated and authorized to act in the absence of the nursing administrator on a 24-hour basis.

 

b)         Nursing Staff

 

1)         A sufficient number of registered professional nurses shall be on duty at all times to assess, plan, assign, supervise, and evaluate nursing care and provide patients nursing care for which the judgment and specialized skills of a registered nurse are required.

 

2)         Licensed practical nurses and other nursing personnel shall be qualified through training, education, and experience, and shall have demonstrated abilities to give nursing care that does not require the skill and judgment of a registered professional nurse.  Auxiliary nursing personnel shall be assigned and supervised by a registered professional nurse and shall be given only those duties for which they are trained.

 

3)         The number of registered professional nurses, licensed practical nurses and other nursing personnel assigned shall be consistent with the types of nursing care needed by the patients and the capabilities of the staff. Patients shall be evaluated near the end of each change of shift by criteria developed by the nursing service.

 

c)         Staffing Standards

 

1)         Staffing schedules shall reflect actual nursing personnel required for the FEC.  Staffing patterns shall reflect consideration of nursing goals, standards of nursing practice, and the needs of the patients.

 

2)         Staffing schedules shall accomplish the following:

 

A)        Identification of the nurse in charge.

 

B)        Assignment of personnel in a manner that gives consideration to patient care and minimizes the risk of cross-infections.

 

C)        Projection of future time schedules indicating assignment of personnel by name, status, date and duty tour.

 

D)        Time schedules shall be kept in detail, indicating the assignment of nursing personnel by name, status, date, and patient care assignment.  Actual time reports shall be kept verifying personnel attendance by name, date, patient care assignment, and time of actual attendance.

 

d)         Planning, decision making, and formulation of policies that affect the operation of the nursing service, the care of patients, or the environment of patients shall include nursing service representatives, and their recommendations shall be considered.

 

e)         Job descriptions shall be written for each position classification in the nursing service and shall delineate the functions, responsibilities, and qualifications for each classification.  Copies of job descriptions shall be available to nursing personnel.

 

f)         Procedures shall be maintained to ensure that nursing personnel for whom licensure is required have valid and current licenses in the State of Illinois and to verify licensure status.

 

g)         The current license and credentials of private duty and agency nurses shall be verified prior to assignment.  The nursing service shall maintain adequate supervision of private duty and agency nurses and shall require that they abide by the appropriate policies and procedures and maintain the standards of the FEC and the nursing service.

 

h)         Nursing policies and procedures shall be developed, reviewed periodically at least once a year, and revised as necessary by nursing representatives in cooperation with appropriate representatives from administration, the medical staff and other concerned FEC services or departments.  The policies and procedures shall be dated to indicate the time of the most recent review or revision.

 

i)          Written policies shall include, but not be limited to, the following:

 

1)         Criteria pertaining to the performance of special procedures and the circumstances and supervision under which these may be performed by nursing personnel.

 

2)         Communication and implementation of diagnostic and therapeutic orders, including verbal orders.  The responsibility and mechanism for nursing service to obtain clarification of an order when indicated.

 

3)         Administration of medication.

 

4)         Assignments for providing nursing care to patients.

 

5)         Documentation in patients' records by nursing personnel.

 

6)         Infection control.

 

7)         Patient safety.

 

8)         Nursing role in other FEC services, including, but not limited to, such services as pharmacy and housekeeping.

 

9)         Emotional and attitudinal support.

 

j)          A nursing procedure manual shall be developed, and copies shall be available to the nursing staff and to other services and departments, including members of the medical staff and students.

 

k)         The procedure manual shall provide a ready reference on nursing procedures and a basis for standardization of procedures and equipment in the FEC.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1750  Accounting

 

Accounting procedures shall be carried out in accordance with a recognized system of health care accounting, shall be adequate to permit satisfactory auditing, and shall allow separation of expenses and income from the hospital that owns or controls the FEC.  An audit shall be performed at least annually by a qualified auditor independent of the freestanding emergency center.

 

Section 518.1800  Quality Assurance and Reporting

 

a)         The freestanding emergency center shall develop and implement a quality assessment and improvement program designed to meet at least the following:

 

1)         Ongoing monitoring and evaluation of the quality and accessibility of care and services provided, including, but not limited to:

 

A)        Infection control,

 

B)        Patient satisfaction,

 

C)        Compliance with EMS System protocols, and

 

D)        Timely patient transfers to hospitals;

 

2)         Identification and analysis of problems; and

 

3)         Identification and implementation of corrective action or changes in response to problems.

 

b)         The freestanding emergency center shall report the following to the Department:

 

1)         Reports of any patient transfers from the FEC to a hospital shall be faxed to the Chief, Division of Health Care Facilities and Programs at (217)782-0382 within 48 hours after the transfer. (Section 32.5(a)(10) of the Act) Reports shall list the patient's name, diagnosis, date and time of arrival at the FEC, and date, time, destination and mechanism of transfer from the FEC.

 

2)         Reports of morbidity and mortality rates for patients treated at the FEC shall be submitted on a quarterly basis.  (Section 32.5(a)(11) of the Act)

 

3)         Reports of all patients transferred to trauma centers shall be submitted on a quarterly basis.

 

4)         Reports of injuries allegedly caused by a violent act shall be reported in accordance with Section 55.80 of the Civil Administrative Code of Illinois and the Violent Injury Reporting Code.

 

c)         Each freestanding emergency center shall submit a data report, completed by each vehicle service provider for every emergency pre-hospital or inter-hospital transport, to the Department's Division of Emergency Medical Services and Highway Safety on March 1, June 1, September 1 and December 1 of each year, covering run report data from the preceding quarter.  The report shall be in one of the following formats:

 

1)         Copies of the Department-issued scannable run report form, or

 

2)         A data diskette containing the prescribed data elements.

 

A)        The data elements shall be in a format compatible with the Department's database input specifications, and

 

B)        Department review and approval of data format compatibility is required prior to submission.

 

d)         Each FEC shall develop and implement a mechanism for linking run reports with emergency department, trauma center and admission records from the hospitals that receive emergency patients within the System.  This mechanism shall facilitate tracking of case outcomes for purposes of internal quality control, medical study and improvement of both adult and pediatric patients.

 

e)         The FEC shall use the single form designated or approved by the Resource Hospital.

 

f)         The FEC shall report any injury resulting from the discharge of a firearm or any injury sustained in the commission of or as a victim of a criminal offense.  (Section 3.2 of the Criminal Identification Act)

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1850  Orders for Medications and Treatments

 

a)         No medication or treatment or diagnostic test shall be administered to a patient except on the written order of a member of the medical staff or a house staff member under the supervision of a member of the medical staff.  Verbal orders shall be signed before the member of the medical staff or the house staff member leaves the area. Telephone orders shall be used sparingly and countersigned within 24 hours.

 

b)         Members of the medical staff and house staff members shall give orders for medication and treatment only to the licensed, registered or certified professional persons who are authorized by law to administer or dispense the medication or treatment in the course of practicing their identified specific discipline.

 

c)         The medical directors of the laboratory, radiology or other diagnostic services may respectively authorize the performance of diagnostic tests and procedures at the request of other than members of the medical staff in accordance with policies approved by the medical staff and Board.

 

Section 518.1900  Infection Control

 

a)         The freestanding emergency center shall develop policies and procedures for the prevention and control of infections within the facility, which shall be approved by the owning or controlling hospital.  The person responsible for infection control in the FEC shall be a part of the hospital's Infection Control Committee.

 

b)         Policies and procedures for the reporting and care of individuals with communicable diseases shall be in accordance with the Control of Communicable Diseases Code.

 

c)         When patients are diagnosed with or present signs and symptoms of a communicable disease, precautionary measures shall be taken to avoid cross-infection to personnel, other patients or the public, in accordance with the Control of Communicable Diseases Code.

 

d)         Policies and procedures for the care of persons diagnosed with an infectious disease shall include orders to the medical, nursing and non-professional staffs providing for isolation technique in accordance with the Control of Communicable Diseases Code.

 

e)         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 shall take appropriate safeguards to avoid transmission of the disease agent pursuant to Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings and Guidelines for Infection Control in Health Care Personnel.

 

f)         Thorough hand scrubbing shall be required after touching any contaminated or infected material.

 

g)         Policies and procedures shall be established related to subsections (a) through (f) and including, but not limited to, the following items:

 

1)         The admission and isolation of patients with specific and/or suspected infectious diseases, and protective isolation of appropriate patients.

 

2)         In-service education programs on the control of infectious diseases.

 

3)         Policies and procedures for isolation techniques appropriate to the working diagnosis of the patient, and protective routines for personnel and visitors.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.1950  Sterilization and Processing of Supplies

 

a)         All sterilization and processing of all sterile supplies and equipment shall be under competent, qualified supervision.

 

1)         The director or person responsible for sterile supplies and equipment shall be responsible to the chief executive officer.  This person shall be qualified for the position by education, training and experience.

 

2)         The number of supervisory and support personnel shall be related to the scope of the services provided.  New employees shall receive initial orientation and on-the-job training, and all employees shall participate in a continuing in-service education program, which shall be documented.

 

3)         Educational efforts, though directed primarily at sterile-supply processing and handling techniques, shall also include management concepts, safety, personal hygiene, health requirements and hand-washing, and work attire.

 

b)         Written policies and procedures shall be established for the decontamination and sterilization activities performed in the freestanding emergency center and shall relate, but are not limited, to the following:

 

1)         Receiving, decontaminating, cleaning, preparing, disinfecting and sterilizing reusable items.

 

2)         Assembly, wrapping, storage, distribution, and quality control of sterile equipment and medical supplies.  Load control numbers shall be used to designate the sterilization equipment used for each item, including the sterilization date and cycle.

 

3)         Use of sterilization process monitors, including temperature and pressure recordings, and the use and frequency of appropriate chemical indicator and bacteriological spore tests for all sterilizers.

 

4)         Designation of the shelf life for each FEC-wrapped and -sterilized medical item and, to the maximum degree possible, for each commercially prepared item.

 

A)        Designation of a shelf life may be a specific expiration date, i.e., 30 days, six months, etc., based on manufacturer's recommendation, a nationally recognized authority, or other standard approved by the owning or controlling hospital's Infection Control Committee.

 

B)        Designation of shelf life may be event related if policies and procedures, approved by the owning or controlling hospital's Infection Control Committee, address at least the following:

 

i)          Requirements for wrapping, storing and rotating sterile supplies;

 

ii)         Definition of an event that may cause a sterile item to be or be suspected of being compromised, such as the package being wet or torn, or the seal being broken or tampered with;

 

iii)        Clear direction that final inspection of the package and the ultimate decision to use the contents of the package rest with the clinician; and

 

iv)        Orientation, in-service and other follow-up to assure that all necessary staff understand and implement the policies and procedures.

 

C)        A facility may choose to use both a specific expiration date and event-related shelf life designation specific for certain wrappings, areas of the FEC, etc., as long as the policies and procedures, as approved by the Infection Control Committee, and training of staff define this practice.

 

5)         Acquisition of supplies after normal working hours or any time the central supply service or sterile supply unit is considered "closed" or unstaffed.

 

6)         Preventive maintenance of all central supply service equipment, including performance verification records and reports.

 

7)         The recall and disposal or reprocessing of outdated sterile supplies.

 

8)         The emergency collection and disposition of supplies when special warnings have been issued by the manufacturer.  The attending physician shall be notified if patient exposure is known.

 

9)         Specific aeration requirements for each category of gas-sterilized items to eliminate the hazard of toxic residues.

 

10)        The cleaning and sanitizing of work surfaces, floors, utensils and equipment used in central supply service functions.

 

c)         Space shall be provided for the efficient operation of all central supply service functions.  Functional design and work-flow patterns shall separate soiled and contaminated supplies from supplies that are clean and sterile.  Equipment of adequate design, size and type shall be provided for decontaminating, disinfecting, cleaning, packaging, sterilizing, storing and distributing medical instruments, supplies and equipment used in patient care.

 

d)         Equipment and Procedures

 

1)         The facilities, equipment, and procedures for cleanup, preparation, and sterilization shall be adequate to allow proper cleaning, processing, and sterilizing of patient care supplies and equipment.

 

2)         When cleanup, preparation, and sterilization functions are carried out in the same room or unit (as in a central sterilizing department), the physical facilities and equipment and the policies and procedures for their use shall separate soiled or contaminated supplies and equipment from the clean or sterilized supplies and equipment.

 

3)         Sterilization equipment shall be maintained in good repair and be under a preventive maintenance program.

 

4)         All pressure steam autoclaves shall have recording thermometers, and the sterilization performance shall be otherwise monitored.

 

e)         Sterilization of Instruments and Utensils

 

1)         All surgical instruments not adversely affected by high temperature shall be sterilized by pressure steam sterilization.

 

2)         Whenever possible, throughout the FEC, sterilization shall be accomplished by pressure steam sterilization.  Hot air sterilization or gas sterilization may be used.  When gas sterilization is used, there shall be policies and tested procedures for proper aeration to permit safe use. Pressure steam sterilization of reusable syringes and needles is required.

 

3)         All instruments, whether used on infected cases or clean cases, shall be cleaned before sterilization.  Instruments used on infected cases shall be disinfected before transport to central supply.

 

4)         Boiling is not an approved method of sterilization.

 

f)         Water Sterilization

 

1)         When non-commercial sterile water is used, water sterilization equipment shall be maintained and operated in a manner that will protect the sterilized water from contamination.

 

2)         An acceptable method for checking the sterility of the water shall be used. Water may be sterilized either in water sterilizers or autoclaved in appropriate flasks.

 

g)         Sterilization and Storage of Supplies and Equipment

 

1)         Supplies and equipment shall be properly wrapped and labeled before sterilization.

 

2)         The effectiveness of sterilization shall be checked. This shall include bacteriological testing of all sterilization units throughout the facility. Indicators shall be used to show that a wrapped package has been sterilized.  A procedure shall be established for the recall of expired or inadequately sterilized goods for both in-house and commercially sterilized supplies and equipment.

 

3)         Supplies and equipment commercially prepared so as to retain sterility indefinitely are acceptable.  The FEC shall verify the sterility of these materials.

 

4)         Sterile equipment and supplies shall be stored properly in clean cabinets, cupboards or other suitable enclosed spaces.  An orderly system of rotation of supplies is recommended so that supplies stored first will be used first.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2000  Laboratory Services

 

The freestanding emergency center shall have a clinical laboratory to perform services commensurate with the FEC's needs for its patients, which is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88) and 42 CFR 493.  Anatomical pathology services shall be available either in the FEC or by arrangement with other facilities.

 

a)         Adequacy of Laboratory Services.  Clinical laboratory services adequate for the individual FEC shall be maintained in the FEC, as determined by the following:

 

1)         The extent and complexity of services are commensurate with the size, scope and nature of the FEC and the demands of the medical staff upon the laboratory.

 

2)         Basic laboratory services, necessary for routine examinations as defined in subsection (b) of this Section, are provided in the FEC.

 

b)         Clinical Laboratory Examinations.  Basic clinical laboratory examinations, including chemistry, microbiology, hematology, serology and clinical microscopy, shall be carried out as required by the medical staff.

 

1)         Other laboratory examinations may be provided under arrangements by the FEC with another laboratory that is certified under CLIA 88.

 

2)         In the case of work performed by an outside laboratory, the original report from this laboratory shall be contained in the medical record.

 

c)         Availability of Facilities and Services

 

1)         Facilities and services shall be available at all times.

 

2)         Where services are provided by an outside laboratory, the conditions, procedures, and availability of examinations performed are to be in writing and available in the FEC.

 

d)         Laboratory Report

            Signed or otherwise authenticated reports shall be filed with the patient's medical record and duplicate copies maintained in the laboratory.

 

1)         The laboratory director shall be responsible for the laboratory reports.

 

2)         All tests and procedures shall be ordered by a member of the medical staff or by others in accordance with approved policies.

 

e)         Pathologist Services.  Services of a pathologist shall be provided as indicated by the needs of the FEC.

 

1)         Services are to be under the supervision of a pathologist certified by the American Board of Pathology or who possesses training and experience acceptable to the Department and equivalent to such certification, and who is licensed to practice medicine in all of its branches in Illinois, on a full-time, regular part-time or regular consultive basis.  If the latter pertains, the FEC shall provide for, at a minimum, semimonthly consultive visits by a pathologist.

 

2)         The pathologist shall participate in staff, departmental and clinicopathologic conferences.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2010  Radiological Services

 

a)         The freestanding emergency center shall maintain and provide radiological services sufficient to perform and interpret the radiological examinations necessary for the diagnosis and treatment of patients, to the extent that the complexity of services is commensurate with the size and scope of the FEC. Additional required services shall be provided by shared services or referral of patients.

 

b)         The physician responsible for the direction of a radiological department or service shall be board certified or eligible for certification by the American Board of Radiology or equivalent.  The physician shall have a written agreement with the FEC to direct the radiological services on a full-time, part-time, or consulting basis and be an approved member of the medical staff. The responsibilities of the physician shall be identified in a policy and procedures manual or other document.

 

c)         Technicians employed in the radiological services shall be accredited pursuant to 32 Ill. Adm. Code 401 as appropriate and have sufficient training and experience to carry out the procedures safely and efficiently commensurate with the size and scope of the service.  A procedure and means for evaluating qualifications shall be established and used by the FEC.

 

d)         Radiological services shall be available at all times.

 

e)         Complete, signed reports of the radiological examinations shall be made part of the patient's record, and duplicate copies shall be kept in the department for a period of time established by the FEC.

 

f)         Written reports of each radiological interpretation, consultation and treatment shall be signed by the physician responsible for conducting the procedure and shall be a part of the patient's medical record.  Maintenance and filing of records shall be coordinated with direction and supervision by the medical record administrator.

 

g)         X-ray or roentgen photographs shall be retained in accordance with the X-ray Retention Act, which requires retention for five years and longer when notification of litigation is received.

 

h)         Radiological facilities operated by an FEC constitute a "radiation installation" within the meaning of the Radiation Protection Act of 1990 and are required to be registered with the Illinois Emergency Management Agency.

 

i)          Each radiological department or identified distinct radiological service shall prepare and maintain a policies and procedures manual, which shall be reviewed and updated annually and shall include, but not be limited to, the following requirements:

 

1)         The FEC shall establish and enforce safety regulations that will protect both patient and radiological worker from excessive or stray radiation pursuant to the Radiation Protection Act of 1990 and the federal regulations promulgated thereunder.

 

2)         When a radiation hazard exists, the FEC shall periodically obtain a survey and report by a diagnostic imaging specialist or therapeutic radiological physicist that indicates whether satisfactory conditions exist.

 

3)         Personnel Monitoring shall be performed pursuant to 32 Ill. Adm. Code 340.210 and 340.520.

 

A)        Procedures for personnel monitoring shall be maintained for each individual working in the area of radiation where there is a reasonable possibility an individual will exceed 10% of annual limit.

 

B)        Personnel monitoring records resulting from the use of film badges or dosimeters shall be maintained. Readings shall be on at least a quarterly basis.

 

C)        Upon termination of employment, each worker shall be provided with a summary of the worker's exposure record.

 

D)        Permanent records of exposure on all monitored personnel shall be maintained for review by the Department.

 

4)         Monthly and yearly reports shall be maintained on the number of examinations done and kinds of treatment given.

 

5)         The use of all radiological apparatus shall be limited to personnel designated as qualified by the physician responsible for the direction and supervision of the department or service.  Qualified personnel shall comply with the Radiation Protection Act of 1990 and the regulations promulgated thereunder, specifically 32 Ill. Adm. Code 401.  The use of fluoroscopes shall be limited to persons licensed under the Medical Practice Act of 1987, the Illinois Dental Practice Act, or the Podiatric Medical Practice Act of 1987, and to personnel who meet the requirements in 32 Ill. Adm. Code 360.50(n)(1) through (4).

 

6)         Radiological personnel accredited pursuant to 32 Ill. Adm. Code 401 shall participate in continuing education pursuant to 32 Ill. Adm. Code 401.140.  Physicians shall participate in training pursuant to Subpart J of 32 Ill. Adm. Code 335 as applicable.  The physician is responsible for the direction and supervision of radiological services.  The continuing education shall be documented.

 

7)         At all times, reasonable privacy shall be provided for the radiological patient relative to dressing, evacuation, and the study being performed.

 

8)         Safety policies shall be written for the radiological services to protect patients and personnel.  These policies shall relate to radiation pursuant to 32 Ill. Adm. Code 310, 335, 340, and 360, electrical and mechanical hazards, prevention and containment of fire and explosion, and prevention and treatment of any untoward reaction to contrast media.

 

9)         Written policies and procedures shall be enforced for the radiological services that relate to the management of critically ill patients and to the administration of diagnostic agents by nonphysicians.

 

10)       When nonphysicians are permitted to administer diagnostic agents intravenously for radiological evaluations, written safety guidelines shall specify which individuals have this authority and require that a physician be immediately available. If radioactive materials are being administered, accreditation and supervision rules apply.  Refer to 32 Ill. Adm. Code 335.1050.

 

11)       An emergency drug tray shall always be present in the room or immediately available where parenteral diagnostic agents for radiologic evaluations are being administered.  A system shall be established for maintaining an emergency drug tray with appropriate content and no outdated medications or missing items.  Oxygen, airways, syringes and needles, intravenous administration sets, and appropriate parenteral solutions shall be available at all times.

 

12)       Written safety policies shall provide for the steps to be followed in the event of a spill of radioactive material pursuant to Subpart M of 32 Ill Adm. Code 340; for specific authority for any nonphysician personnel who administer radioactive material intravenously pursuant to 32 Ill. Adm. Code 335.1050; for the recording of cumulative radiation exposure of all personnel pursuant to 32 Ill Adm. Code 340.1160 and 340.520; a requirement for protective security from all radioactive areas for all unauthorized personnel pursuant to Subpart G of 32 Ill. Adm. Code 340 and 32 Ill. Adm. Code 340.810; and the establishment of a radiation protection survey at least once per week pursuant to 32 Ill. Adm. Code 335.

 

13)       Instrument logbooks maintained by Radiological Services shall include calibration records of equipment and monitors, maintenance and repair records, and the findings of outside evaluators (if used), with the corrective action taken pursuant to 32 Ill. Adm. Code 340.1130.

 

(Source:  Amended at 47 Ill. Reg. 12120, effective July 28, 2023)

 

Section 518.2020  Comprehensive Emergency Treatment Services

 

Each freestanding emergency center shall provide Comprehensive Emergency Treatment Services, as defined in this Section and in the Hospital Licensing Requirements, 24 hours per day, on an outpatient basis, as follows:

 

a)         At least one board certified emergency physician shall be present at the FEC 24 hours per day.  (Section 32.5(a)(2)(C) of the Act)

 

b)         Physician specialists representing the major specialties, and sub-specialties such as plastic surgery, dermatology, ophthalmology, etc., shall be available immediately for consultation and onsite, if necessary, within 30 minutes.

 

c)         Ancillary services, including laboratory and x-ray, shall be staffed at all times.  Pharmacy shall be staffed or "on call" at all times.

 

d)         Each FEC shall provide facilities for immediate life-saving measures.

 

e)         Policies and procedures governing the acceptance and care of emergency patients shall be established.

 

f)         A record shall be maintained on each patient who presents himself/herself for emergency services.

 

g)         Supplies and equipment shall be available and ready for use.

 

h)         This Section shall not be construed to affect facility-patient arrangements regarding payment for care.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2030  Notification of Emergency Personnel

 

a)         For purposes of this Section:

 

1)         "Emergency Services Provider Agency" means any entity that uses vehicles, personnel and equipment for the pre-hospital or inter-hospital transportation and care of patients requiring emergency care or life support services in accordance with the Act.

           

2)         "Ambulance Personnel" means any person employed by an emergency services provider agency who is or was involved in the pre-hospital or inter-hospital transportation and care of a patient requiring emergency care or life support services as an ambulance crew member, including the vehicle driver.

 

b)         Each freestanding emergency center shall provide notification to police officers, emergency medical technicians and ambulance personnel who have provided or are about to provide emergency care or life support services to a patient who has been diagnosed as having a dangerous communicable or infectious disease. (Section 6.08(a) of the Hospital Licensing Act) The notification shall include at a minimum the requirements of this Section.

 

c)         In reporting communicable disease cases, the freestanding emergency center shall comply with the Control of Communicable Diseases Code.

 

d)         The freestanding emergency center shall send the letter of notification to the emergency services provider agency within 72 hours after the FEC receives actual knowledge of a confirmed diagnosis of any of the communicable diseases (see subsection (c)) in regard to any patient who has been transported to the FEC by police officers, emergency medical technicians or ambulance personnel.  (Section 6.08(c) of the Hospital Licensing Act)

 

e)         If there is a confirmed diagnosis of AIDS, the FEC shall send the letter of notification to the emergency services provider agency within 72 hours only if one or both of the following conditions exist:

 

1)         The police officers, emergency medical technicians or ambulance personnel have indicated on the ambulance run sheet that a reasonable possibility exists that they have had blood or body fluid contact with the patient.

 

2)         The FEC has reason to know of a possible exposure of the police officers, emergency medical technicians or ambulance personnel to the blood or body fluids of the patient.  (Section 6.08(c) of the Hospital Licensing Act)

 

f)         Notification letters shall be sent to the designated contact at the emergency services provider agency listed on the ambulance run sheet and shall include at least the following information. Such notification letters shall not contain the patient's name or any patient-identifying information.  (Section 6.08(d) of the Hospital Licensing Act)

 

1)         The names of the police officers, emergency medical technicians, ambulance personnel, and other crew members listed on the ambulance run sheet,

 

2)         The name of the communicable disease diagnosed,

 

3)         The date the patient was transported,

 

4)         A statement that this information shall be maintained as a confidential medical record, and

 

5)         A statement that upon receipt of the notification letter, the provider agency shall contact all personnel involved in the pre-hospital or inter-hospital care and transport of the patient.  (Section 6.08(d) of the Hospital Licensing Act)

 

g)         Upon discharge of a patient with a communicable disease to emergency transport personnel, the FEC shall notify the emergency transport personnel of appropriate precautions against the communicable disease, but shall not identify the name of the patient.  (Section 6.08(e) of the Hospital Licensing Act)

 

h)         The FEC may take any measures in addition to those required in this Section to notify police officers, emergency medical technicians or ambulance personnel of possible exposure to any communicable disease. (Section 6.08 of the Hospital Licensing Act) However, such measures shall not violate the confidentiality of the medical record of the patient, or conflict with the provisions of this Section.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2040  Community or Areawide Planning

 

Freestanding emergency centers may participate in a community or areawide plan that provides for emergency services, as described in Section 250.730 of the Hospital Licensing Requirements.

 

Section 518.2050  Disaster and Mass Casualty Program

 

a)         Each freestanding emergency center shall have and maintain a disaster and mass casualty program.  Such program shall be developed in cooperation with the hospitals of the area and with official and nonofficial agencies concerned. This program shall include the possibility of disaster involving loss of the FEC or serious impairment of its facilities.

 

b)         In instances where FECs are participating in an areawide plan for emergency services, the plan shall include responsibilities to be shared for a disaster and mass casualty program.

 

Section 518.2060  Emergency Services for Sexual Assault Survivors

 

a)         All freestanding emergency centers are required to render care to sexual assault survivors.  Care shall be in accordance with Section 545.60 of the Sexual Assault Survivors Emergency Treatment Code. The FEC shall submit a sexual assault treatment plan in accordance with the Sexual Assault Survivors Treatment Code even if the plan is to participate in the plan submitted by the Associate or Resource Hospital.

 

b)         An FEC may fulfill its obligation to provide emergency service to sexual assault survivors by participating in an areawide plan for emergency service in accordance with 77 Ill. Adm. Code 545.50.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2070  Pharmacy Service

 

a)         The freestanding emergency center shall provide a pharmacy or drug and medicine service (service) for the care and treatment of patients.

 

b)         A pharmacy or drug and medicine service policy and procedure manual shall identify the service and manner of operation.

 

c)         The service shall be under the direction of a pharmacist employed by the FEC on a full-time, part-time or consulting basis. Responsibilities of the pharmacist shall be identified in the policy and procedure manual or other document.

 

d)         A pharmacist shall staff the pharmacy during all hours when the pharmacy is open.  At all other times, the pharmacy shall be locked.  A pharmacist or pharmaceutical service shall be on call when the pharmacy is not open.

 

e)         When a pharmacist is absent from the FEC, a registered professional nurse may have access to the pharmacy.  The nurse, after contacting the on call pharmacist, may obtain a single dose, manufacturer's original package, or container of a drug or medication prepackaged under the supervision of a pharmacist necessary to administer to a patient in carrying out treatment and medication orders of a prescriber.  A signed receipt for the drugs and medicines removed shall be left for the pharmacist.

 

f)         Vending machines for the storage and supply of drugs used in the facility shall be stocked only under the supervision of a pharmacist.  They shall be securely locked, and shall provide a record of what was supplied and to whom. The drugs contained in the vending machines may be released only by a registered professional nurse, licensed practical nurse if the FEC's policy allows, physician or pharmacist.

 

g)         All drugs and medicines shall be stored and dispensed in accordance with applicable State laws and rules and federal laws.

 

h)         Pharmacy Personnel

 

1)         A pharmacist shall be available or on call at all times.

 

2)         The number of registered pharmacists and other supportive personnel provided shall be consistent with the size and activity of the service.

 

3)         Pharmacy apprentices, if employed, shall be under the direct and personal supervision of a pharmacist.

 

i)          A pharmacy shall be in an identified area or room that complies with the requirements of the Pharmacy Practice Act.

 

j)          Drugs and medicines shall be plainly labeled with the name of the manufacturer, lot and control number, and stored in specifically identified and well-illuminated medicine cabinets, closets, refrigerators, or other locations provided with lighting, ventilation and temperature control and fully protected from access by unauthorized persons.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2080  Housekeeping Service

 

a)         The FEC shall have an organized housekeeping department or service, under competent supervision.

 

b)         The director of housekeeping services shall be qualified for the position by education, training, and experience.

 

1)         The number of supervisory and support personnel shall be related to the size and complexity of the facility and to the scope of the services provided.

 

2)         To guide personnel in providing a hygienic environment for patients and staff, specific housekeeping procedures shall be developed and available for all departments and services. Procedures shall identify techniques and products used and shall include, but not be limited to, the following:

 

A)        the use, cleaning, and care of equipment;

 

B)        the selection, measurement, and proper use of housekeeping and cleaning supplies, their storage, and transportation;

 

C)        the maintenance of cleaning schedules, including frequency of cleaning of observation/treatment and major procedure rooms;

 

D)        techniques for evaluation of cleaning effectiveness;

 

E)        personal hygiene and handwashing.

 

c)         Participation by housekeeping personnel in a relevant continuing education program shall be documented.

 

d)         The entire facility, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment, and furnishings, shall be maintained in good repair, clean and free of insects, rodents and trash.

 

1)         Dusting, mopping, and vacuum cleaning shall be done in a manner that will not spread dust or other particulate matter.

 

2)         Adequate supplies and equipment for housekeeping functions shall be provided, with cleaning compounds and hazardous substances properly labeled and stored.

 

3)         Venetian blinds, decorative curtains and draperies shall be of fire resistant materials and shall be kept clean at all times. Venetian blinds, decorative curtains and draperies shall be prohibited in treatment rooms.  When control of excessive sunlight is necessary, washable pull shades (to be damp dusted daily) may be used.

 

Section 518.2090  Insect and Rodent Control

 

Any condition on the freestanding emergency center site conducive to harboring or breeding insects, rodents or other vermin shall be prohibited.

 

a)         All outside doors, windows and other openings shall be effectively screened, except in air-conditioned buildings where doors and windows are normally kept closed and are opened for minimal use, automatically operated doors or infrequently used fire exits. Screens shall be kept in good repair and shall have no fewer than 16 meshes per inch.  All screen doors shall open outward where building design permits and be equipped with self-closing devices.  Fire and panic laws shall be considered in screen installation and maintenance.

 

b)         Other methods of preventing the entrance of insects, such as blast-fans, electrocution screens, fly traps, sprays, etc., may be used only as a supplement to the use of screens. Fly strips, paper, swatters, insecticide sprays and powders, fly traps, etc., shall be used only in such a manner and place that dead, injured, or affected insects, or the spray or powder itself, cannot fall on or otherwise come in contact with any food or food product, sterile/clean equipment and supplies or patient treatment areas.

 

c)         All rooms shall be free from insects, rodents or other vermin.

 

d)         Any chemical substance of a poisonous nature used to control or eliminate various types of vermin shall be properly colored or labeled to identify it as a poison. Identification, storage and use shall be in accordance with local, State and federal laws.

 

e)         If pest control services are contracted with an outside firm, that firm shall be a Pest Control Business that is licensed by the Department.  If services are provided by FEC personnel, and restricted-use pesticides are applied, the person responsible for the application shall be an institutional multi-housing pest control operator who is certified by the Department.

 

f)         The FEC shall maintain an up-to-date list of all pest control products used, areas where they are used, and areas where specific formulations shall not be used.  This document shall be readily available, in case of accidental poisoning.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2100  Laundry Service

 

a)         Laundry service shall be provided by an organized laundry service under competent supervision or by contract with another entity.

 

1)         If laundry services are provided by an outside entity, a written contract shall be available and shall specify that the laundry meets the same standards required in this Section.  The linens shall be transported in sanitary vehicles. Clean and soiled linens shall not be transported in the same vehicle at the same time.

 

2)         Equipment and construction shall be as required in Section 518.2180.

 

b)         The freestanding emergency center laundry shall be:

 

1)         Located so that steam, odors, lint and objectionable noises do not reach patient or personnel areas;

 

2)         Well-lighted, ventilated and adequate in size for the needs of the FEC and for the protection of employees;

 

3)         Maintained in a safe, sanitary, lint-free condition and kept in good repair; and

 

4)         Not part of a storage area.

 

c)         A supply of clean linen shall be provided that is adequate for the capacity and use of the facility.

 

d)         Written procedures shall be developed and maintained pertaining to the handling, storage, transportation and processing of linens to prevent the spread of infection and assure the maintenance of clean linen.

 

e)         All linens shall be mechanically washed using soap or detergent and warm or hot water.  Linens shall be disinfected by using one of the following procedures:

 

1)         Thermal Disinfection: Linen shall be exposed to hot water of at least 160°F for a cumulative time of at least 25 minutes.

 

2)         Chemical and Thermal Disinfection: Linen shall be exposed to wash and bleach bath water of at least 140°F.  The bleach bath shall be at least 10 minutes long and have a starting bleach concentration of 100 ppm. This bleach concentration shall be measured by titration on a periodic basis.

 

3)         Other: A step-wise wash process that has been previously documented by microbiological study published in a scientific journal. The results shall indicate no surviving pathogenic microorganisms and a low level of other organisms. Low level is defined as nine out of 10 samples with fewer than two colonies per 10 square centimeters of test surface.

 

f)         All washed linens shall be thoroughly rinsed. A neutralizing rinse is recommended.

 

g)         Separate areas shall be maintained for storage of clean linen and soiled linen.  Linen storage areas shall be adequate in size for the needs of the facility and shall not be used for any other purpose.  Storage shall not be permitted in areas or rooms where plenums of air conditioning or ventilating systems are located.

 

h)         Hand-washing and toilet facilities for laundry personnel shall be provided at locations convenient to the laundry.

 

i)          Soiled and clean linen carts shall be so labeled and shall be provided with covers made of washable materials that shall be laundered or suitably cleaned daily.

 

j)          Soiled Linen

 

1)         Radioactive contaminated linen and linen from pathology shall be separately transported, stored and washed.

 

2)         Isolation and other potentially infectious linens shall be bagged at the location where they are used in durable, leak-proof bags resistant to puncture and tears and shall be labeled or identified as infectious at the site of use.

 

3)         Soiled linen shall not be sorted or pre-rinsed in patient care areas. Soiled linen may be sorted in a separate enclosed room by a person instructed in methods of infection control.  These personnel shall not have responsibility for immediately handling clean linen.

 

4)         Soiled linen shall be stored and transported in a manner that does not permit contamination of clean linen, corridors and areas occupied by patients.

 

5)         All carts and other containers used to store or to transport clean or soiled linen shall be identified for soiled linen only or for clean linen only and shall be kept covered when not in use.

 

6)         If laundry chutes are used for transporting soiled linen, all soiled linen shall be bagged.  The chutes shall be designed to maintain a negative air pressure within the chute and shall be kept in a clean and sanitary condition. If chutes are used, they shall meet all of the requirements of NFPA 101, Section 9.5.

 

k)         Clean Linen

 

1)         Clean linen shall be sorted, handled and transported in such a manner as to prevent cross-contamination.

 

2)         Clean linen carts shall be used only for the purpose of transportation or storage of clean linen.

 

3)         Persons processing clean linen shall be dressed in clean garments at all times while on duty. They shall not handle soiled linen.

 

4)         Clean linen received from a commercial laundry shall be completely wrapped in convenient-size bundles or otherwise protected and shall be delivered to a designated clean area of the FEC.

 

5)         Clean linens shall be adequately protected from contamination.  Clean linen in patient care areas shall be stored in clean, ventilated closets, rooms or alcoves, used only for that purpose. Corridors shall not be used for storage of linen.

 

6)         If clean linen is stored in the laundry area, it shall be stored in a room separate from the sorting room, laundry room or soiled linen room.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2110  Food Service

 

Food service, if provided by the freestanding emergency center, shall be provided in compliance with the Food Service Sanitation Code and local ordinances.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2120  Maintenance

 

The freestanding emergency center shall have an organized engineering and/or maintenance department under competent supervision.  The requirements of NFPA 99 shall apply in addition to the following:

 

a)         Maintenance services shall be under the supervision of a qualified engineer or persons who have had commensurate experience in the maintenance of public or private plants, preferably health care facilities.

 

b)         Personnel engaged in maintenance activities shall receive orientation and follow-up training, including training in principles of asepsis, cross-infection control, and safe practices.

 

c)         The FEC shall have an effective, organized, detailed preventive maintenance program.  Written instructions for operating and maintaining equipment and the various mechanical, electrical, and other systems contained in the FEC shall be available to maintenance personnel.

 

d)         Maintenance and repairs shall be carried out in accordance with applicable codes and requirements of local jurisdictions, and applicable rules of the State Fire Marshal and the Department.

 

e)         Space and equipment shall be provided for the managerial activities of the supervisor of maintenance for repair work and for storage of maintenance materials.  Paints and oils shall not be stored in patient areas.

 

f)         The FEC structure and its component parts shall be kept in good repair and shall be maintained with consideration for the safety and comfort of the occupants of the building.  Mechanical and electrical equipment shall be maintained in good repair and operating condition at all times.

 

g)         Roads, walks, and parking areas shall be properly maintained.

 

h)         Grounds and buildings shall be maintained as follows:

 

1)         In a clean condition free of safety hazards;

 

2)         In a manner that will prevent standing water, flooding or leakage; and

 

3)         Free of excessive noise, odors, pollens, dusts, or other environmental pollutants and such nuisances as may adversely affect the health or welfare of patients.

 

i)          Ventilation, heating, air conditioning, and air changing systems shall:

 

1)         Be maintained in good repair and shall be operated in a manner that will prevent the spread of infection and provide for patient comfort;

 

2)         Be maintained and operated so that air shall not be circulated from laboratories, toilet rooms, janitors' closets, storage rooms, shop areas, soiled linen and soiled utility to any other part of the facility; and

 

3)         Be provided, as needed, with acceptable air filtration equipment that is cleaned and serviced at adequate intervals.

             

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2130  Fire Safety

 

a)         Buildings and equipment shall be maintained so as to prevent fire and other hazards to personal safety.

 

b)         Exits, stairways, doors, and corridors shall be kept free of obstructions.

 

c)         Flammable and combustible liquids shall be labeled, stored, handled and used in compliance with NFPA 30 .

 

d)         Flammable and non-flammable gases shall be labeled, handled, and used in compliance with NFPA 99.  Separate storage for flammable and oxidizing gases shall be provided.

 

e)         A master fire plan, developed to suit the needs of the facility, and acceptable to the Department, shall be maintained.

 

f)         Fire regulations listing the fire stations, procedures and staff emergency duties by title or position shall be posted conspicuously on each floor at appropriate locations, and shall be available in each unit, section and department.

 

g)         Employees shall be trained in procedures to be followed in the master fire plan.

 

h)         Fire drills shall be conducted at irregular intervals at least l2 times per year.  A record shall be kept of the staff performance and results, and indicated corrective measures shall be made.

 

i)          Portable fire extinguishers, provided in accordance with NFPA l0, shall be inspected at least annually, recharged or repaired as needed and labeled with the dates of the last inspection.

 

j)          Sprinkler systems, fire hoses, fire detection and alarm devices, and other equipment for use in the fire safety program shall be connected and maintained in a fully functional condition at all times.

 

k)         Fire detection and protection systems shall be inspected no less frequently than twice a year by a recognized, competent authority.  A written report of the inspection shall be kept on file at the FEC for at least three years following the date of inspection.

 

l)          The FEC shall maintain a procedure for reporting to a designated administrative officer, on a standard form adopted for the purpose, all accidents to patients, employees or visitors. The report shall include all pertinent information and shall be kept on file for no fewer than six years after the occurrence is reported.

 

m)        The FEC shall maintain a procedure to investigate fires. The FEC shall notify the Department of all fires within 24 hours after the occurrence. A written report of the investigation containing all pertinent information shall be made and a copy forwarded to the Department.  The report shall remain on file for no fewer than six years.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2140  Water Supply

 

The Department's rules titled Public Area Sanitary Practice Code shall apply, except when they differ from this Part.

 

a)         Water supplies of FECs shall be operated in conformance with the following requirements:

 

1)         All water used in operation of the FEC facility shall be provided from a public water supply or from an alternative source.  The source of water supply shall be approved by the Department.

 

2)         The construction, maintenance, and operation of any treatment process that might change the physical, chemical, or bacterial characteristics of the water shall be approved by the Department.

 

3)         Hot water shall be available at sinks and lavatories at all times.  Water shall be adequate in volume and pressure for all medical purposes.

 

4)         The water system shall be operated with a hot water system adequate for all medical purposes.

 

5)         The hot water supply shall be regulated by thermostatic or other control devices, which shall be either locked or located in places not accessible to patients or the general public so that the hot water used by patients and by the public is maintained at an even temperature that cannot cause personal injury.

 

b)         As part of the disaster and mass casualty program, a plan for the emergency supply of water shall be available.  This plan shall be approved by the Department, and shall include at least written contracts with any outside firms, a listing of procedures to be followed, the amounts of water needed by different departments, the means of dispensing water within the FEC, and procedures for sanitizing in the case of contamination.  Plans using existing piping are recommended.

 

c)         All plumbing shall be designed, installed, and maintained in accordance with the requirements of the Illinois Plumbing Code, except when that Code and this Part differ.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2150  Garbage, Waste and Sewage Handling and Disposal

 

a)         All garbage and refuse shall be collected, stored, and disposed of in a manner that will not permit the transmission of a contagious disease, create a nuisance or fire hazard, or provide a breeding place for vermin or rodents.

 

b)         Solid waste shall be handled in a safe and sanitary manner within the facility. Garbage and refuse receptacles within the facility shall be made of metal or other appropriate material provided with disposable liners or shall be cleaned and disinfected after each emptying. Receptacles in areas where wet or hazardous wastes are generated shall have tight-fitting lids and shall be kept closed except during use.  Carts used for transport shall be of easily cleanable construction, and shall be kept in a sanitary condition. Trash chutes shall be kept clean and sanitary. Pulping-transport systems, where installed, shall be operated and maintained in a safe and sanitary manner.  All refuse shall be in impervious bags during transport within the facility.  Potentially hazardous waste shall be identified and bagged in durable bags resistant to puncture and tears. Waste may be single bagged if it can be put in the bag without contaminating the outside; otherwise, double bagging is required. Wastes capable of producing injury, such as needles and scalpel blades, shall be stored and transported in rigid containers.  Blood specimens may be carefully poured down the drain.

 

c)         Collected garbage and refuse shall be stored in stable, durable, watertight, vermin- and rodent-proof containers, with tight-fitting lids.  Lids shall be kept closed except during use. Containers shall be emptied at frequent intervals, and shall be kept clean and sanitary. Garbage storage areas shall be kept in a clean and nuisance-free condition.

 

d)         Final disposal of general solid waste shall be by incineration or grinding and flushing to the municipal sewerage system, or removal to a sanitary landfill that is approved by the Illinois Environmental Protection Agency.  Incinerators shall be those approved by the Illinois Environmental Protection Agency for the types of wastes being generated.  Surgical, obstetrical and other tissue wastes shall be disposed of by grinding and flushing, incineration or burial.  Other potentially infectious wastes shall be rendered safe by grinding and flushing, incineration or steam autoclaving.

 

e)         Any blood or blood components, organs, semen, or other human tissue showing exposure to HIV or to any other identified causative agent of AIDS, or originating from a patient diagnosed with AIDS, as defined in 77 Ill. Adm. Code 697.20 shall be disposed of by the FEC in accordance with subsection (f) of this Section, or delivered in accordance with subsection (g) of this Section to a research facility to use such blood, blood components, organs, semen or other human tissue for AIDS research.

 

f)         Any such blood, blood components, organs, semen, or other human tissue, and any other materials or paraphernalia exposed to, or contaminated by, such blood, blood components, organs, semen, or other human tissue shall be completely incinerated, sterilized, or sealed to render the materials innocuous before disposal or removal from the premises.

 

1)         Materials shall be incinerated in accordance with the requirements of the Pollution Control Board concerning the operation of an incinerator (35 Ill. Adm. Code 724).

 

2)         Materials shall be sterilized by autoclaving in accordance with the recommendations of the manufacturer of the autoclave. The effectiveness of the autoclave shall be verified and documented at least weekly with a biological spore assay containing B. stearothermophilus.

 

3)         Incinerated or sterilized materials shall be disposed of through routine waste disposal methods without precautions against possible contamination.

 

4)         Materials that have not been incinerated or sterilized shall be disposed of by a waste hauler with a permit from the Illinois Environmental Protection Agency under rules of the Pollution Control Board (35 Ill. Adm. Code 809). These materials shall be sealed, transported, and stored in biohazard containers. These containers shall be marked "Biohazard", shall bear the universal biohazard symbol, and shall be orange, orange and black, or red. The containers shall be rigid and puncture resistant, such as a secondary metal or plastic can with a lid that can be opened by a step-on pedal. These containers shall be lined with one or two high-density polyethylene or polypropylene plastic bags with a total thickness of at least 2.5 mil or equivalent material. The containers that are marked "Biohazard" shall be sealed before being removed from the FEC.

 

g)         When an FEC delivers such blood, blood components, organs, semen or other human tissue to any research facility, the FEC shall file a report with the Department (Division of Laboratories), which shall include at least the following information:

 

1)         A copy of the request from the research facility for blood or human tissue;

 

2)         The quantity of blood or human tissue delivered;

 

3)         The name and location of the research facility to which the blood or human tissue was delivered; and

 

4)         The date and time of delivery.

 

h)         A research facility, for the purposes of this Section, shall mean any clinical laboratory licensed under the Clinical Laboratory and Blood Bank Act, or any hospital licensed under the Hospital Licensing Act.

 

i)          All sewage and liquid wastes shall be disposed of in a municipal sewerage system where such facilities are available.  When a municipal sewerage system is not available, sewage and liquid wastes shall be collected, treated, and disposed of in an independent plant, the construction, maintenance, and operation of which are approved by the Department or by the Illinois Environmental Protection Agency.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2160  Submission of Architectural Plans

 

a)         New Construction, Addition, or Major Alteration

 

1)         When construction is contemplated, either for new buildings or additions or alterations to existing buildings coming within the scope of this Part, design development drawings and outline specifications shall be submitted to the Department for review.  Approval of design development drawings and specifications shall be obtained from the Department prior to starting final working drawings and specifications. The Department will provide comments or approval within 30 working days after receipt of the drawings and specifications and the submission being deemed complete.

 

2)         Final Drawings

 

A)        The final working drawings and specifications shall be submitted to the Department for review and approval prior to beginning of construction. For final approval to remain valid, contracts shall be signed within one year after the approval date. Alternate methods of design development and construction may be acceptable subject to the approval of the Department. The Department will provide comments or approval within 30 working days after receipt of the final drawings and the submission being deemed complete.

 

B)        The Department shall be notified upon the award of construction contracts.

 

3)         Any contract modifications that affect or change the function, design, or purpose of a facility shall be submitted to the Department for approval prior to authorizing the modifications. The Department will provide comments or approval within 60 working days after receipt of the drawings and specifications.

 

4)         Upon 90% of completion, the pre-occupancy certification package shall be submitted to the Department.

 

5)         As-built drawings shall be maintained by the freestanding emergency center.

 

b)         Minor Alterations and Remodeling. Minor alterations or remodeling changes that do not affect the structural integrity of the building, that do not change functional operation, that do not affect fire safety, and that do not increase capacity over that for which the FEC is licensed need not be submitted for approval.

 

c)         Alterations of Water Supply, Plumbing and Drainage. No system of water supply, plumbing, sewage, garbage or refuse disposal shall be installed, nor any such existing system materially altered or extended, until complete plans and specifications for the installation, alteration or extension have been submitted to the Department and have been reviewed and approved.

 

d)         Codes and Standards

 

1)         Nothing stated in this Part shall relieve the licensee from compliance with building codes, ordinances and regulations that are enforced by city, county or local jurisdictions.

 

2)         The recommendations of the International Building Code shall apply insofar as those recommendations are not in conflict with the standards set forth in this Part or with NFPA 101.

 

A)        The portions of the International Building Code requiring smoke detectors in all patient rooms and automatic door closers on all patient room doors are hereby specifically excluded from these requirements.

 

B)        The International Building Code is intended as a model code for municipalities with no building code of their own.

 

C)        NFPA 101-A shall apply only if the Department determines that the proposed equivalent system is safe and does not constitute a hazard to the life and safety of the staff and patients.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2170  Preparation of Drawings and Specifications – Submission Requirements

 

Drawings and specifications shall be prepared by or under the immediate supervision of an architect registered in the State of Illinois.  The requirements contained in this Section have been established for the guidance of the FEC and the architect to provide a standard method of preparation of drawings and specifications.

 

a)         First Stage Submission – Design Development Drawings and Outline Specifications

 

1)         The preliminary sketch plans shall indicate in detail the assignment of all spaces and the size of areas and rooms, and shall indicate in outline the fixed and movable equipment and furniture.

 

A)        The plans shall be drawn at a scale sufficiently large to clearly present the proposed design and not exceed 30 x 42 inches.

 

B)        The drawings shall include:

 

i)          A plan of each floor, including the basement or ground floor;

 

ii)         Roof plan;

 

iii)        Plan showing roads, parking areas, sidewalks, etc., and elevations of all facades;

 

iv)        Sections through the building;

 

v)         All adjacent areas clearly labeled if addition or alteration; and

 

vi)        Fire and smoke separation diagrams.

 

2)         Outline specifications shall provide a general description of the construction, including finishes; acoustical material, its extent and type; extent of the conductive floor covering; heating and ventilating systems; and the type of elevators.

 

3)         The total gross floor area and bed count shall be shown on the drawings.

 

4)         A brief narrative of the proposed program shall be provided.

 

b)         Second Stage Submission – Working Drawings and Specifications

All working drawings shall be well prepared so that clean and distinct prints may be obtained; drawings shall be accurately dimensioned and include all necessary explanatory notes, schedules and legends.  Working drawings shall be complete and adequate for contract purposes. Separate drawings, not to exceed 30 x 42 inches, shall be prepared for each of the following branches of work: architectural, structural, mechanical and electrical, and shall include or contain the following:

 

1)         Architectural Drawings

 

A)        Site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, walks, and the extent of the areas to be landscaped.  All structures and improvements that are to be removed under the construction contract shall be shown;

 

B)        Plan of each floor and roof;

 

C)        Elevations of each facade;

 

D)        Sections through building;

 

E)        Elevators and dumbwaiters. Drawings delineating shaft details and dimensions, sizes of cab platforms and doors, travel distances, including elevation height of landings, pit sizes and machine rooms;

 

F)         Laundry, laboratories, and similar areas shall be detailed at a scale to show the location, type, size and connection of all fixed and movable equipment;

 

G)        Scale details as necessary; scale details to 1½ inch to the foot may be necessary to properly indicate portions of the work; and

 

H)        Schedule of finishes.

 

2)         Structural Drawings

 

A)        Plans of foundations, floors, roofs and all intermediate levels shall show a complete design with sizes, sections, the relative location of the various members, and a schedule of beams, girders and columns.

 

B)        Floor levels, column centers, and offsets shall be dimensioned.

 

C)        Special openings and pipe sleeves shall be dimensioned or otherwise noted for easy reference.

 

D)        Details of all special connections, assemblies and expansion joints shall be given.

 

E)        Notes on design data shall include the name of the governing building code, values of allowable unit stresses, assumed live loads, wind loads, earthquake load, and soil-bearing pressures.

 

F)         For special structures, a stress sheet shall be incorporated in the drawings showing:

 

i)          Outline of structure;

 

ii)         All load assumptions used;

 

iii)        Stresses and bending moments separately for each kind of loading;

 

iv)        Maximum stress and/or bending moment for which each member is designed, when not readily apparent from subsection (b)(3); and

 

v)         Horizontal and vertical reactions at column bases.

 

3)         Mechanical Drawings.  These drawings with specifications shall show the complete heating, cooling and ventilation systems, plumbing, drainage, stand pipe and sprinkler systems.

 

A)        Heating, Cooling and Ventilation

 

i)          Radiators, coils and steam-heated equipment such as sterilizers, warmers and steam tables;

 

ii)         Heating and steam mains and branches with pipe sizes;

 

iii)        Diagram of heating and steam risers with pipe sizes;

 

iv)        Sizes, types and heating surfaces of boilers, furnaces with stokers and oil burners, if any;

 

v)         Pumps, tanks, boiler breeching and piping and boiler room accessories;

 

vi)        Air conditioning systems with required equipment, water and refrigerant piping and ducts;

 

vii)       Supply and exhaust ventilating systems with connections and piping; and

 

viii)      Air quantities for all room supply and exhaust ventilating duct openings.

 

B)        Plumbing, Drainage and Stand Pipe Systems

 

i)          Size and elevation of street sewer, house sewer, house drains, street water main and water service into the building;

 

ii)         Location and size of soil, waste, and vent stacks with connections to house drains, cleanouts, fixtures and equipment;

 

iii)        Size and location of hot, cold and circulating mains, branches, and risers from the service entrance, and tanks;

 

iv)        Riser diagram of all plumbing stacks with vents, water risers and fixture connections;

 

v)         Gas, oxygen and similar piped systems;

 

vi)        Standpipe and sprinkler systems; and

 

vii)       All fixtures and equipment that require water and drain connections.

 

4)         Electrical Drawings.  Drawings shall show all electrical wiring, outlets and equipment that require electrical connections.

 

A)        Electrical service entrance with switches and feeders to the public service feeders, characteristics of the light and power current, transformers and their connections if located in the building.

 

B)        Location of main switchboard, power panels, light panels and equipment. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches.

 

C)        Light outlets, receptacles, switches, power outlets and circuits.

 

D)        Telephone layout showing service entrance, telephone switchboard, strip boxes, telephone outlets and branch conduits as approved by the telephone company.  Where public telephones are used for inter-communication, a separate room and conduits for racks and automatic switching equipment shall be provided as required by the telephone company.

 

E)        Nurse call systems with outlets for treatment rooms, duty stations, corridor signal lights, annunciators and wiring diagrams.

 

F)         Doctors' call and doctors' in-and-out systems with all equipment wiring, if provided.

 

G)        Fire alarm system with stations, signal devices, control board and wiring diagrams.

 

H)        Emergency electrical system with outlets, transfer switch, source of supply, feeders and circuits.

 

I)         All other electrically operated systems and equipment.

 

5)         Additions to Existing Structures

 

A)        Procedures and requirements for working drawings and specifications are to be followed, and the following information shall be submitted:

 

i)          Type of activities within the existing building and distribution of existing treatment rooms, etc.;

 

ii)         Type of construction of existing building and number of stories in height;

 

iii)        Plans and details showing attachment of new construction to the existing structure; and

 

iv)        Mechanical and electrical systems tying into existing system.

 

B)        The Department may require submission of architectural drawings of all or any part of the existing structure if necessary for the Department's review.

 

6)         Specifications.  Specifications shall supplement the drawings and shall comply with the following:

 

A)        The specifications shall fully describe, except where fully indicated and described on the drawings, the materials, workmanship, kind, sizes, capacities, finishes, and other characteristics of all materials, products, articles and devices.

 

B)        The specifications shall include:

 

i)          Cover or title sheet;

 

ii)         Index;

 

iii)        Invitation for bids;

 

iv)        General conditions;

 

v)         General requirements;

 

vi)        Sections describing material and workmanship in detail for each class of work; and

 

vii)       Bid form.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2180  Construction Details

 

a)         Compartmentation, exits, automatic extinguishing systems and other details relating to fire prevention and fire protection shall comply with requirements listed in the appropriate sections of NFPA 101.

 

b)         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.

 

c)         Doors

 

1)         Doors to observation/treatment rooms shall not be lockable from inside the room.

 

2)         Special Locking Arrangements: Electronic locking devices may be installed at specific locations to restrict egress or ingress for patient/staff safety or security, provided that each of the following is complied with and after receiving approval from the Department:

 

A)        The facility shall submit a narrative to the Department providing a rationale for having a locked door in a required means of egress.  The rationale shall relate to security issues.

 

B)        The building shall be fully sprinklered.

 

C)        All locking system components shall be U.L. listed.

 

D)        Cross corridor, smoke or control doors that are located in a required means of egress shall be secured only with electronic locks and automatic release devices.  The use of only manual keys or tools to unlock the door is not permitted.

 

E)        Locked doors shall have continuous staff supervision (direct or electronic remote).

 

F)         No other type of locking arrangement shall be used in a required means of egress.

 

G)        All locked doors shall release automatically with actuation of the fire alarm system.

 

H)        All doors shall release automatically with loss of electrical power to the locking device.

 

I)         All locks shall initiate an irreversible process that will release the lock within 15 seconds whenever a force of not more than 15 pounds is continuously applied to the release device (lever type handle or panic bar) for a period of not more than three seconds. Relocking of such doors shall be by manual means only.  Operation of the release device shall activate a sign in the vicinity of the door to assure those attempting to exit that the system is functional. Delays of up to 30 seconds may be acceptable, based on the program narrative.

 

J)         Permanent signs shall be posted on locked doors that state: "Push until alarm sounds.  Door will be opened in 15 seconds." Sign letters must be at least 1 inch high with ⅛ inch stroke. Signs may be omitted for security reasons, based on review and approval by the Department of the written rationale.

 

K)        Emergency lighting shall be provided at all locked door locations.

 

L)        The FEC shall fully apprise the local fire department of locked doors or units and all related details of the system.

 

M)       Any discharge exit door may be locked against entry.

 

N)        Additional electronic release of locked doors initiated from a staff duty station is to be provided.

 

O)        No more than one such device may be installed in any path of travel to exit discharge.

 

d)         The minimum width of all doors to rooms needing access for beds or stretchers shall be 3'8".  Doors to rooms needing access for wheelchairs shall have a minimum width of 2'10".

 

e)         Doors on all openings between corridors and rooms or spaces subject to occupancy, except elevator doors, shall be swing type. Openings to patient toilets and other small wet-type areas not subject to fire hazard are exempt from this requirement.  Sliding doors with a break and swing feature are acceptable.

 

f)         Doors, except those to spaces such as small closets that are not subject to occupancy, shall not swing into corridors in a manner that might obstruct traffic flow or reduce the required corridor width.  (Large walk-in type closets are considered as occupiable spaces.)

 

g)         Windows shall be designed so that persons cannot accidentally fall out of them when they are open, or shall be provided with guards.

 

h)         Glazing.  Doors, sidelights, borrowed lights, and windows in which the glazing extends down to within 18 inches of the floor (thereby creating possibility of accidental breakage by pedestrian traffic) shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken.  Fire-rated glass shall be used where required for fire safety.

 

i)          Where labeled fire doors are required, these shall be certified by an independent testing laboratory as meeting the construction requirements equal to those for fire doors in NFPA 80.  Reference to a labeled door includes labeled frame and hardware.

 

j)          Elevator shaft openings shall be class B 1½ hour labeled fire doors.

 

k)         Linen and refuse chutes shall meet or exceed the requirements of NFPA 82.

                                                                                   

l)          Thresholds and expansion joint covers shall be made flush with the floor surface to facilitate use of wheelchairs and carts.

 

m)        Grab bars shall be provided at all patients' toilets.  The bars shall have 1½ inch clearance to walls and shall have sufficient strength and anchorage to sustain a concentrated load of 250 pounds.

 

n)         An accessible shower shall be provided.  Safety glass or plastic glazing materials shall be used for shower doors.  A grab bar shall be provided as specified in subsection (m).  A recessed soap dish shall be provided. The shower base shall have a nonslip service.

 

o)         Hand-washing facilities shall be located and arranged to permit their proper use and operation.  Particular care shall be given to the clearances required for blade-type operating handles.

 

p)         Paper towel dispensers and waste receptacles (or electric hand dryers) shall be provided at all hand-washing facilities except scrub sinks.

 

q)         Lavatories and hand-washing facilities shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the fixture.

 

r)          X-ray and gamma ray installations shall comply with NCRP Report No. 147 and Report No. 102. The completed installation shall be tested, and all defects shall be corrected before use.

 

s)         Ceiling heights shall be as follows:

           

1)         Radiographic, major procedure rooms, and other rooms containing ceiling-mounted equipment or ceiling-mounted surgical light fixtures shall have height required to accommodate the equipment or fixtures.

 

2)         All other rooms shall have not less than 8'0" ceilings, except that ceiling heights in corridors, storage rooms, toilet rooms and other minor rooms shall be not less than 7'8".  Suspended tracks, rails, and pipes located in the path of normal traffic shall be not less than 6'8" above the floor.

 

t)          Rooms containing heat-producing equipment (such as boiler or heater rooms and laundries) shall be insulated and ventilated to prevent any floor surface above from exceeding a temperature of 10°F (6°C) above the ambient room temperature.

 

u)         The FEC shall be located on the same level as the ambulance and walk-in entrance.

                                                                                                 

v)         Response to Natural Disasters

 

1)         General Requirements.  An emergency radio communication system is desirable in each facility.  If installed, this system shall be self-sufficient in time of emergency and shall also be linked with the available community system and State emergency medical network system, including connections with police, fire, and civil defense system.

 

2)         Earthquakes.  In areas where local experience shows that earthquakes have caused loss of life or extensive property damage, buildings and structures shall be designed to withstand the force assumptions specified in the International Building Code. 

 

3)         Tornadoes and Floods. Special provisions shall be made in the design of buildings in regions where local experience shows loss of life or damage to buildings resulting from tornadoes or floods.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2190  Finishes

 

a)         Cubicle and window curtains and draperies shall be noncombustible or flame retardant and shall pass both the large- and small-scale tests of NFPA 701.

 

b)         Flame spread and smoke developed ratings of finishes shall be in accordance with NFPA 101.

           

c)         Floor materials shall be easily cleanable and have wear resistance appropriate for the location involved. Floors in toilets, janitor's closets and similar areas shall be water resistant.  In all areas frequently subject to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions.

 

d)         Wall bases in soiled workrooms and other areas that are frequently subject to wet cleaning methods shall be made integral and coved with the floor, tightly sealed to the wall, and constructed without surface voids that can harbor vermin.

 

e)         All wall finishes shall be washable and, in the immediate area of plumbing fixtures, shall be smooth and moisture resistant.  Walls in spaces subject to frequent cleaning shall be of suitable materials.

 

f)         Floor and wall penetrations by pipes, ducts, and conduits shall be tightly sealed to minimize entry of vermin, smoke and fire.  Joints of structural elements shall be similarly sealed.

 

g)         Ceilings shall be cleanable and shall have a finished surface that covers all overhead duct work and piping.  Finished ceilings may be omitted in mechanical and equipment spaces, shops, general storage areas, and similar spaces, unless required for fire-resistive purposes.

 

h)         The following areas shall have acoustical ceilings:

 

1)         Corridors in patient areas,

 

2)         Nurses' stations, and

 

3)         Waiting areas.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2200  Structural Requirements

 

a)         In addition to compliance with this Part, all applicable local or State building codes and regulations shall be observed.

 

b)         The buildings and all parts thereof shall be of sufficient strength to support all dead, live, and lateral loads without exceeding the working stresses permitted for the materials of their construction in generally accepted good engineering practice.

 

c)         Special provision shall be made for machines or apparatus loads that would cause a greater load than the specified minimum live load.

 

d)         Consideration shall be given to structural members and connections of structures that may be subject to earthquakes or tornadoes.  Floor areas where partition locations are subject to change shall be designed to support for the partition, a uniformly distributed load of 25 p.s.f.

 

e)         Construction shall be in accordance with NFPA 101 and the minimum requirements contained in this Part.

 

1)         Foundations shall rest on natural solid ground and shall be carried to a depth of not less than one foot below the estimated frost line or shall rest on leveled rock or load-bearing piles or caissons when solid ground is not encountered.  Footings, piers and foundation walls shall be adequately protected against deterioration from the action of ground water. Test borings shall be taken to establish proper soil-bearing values for the soil at the building site.

 

2)         Assumed live load shall be in accordance with the International Building Code.

 

f)         Chapter 18, New Health Care Occupancies, of NFPA 101 shall apply in its entirety.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2210  Mechanical Requirements

 

a)         General Requirements

 

1)         Mechanical systems shall be tested, balanced and operated to demonstrate that these systems are installed and will perform according to the plans and specifications.

 

2)         Upon completion of the mechanical systems, the owner shall obtain a complete set of manufacturers' installation, operating, maintenance and preventive maintenance instructions, and a parts list with numbers and a description for each piece of equipment.  The owner shall also obtain instruction in the operational use of the systems and equipment as required.

 

b)         Thermal and Acoustical Insulation

 

1)         Insulation shall be provided for the following when located within the building:

 

A)        Boilers, smoke breeching and stacks;

 

B)        Steam supply and condensate return piping;

 

C)        Hot water piping above 120°F and all water heaters, generators, and converters.  Exposed hot water supplies to fixtures need not be insulated except where exposed to contact by physically handicapped persons;

 

D)        Chilled water, refrigerant, other process piping and equipment operating with fluid temperatures below ambient dew point;

 

E)        Water supply, storm and drainage piping on which condensation may occur;

 

F)         Air ducts and casings with outside surface temperature below ambient dew point; and

 

G)        Other piping, ducts and equipment as necessary to maintain the efficiency of the system.

 

2)         Insulation on cold surfaces shall include an exterior vapor barrier.

 

3)         Insulation, including finishes and adhesives on exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as determined by an independent testing laboratory in accordance with NFPA 255.

 

4)         Pipe insulation shall have a flame spread rating of 25 or less and a smoke developed rating of 150 or less.

 

5)         No duct linings shall be permitted.

 

c)         Steam and Hot Water Systems

 

1)         Boilers shall have the capacity to supply the normal requirements of all systems and equipment.  The number and arrangement of boilers shall be such that when one boiler breaks down or is temporarily taken out of service, the capacity of the remaining boilers shall be sufficient to provide hot water service, steam for sterilization, and heating for all treatment rooms.

 

2)         Boiler feed pumps, heating circulating pumps, condensate return pumps and fuel oil pumps shall be connected and installed to provide normal and standby service.

 

3)         Supply and return mains and risers of cooling, heating and process steam systems shall be valved to isolate the various sections of each system.  Each piece of equipment shall be valved at supply and return ends.

 

4)         Humidifiers used in conjunction with air handling systems shall be of the direct steam injection type.

 

d)         Air Conditioning, Heating and Ventilating Systems

 

1)         The FEC shall employ the most economical and energy-efficient systems, in accordance with this subsection (d), to provide a comfortable, clean and controlled environment.

 

A)        The requirements of this subsection (d) do not relieve the designer from providing system capacities and components as required to maintain control of air quality, odor, ventilation rates, space temperatures and space humidity as set forth in this subsection (d).

 

B)        The design of air conditioning, heating and ventilation systems shall be based on no less than the recommended outdoor design conditions listed in the ASHRAE Handbook – Fundamentals for 99% occurrence (winter) and 1% occurrence (summer).

 

2)         Ventilation Systems

 

A)        Air handling systems shall conform to NFPA 90A.

 

B)        Fire dampers, smoke dampers and smoke control systems shall be constructed, located and installed in accordance with the requirements of NFPA 90A.

 

C)        Ducts that penetrate construction intended for x-ray or other ray protection shall preserve the effectiveness of the protection.

 

D)        Outdoor air intakes shall be located at least 15 feet from exhaust outlets of ventilation systems, combustion equipment stacks, medical/surgical vacuum systems, plumbing vents, or areas that may collect vehicular exhaust or other noxious fumes, unless other provisions are made to minimize recirculation of exhaust into outdoor air intakes.  Plumbing and vacuum vents that terminate above the level of the top of the air intake may be located as close as 10 feet.  The bottom of outdoor air intakes serving central systems shall be located as high as practical but at least 6 feet above ground level, or, if installed above the roof, 3 feet above the roof level.

 

E)        Exhaust outlets from areas that may be contaminated by dangerous or noxious dust, fumes, mists, gases, odors, infectious material or other contaminants harmful to people shall be above the roof level. The discharge to the atmosphere shall be located as far as possible but not less than 25 feet from any operable window, door and/or outdoor intake for a fan that discharges air to an occupied space.

 

F)         The ventilation systems shall be designed and balanced to provide the ventilation and pressure relationships specified in this Section.

 

G)        If the ventilation rates required in this Section do not provide sufficient make-up air for use by hoods, safety cabinets and exhaust fans, the additional make-up air shall be provided to maintain required pressure balance.

 

H)        An all outdoor air system may be used where required by local codes, provided that some form of air-to-air or air-to-water heat recovery system is included to reclaim the energy otherwise discharged with the air exhausted to the outside.

 

I)         To provide maximum energy conservation, air supplied to patient care areas not required as make-up air for 100% exhaust systems shall be recirculated.  Any air within the FEC that is circulated between patient rooms, or patient rooms and other areas of the FEC, shall pass through filters having a minimum efficiency reporting value (MERV) 14 rating (see subsection (d)(3) on filters).

 

J)         To provide maximum energy conservation, air supplied to housekeeping, administration and other nonsensitive areas not required as make-up air for 100% exhaust systems shall be recirculated.  These areas require filters having a MERV 8 rating on the inlet side of the air handling unit.

 

K)        When a central system serves areas with different filtration requirements, the most stringent filtration requirement will be provided for the complete system.

 

L)        All outside air supplied to patient care areas shall pass through 90% filters (see subsection (d)(3) on filters).

 

M)       Minimum air circulation requirements indicated in this Section are applicable to occupied spaces.  During unoccupied periods, minimum air circulation may be provided as required to maintain space design temperature conditions.

 

N)        Where fan coil or terminal room unit systems are provided in areas to be occupied by patients, through-the-wall outside air ventilation is not acceptable.  A separate central ventilation system, with final filters having a MERV 14 rating, shall supply the required outdoor air ventilation.

 

O)        Only fully ducted systems are acceptable.  Interstitial spaces shall not be used as plenums for supply/return/exhaust.

 

3)         Filters

 

A)        All central ventilation or air conditioning systems shall be equipped with filters having efficiencies no less than those specified in the area requirements (see subsection (e)).

 

B)        Where two filter beds are required, filter bed No. 1 shall be located upstream of the air conditioning equipment and filter bed No. 2 shall be located downstream of the supply fan and air conditioning equipment.

 

C)        Where only one filter bed is required, it shall be located upstream of the air conditioning equipment.

 

D)        All filter efficiencies shall be average atmospheric dust spot efficiencies tested in accordance with ASHRAE Handbook – Fundamentals.

 

E)        Filter frames shall be durable and shall provide an air-tight fit with the enclosing ductwork.  All joints between filter segments and enclosing ductwork shall be gasketed or sealed to provide a positive seal against air leakage.

 

F)         A local indicating device shall be installed across each filter bed serving central air systems to measure the static pressure drop across the bed.

 

e)         Area Requirements

 

1)         Administration, Public Area, Medical Records and Housekeeping Offices

 

A)        Filters

 

i)          Central ventilation systems shall be provided with prefilters having a MERV 8 rating.

 

ii)         Units that recirculate air within a room shall be provided with filters having a MERV 4 rating.

 

B)        Space Design Conditions

 

i)          Temperature, measured via a dry bulb, shall be 75°F.

 

ii)         The minimum relative humidity in winter shall be 30%.

 

iii)        The maximum relative humidity in summer shall be 60%.

 

C)        Air Circulation

 

i)          Total air supplied to each space shall be as required to maintain space design conditions.

 

ii)         Outdoor air supplied shall be not less than 20% of the total air supplied.

 

D)        Space Pressurization. The ventilation system shall be designed and balanced so that space pressure, in relation to surrounding areas of the building, is neutral.

 

E)        Recirculation of air within a room is permitted.

 

2)         Laboratories

 

A)        Filters

 

i)         Central ventilation systems shall be provided with prefilters having a MERV 8 rating and final filters having a MERV 14 rating.

 

ii)        Units that recirculate air within a room shall be provided with filters having a MERV 8 rating.

 

B)        Space Design Conditions

 

i)          Temperature, measured via a dry bulb, shall be 75°F.

 

ii)        The minimum relative humidity, in winter, shall be 30%.

 

iii)       The maximum relative humidity, in summer, shall be 60%.

 

C)        Space Pressurization

The ventilation system shall be designed and balanced so that space pressure, in relation to surrounding areas of the building, is negative.

 

D)        Recirculation of air within a room is permitted, except in areas listed in subsection (e)(2)(E), where all air must be exhausted directly to the outdoors.

 

E)       Air from the following areas shall be exhausted directly to the outdoors:

 

i)           All fume hoods;

 

ii)          Histology;

 

iii)         Bacteriology; and

 

iv)         Glass-washing areas.

 

F)         All air exhausted from fume hoods shall be made up with outside air.

 

G)        Laboratory hoods shall meet the following general requirements:

 

i)          Have an average face velocity of not less than 75 feet per minute;

 

ii)         Be connected to an exhaust system that is separate from the building exhaust system;

 

iii)        Have an exhaust duct system of noncombustible, corrosion-resistant material consistent with the usage of the hood; and

 

iv)        Have an exhaust fan located at the discharge end of the duct system unless provided with a welded stainless steel duct from fan outlet to termination.

 

H)        Laboratory hoods shall meet the following special requirements:

 

i)          Each hood that processes infectious or radioactive materials shall have a minimum face velocity of 100 feet per minute, shall be connected to an independent exhaust system, shall be provided with filters with 99.97% efficiency (based on the dioctylphthalate test method as described in DOD Penetration Test Method MIL STD No. 282) in the exhaust system, and shall be designed and equipped to permit the safe removal, disposal and replacement of contaminated filters.

 

ii)         Duct systems serving hoods in which radioactive and/or strong oxidizing agents such as prechloric or nitric acid are used shall be constructed of stainless steel and shall be equipped with wash-down facilities.

 

3)         Radiology Suite; X-Ray Diagnostic, Fluoroscopy and Special Procedures

 

A)        Filters

 

i)          Central ventilation systems shall be provided with prefilters having a MERV 8 rating and final filters having a MERV 14 rating.

 

ii)         Units that recirculate air within a room shall be provided with filters having a MERV 8 rating.

 

iii)        The exhaust from isotope storage shall be provided with filters with 99.97% efficiency (based on the dioctylphthalate test methods as described in DOD Penetration Test Method MIL STD No. 282).

 

B)        Space Design Conditions

 

i)          Temperature, measured via a dry bulb, shall be 75°F.

 

ii)         The minimum relative humidity, in winter, shall be 30%.

 

iii)        The maximum relative humidity, in summer, shall be 60%.

 

C)        Air Circulation

 

i)          Total air supplied to each space shall be as required to maintain space design conditions.

 

ii)         Outdoor air supplied shall be not less than 20% of the total air supplied.

 

D)        Space Pressurization

The ventilation system shall be designed and balanced so that space pressure, in relation to surrounding areas of the building, is neutral.

 

E)        The recirculation of air within a room is permitted.

 

4)         Pharmacy Suite

 

A)        Filters

 

i)          Central ventilation systems shall be provided with prefilters having a minimum MERV 8 rating and final filters having a MERV 14 rating.

 

ii)         Units that recirculate air within a room shall be provided with filters having a MERV 8 rating.

 

B)        Space Design Conditions

 

i)          Temperature, measured via a dry bulb, shall be 75°F.

 

ii)         The minimum relative humidity, in winter, shall be 30%.

 

iii)        The maximum relative humidity, in summer, shall be 60%.

 

C)        Air Circulation

 

i)         Total air supplied to each space shall be as required to maintain space design conditions.

 

ii)        Outdoor air supplied shall be not less than 20% of the total air supplied.

 

D)        Space Pressurization

The ventilation system shall be designed and balanced so that space pressure, in relation to surrounding areas of the building, is neutral.

 

E)        The recirculation of air within a room is permitted. 

 

5)         Observation/Treatment Rooms

 

A)        Filters

 

i)          Central ventilation systems shall be provided with prefilters having a MERV 8 rating and final filters having a MERV 14 rating.

 

ii)         Units that recirculate air within a room shall be provided with filters having a MERV 8 rating.

 

B)        Space Design Conditions

 

i)          Temperature, measured via a dry bulb, shall be 75°F.

 

ii)         The minimum relative humidity, in winter, shall be 30%.

 

iii)        The maximum relative humidity, in summer, shall be 60%.

 

C)        Air Circulation (Patient Rooms)

 

i)         The total air supplied per bed shall be 15 cubic feet per minute (cfm).

 

ii)         The outdoor air supplied per bed shall be 10 cfm.

 

D)        Air Circulation

 

i)          Total air supplied to each space shall be as required to maintain space design conditions.

 

ii)         Outdoor air supplied shall be not less than 20% of the total air supplied.

 

E)        Space Pressurization

The ventilation system shall be designed and balanced so that space pressure, in relation to surrounding areas of the building, is neutral.

 

F)         Recirculation of air within a room is permitted. 

 

G)        Isolation Rooms

These rooms may be used two ways: to protect the patient from the facility environment or to protect the facility environment from the patient. Isolation rooms shall have the same conditions as other treatment rooms, except that the air flow shall be capable of being either into the room or out of the room. When isolation procedures are in place (pursuant to the Control of Communicable Diseases Code), all air shall be exhausted directly to the outdoors.

 

6)         Central Sterile Supply

 

A)        Filters

Central ventilation systems shall be provided with prefilters having a MERV 8 rating and final filters having a MERV 14 rating.

 

B)        Space Design Conditions

 

i)          The temperature, measured via a dry bulb, shall be 75°F.

 

ii)         The minimum relative humidity, in winter, shall be 30%.

 

iii)        The maximum relative humidity, in summer, shall be 60%.

 

C)        Air Circulation

 

i)          Total air supplied to each space shall be as required to maintain space design conditions.

 

ii)         Outdoor air supplied shall be not less than 20% of the total air supplied.

 

D)        Air flow shall be from the clean area toward the soiled or decontamination area.

 

E)        Sterilization Room

 

i)          Where only steam autoclaves are installed, the air exhausted from the sterilizer area for heat control may be recirculated through a central system that is provided with filters having a MERV 14 rating.

 

ii)         Where ethylene oxide sterilizers are used, all air contaminated with ethylene oxide above 1 part per million (PPM) shall be exhausted directly outdoors.  No air shall be recirculated that has more than 1 PPM of ethylene oxide present.

 

7)         Linen Services; Laundry

 

A)        Filters

Central ventilation systems shall be provided with prefilters having a MERV 8 rating and final filters having a MERV 13 rating.

 

B)        Space Design Conditions:  The temperature, measured via a dry bulb in winter, shall be 70°F.

 

C)        All air from the soiled storage and sorting area shall be exhausted directly to outdoors.

 

D)        Air flow shall be from the clean area to the soiled area. Air from the clean area may be used to make up air exhausted from the soiled area.

 

E)        Air from the clean area may be recirculated within the laundry complex, but shall pass through a lint screen or trap before returning to the air handling unit.

 

F)         The entire laundry ventilation system shall be controlled so that air flow is into the laundry from the FEC.

 

G)        Circulation and ventilation rates may be variable, but sufficient outside air shall be supplied to make up for exhaust. Minimum circulation of unconditioned air at summer design conditions shall be 2 cfm (cubic feet per minute) per square foot or 12 air changes per hour, whichever is larger.

 

8)         Miscellaneous Supporting Areas

Space temperatures in these areas shall be maintained for occupant comfort. Ventilation systems shall be designed and balanced so that air flows into these spaces from adjacent areas.

 

A)        Anesthesia Storage Rooms

 

i)          All air shall be exhausted directly to the outdoors.

 

ii)         Minimum exhaust ventilation rates shall be six air changes per hour.

 

iii)        The ventilation system shall comply with NFPA 99, including the option to provide a gravity (non-mechanical) ventilation system.

 

iv)        Supply air makeup for exhaust requirements may be provided from a mechanical ventilation system or by transfer from adjacent areas.

 

B)        Soiled Holding and Work Rooms

 

i)          All air shall be exhausted directly to the outdoors.

 

ii)         Minimum exhaust ventilation rates shall be 10 air changes per hour.

 

iii)        Supply air makeup for exhaust requirements may be provided from a mechanical ventilation system or by transfer from adjacent areas.

 

C)        Toilet Rooms

 

i)          Exhaust air may be recirculated through a central ventilation system that is provided with final filters having a MERV 14 rating.  Otherwise, all air shall be exhausted directly to the outdoors.

 

ii)         Minimum exhaust ventilation rate shall be 1.5 cfm per square foot of floor area, but no less than 50 cfm.

 

iii)        Supply air makeup for exhaust requirements may be provided from a mechanical ventilation system or by transfer from adjacent areas.

 

D)        Janitor Closets, Linen and Trash Chute Rooms

 

i)          All air shall be exhausted directly to the outdoors.

 

ii)         Minimum exhaust ventilation rate shall be 1.5 cfm per square foot of floor area, but not less than 50 cfm.

 

iii)        Supply air makeup for exhaust requirements may be provided from a mechanical ventilation system or by transfer from adjacent areas.

 

E)        Boiler rooms shall be provided with sufficient outdoor air to maintain combustion rates of equipment and limit temperatures in working stations to 97°F effective temperature (97°F and 50% relative humidity or its equivalent) as defined by ASHRAE Handbook – Fundamentals.

 

F)         Rooms containing heat-producing equipment, such as boiler rooms, heater rooms, food preparation centers, laundries or sterilizer or mechanical equipment rooms, shall be insulated and ventilated to prevent any floor surface above from exceeding a temperature of 100°F.

 

            (Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2220  Plumbing and Other Piping Systems

 

a)         General Requirements

            All plumbing systems shall be designed and installed in accordance with the Illinois Plumbing Code, except that the number of waterclosets, urinals, lavatories, drinking fountains and other fixtures shall be as required by this Part.

 

b)         Plumbing Fixtures

 

1)         Plumbing fixtures shall be of nonabsorptive, acid-resistant materials.

 

2)         The water supply spout for lavatories and sinks required for filling pitchers and for medical and nursing staff hand washing shall be mounted so that its discharge point is a minimum perpendicular distance of 5 inches above the rim of the fixture.

 

3)         Hand-washing lavatories used by medical and nursing staff shall be trimmed with valves that can be operated without the use of hands where specifically required in this Part.

 

A)        When blade handles are used for this purpose the blade handles shall not exceed 4½ inches in length, except that the handles on clinical sinks shall not be less than 6 inches in length.

 

B)        The hand-washing and/or scrub sinks for major procedure rooms shall be trimmed with valves that are asceptically operated (i.e., knee or foot controls) without the use of hands.  Wrist blades are not acceptable.

 

4)         Clinical rim flush sinks shall have an integral trap in which the upper portion of a visible trap seal provides a water surface.

 

c)         Water Supply Systems

 

1)         Systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand periods.

 

2)         Each water service main, branch main, riser and branch to a group of fixtures shall be valved.  Stop valves shall be provided at each fixture.

 

3)         Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.

 

           

4)         Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times.  Hot water at shower and hand-washing facilities shall not exceed 110°F (43°C).

 

d)         Water Heaters and Tanks

 

1)         The water-heating equipment shall have sufficient capacity to supply water at the temperatures and quantities in the following areas:

 

	Clinical
gallons/hour/bed	6½
liters/second/bed	.007
temperature °F	100
temperature °C	43

 

            Water temperatures are to be taken at hot water point of use or inlet to processing equipment.

 

2)         Storage tanks shall be fabricated of corrosion-resistant metal or lined with non-corrosive material.

 

e)         Drainage Systems

 

1)         Drain lines from sinks in which acid wastes may be poured shall be fabricated from acid-resistant material.

 

2)         Insofar as possible, drain piping shall not be installed over major procedure rooms and similar critical areas.  Special precautions shall be taken to protect these areas from possible leakage or condensation from such overhead piping systems.

 

3)         Building sewers shall discharge into a public sewerage system.

 

4)         Where a public sewerage system is not available, plans for any private sewage disposal system shall be submitted to the Illinois Environmental Protection Agency for review for approval before construction is started.

 

f)         Nonflammable medical gas systems shall be installed in accordance with NFPA 99.

 

g)         Clinical vacuum (suction) systems shall be installed in accordance with NFPA 99.

 

h)         Medical compressed air systems shall be installed in accordance with NFPA 99.

 

i)          Oxygen, vacuum and medical compressed air shall be piped to the locations indicated in TABLE A with the required station outlets.

 

j)          Service outlets for central housekeeping vacuum systems, if used, shall not be located within major procedure rooms.

 

k)         Fire Extinguishing Systems

All fire extinguishing systems shall be designed, installed and maintained in accordance with NFPA 101, NFPA 13, and NFPA 25.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2230  Electrical Requirements

 

a)         General Requirements

 

1)         All materials including equipment, conductors, controls, and signaling devices shall be installed in compliance with applicable sections of the NFPA 70, including Article 517, and as necessary to provide a complete electrical system.

 

2)         All electrical installations, including alarm, nurses' call and communication systems, shall be tested to demonstrate that the equipment installation and operation conforms to this Part.

 

b)         Switchboards and Power Panels

            These items shall comply with NFPA 70.  The main switchboard shall be located in an area separate from plumbing and mechanical equipment and be accessible only to authorized persons.

 

c)         Panelboards.  Panelboards serving lighting and appliance circuits shall be located on the same floor as the circuits they serve.  This requirement does not apply to the life safety system.

 

d)         Lighting

 

1)         All spaces occupied by people, machinery, and equipment within buildings, approaches to and through exits from buildings, and parking lots shall have lighting.

 

2)         Treatment rooms shall have general lighting in addition to local lighting provided by special lighting units at the treatment tables.  The general lighting shall provide a minimum of 100 footcandles at the treatment tables.  Each fixed special lighting unit at the tables shall be connected to an independent circuit.

 

e)         Receptacles (Convenience Outlets)

 

1)         Each treatment room shall have at least two receptacles installed on each wall or eight receptacles in diversified locations per room.

 

2)         Each observation/treatment room shall have duplex grounding type receptacles as specified in Article 517-18 and Article 517-19 of NFPA 70.  The mounting height of these receptacles shall be 22 to 42 inches above the finished floor.

 

3)         Duplex receptacles for general use shall be installed approximately 50'0" apart in all corridors and within 25'0" of the ends of corridors.  These receptacles shall be circuited to the emergency system. 

 

f)         At least two x-ray film illuminators shall be installed in each treatment room and in the x-ray viewing room of the radiology department. More than two units shall be installed as needed.

 

g)         Nurses' Calling System

 

1)         Each observation/treatment room shall be served by at least one calling station.  Calls shall register with nursing staff and shall activate a visible signal in the corridor at the observation/treatment room door.  In multicorridor nursing units, additional visible signals shall be installed at corridor intersections. In rooms containing two or more calling stations, indicating lights shall be provided at each station. Nurses' calling systems that provide two-way voice communications shall be equipped with an indicating light at each calling station, which will remain lighted as long as the voice circuit is operating.

 

2)         Nurse call duty stations shall be installed in the clean work room, soiled work room, medicine preparation room, nourishment station and nurses' lounge of the unit.

 

3)         A nurses' call emergency station shall be provided for patients' use at each patient's toilet and at the shower.  These stations are to be the pull-cord type with the cord reaching within 6 inches of the floor.  The cords are to be located within reach of a patient.

 

4)         In areas where patients are under constant surveillance, the nurses' calling system may be limited to a bedside station that will actuate a signal that can be readily seen by the other nurses.

 

5)         A communications system that may be used by nurses to summon assistance shall be provided in each treatment room.

 

h)         Communication System

 

1)         A loud speaker-type sound system shall be provided throughout the facility to allow for announcements, such as paging of personnel and other necessary audio functions.

 

2)         Speakers shall be located in all areas to allow personnel to adequately hear all audio outputs from the system.

 

3)         The system shall be used as the communication link for emergency announcements, i.e., code blue, impending disasters and others.  The audio line at the last speaker in the audio circuits shall be electrically supervised against opens and grounds.  The supervision shall be indicated at a building location that is staffed 24 hours a day.

 

i)          Emergency Electric Service

 

1)         To provide electricity during an interruption of the normal electric supply, an emergency source of electricity shall be provided and connected to the life safety branch, the critical branch, and the equipment branch for lighting and power as established in NFPA 70-517.

 

2)         The source of this emergency electric service shall be as follows:

 

A)        An emergency generating set when the normal service is supplied by one or more central station transmission lines.

 

B)        An emergency generating set or a central station transmission line when the normal electric supply is generated on the premises.

 

3)         Emergency Generating Set

 

A)        The required emergency generating set, including the prime mover and generator, shall be located on the premises.  Where stored fuel is required for the emergency generator operations, the storage capacity shall be sufficient for not less than 24 hours continuous operation.

 

B)        The emergency generator set may be used during periods of high energy demands on local utilities.  In the event of an outage of the normal power source, the normal loads shall immediately be removed from the emergency generator set, and the life safety branch, the critical branch, and the equipment branch shall be connected to the generator.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.2240  Building Requirements

 

a)         Location

            The freestanding emergency center shall be conveniently accessible to the population served.  In selecting location, consideration shall be given to factors affecting source and quantity of patient load, including highway systems, public transportation, industrial plants, and recreational areas.

 

b)         Parking

            One parking space for each staff member on duty at any one time and no fewer than two spaces for each major procedure room and each observation/treatment room shall be provided.  Handicapped parking spaces shall be provided as required in the Illinois Accessibility Code. Additional spaces shall be provided for emergency vehicles.  Street, public, and shared lot spaces shall be exclusive for the use of the emergency facility. All required parking spaces shall be conveniently located to the emergency entrance.

 

c)         Administration and Public Areas

 

1)         The ambulance and walk-in entrance shall be located at grade level and be able to accommodate wheelchairs.

 

A)        All entrances shall be covered to permit protected transfer of patients from ambulances, and a ramp for wheelchairs and stretchers shall be provided in addition to steps.  Doors to emergency services shall be not less than 4 feet wide.

 

B)        The emergency entrance shall have vision panels to minimize conflict between incoming and outgoing traffic and to allow for observation of the unloading area from the control station.

 

2)         A lobby and waiting area shall be provided and shall provide:

 

A)        Convenient access to wheelchairs and stretchers;

 

B)        A control station that may be used for triage functions, is in direct communication with medical staff and has direct visual control of the emergency entrance, observation of arriving vehicles, and access to treatment and lobby areas;

 

C)        Waiting areas convenient to the reception and interview areas;

 

D)        Public toilet facilities for males, females and/or families. Unisex toilet facilities are prohibited.

 

3)         Facilities for conducting interviews with patients and others shall be provided and shall include provisions for acoustical and visual privacy.

 

4)         General and individual offices shall be provided.

 

5)         Clerical spaces shall be provided.

 

6)         Multipurpose rooms for staff conferences and consultation shall be provided.

 

7)         Equipment and general storage areas shall be provided.

 

d)         Clinical Facilities

 

1)         At least one major procedure room shall be provided and shall meet the following requirements:

 

A)        A minimum clear area of 360 square feet exclusive of cabinets, shelves, door swings and fixed obstructions;

 

B)        A minimum clear dimension of 16 feet;

 

           

C)        Emergency communication equipment connected to the nurses' control station;

 

D)        X-ray film illuminator (as necessary);

 

E)        Mechanical and electrical systems and devices that meet requirements for hospital surgical rooms in the Hospital Licensing Requirements (77 Ill. Adm. Code 250).

 

2)         Where additional procedure rooms are set up for multi-patient use, these rooms shall meet the following requirements:

 

A)        A minimum clear area of not less than 180 square feet per patient stretcher or bed;

 

B)        A minimum clear dimension of 10 feet per space;

 

C)        Emergency communication equipment connected to the nurses' control station;

 

D)        X-ray film illuminator (as necessary);

 

E)        Mechanical and electrical devices that meet requirements for hospital surgical rooms in 77 Ill. Adm. Code 250.

 

3)         A holding area for stretchers and wheelchairs within the clinical area shall be provided and under staff control and located so as not to block means of egress.

 

4)         A poison control service shall be provided that contains the following services:

 

A)        Immediately accessible antidotes;

 

B)        A file of information concerning common poisons; and

 

C)        Communications links with regional and national poison centers and regional  EMS centers.

 

5)         A nurses' work and control station shall be located to permit visual control and access to clinical areas and shall contain space and equipment to allow the following services to be provided:

 

A)        Charting;

 

B)        Storage of files;

 

C)        Staff consultation; and

 

D)        Communication link with examination/treatment, lobby and waiting area control, laboratory, radiology and on-call staff.

 

6)         A cardiopulmonary resuscitation (CPR) emergency cart shall be located away from traffic and available to all areas.

 

7)         Scrub stations shall be provided at each trauma/cardiac room with water and soap controls operable without the use of hands.

 

e)         Radiology

 

1)         Facilities for basic diagnostic radiological procedures shall be provided and shall include the following:

 

A)        Space adequate to accommodate needed equipment with a minimum clearance of 3 feet on all four sides of the table;

 

B)        A shielded control alcove with windows providing a full view of the examination table and the patient; and

 

C)        A patient toilet accessible from the radiology room.

 

2)         Film processing facilities shall be provided (if required).

 

3)         Viewing and administrative areas shall be provided.

 

4)         Storage facilities for exposed film shall be provided (if required).

 

5)         Dressing rooms or booths with convenient toilet access shall be provided.

 

f)         Laboratory

 

1)         Laboratory facilities shall be provided for the performance of tests in hematology, clinical chemistry, urinalysis, microbiology, anatomic pathology and cytology to meet the work load.

 

2)         Laboratory facilities shall provide for the following procedures to be performed on-site:  blood counts, urinalysis, blood glucose, electrolytes, blood urea and nitrogen (BUN), coagulation, and transfusions (type capability). If transport time by an ambulance to the nearest hospital is 10 minutes or less, plasma expanders may be used.  If transport time by ambulance to the nearest hospital is greater than 10 minutes, then type O negative blood shall be available for transfusion.  Facilities shall also be included for specimen collection and processing.

 

3)         The following shall be provided in the laboratory suite:

 

A)        Work counters with space for items such as microscopes, chemical analyzers, incubators and centrifuges; work counters shall include sinks and provisions for fluid disposal, eye washes, vacuum, gases, electrical services and piped-in air;

 

B)        Hand-washing lavatories operable without the use of hands at strategic locations for convenience of use;

 

C)        Storage facilities;

 

D)        Chemical safety provisions, including emergency showers, eye-flushing devices and blankets; floor drains at the emergency shower locations;

 

E)        Flammable liquid storage in the form of vented cabinets designed for use with flammable liquids;

 

F)         Specimen collection facilities including:  blood collection area with work counter; space for patient seating and hand washing; a urine and feces collection room equipped with water and lavatory;

 

G)        A terminal sterilization facility for contaminated specimens (autoclave or electric oven), unless contaminated waste is disposed of through a licensed waste management service in accordance with Section 518.2150(f)(4); and

 

H)        If radioactive materials are employed, facilities for long-term storage and disposal of these materials, appropriately shielded to prevent exposure.

 

g)         Staff locker rooms and toilets shall be provided.

 

h)         At least one housekeeping room per floor shall be provided.  The housekeeping room shall contain a service sink and storage for housekeeping supplies and equipment and shall be located within the FEC.

 

i)          Utility Rooms

 

1)         A clean utility room shall be provided and contain the following:

 

A)        Storage for clean and sterile supplies and equipment;

 

B)        Work counters;

 

C)        Hand-washing sinks operable without the use of hands;

 

D)        Ice maker;

 

E)        Under-counter refrigerator; and

 

F)         Communications equipment.

 

2)         A soiled utility room shall be provided and contain the following:

 

A)        Storage for soiled supplies and equipment;

 

B)        Work counters;

 

C)        Hands-free hand-washing sinks;

 

D)        Communications equipment; and

 

E)        Clinical service sink.

 

j)          Sterile supply and processing rooms shall be provided and may be combined with the clean and soiled utility rooms if the program narrative is approved.

 

1)         One-way flow shall be maintained between the soiled supplies, clean-up, sterilizing, and storage functions.

 

2)         Storage spaces for clean and sterile supplies and equipment shall be provided.

 

3)         Storage spaces for soiled supplies and equipment shall be provided.

 

4)         There shall be no direct access between the soiled and clean sides of sterile supply and processing.

 

5)         Work counters and hand-washing sinks operable without the use of hands shall be provided.

 

6)         A clinical service sink shall be provided on the soiled side.

 

7)         The soiled side shall have equipment for cleaning, such as ultrasound, washers, and deep three-compartment sink and tray assembly.

 

8)         A pass-through sterilizer shall be provided.

 

9)         Space shall be provided in the soiled side for processing equipment and tray assembly, such as steris machines, dryers, tube racks, wrapping and labelling counters. The steris machine shall be located in a clean utility room.  Only tray loading is permitted in the soiled side.

 

k)         A nourishment room for the use of patients, conveniently located to the clinical area, shall contain the following:

 

1)         Work counter;

 

2)         Refrigerator;

 

3)         Ice maker;

 

4)         Hands-free hand-washing sink; and

 

5)         Storage for supplies.

 

l)          Facilities shall be provided for observing patients until they can be transferred to an appropriate hospital.  The size and type of equipment shall be what is required for anticipated patient load and lengths of stay.  Each observation bed shall provide for:

 

1)         Direct visual observation of each patient from the nurses' station;

 

2)         Patient privacy;

 

3)         Access to patient toilets;

 

4)         Secure storage of patients' belongings;

 

5)         Medication dispensing;

 

6)         Bedpan storage and cleaning;

 

7)         Hand-washing facilities without the use of hands;

 

8)         Communications system with nurses station; and

 

9)         Monitoring capabilities.

 

m)        A consultation/communications room shall be located within access of the diagnostic and treatment facilities and shall provide sound isolated for privacy and confidentiality of consultation for the use of the staff during the tele-medicine consultation.  The room shall contain the following:

 

1)         Computer support and telecommunications support equipment necessary for the consultation task;

 

2)         View screens;

 

3)         Work counters;

 

4)         Storage areas; and

 

5)         Additional refrigeration units as required by equipment.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

Section 518.ILLUSTRATION A   Seismic Zone Map

 

 

 

Section 518.TABLE A   Piping Locations for Oxygen, Vacuum and Medical Compressed Air

 

 

Location	Oxygen	Vacuum	Compressed Air
Patient Treatment Room	A	A
Examination and Treatment Rooms	D	D

 

A = One outlet accessible to each bed.  One outlet may serve 2 beds.

 

D = One outlet.

 

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)

 

Section 518.TABLE B          Insulation/Building Perimeter

 

1)         Zones for insulation/building perimeter requirements shall consist of the counties listed here.

 

Zone 1 includes the following counties:

 

Boone	Ford	Kane	Lee	Ogle	Tazewell
Bureau	Grundy	Kankakee	Livingston	Peoria	Warren
Carroll	Henderson	Kendall	Marshall	Putnam	Whiteside
Cook	Henry	Knox	McHenry	Rock Island	Will
DeKalb	Iroquois	Lake	McLean	Stark	Winnebago
DuPage	JoDaviess	LaSalle	Mercer	Stephenson	Woodford

 

                        Zone 2 includes the following counties:

 

Adams	Clark	Effingham	Jersey	McDonough	Pike
Bond	Coles	Fayette	Logan	Menard	Sangamon
Brown	Crawford	Fulton	Macon	Montgomery	Schuyler
Calhoun	Cumberland	Greene	Macoupin	Morgan	Scott
Cass	DeWitt	Hancock	Madison	Moultrie	Shelby
Champaign	Douglas	Jasper	Mason	Piatt	Vermilion
Christian	Edgar

 

                        Zone 3 includes the following counties:

 

Alexander	Gallatin	Johnson	Perry	St. Clair	Washington
Clay	Hamilton	Lawrence	Pope	Saline	Wayne
Clinton	Hardin	Marion	Pulaski	Union	White
Edwards	Jackson	Massac	Randolph	Wabash	Williamson
Franklin	Jefferson	Monroe	Richland

 

2)         The following minimum building perimeter insulation R values shall be provided:

 

	Roof	Walls	Floors
Zone 1	R-38	R-17	R-19
Zone 2	R-30	R-17	R-19
Zone 3	R-30	R-12	R-11

 

3)         All windows shall be glazed with double glazed insulating glass. All exterior windows and door frames shall be constructed of non-cold conducting materials such as wood or metal with at thermal break.

 

Section 518.TABLE C   Minimum Efficiency Reporting Values

 

Minimum Efficiency Reporting Values (MERV) ASHRAE Standard 52.2
Group Number	MERV Rating	E1 Average Particle Size Efficiency (PSE) 0.3-1.0 Microns	E2 Average Particle Size Efficiency (PSE) 1.0-3.0 Microns	E3 Average Particle Size Efficiency (PSE) 3.0-10.0 Microns	Average Arrestance (ASHRAE 52.1)	Minimum Final Resistance (in Water Gauge)
	MERV 1	-	-	< 20%	<65%	0.3m
	MERV 2	-	-	< 20%	65-69.9%	0.3m
1	MERV 3	-	-	< 20%	70-74.9%	0.3m
	MERV 4	-	-	< 20%	75% or >	0.3m
	MERV 5	-	-	20-34.9%	-	0.6m
2	MERV 6	-	-	35-49.9%	-	0.6m
	MERV 7	-	-	50-69.9%	-	0.6m
	MERV 8	-	-	70-84.9%	-	0.6m
	MERV 9	-	<50%	85% or >	-	1.0m
3	MERV 10	-	50-64.9%	85% or >	-	1.0m
	MERV 11	-	65-79.9%	85% or >	-	1.0m
	MERV 12	-	80-89.9%	90% or >	-	1.0m
	MERV 13	< 75%	90% or >	90% or >	-	1.4m
4	MERV 14	75-84.9%	90% or >	90% or >	-	1.4m
	MERV 15	85-94.9%	90% or >	90% or >	-	1.4m
	MERV 16	95% or >	95% or >	95% or >	-	1.4m

 

Notes:

 

1.         ASHRAE Standard 52.2 tests are to be conducted at one of seven air flow rates.

 

118 FPM (.60 m/s)	492 FPM (2.50 m/s)
246 FPM (1.25 m/s)	630 FPM (3.20 m/s)
295 FPM (1.50 m/s)	748 FPM (3.80 m/s)
374 FPM (1.90 m/s)

2.         The air flow rate at which the filter was tested is included in the MERV rating (MERV 10 @ 2.5m/s).

 

3.         Filters with an E3 efficiency of less than 20% (MERV 1 through MERV 4) must also be tested for arrestance per ASHRAE Standard 52.1.

 

4.         Final resistance must be at least twice the initial resistance at the test air flow rate,  or the values shown in the table above, whichever is greater.

 

(Source:  Added at 33 Ill. Reg. 8317, effective June 4, 2009)