Section 545.67  Compliance Review

a)         The Department will conduct on-site reviews of approved sexual assault treatment plans with hospital and approved pediatric health care facility personnel at least once during each 3-year approval period to ensure that the established procedures are being followed.  (Section 2.05(a) of the Act)

b)         If the Department determines that the hospital or approved pediatric health care facility is not in compliance with its approved plan, the Department will provide the hospital or approved pediatric health care facility with a written list of the specific items of noncompliance within 10 working days after the conclusion of the on-site review. The hospital or approved pediatric health care facility shall have 10 working days to submit to the Department a plan of correction that contains the hospital's or approved pediatric health care facility's specific proposals for correcting the items of noncompliance.  The Department will review the plan of correction and notify the hospital or approved pediatric health care facility in writing within 10 working days as to whether the plan is acceptable or unacceptable.  (Section 2.1(a) of the Act)

c)         The plan of correction shall include the following specific proposals for correcting items of noncompliance:

1)         A time frame for implementing corrections;

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

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

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

d)         If the Department finds the plan of correction unacceptable, the hospital or approved pediatric health care facility shall have 10 working days to resubmit an acceptable plan of correction.  Upon notification that its plan of correction is acceptable, a hospital or approved pediatric health care facility shall implement the plan of correction within 60 days.  (Section 2.1(a) of the Act)

e)         The failure of a hospital to submit an acceptable plan of correction or to implement the plan of correction, within the time frames required in this Section, will subject a hospital to the imposition of a fine by the Department.  The Department will impose a fine of up to $500 per day until the Department has determined that the hospital is in compliance with the requirements of the Act and this Section.  (Section 2.1-1(b) of the Act)

f)         If an approved pediatric health care facility fails to submit an acceptable plan of correction or to implement the plan of correction within the time frames required in the Act and this Section, then the Department will notify the approved pediatric health care facility that the approved pediatric health care facility shall not provide medical forensic services under the Act and this Part.  If an approved pediatric health care facility submits two plans of correction that are found to not be acceptable by the Department, the facility shall become subject to the imposition of a fine by the Department and the termination of its approved sexual assault treatment plan.  The Department, subject to subsection (g), will impose a fine of up to $500 per patient provided services in violation of the Act and this Part.  (Section 2.1(b) of the Act)

g)         Before imposing a fine pursuant to the Act and this Section, the Department will provide the hospital or approved pediatric health care facility via certified mail with written notice and an opportunity for an administrative hearing.  A hospital or approved pediatric health care facility shall submit a written hearing request to the Department within 10 working days after receipt of the Department's notice.  All hearings shall be conducted in accordance with the Department's rules, Practice and Procedure in Administrative Hearings.  (Section 2.1(c) of the Act)

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

i)          The Department will comply with the patient record confidentiality requirements set out in Section 6.14b of the Hospital Licensing Act.  (Section 2.06 of the Act)

(Source:  Amended at 47 Ill. Reg. 18705, effective January 1, 2024)