Section 210.1900  Standards of Professional Practice

a)         A qualified consulting committee shall be appointed in writing by the operator and/or owner of the Postsurgical Recovery Care Center Model and shall establish and enforce standards for professional work in the Model and standards of competency for medical staff.  The consulting committee shall meet not less than quarterly and shall document all meetings with written minutes.  These written minutes shall be maintained at the Model and shall be available for inspection by the Department.

1)         The consulting committee shall review development and content of the written policies and procedures of the Postsurgical Recovery Care Center Model, the procedures for granting privileges, and the quality of the postsurgical recovery care services provided. Evidence of such review shall be recorded in the minutes.

2)         Credentials shall be provided by those physicians, dentists, and podiatrists seeking admitting privileges.  These credentials shall be reviewed by the consulting committee, and specific practice privileges shall be available for the Model's staff use and public information within the Model.

3)         Each member of the medical staff granted specific admitting privileges shall provide documentation indicating the name of the Illinois licensed hospital(s) where they have privileges,  which include approval to perform at least the same level of services which the physician seeks to provide in the Model.  Such statements or documentation shall be available for inspection by the Department.  A list of privileges granted each medical staff member of the Postsurgical Recovery Care Center Model shall be available at all times for use by the staff of the Postsurgical Recovery Care Center Model and for inspection by Department staff.

b)         A physician shall be designated "Medical Director."

1)         The Medical Director shall assure compliance with the policies and procedures pertaining to medical procedures, approved by the consulting committee.

2)         The Medical Director shall be responsible for the implementation of medical policies and procedures contained in the Model's policies and procedures governing the professional personnel involved in direct care of patients.

3)         The Medical Director shall establish and assure compliance of standards for the observation of patients by nursing personnel during the postoperative period.

c)         A qualified physician shall be on-call and able to be physically present in the Model within 15 minutes after a request from the nurse in charge at all times when patients are present in the Postsurgical Recovery Care Center Model.

d)         The qualified consulting committee in a licensed ambulatory surgical treatment center may act as the consulting committee in the Postsurgical Recovery Care Center Model.