Section 260.1850  Medical Oversight

a)         The facility shall ensure that comprehensive multidisciplinary rounds, led by a site provider, are conducted twice per week.  A site physician shall attend rounds a minimum of once per week. Subsequent rounds may be overseen by an APRN when available.

b)         The site provider or designee shall be on call 24 hours per day.

c)         Medical Advisory Committee

1)         The facility's medical advisory committee shall consist of multidisciplinary team members, including:

A)        A primary care physician;

B)        A pediatrician;

C)        A pulmonologist or an ear, nose and throat (ENT) physician;

D)        A registered nurse;

E)        A respiratory therapist;

F)         Representatives from a hospital's emergency department, NICU/PICU; and

G)        A site interdisciplinary team representative.

2)         The medical advisory committee shall develop annual goals and document them in writing, and shall meet quarterly to review quality indicators and other strategic data for the organization.  The quality indicators and other strategic data shall consist, at a minimum, of infection control, emergency transfers, evidence-based and best practice protocols, and family satisfaction surveys.

3)         The medical advisory committee shall review all updates or amendments to clinical policies and procedures. Documentation of amended reviews shall be kept on file at the facility for no less than five years.

4)         Minutes from the medical advisory committee's meetings shall be kept on file at the facility for no less than five years.

(Source:  Amended at 45 Ill. Reg. 13925, effective October 25, 2021)