Statutes > Illinois Statutes > CHAPTER 210 HEALTH FACILITIES > 210 ILCS 85/ Hospital Licensing Act.

210 ILCS 85/ Hospital Licensing Act.

    (210 ILCS 85/1) (from Ch. 111 1/2, par. 142)
    Sec. 1. This Act may be cited as the Hospital Licensing Act.
(Source: Laws 1953, p. 811.)

    (210 ILCS 85/2) (from Ch. 111 1/2, par. 143)
    Sec. 2. Purpose; findings.
    (a) The purpose of this Act is to provide for the better protection of the public health through the development, establishment, and enforcement of standards (1) for the care of individuals in hospitals, (2) for the construction, maintenance, and operation of hospitals which, in light of advancing knowledge, will promote safe and adequate treatment of such individuals in hospital, and (3) that will have regard to the necessity of determining that a person establishing a hospital have the qualifications, background, character and financial resources to adequately provide a proper standard of hospital service for the community.
    (b) The Illinois General Assembly finds:
        (1) That the citizens of Illinois are not served by
     the inappropriate use of economic criteria in determining an individual's qualifications for initial or continuing medical staff membership or privileges.
        (2) That the inappropriate use of economic criteria
     in determining an individual's qualifications for initial or continuing medical staff membership or privileges may deprive the citizens of Illinois access to a choice of the health care providers.
        (3) That it is in the interest of the people of the
     State of Illinois to establish safeguards that (i) require hospitals and hospital based providers to explain to individual providers the reasons, including economic factors, for credentialing decisions, (ii) allow an opportunity for a fair hearing, and (iii) report economic credentialing to the Hospital Licensing Board for further study. As used in this Section and defined by the American Medical Association, "economic credentialing" means the use of economic criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing medical staff membership or privileges.
(Source: P.A. 88‑654, eff. 1‑1‑95.)

    (210 ILCS 85/3)
    Sec. 3. As used in this Act:
    (A) "Hospital" means any institution, place, building, or agency, public or private, whether organized for profit or not, devoted primarily to the maintenance and operation of facilities for the diagnosis and treatment or care of 2 or more unrelated persons admitted for overnight stay or longer in order to obtain medical, including obstetric, psychiatric and nursing, care of illness, disease, injury, infirmity, or deformity.
    The term "hospital", without regard to length of stay, shall also include:
        (a) any facility which is devoted primarily to
    providing psychiatric and related services and programs for the diagnosis and treatment or care of 2 or more unrelated persons suffering from emotional or nervous diseases;
        (b) all places where pregnant females are received,
    cared for, or treated during delivery irrespective of the number of patients received.
    The term "hospital" includes general and specialized hospitals, tuberculosis sanitaria, mental or psychiatric hospitals and sanitaria, and includes maternity homes, lying‑in homes, and homes for unwed mothers in which care is given during delivery.
    The term "hospital" does not include:
        (1) any person or institution required to be licensed
    pursuant to the Nursing Home Care Act or the MR/DD Community Care Act;
        (2) hospitalization or care facilities maintained by
    the State or any department or agency thereof, where such department or agency has authority under law to establish and enforce standards for the hospitalization or care facilities under its management and control;
        (3) hospitalization or care facilities maintained by
    the federal government or agencies thereof;
        (4) hospitalization or care facilities maintained by
    any university or college established under the laws of this State and supported principally by public funds raised by taxation;
        (5) any person or facility required to be licensed
    pursuant to the Alcoholism and Other Drug Abuse and Dependency Act;
        (6) any facility operated solely by and for persons
    who rely exclusively upon treatment by spiritual means through prayer, in accordance with the creed or tenets of any well‑recognized church or religious denomination;
        (7) an Alzheimer's disease management center
    alternative health care model licensed under the Alternative Health Care Delivery Act; or
        (8) any veterinary hospital or clinic operated by a
    veterinarian or veterinarians licensed under the Veterinary Medicine and Surgery Practice Act of 2004 or maintained by a State‑supported or publicly funded university or college.
    (B) "Person" means the State, and any political subdivision or municipal corporation, individual, firm, partnership, corporation, company, association, or joint stock association, or the legal successor thereof.
    (C) "Department" means the Department of Public Health of the State of Illinois.
    (D) "Director" means the Director of Public Health of the State of Illinois.
    (E) "Perinatal" means the period of time between the conception of an infant and the end of the first month after birth.
    (F) "Federally designated organ procurement agency" means the organ procurement agency designated by the Secretary of the U.S. Department of Health and Human Services for the service area in which a hospital is located; except that in the case of a hospital located in a county adjacent to Wisconsin which currently contracts with an organ procurement agency located in Wisconsin that is not the organ procurement agency designated by the U.S. Secretary of Health and Human Services for the service area in which the hospital is located, if the hospital applies for a waiver pursuant to 42 USC 1320b‑8(a), it may designate an organ procurement agency located in Wisconsin to be thereafter deemed its federally designated organ procurement agency for the purposes of this Act.
    (G) "Tissue bank" means any facility or program operating in Illinois that is certified by the American Association of Tissue Banks or the Eye Bank Association of America and is involved in procuring, furnishing, donating, or distributing corneas, bones, or other human tissue for the purpose of injecting, transfusing, or transplanting any of them into the human body. "Tissue bank" does not include a licensed blood bank. For the purposes of this Act, "tissue" does not include organs.
(Source: P.A. 96‑219, eff. 8‑10‑09; 96‑339, eff. 7‑1‑10; 96‑1000, eff. 7‑2‑10.)

    (210 ILCS 85/4) (from Ch. 111 1/2, par. 145)
    Sec. 4. No person shall establish a hospital without first obtaining a permit from the Department and no person shall open, conduct, operate, or maintain a hospital without first obtaining a license from the Department.
    Nothing in this Act shall be construed to impair or abridge the power of municipalities to license and regulate hospitals, provided that the municipal ordinance substantially complies with the minimum standards and regulations developed by the Department pursuant to the provisions of this Act. Such compliance shall be determined by the Department subject to review as provided in Section 13 of this Act. Section 13 of this Act shall also be applicable to the judicial review of final administrative decisions of the regulatory agency of the municipality. Any municipality having an ordinance licensing and regulating hospitals which provides for minimum standards and regulations substantially in compliance with those developed pursuant to this Act shall make such periodic reports to the Department as the Department deems necessary. This report shall include a list of hospitals meeting standards substantially equivalent to those promulgated by the Department under this Act, and upon the receipt of such report the Department may then issue a license to such hospital.
(Source: Laws 1965, p. 2350.)

    (210 ILCS 85/4.5)
    Sec. 4.5. Hospital with multiple locations; single license.
    (a) A hospital located in a county with fewer than 3,000,000 inhabitants may apply to the Department for approval to conduct its operations from more than one location within the county under a single license.
    (b) The facilities or buildings at those locations must be owned or operated together by a single corporation or other legal entity serving as the licensee and must share:
        (1) a single board of directors with responsibility
     for governance, including financial oversight and the authority to designate or remove the chief executive officer;
        (2) a single medical staff accountable to the board
     of directors and governed by a single set of medical staff bylaws, rules, and regulations with responsibility for the quality of the medical services; and
        (3) a single chief executive officer, accountable to
     the board of directors, with management responsibility.
    (c) Each hospital building or facility that is located on a site geographically separate from the campus or premises of another hospital building or facility operated by the licensee must, at a minimum, individually comply with the Department's hospital licensing requirements for emergency services.
    (d) The hospital shall submit to the Department a comprehensive plan in relation to the waiver or waivers requested describing the services and operations of each facility or building and how common services or operations will be coordinated between the various locations. With the exception of items required by subsection (c), the Department is authorized to waive compliance with the hospital licensing requirements for specific buildings or facilities, provided that the hospital has documented which other building or facility under its single license provides that service or operation, and that doing so would not endanger the public's health, safety, or welfare. Nothing in this Section relieves a hospital from the requirements of the Health Facilities Planning Act.
(Source: P.A. 89‑171, eff. 7‑19‑95.)

    (210 ILCS 85/4.6)
    Sec. 4.6. Additional licensing requirements.
    (a) Notwithstanding any other law or rule to the contrary, the Department may license as a hospital a building that (i) is owned or operated by a hospital licensed under this Act, (ii) is located in a municipality with a population of less than 60,000, and (iii) includes a postsurgical recovery care center licensed under the Alternative Health Care Delivery Act for a period of not less than 2 years, an ambulatory surgical treatment center licensed under the Ambulatory Surgical Treatment Center Act, and a Freestanding Emergency Center licensed under the Emergency Medical Services (EMS) Systems Act. Only the components of the building which are currently licensed shall be eligible under the provisions of this Section.
    (b) Prior to issuing a license, the Department shall inspect the facility and require the facility to meet such of the Department's rules relating to the establishment of hospitals as the Department determines are appropriate to such facility. Once the Department approves the facility and issues a hospital license, all other licenses as listed in subsection (a) above shall be null and void.
    (c) Only one license may be issued under the authority of this Section. No license may be issued after 18 months after the effective date of this amendatory Act of the 91st General Assembly.
(Source: P.A. 91‑736, eff. 6‑2‑00.)

    (210 ILCS 85/5) (from Ch. 111 1/2, par. 146)
    Sec. 5. (a) An application for a permit to establish a hospital shall be made to the Department upon forms provided by it. This application shall contain such information as the Department reasonably requires, which shall include affirmative evidence on which the Director may make the findings required under Section 6a of this Act.
    (b) An application for a license to open, conduct, operate, and maintain a hospital shall be made to the Department upon forms provided by it and shall contain such information as the Department reasonably requires, which may include affirmative evidence of ability to comply with the provisions of this Act and the standards, rules, and regulations, promulgated by virtue thereof.
    (c) All applications required under this Section shall be signed by the applicant and shall be verified. Applications on behalf of a corporation or association or a governmental unit or agency shall be made and verified by any two officers thereof.
(Source: Laws 1965, p. 2350.)

    (210 ILCS 85/6) (from Ch. 111 1/2, par. 147)
    Sec. 6. (a) Upon receipt of an application for a permit to establish a hospital the Director shall issue a permit if he finds (1) that the applicant is fit, willing, and able to provide a proper standard of hospital service for the community with particular regard to the qualification, background, and character of the applicant, (2) that the financial resources available to the applicant demonstrate an ability to construct, maintain, and operate a hospital in accordance with the standards, rules, and regulations adopted pursuant to this Act, and (3) that safeguards are provided which assure hospital operation and maintenance consistent with the public interest having particular regard to safe, adequate, and efficient hospital facilities and services.
    The Director may request the cooperation of county and multiple‑county health departments, municipal boards of health, and other governmental and non‑governmental agencies in obtaining information and in conducting investigations relating to such applications.
    A permit to establish a hospital shall be valid only for the premises and person named in the application for such permit and shall not be transferable or assignable.
    In the event the Director issues a permit to establish a hospital the applicant shall thereafter submit plans and specifications to the Department in accordance with Section 8 of this Act.
    (b) Upon receipt of an application for license to open, conduct, operate, and maintain a hospital, the Director shall issue a license if he finds the applicant and the hospital facilities comply with standards, rules, and regulations promulgated under this Act. A license, unless sooner suspended or revoked, shall be renewable annually upon approval by the Department. Each license shall be issued only for the premises and persons named in the application and shall not be transferable or assignable. Licenses shall be posted in a conspicuous place on the licensed premises. The Department may, either before or after the issuance of a license, request the cooperation of the State Fire Marshal, county and multiple county health departments, or municipal boards of health to make investigations to determine if the applicant or licensee is complying with the minimum standards prescribed by the Department. The report and recommendations of any such agency shall be in writing and shall state with particularity its findings with respect to compliance or noncompliance with such minimum standards, rules, and regulations.
    The Director may issue a provisional license to any hospital which does not substantially comply with the provisions of this Act and the standards, rules, and regulations promulgated by virtue thereof provided that he finds that such hospital has undertaken changes and corrections which upon completion will render the hospital in substantial compliance with the provisions of this Act, and the standards, rules, and regulations adopted hereunder, and provided that the health and safety of the patients of the hospital will be protected during the period for which such provisional license is issued. The Director shall advise the licensee of the conditions under which such provisional license is issued, including the manner in which the hospital facilities fail to comply with the provisions of the Act, standards, rules, and regulations, and the time within which the changes and corrections necessary for such hospital facilities to substantially comply with this Act, and the standards, rules, and regulations of the Department relating thereto shall be completed.
(Source: P.A. 80‑56.)

    (210 ILCS 85/6.01)
    Sec. 6.01. Domestic violence. A hospital licensed under this Act must comply with the standards relating to domestic violence established by the Department. In establishing these standards, the Department shall take into consideration similar standards adopted by the Joint Commission on Health Care Accreditation or other accrediting organization. Nothing in this Section requires a hospital to become accredited by the Joint Commission on Health Care Accreditation or any other accreditation program.
(Source: P.A. 91‑163, eff. 1‑1‑00.)

    (210 ILCS 85/6.05) (from Ch. 111 1/2, par. 147.05)
    Sec. 6.05. (Repealed).
(Source: P.A. 89‑507, eff. 7‑1‑97. Repealed by P.A. 92‑790, eff. 8‑6‑02.)

    (210 ILCS 85/6.06) (from Ch. 111 1/2, par. 147.06)
    Sec. 6.06. The Department shall prescribe, by regulation, standards for hospitals to meet in order to assure proper identification of newborn infants. Such regulations shall include but not be limited to standards that are consistent with procedures for the identification of newborn infants recommended by the American Academy of Pediatrics.
(Source: P.A. 83‑615.)

    (210 ILCS 85/6.07) (from Ch. 111 1/2, par. 147.07)
    Sec. 6.07. The Department shall by regulation require the availability and proper use of hypothermic thermometers or electronic thermometers capable of aiding in the diagnosis of hypothermia in adequate quantity in hospitals.
(Source: P.A. 84‑313.)

    (210 ILCS 85/6.08) (from Ch. 111 1/2, par. 147.08)
    Sec. 6.08. (a) Every hospital shall provide notification as required in this Section to police officers, firefighters, 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. Such notification shall not include the name of the patient, and the emergency services provider agency and any person receiving such notification shall treat the information received as a confidential medical record.
    (b) The Department shall establish by regulation a list of those communicable reportable diseases and conditions for which notification shall be provided.
    (c) The hospital shall send the letter of notification within 72 hours after a confirmed diagnosis of any of the communicable diseases listed by the Department pursuant to subsection (b), except confirmed diagnoses of Acquired Immunodeficiency Syndrome (AIDS). If there is a confirmed diagnosis of AIDS, the hospital shall send the letter of notification only if the police officers, firefighters, 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, or if hospital personnel providing the notification have reason to know of a possible exposure.
    (d) Notification letters shall be sent to the designated contact at the municipal or private provider agencies listed on the ambulance run sheet. Except in municipalities with a population over 1,000,000, a list attached to the ambulance run sheet must contain all municipal and private provider agency personnel who have provided any pre‑hospital care immediately prior to transport. In municipalities with a population over 1,000,000, the ambulance run sheet must contain the company number or unit designation number for any fire department personnel who have provided any pre‑hospital care immediately prior to transport. The letter shall state the names of crew members listed on the attachment to the ambulance run sheet and the name of the communicable disease diagnosed, but shall not contain the patient's name. Upon receipt of such notification letter, the applicable private provider agency or the designated infectious disease control officer of a municipal fire department or fire protection district shall contact all personnel involved in the pre‑hospital or inter‑hospital care and transport of the patient. Such notification letter may, but is not required to, consist of the following form:
NOTIFICATION LETTER
(NAME OF HOSPITAL)
(ADDRESS)
    TO:...... (Name of Organization)
    FROM:.....(Infection Control Coordinator)
    DATE:.....
    As required by Section 6.08 of the Illinois Hospital Licensing Act, .....(name of hospital) is hereby providing notification that the following crew members or agencies transported or provided pre‑hospital care to a patient on ..... (date), and the transported patient was later diagnosed as having .....(name of communicable disease): .....(list of crew members). The Hospital Licensing Act requires you to maintain this information as a confidential medical record. Disclosure of this information may therefore result in civil liability for the individual or company breaching the patient's confidentiality, or both.
    If you have any questions regarding this patient, please contact me at .....(telephone number), between .....(hours). Questions regarding exposure or the financial aspects of obtaining medical care should be directed to your employer.
    (e) Upon discharge of a patient with a communicable disease to emergency personnel, the hospital shall notify the emergency personnel of appropriate precautions against the communicable disease, but shall not identify the name of the disease.
    (f) The hospital may, in its discretion, take any measures in addition to those required in this Section to notify police officers, firefighters, emergency medical technicians, and ambulance personnel of possible exposure to any communicable disease. However, in all cases this information shall be maintained as a confidential medical record.
    (g) Any person providing or failing to provide notification under the protocol required by this Section shall have immunity from any liability, either criminal or civil, that might result by reason of such action or inaction, unless such action or inaction is willful.
    (h) Any person who willfully fails to provide any notification required pursuant to an applicable protocol which has been adopted and approved pursuant to this Section commits a petty offense, and shall be subject to a fine of $200 for the first offense, and $500 for a second or subsequent offense.
    (i) Nothing in this Section shall preclude a civil action by a firefighter, emergency medical technician, or ambulance crew member against an emergency services provider agency, municipal fire department, or fire protection district that fails to inform the member in a timely fashion of the receipt of a notification letter.
(Source: P.A. 92‑363, eff. 1‑1‑02.)

     (210 ILCS 85/6.09)(from Ch. 111 1/2, par. 147.09)
    Sec. 6.09. (a) In order to facilitate the orderly transition of aged and disabled patients from hospitals to post‑hospital care, whenever a patient who qualifies for the federal Medicare program is hospitalized, the patient shall be notified of discharge at least 24 hours prior to discharge from the hospital. With regard to pending discharges to a skilled nursing facility, the hospital must notify the case coordination unit, as defined in 89 Ill. Adm. Code 240.260, at least 24 hours prior to discharge or, if home health services are ordered, the hospital must inform its designated case coordination unit, as defined in 89 Ill. Adm. Code 240.260, of the pending discharge and must provide the patient with the case coordination unit's telephone number and other contact information.
    (b) Every hospital shall develop procedures for a physician with medical staff privileges at the hospital or any appropriate medical staff member to provide the discharge notice prescribed in subsection (a) of this Section. The procedures must include prohibitions against discharging or referring a patient to any of the following if unlicensed, uncertified, or unregistered: (i) a board and care facility, as defined in the Board and Care Home Act; (ii) an assisted living and shared housing establishment, as defined in the Assisted Living and Shared Housing Act; (iii) a facility licensed under the Nursing Home Care Act or the MR/DD Community Care Act; (iv) a supportive living facility, as defined in Section 5‑5.01a of the Illinois Public Aid Code; or (v) a free‑standing hospice facility licensed under the Hospice Program Licensing Act if licensure, certification, or registration is required. The Department of Public Health shall annually provide hospitals with a list of licensed, certified, or registered board and care facilities, assisted living and shared housing establishments, nursing homes, supportive living facilities, facilities licensed under the MR/DD Community Care Act, and hospice facilities. Reliance upon this list by a hospital shall satisfy compliance with this requirement. The procedure may also include a waiver for any case in which a discharge notice is not feasible due to a short length of stay in the hospital by the patient, or for any case in which the patient voluntarily desires to leave the hospital before the expiration of the 24 hour period.
    (c) At least 24 hours prior to discharge from the hospital, the patient shall receive written information on the patient's right to appeal the discharge pursuant to the federal Medicare program, including the steps to follow to appeal the discharge and the appropriate telephone number to call in case the patient intends to appeal the discharge.
    (d) Before transfer of a patient to a long term care facility licensed under the Nursing Home Care Act where elderly persons reside, a hospital shall as soon as practicable initiate a name‑based criminal history background check by electronic submission to the Department of State Police for all persons between the ages of 18 and 70 years; provided, however, that a hospital shall be required to initiate such a background check only with respect to patients who:
        (1) are transferring to a long term care facility for
    the first time;
        (2) have been in the hospital more than 5 days;
        (3) are reasonably expected to remain at the long
    term care facility for more than 30 days;
        (4) have a known history of serious mental illness or
    substance abuse; and
        (5) are independently ambulatory or mobile for more
    than a temporary period of time.
    A hospital may also request a criminal history background check for a patient who does not meet any of the criteria set forth in items (1) through (5).
    A hospital shall notify a long term care facility if the hospital has initiated a criminal history background check on a patient being discharged to that facility. In all circumstances in which the hospital is required by this subsection to initiate the criminal history background check, the transfer to the long term care facility may proceed regardless of the availability of criminal history results. Upon receipt of the results, the hospital shall promptly forward the results to the appropriate long term care facility. If the results of the background check are inconclusive, the hospital shall have no additional duty or obligation to seek additional information from, or about, the patient.
(Source: P.A. 95‑80, eff. 8‑13‑07; 95‑651, eff. 10‑11‑07; 95‑876, eff. 8‑21‑08; 96‑339, eff. 7‑1‑10; 96‑1372, eff. 7‑29‑10.)

    (210 ILCS 85/6.10) (from Ch. 111 1/2, par. 147.10)
    Sec. 6.10. The Department shall adopt rules requiring hospitals licensed under this Act to offer testing for infection with human immunodeficiency virus (HIV) to patients upon request. Such rules shall provide for appropriate pre‑test and post‑test counseling, and may provide for payment of the cost of testing the medically indigent in appropriate cases.
    Tests requested or administered under such rules shall be subject to the provisions of the AIDS Confidentiality Act.
(Source: P.A. 86‑764; 86‑1028.)

    (210 ILCS 85/6.11) (from Ch. 111 1/2, par. 147.11)
    Sec. 6.11. In licensing any hospital which provides for the diagnosis, care or treatment for persons suffering from mental or emotional disorders or for mentally retarded persons, the Department shall consult with the Department of Human Services in developing standards for and evaluating the psychiatric programs of such hospitals.
(Source: P.A. 89‑507, eff. 7‑1‑97.)

    (210 ILCS 85/6.12) (from Ch. 111 1/2, par. 147.12)
    Sec. 6.12. The provisions of the Illinois Administrative Procedure Act are hereby expressly adopted and shall apply to all administrative rules and procedures of the Department of Public Health under this Act, except that Section 5‑35 of the Illinois Administrative Procedure Act relating to procedures for rule‑making does not apply to the adoption of any rule required by federal law in connection with which the Department is precluded by law from exercising any discretion.
(Source: P.A. 87‑435; 88‑45.)

    (210 ILCS 85/6.13) (from Ch. 111 1/2, par. 147.13)
    Sec. 6.13. Any hospital licensed unde