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Updates to Hospital Licensing Requirements Affect Illinois Hospitals

Several updates to the Illinois Hospital Licensing Requirements were published in the Illinois Register on June 8, 2018. The effective date of the rules was May 24, 2018. Of significant interest to the hospitals in Illinois is the amendment to expressly allow an advanced practice nurse or physician assistant with appropriate clinical privileges to admit patients to the hospital. The effect of this amendment is that once the medical staff bylaws are updated, an advanced practice nurse or a physician assistant will be able to admit patients to a hospital without a physician’s order. Patients will still need to be assigned a member of the medical staff to supervise their professional care, but the grey area of the ability of APNs and physician assistants to admit patients has now been eliminated.

In addition, the rule implements Illinois law that requires all patients to receive a notice of being placed on observation status within 24 hours of such observation status being created. The notice goes to the patient or legal representative, and it is required to be in writing and acknowledged by the patient. Each hospital is also required to have a written policy for handling the notice when a patient is unable to acknowledge the notice and attempts to notify the patient’s legal representative have been unsuccessful. The requirement is in addition to the existing Medicare-required notice.

The rulemaking also requires each hospital to adopt and implement sepsis, severe sepsis or septic shock policies of the hospital based on generally accepted standards of care. The standards have to be updated no less than every three years. The protocols must also include the identification, care and treatment of both adults and children, and coordinate care between the emergency department and inpatient treatment. This rule change implements existing state law.

In addition, the rulemaking requires Hospitals to report opioid cases that result in an overdose to the Illinois Department of Public Health. The term "overdose" is defined in the Illinois Controlled Substances Act as a substance-induced psychological event that results in a life-threatening emergency to the individual. All opioid overdose reports must be filed within 48 hours of an emergency department or healthcare professional providing treatment. Name, address and other personal information are not included in the overdose report. Those who make the report are also protected from having their names disclosed.

Rule changes were also implemented requiring hospitals to provide information on Sudden Infant Death Syndrome to parents prior to discharging a newborn infant. The materials need to include information concerning safe sleep environments developed by the American Academy of Pediatrics or a statewide or nationally-recognized SIDS or medical association.

The rules also provide various updates to building codes and safety codes that hospitals are required to follow.

Aside from the various reporting requirements, the rulemaking presents an opportunity to expand the professionals who can admit patients at your hospital. This expanded authority may ease the burden on overworked professional staff. However, these changes cannot be implemented without changes to the medical staff bylaws and appropriate credentialing

© 2019 Heyl, Royster, Voelker & Allen, P.C

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About this Author

Deanna Mool, Heyl Royster, healthcare regulatory lawyer, Estate Planning attorney, FCA
Of Counsel

Deanna’s practice is primarily focused on healthcare regulatory law (including HIPAA, Stark, and Anti-Kickback compliance, False Claims Act issues, and contracting), and Estate Planning.

In the practice of healthcare law, Deanna has represented hospitals, nursing homes, assisted living facilities, physicians, audiologists, nurses and other healthcare professionals. She gained valuable healthcare law experience as General Counsel to the Illinois Department of Public Health (1996-2001). She also served as in-house counsel at the SIU School of...

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