Section 205.220  Organizational Plan

a)         An organizational plan shall be known to the staff and available for public information in the facility.  The document shall clearly set forth the organization, duties, responsibility, accountability and relationships of professional staff, including a designated qualified infection control professional, a designated grievance officer, and other personnel.

b)         The plan shall include details of a quality assessment and performance improvement program, an infection control program, a patient rights plan, and a disaster preparedness plan. 

c)         The organizational plan shall be submitted to the governing body for review and approval and shall be submitted to the Department with the initial licensure application.  

d)         All owners, administrators, professional staff and ancillary personnel shall act in accordance with the organizational plan.

e)         The Department will review the organizational plan at regular inspections.

(Source:  Amended at 38 Ill. Reg. 19208, effective September 9, 2014)