Section 640.45  Department of Public Health Action

a)         Department Review

1)         The Department will develop a plan for determining the degree of compliance with this Part on a periodic basis not to exceed three years.

2)         During the site visit, the hospital will receive a determination of substantial compliance or substantial failure.

b)         Department Oversight

The Department may deny designation or redesignation or revoke designation of any hospital that fails to achieve substantial compliance with the requirements for designation or redesignation set forth in this Part.  The Department will consider the following factors in deciding whether to deny designation or redesignation or to revoke designation:

1)         Failure to complete the letter of agreement within 90 days after receipt of the official site visit report;

2)         Failure to have and to comply with an approved Maternity and Neonatal Service Plan;

3)         Failure to complete the site visit and accompanying site visit report documentation;

4)         Failure to comply with all of the requirements of this Part for the level of designation.

5)         Failure to participate in and comply with CQI programs, including the Regional Quality Council or other programs designed or implemented by the APC or the Department;

6)         Failure to notify the Department of the loss of, or change in, an essential resource required for its level of designation;

c)         The Department will notify the hospital within 30 days after the site visit as to whether the hospital has achieved substantial compliance with this Part. The notification will include specific requirements with which substantial compliance has not been achieved. If the hospital has not achieved substantial compliance within 90 days after having received the notice, the Department will deny or revoke the designation. If progress toward substantial compliance is being made, per written documentation of the APC, the Department will continue to work with the hospital and its APC to achieve designation.

d)         The Illinois Administrative Procedure Act  and the Department's Practice and Procedure in Administrative Hearings  shall apply to all hearings challenging Department decisions, including those related to designation, redesignation, and denial or revocation of designation.

(Source:  Amended at 35 Ill. Reg. 2583, effective January 31, 2011)