TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES PART 250 HOSPITAL LICENSING REQUIREMENTS SECTION 250.105 INCORPORATED AND REFERENCED MATERIALS
Section 250.105 Incorporated and Referenced Materials
a) The following regulations and standards are incorporated in this Part:
1) Private and Professional Association Standards
A) American Society for Testing and Materials (ASTM), Standard No. E90-99 (2009): Standard Test Method for Laboratory Measurement of Airborne Sound Transmission Loss of Building Partitions and Elements, which may be obtained from the American Society for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959
B) ASTM E 662 (2012), Standard Test Method for Specific Optical Density of Smoke Generated by Solid Materials, which may be obtained from the American Society for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959
C) ASTM E 84 (2010), Standard Test Method for Surface Burning Characteristics of Building Materials, which may be obtained from the American Society for Testing and Materials, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959
D) The following standards of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE), which may be obtained from the American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc., 180 Technology Parkway NW, Peachtree, GA 30092:
i) ASHRAE Handbook of Fundamentals (2009)
ii) ASHRAE Handbook for HVAC Systems and Equipment (2004)
iii) ASHRAE Handbook-HVAC Applications (2007)
iv) ASHRAE Guideline 12-2020, "Managing the Risk of Legionellosis Associated with Building Water Systems" (March 30, 2021)
v) ASHRAE Standard 188-2021, "Legionellosis: Risk Management for Building Water Systems" (August 2021)
E) The following standards of the National Fire Protection Association (NFPA), which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169:
i) NFPA 101 (2012): Life Safety Code and all applicable references under Chapter 2, Referenced Publications
ii) NFPA 101A (2013): Guide on Alternative Approaches to Life Safety
F) American Academy of Pediatrics and American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, Eighth Edition (September 2017), which may be obtained from the American College of Obstetricians and Gynecologists online at: https://publications.aap.org/aapbooks/book/522/Guidelines-for-Perinatal-Care?autologincheck=redirected or by phone at 800-762-2264, 409 12th Street SW, Washington, DC 20024-2188 (See Section 250.1820.)
G) American College of Obstetricians and Gynecologists, Guidelines for Women's Healthcare, Fourth Edition (2014), which may be obtained online at: https://www.scribd.com/document/359258258/american-college-of-obstetricians-and-gynecologists-guidelines-for-women-s-health-care-a-resource-manual (See Section 250.1820.)
H) American Academy of Pediatrics (AAP), Red Book: Report of the Committee on Infectious Diseases, 32nd Edition (January 2021), available at: https://publications.aap.org/redbook or from the American Academy of Pediatrics, 345 Park Blvd., Itasca, IL 60143 (See Section 250.1820.)
I) American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Pediatric and Basics and Advanced Life Support and Part 5: Neonatal Resuscitation (October 2020), available at: https://tinyurl.com/38zny85p and https://tinyurl.com/2s3dpb8c, respectively, or from the American Heart Association, 7272 Greenville Ave., Dallas, TX 75231 (See Section 250.1830.)
J) National Association of Neonatal Nurses, Position Statement #3074 Minimum RN Staffing in the NICU (September 2021), available at: http://nann.org/about/position-statements or from the National Association of Neonatal Nurses, 8735 W. Higgins Road, Suite 300, Chicago, IL 60631 (See Section 250.1830.)
K) National Council on Radiation Protection and Measurements (NCRP), Report 49: Structural Shielding Design and Evaluation for Medical Use of X-rays and Gamma Rays of Energies up to 10 MeV (1976) and NCRP Report 102: Medical X-Ray, Electron Beam and Gamma-Ray Protection for Energies Up to 50 MeV (Equipment Design, Performance and Use) (1989), which may be obtained from the National Council on Radiation Protection and Measurements, 7910 Woodmont Ave., Suite 400, Bethesda, Maryland 20814-3095 (See Sections 250.2440 and 250.2450.)
L) DOD Penetration Test Method MIL STD 282 (2020): Filter Units, Protective Clothing, Gas-mask Components and Related Products: Performance Test Methods, available at: https://publishers.standardstech.com/stgnet (See Section 250.2480.)
M) National Association of Plumbing-Heating-Cooling Contractors (PHCC), National Standard Plumbing Code (2009), which may be obtained from the National Association of Plumbing-Heating-Cooling Contractors, 180 S. Washington Street, Suite 100, Falls Church, VA 22046 (703-237-8100)
N) International Building Code (2012), which may be obtained from the International Code Council, 4051 Flossmoor Road, Country Club Hills, IL 60478 (See Section 250.2420.)
O) American National Standards Institute, ANSI A117.1 (2009), Standard for Accessible and Usable Buildings, which may be obtained from the American National Standards Institute, 25 West 43rd Street, 4th Floor, New York, NY 10036 (See Section 250.2420.)
P) ASME Standard A17.1-2007, Safety Code for Elevators and Escalators, which may be obtained from the American Society of Mechanical Engineers (ASME) International, 22 Law Drive, Box 2900, Fairfield, NJ 07007-2900
Q) Accreditation Council for Graduate Medical Education, Common Program Requirements (Residency) (2022), available at: https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency_2022v2.pdf or from the Accreditation Council for Graduate Medical Education, 401 N. Michigan Ave., Suite 2000, Chicago, IL 60611 (See Section 250.315.)
R) The Joint Commission, 2022 Hospital Accreditation Standards (HAS), available at: https://store.jcrinc.com/2022-accreditation-standards-books/ or from the Joint Commission, 1515 W. 22nd St. Ste. 1300W, Oakbrook Terrace, IL 60523 (See Section 250.1035.)
S) National Quality Forum, Safe Practices for Better Health Care (2010), available at: https://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx or from the National Quality Forum, 10991 14th Street NW, Suite 500, Washington DC 20005, or from www.qualityforum.org
2) Federal Government Publications
A) Department of Health and Human Services, Centers for Disease Control and Prevention, "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" (July 2023) available at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf
B) Department of Health and Human Services, Centers for Disease Control and Prevention, Infection Control in Healthcare Personnel, available in two parts: "Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services" (October 25, 2019) and "Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients" (October 3, 2022), both available at: https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html
C) Department of Health and Human Services, Centers for Disease Control and Prevention, "Guidelines for Environmental Infection Control in Health-Care Facilities": (July 2019), available at: https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html
D) Department of Health and Human Services, Centers for Disease Control and Prevention, Guideline for Hand Hygiene in Health Care Settings (October 25, 2002) available at: https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html
E) Department of Health and Human Services, Centers for Disease Control and Prevention, "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008", (May 2019), available at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf
F) Department of Health and Human Services, Centers for Disease Control and Prevention, "Core Elements of Hospital Stewardship Programs", (2019), which is available at: https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf, and "Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals", which is available at: https://www.cdc.gov/antibiotic-use/core-elements/small-critical.html
G) Department of Health and Human Services, Centers for Disease Control and Prevention, "Toolkit for Controlling Legionella in Common Sources of Exposure", which is available at: https://www.cdc.gov/legionella/wmp/control-toolkit/index.html
H) National Center for Health Statistics and World Health Organization, Geneva, Switzerland, "International Classification of Diseases", 11th Revision (ICD-11), (2022), available at: https://www.who.int/standards/classifications/classification-of-diseases
I) U.S. Department of Labor, Occupational Safety and Health Administration, "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers" (OSHA 3148-06R 2016), available at: https://www.osha.gov/Publications/osha3148.pdf
J) Department of Health and Human Services, United States Public Health Service, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention, "STOP SV: A Technical Package to Prevent Sexual Violence" (2016), available at: https://www.cdc.gov/violenceprevention/pdf/sv-prevention-technical-package.pdf
K) National Research Council, Recommended Dietary Allowances 10th Edition (1989). Washington, DC: The National Academies Press. Available at: https://doi.org/10.17226/1349
3) Federal Regulations
A) 45 CFR 46.101, To What Does the Policy Apply? (October 1, 2023)
B) 45 CFR 46.103(b), Assuring Compliance with this Policy − Research Conducted or Supported by any Federal Department or Agency (October 1, 2023)
C) 42 CFR 482, Conditions of Participation for Hospitals (October 1, 2023)
D) 21 CFR, Food and Drugs (April 1, 2023)
E) 42 CFR 489.20, Basic Commitments (October 1, 2023)
F) 29 CFR 1910.1030, Bloodborne Pathogens (July 1, 2022)
G) 42 CFR 413.65(d) and (e), Requirements for a determination that a facility or an organization has provider-based status (October 1, 2023)
H) 42 CFR 493, Laboratory Requirements (CLIA regulations) (October 1, 2023)
b) All incorporations by reference of federal regulations and guidelines and the standards of nationally recognized organizations refer to the regulations, guidelines and standards on the date specified and do not include any editions or amendments subsequent to the date specified.
c) The following statutes and State regulations are referenced in this Part:
1) State of Illinois Statutes
A) Hospital Licensing Act [210 ILCS 85]
B) Illinois Health Facilities Planning Act [20 ILCS 3960]
C) Medical Practice Act of 1987 [225 ILCS 60]
D) Podiatric Medical Practice Act of 1987 [225 ILCS 100]
E) Pharmacy Practice Act [225 ILCS 85]
F) Physician Assistant Practice Act of 1987 [225 ILCS 95]
G) Illinois Clinical Laboratory and Blood Bank Act [210 ILCS 25]
H) X-Ray Retention Act [210 ILCS 90]
I) Safety Glazing Materials Act [430 ILCS 60]
J) Mental Health and Developmental Disabilities Code [405 ILCS 5]
K) Nurse Practice Act [225 ILCS 65]
L) Health Care Worker Background Check Act [225 ILCS 46]
M) MRSA Screening and Reporting Act [210 ILCS 83]
N) Hospital Report Card Act [210 ILCS 86]
O) Illinois Adverse Health Care Events Reporting Law of 2005 [410 ILCS 522]
P) Smoke Free Illinois Act [410 ILCS 82]
Q) Health Care Surrogate Act [755 ILCS 40]
R) Perinatal HIV Prevention Act [410 ILCS 335]
S) Hospital Infant Feeding Act [210 ILCS 81]
T) Medical Patient Rights Act [410 ILCS 50]
U) Hospital Emergency Service Act [210 ILCS 80]
V) Illinois Anatomical Gift Act [755 ILCS 50]
W) Illinois Public Aid Code [305 ILCS 5]
X) Substance Use Disorder Act [20 ILCS 301]
Y) ID/DD Community Care Act [210 ILCS 47]
Z) Specialized Mental Health Rehabilitation Act of 2013 [210 ILCS 49]
AA) Veterinary Medicine and Surgery Practice Act of 2004 [225 ILCS 115]
BB) Alternative Health Care Delivery Act [210 ILCS 3]
CC) Gestational Surrogacy Act [750 ILCS 47]
DD) Code of Civil Procedure (Medical Studies) [735 ILCS 5/8-2101]
EE) Sexual Assault Survivors Emergency Treatment Act [410 ILCS 70]
FF) Civil Administrative Code of Illinois (Department of Public Health Powers and Duties Law) [20 ILCS 2310]
GG) AIDS Confidentiality Act [410 ILCS 305]
HH) Nursing Home Care Act [210 ILCS 45]
II) Illinois Controlled Substances Act [720 ILCS 570]
JJ) Early Hearing Detection and Intervention Act [410 ILCS 213]
KK) Home Health, Home Services, and Home Nursing Agency Licensing Act [210 ILCS 55]
LL) Health Care Violence Prevention Act [210 ILCS 160]
MM) Illinois Health Finance Reform Act [20 ILCS 2215]
NN) Fair Patient Billing Act [210 ILCS 88]
OO) Crime Victims Compensation Act [740 ILCS 45]
PP) Human Trafficking Resource Center Notice Act [775 ILCS 50]
QQ) Abandoned Newborn Infant Protection Act [325 ILCS 2]
RR) Emergency Medical Services (EMS) Systems Act [210 ILCS 50]
SS) Radiation Protection Act of 1990 [420 ILCS 40]
TT) Illinois Dental Practice Act [225 ILCS 25]
UU) Criminal Identification Act [20 ILCS 2630]
VV) Latex Glove Ban Act [410 ILCS 180]
2) State of Illinois Administrative Rules
A) Department of Public Health, Illinois Plumbing Code (77 Ill. Adm. Code 890)
B) Department of Public Health, Sexual Assault Survivors Emergency Treatment Code (77 Ill. Adm. Code 545)
C) Department of Public Health, Control of Notifiable Diseases and Conditions Code (77 Ill. Adm. Code 690)
D) Department of Public Health, Food Code (77 Ill. Adm. Code 750)
E) Department of Public Health, Public Area Sanitary Practice Code (77 Ill. Adm. Code 895)
F) Department of Public Health, Maternal Death Review (77 Ill. Adm. Code 657)
G) Department of Public Health, Control of Sexually Transmissible Infections Code (77 Ill. Adm. Code 693)
H) Department of Public Health, Control of Tuberculosis Code (77 Ill. Adm. Code 696)
I) Department of Public Health, Health Care Worker Background Check Code (77 Ill. Adm. Code 955)
J) Department of Public Health, Language Assistance Services Code (77 Ill. Adm. Code 940)
K) Department of Public Health, Regionalized Perinatal Health Care Code (77 Ill. Adm. Code 640)
L) Health Facilities and Services Review Board, Narrative and Planning Policies (77 Ill. Adm. Code 1100)
M) Health Facilities and Services Review Board, Processing, Classification Policies and Review Criteria (77 Ill. Adm. Code 1110)
N) Department of Public Health, Private Sewage Disposal Code (77 Ill. Adm. Code 905)
O) Department of Public Health, Ambulatory Surgical Treatment Center Licensing Requirements (77 Ill. Adm. Code 205)
P) Department of Public Health, HIV/AIDS Confidentiality and Testing Code (77 Ill. Adm. Code 697)
Q) Capital Development Board, Illinois Accessibility Code (71 Ill. Adm. Code 400)
R) State Fire Marshal, Boiler and Pressure Vessel Safety (41 Ill. Adm. Code 120)
S) State Fire Marshal, Fire Prevention and Safety (41 Ill. Adm. Code 100)
T) Illinois Emergency Management Agency, Standards for Protection Against Radiation (32 Ill. Adm. Code 340)
U) Illinois Emergency Management Agency, Use of X-rays in the Healing Arts Including Medical, Dental, Podiatry, and Veterinary Medicine (32 Ill. Adm. Code 360)
V) Illinois Emergency Management Agency, Medical Use of Radioactive Material (32 Ill. Adm. Code 335)
W) Illinois Emergency Management Agency, Registration and Operator Requirements for Radiation Installations (32 Ill. Adm. Code 320)
X) Illinois Emergency Management Agency, Accrediting Persons in the Practice of Medical Radiation Technology (32 Ill. Adm. Code 401)
Y) Illinois Emergency Management Agency, General Provisions for Radiation Protection (32 Ill. Adm. Code 310)
3) Federal Statutes
A) Health Insurance Portability and Accountability Act of 1996 (110 U.S.C. 1936)
B) Emergency Medical Treatment & Labor Act (42 U.S.C. 1395dd)
4) Federal Training Materials
A) Preventing Workplace Violence in Healthcare, available at: https://www.oshatrain.org/courses/mods/776e.html
B) Workplace Violence Prevention for Nurses, available at: https://www.cdc.gov/niosh/topics/violence/
(Source: Amended at 48 Ill. Reg. 7321, effective May 3, 2024) |