Section 640.45 Department of Public Health Action

Section 640

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

fy 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.