IDPH Finalizes Rules on Home Health Referrals, Antibiotic Stewardship Programs, Anesthesia Services

November 18, 2019


IDPH Finalizes Rules on Home Health Referrals, Antibiotic Stewardship Programs, Anesthesia Services, Medical Record Preservation and Emergency and Strike Notices

The Illinois Department of Public Health (IDPH) has adopted amendments to the Hospital Licensing Requirements (77 Ill. Adm. Code 250 et, seq,), updating certain regulations and codifying certain statutory changes (Nov. 8 Illinois Register,  pages 12990 to 13030). These changes are effective immediately.

Referrals for Home Health Services
Sections 250.240 (Admission and Discharge) was updated with language codifying a statutory change requiring hospitals that refer patients to home health, home services or home nursing agencies to refer to agencies that are licensed under the Home Health Home Services and Home Nursing Agency Licensing Act. Hospitals are required to verify an agency’s licensure status through the IDPH website or by obtaining a copy of the agency’s license prior to making a referral.

Antibiotic Stewardship
Section 250.1100 (Infection Control) is amended to add the development of Antibiotic Stewardship Programs to the responsibilities of hospital staff designated as Infection Prevention and Control Professionals. This change was made to align the Hospital Licensing Requirements with the U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) accreditation requirements. Updated resources from HHS and CMS can be found in Section 250.105 (Incorporated and Referenced Materials).

Anesthesia Services
Section 250.1410 (Anesthesia Services) has been amended to allow a history and physical exam of a patient receiving non-emergency surgery to occur up to 30 days prior to the surgery or within 24 hours after admission or registration for a surgery or procedure requiring anesthesia services.  Findings during this exam must be entered into the patient’s record prior to surgery. Previously, the physical was required no more than 48 hours prior to the surgery.

In addition, other clarifying language was made to the anesthesia services section.

Medical Record Preservation
Section 250.1510 (Medical Records) was amended to add new requirements to the preservation section of the rules.  Prior to a hospital change of ownership, the buyer and seller must inform IDPH which party will be responsible for record preservation.  If record preservation is not being done by a single party, the parties must provide a list of which records will be retained by each party.  IDPH will not provide a new hospital license until the plan for record preservation is submitted.

Reporting of Catastrophic Events and Potential Strikes
Section 250.1520 (Reports) has been amended to make two changes to the reporting requirements hospitals must make to the Department. The first reduces the time a hospital has to report under Section (f) that governs catastrophes or threats that requires a transfer of patients.  Hospitals must report such cases within 24 hours after the occurrence and can be done via email at:

Second, hospitals are now required to notify IDPH of an impending strike by direct care staff within 24 hours after receiving notice.  Hospitals will also need to provide IDPH a strike contingency plan no later than three calendar days prior to the impending strike.