Hospital Licensing Rules Related to Behavioral Health

September 4, 2026

Memorandum

The Illinois Dept. of Public Health (IDPH) adopted amendments to the Hospital Licensing Requirements (77 Ill. Adm. Code 250 et seq., Illinois Register, pages 8128 to 8176). The adopted amendments, which are now effective, modernize behavioral health-related hospital licensing requirements while preserving important operational flexibility secured through IHA engagement with IDPH. As a result of these changes, we recommend compliance leaders:

  • Review hospital policies for psychiatric services, restraint and seclusion, and substance use disorder treatment services to confirm alignment with the adopted rules.

  • Communicate operational clarifications to behavioral health, emergency department, nursing, compliance, and legal leaders, particularly where IDPH preserved discretion or reduced documentation burden.

General Provisions
Section 250.105 – Incorporated and Referenced Materials adds the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) to applicable references, aligning the rules with current diagnostic standards.

Section 250.295 – Notification and Posting Requirements adds references to state statutory updates. Following IHA comments, IDPH clarified that the Health Care Violence Prevention Act (210 ILCS 160/) requires hospitals to display, physically or electronically, a notice stating that verbal aggression will not be tolerated and physical assault will be reported to law enforcement. This clarification preserves healthcare workers’ discretion to decide whether to contact law enforcement for a specific incident, rather than creating a mandatory reporting obligation for every case.

Nursing Service and Administration
Section 250.1075 – Use of Restraints and Seclusion updates the reference to federal rules governing use of these interventions to 42 CFR 482.13 (e) and (f). The section also clarifies that an existing requirement for medical staff policy that determines appropriate training and experience to order these interventions must be a written policy.

Psychiatric Services
Section 250.2220 – Establishment of a Psychiatric Service clarifies that only inpatient psychiatric service lines require IDPH approval before establishment, not all psychiatric services. The rule also permits general hospitals without an approved inpatient psychiatric unit to provide psychiatric care to patients with a primary diagnosis of mental illness on an as needed basis, in addition to emergencies, as determined by the hospital and appropriate medical staff. This recognizes longstanding practice and Illinois Medicaid payment for these services for up to three days. The rule further broadens the licensed behavioral health professionals who may determine that a patient no longer requires transfer to an inpatient psychiatric unit and clarifies IDPH permission to discontinue an inpatient service.

Section 250.2230 – The Medical Staff adds that hospital policy must explicitly authorize primary physicians and psychiatric nurse practitioners to treat patients in a psychiatric hospital or unit. The section clarifies that an existing requirement for evidence of a psychiatrist’s consultation(s) in the unit is required and must be timely.

Section 250.2240 – Nursing Service removes a requirement for nursing personnel of a psychiatric unit to be a separate staff from other units, instead requiring that they be qualified to provide inpatient psychiatric services.

Section 250.2260 – Staff and Personnel Development and Training removes a requirement for interdisciplinary staff conferences for all personnel involved in patient care.

Section 250.2280 – Care of Patients requires an existing policy and procedure manual for psychiatric services to now include policies and procedures for care and treatment of patients with a substance use disorder and when ligature risks are identified, a plan and timetable for remediation with policies to minimize patient risk. For inpatient units, a specific room for use of seclusion or restraints, and a space for private visitation must be provided.

Substance Use Disorder Treatment Services
This subpart is modified throughout to modernize terminology in alignment with national standards.

Section 250.2840 – General Requirements for all Hospital Substance Use Disorder Services requires hospitals to direct patients to outpatient substance use disorder resources for referral. Following IHA comments, IDPH eliminated the requirement that this resource be a “list,” allowing hospitals to refer patients to the Illinois Helpline, which is regularly updated and can be tailored to individual needs. IDPH also removed a proposed requirement to document every date, result, and recommendation of patient evaluations within program goal assessments after IHA raised concerns that the requirement was not at parity with documentation in other hospital units.

Section 250.2850 – The Medical and Professional Staff recognizes that consulting medical staff may include telehealth services and permits physicians to be board eligible or board certified. Recovery support specialists/peers are newly recognized as allied health personnel, a part of the consulting medical staff.

Section 250.2880 – Patient Client Legal and Human Rights updates language that previously prohibited patient admission unless a program can specifically meet specialty care needs for mental illness, intellectual disability, or major physical disability, but now prohibits patient exclusion regardless of if the hospital has resources to meet specialty care needs.

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