§205.210. Ownership, Control and Management

a)         The ASTC shall have a governing body that assumes full responsibility for determining, implementing and monitoring policies governing the facility's operation:

 

1)         The governing body shall review and approve the facility's organizational plan.

 

2)         The governing body shall ensure that ASTC policies and programs provide quality health care in a safe environment.

 

3)         The governing body shall have oversight and accountability for the facility's Quality Assessment and Performance Improvement Program; shall allocate sufficient resources for the Program; and shall, at least annually, evaluate the Program's effectiveness.

 

4)         The governing body shall approve an infection control program designed to prevent, identify and manage infections and communicable diseases.  The governing body shall appoint a qualified infection control professional who will direct the infection control program.  The governing body shall, at least annually, evaluate the effectiveness of the infection control program.

 

5)         The governing body shall establish, protect and promote patient rights, including respect for patients' property and privacy, patient safety, the confidentiality of clinical records, and the exercise of patient rights.  The governing body shall designate a grievance officer and shall establish, subject to approval by the governing body, a documented system by which allegations will be reported, investigated and responded to.  Allegations will include allegations of violations/grievances relating to, but not limited to, mistreatment, neglect, or verbal, mental, sexual or physical abuse.

 

6)         The governing body shall have oversight and accountability for developing and maintaining a written Disaster Preparedness Plan pursuant to Section 205.510 and shall review reports and recommendations at least annually.

 

7)         The governing body shall review and approve the facility's organizational plan (see Section 205.220).

 

b)         Ownership, control and management shall be disclosed at the time of application and upon renewal.  The names and addresses of each person with financial interest in the facility shall be submitted to the Department.

 

(Source:  Amended at 38 Ill. Reg. 19208, effective September 9, 2014)