Reporting and Notification Requirements

Section 1130.240  Reporting and Notification Requirements HFSRB shall require health care facilities to provide periodic reports, data, and information as needed to carry out the purposes and provisions of the Act [20 ILCS 3960/13].  Information required to be submitted to HFSRB includes, but is not limited to, reports on capital expenditures, facility and service utilization data, facility bed-capacity information, notices of hospital reductions in services, and any temporary suspensions of service. a)         Annual Report of Capital Expenditures Each health care facility shall submit an annual report of capital expenditures as part of the annual health care facility questionnaires issued by HFSRB.  (See Section 5.3 of the Act.) b)         Health Planning Information HFSRB shall require all health care facilities operating in the State to provide information for the purpose of fulfilling the purposes, provisions and responsibilities specified in the Act.  (See Section 13 of the Act.)  These reports may be on an annual or other basis. c)         Notice of Hospital Reduction of 50% or More in Health Care Services Each hospital is required to notify the State Board, the Illinois Department of Public Health, and the State Senator and 2 State Representatives representing the legislative district in which the hospital is located , of a reduction in services of 50% or more, within 30 days after that reduction [20 ILCS 3960/12.4].  Reporting shall include the identification of the service, reasons for reduction and anticipated duration (permanent or temporary).  Reduction of 50% or more is determined by the following: 1)         If the reduction is in a bed category of service, reduction is determined by the number of physically available beds as compared to the authorized number of beds stated in the Inventory of Health Care Facilities as updated, or the number of staffed beds reported in the Annual Hospital Questionnaire; 2)         If the reduction is in a non-bed category of service (i.e., cardiac surgery, cardiac catheterization, organ transplantation, etc.), reduction is determined when the physical number of procedure rooms, stations or equipment necessary to provide that service is reduced by 50% or more, or the number of clinical staff and/or hours of operation is reduced by 50% or more. A)        If reduction does not reduce the number of procedures by 50% or more, the notification is required only to HFSRB, certifying that the reduction will not reduce the number of procedures performed by 50% or more. B)        If the reduction is temporary for the purpose of maintenance or equipment repair, notification is required to HFSRB only, with a timetable to restore the service. d)         Temporary Suspension of Facility or Category of Service A facility that ceased operation or that ceased to provide a category of service due to unanticipated or unforeseen circumstances (such as the loss of appropriate staff or a natural or unnatural disaster) shall file notice to HFSRB of a temporary suspension of service that is anticipated to exceed 30 days.  The notice shall be filed no later than 30 days after the suspension of the service, and shall include a detailed explanation of the reasons for the suspension, as well as the efforts being made to correct the circumstance and a timetable to reopen the service.  Reports documenting the progress of corrections must be filed every 30 days thereafter until services resume.  Temporary suspensions shall not exceed one year unless otherwise approved by HFSRB. e)         Failure to Provide Required or Requested Information A health care facility or person violates the Act if he or she fails to timely or completely comply with the notice and information requirements in the Act and this Section (see 20 ILCS 3960/13 and 14.1).  This person is subject to the sanctions provided in the Act and Section 1130.790. f)         Changes in a Health Care Facility's Bed Capacity 1)         "Change in the Bed Count of a Health Care Facility" means a change in a health care facility's authorized bed capacity, including reductions, increases with permit or allowable increases without permit. A permit or exemption shall be obtained prior to the construction or modification of a health care facility which changes the bed capacity of a health care facility by: A) increasing the total number of beds; or B) distributing beds among various categories of service; or C) relocating beds from one physical facility to another by more than 20 beds or 10% of total bed capacity as defined by the State Board Inventory , whichever is less, over a 2-year period. [20 ILCS 3960/5] 2)         Projects proposing the establishment or discontinuation of a bed category of service are classified as substantive projects, with a 60-day review period. (See Section 1110.40(c).) 3)         A health care facility that reduces bed capacity, or adds bed capacity without a permit, as specified by the Act, shall notify HFSRB and IDPH of that change.  Such a change is limited to once every two years beginning on the date when the additional beds become operational.  If the facility has already changed its bed capacity through a permit process, then the facility may not add any more beds in those services affected by the permit for two years from the date that those beds established by permit become operational without obtaining an additional permit from HFSRB. 4)         Emergency Preparedness Response Report A)        A health care facility that temporarily increases bed capacity to accommodate extraordinary needs in the service population due to pandemic events and other disasters shall submit written notification of the increase to HFSRB within 30 days after the bed increase decision. The notification shall include: i)          the number of beds increased; ii)         a detailed description of conditions necessitating the bed capacity increase; iii)        the impact on normal admission activity; iv)        the anticipated length of time the increase is needed, indicating the prospective date when beds will be taken out of circulation; and v)         the signature of a senior representative of the health care facility, verifying the information in the report. B)        The facility shall submit written notification to HFSRB, indicating the date that the temporary bed capacity has been taken out of circulation.  This notification shall be received by HFSRB within 30 days after the date that the facility's normal bed capacity was resumed. g)         Change in Name or Change in Legal Status A change in a facility's legal name or a facility's legal status (i.e., a corporate reorganization) that does not constitute a change of ownership, as defined in Section 1130.140, is to be reported to HFSRB within 90 days after occurrence. h)         Notice of New Services Added to Multi-Specialty ASTCs 1)         Multi-specialty ASTCs adding new services shall notify HFSRB of the services being added and the effective date of those services.  The notification of each new service added shall be submitted to HFSRB no later than 30 days after the service addition.  Beginning January 1, 2018, multi-specialty ASTCs seeking to add additional ASTC services shall apply for a CON permit pursuant to the provisions of Section 1110.1540. 2)         Multi-specialty ASTCs that, as a condition of CON permit issuance, agreed to apply for CON permits when adding services, shall continue to apply for CON permits when adding new services.