Conditions of Licensure

Section 205 TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER b: HEALTH CARE FACILITIES PART 205 AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS SECTION 205.118 CONDITIONS OF LICENSURE Section 205.118  Conditions of Licensure a) No person shall open, conduct or maintain an ambulatory surgical treatment center without first obtaining a license from the Department . (Section 4 of the Act) 1) A person or facility not licensed under the Act or the Hospital Licensing Act shall not hold itself out to the public as a "surgery center" or as a "center for surgery" . (Section 6 of the Act) 2) Any person opening, conducting or maintaining an ambulatory surgical treatment center without a license issued pursuant to the Act shall be guilty of a business offense punishable by a fine of $10,000 and each day's violation shall constitute a separate offense . 3) Any person opening, conducting or maintaining an ambulatory surgical treatment center who violates any other provision of the Act shall be guilty of a business offense punishable by a fine of not more than $10,000 . (Section 12 of the Act) 4) The operation or maintenance of an ambulatory surgical treatment center in violation of the Act or this Part is declared a public nuisance inimical to the public welfare. The Director of the Department, in the name of the People of the State, through the Attorney General or the State's Attorney of the county in which the violation occurs, may, in addition to other remedies provided in the Act , bring action for an injunction to restrain such violation or to enjoin the future operation or maintenance of any such ambulatory surgical treatment center . (Section 13 of the Act) b) The applicant shall file a statement of ownership as provided in Section 205.210(b). The applicant shall agree to update the information required in the statement of ownership every six months from the initial date of filing. (Section 7a of the Act) c) Every facility licensed under the Act, and any premises proposed to be conducted as a facility by an applicant for a license, shall be open during its regular business hours to an inspection authorized in writing by the Director.  No notice need be given to any person prior to any inspection. (Section 9 of the Act) d) Any corporation operating an ambulatory surgical treatment center devoted primarily to providing facilities for abortion must have a physician who is licensed to practice medicine in all of its branches and is actively engaged in the practice of medicine at the ambulatory surgical treatment center, on the Board of Directors as a condition to licensure of the ambulatory surgical treatment center. (Section 6.1 of the Act) e) Each license shall be issued only for the premises and persons named in the application and shall not be transferable or assignable (Section 6 of the Act).  Only those facilities, services, programs and procedures included in the application shall be licensed.  A new application is required for any one or more of the following: 1)         Change in ownership of the facility.  A change of ownership occurs when: A)        Ownership and responsibility for the operation of the assets constituting the licensed entity are transferred from the licensee to another person or another legal entity, including, but not limited to, a corporation, limited liability company, partnership or sole proprietor, as part of an asset purchase or similar transaction; B)        In a partnership, when the removal, addition or substitution of a partner alters control of the partnership by more than 51%; or C)        In a corporation, when the licensee corporation merges into another corporation or is party to a consolidation transaction with one or more corporations, resulting in the creation of a new corporation. 2)         Change in location of the facility. 3)         Any remodeling or other change in the facility's physical plant that increases or decreases the number of rooms in which surgical procedures are performed. f)         The transactions described in subsection (e)(1) do not constitute a change in ownership when all of the entities that are parties to the transaction are under common control or ownership before and after the transaction is completed.  In these transactions, the name of the corporation, its officers, its independent subsidiaries and any other relevant information that the Department may require shall be made available to the Department upon request. g)         The transfer of corporate stock, the change of a membership interest, or the merger of another corporation into the licensee corporation does not constitute a change of ownership if the licensee corporation remains in existence. h) The license shall be valid for one year, unless sooner suspended or revoked, and shall be renewable annually upon approval by the Department and payment of a license fee of $300 as provided in Section 205.125. (Section 6 of the Act) i) The license shall be posted in a conspicuous place on the licensed premises.  A placard or registry of all physicians on staff in the facility shall be centrally located and available for inspection to any interested persons. (Section 6 of the Act) j)          The facility shall give written notice to the Department no later than seven days after any one or more of the following: 1)         Any personnel changes involving the facility's administrative staff, medical director or supervising nurse. 2)         For a corporation, any change in any shareholders equity involving 5% or more interest. 3)         Any change in the Registered Agent or person or persons legally authorized to receive service of process for the facility. k) An ambulatory surgical treatment center that elects to have an agreement with the federal Centers for Medicare and Medicaid Services, as provided in 42 CFR 416, must also meet the Medicare conditions as an ambulatory surgical center, as set forth in 42 CFR 416, and have an active agreement with the federal Centers for Medicare and Medicaid Services to participate in Medicare as an ambulatory surgical center provider in Illinois .  (Section 6.8 of the Act) l) The Director may issue a provisional license to any ambulatory surgical treatment center that does not substantially comply with the provisions of the Act and this Part provided that the Director finds that the ambulatory surgical treatment center will undertake changes and corrections that upon completion will render the ambulatory surgical treatment center in substantial compliance with the provisions of the Act and this Part , and provided that the health and safety of the patients of the ambulatory surgical treatment center will be protected during the period for which such provisional license is issued. The Director will advise the licensee of the conditions under which the provisional license is issued, including the manner in which the facilities fail to comply with the provisions of the Act and this Part , and the time within which the changes and corrections necessary for the ambulatory surgical treatment center to substantially comply with the Act and this Part , shall be completed. (Section 6 of the Act) m)        A facility suspending its operations for more than one day as the result of unplanned damage from a natural or human-caused disaster, or business-related matters, shall notify the Department and the Health Facilities Services Review Board of any such suspension and may not reinstate operations without Department approval. 1)         Within 24 hours of suspension of operations, the facility shall submit the following to the Department: A)        A description of the event, changes, and modifications to the facility that occurred that required the suspension of facility operations. B)        A projected date for resumption of full services. The projected time frame for the resumption of full services must be consistent with the repairs or renovation required or change in business management. 2)         The facility shall submit monthly progress reports to the Department that include any changes to the projected re-opening date. 3)         Upon written notification to the Department that the facility is in compliance with all licensing requirements and ready to resume operations, the Department will determine the need for an onsite survey to confirm the facility is operationally safe and approved to resume those operations. 4)         If the facility is determined by the onsite survey not to be in compliance with the licensing requirements of the Act and this Part, the Department may issue a provisional license pursuant to subsection (l) or take adverse licensure action, as described in Section 205.840. n)         Notification of Closure of a facility.  The licensee shall notify the Department of the impending closure of the facility at least 90 days prior to the closure.  The facility shall implement the policies for preservation of patient medical records and approved procedures in accordance with Section 205.610(c).  Notification to the Department shall include the address (i.e., physical location) of all medical records and medical staff credentialing files and a contact name, phone number, and email address for the keeper of these records.