§ 3.117 — Hospital designations

Illinois § 3.117

• Jurisdiction: Illinois
• Topic: REGULATION
• Ch. 210: HEALTH FACILITIES AND REGULATION
• Act 210 ILCS 50/: Emergency Medical Services (EMS) Systems Act.

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(a) The Department shall attempt to designate Primary Stroke Centers in all areas of the State. (1) The Department shall designate as many certified Primary Stroke Centers as apply for that designation provided they are certified by a nationally recognized certifying body, approved by the Department, and certification criteria are consistent with the most current nationally recognized, evidence-based stroke guidelines related to reducing the occurrence, disabilities, and death associated with stroke. (2) A hospital certified as a Primary Stroke Center by a nationally recognized certifying body approved by the Department, shall send a copy of the Certificate and annual fee to the Department and shall be deemed, within 30 business days of its receipt by the Department, to be a State-designated Primary Stroke Center. (3) A center designated as a Primary Stroke Center shall pay an annual fee as determined by the Department that shall be no less than $100 and no greater than $500. All fees shall be deposited into the Stroke Data Collection Fund. (3.5) With respect to a hospital that is a designated Primary Stroke Center, the Department shall have the authority and responsibility to do the following: (A) Suspend or revoke a hospital's Primary Stroke Center designation upon receiving notice that the hospital's Primary Stroke Center certification has lapsed or has been revoked by the State recognized certifying body. (B) Suspend a hospital's Primary Stroke Center designation, in extreme circumstances where patients may be at risk for immediate harm or death, until such time as the certifying body investigates and makes a final determination regarding certification. (C) Restore any previously suspended or revoked Department designation upon notice to the Department that the certifying body has confirmed or restored the Primary Stroke Center certification of that previously designated hospital. (D) Suspend a hospital's Primary Stroke Center designation at the request of a hospital seeking to suspend its own Department designation. (4) Primary Stroke Center designation shall remain valid at all times while the hospital maintains its certification as a Primary Stroke Center, in good standing, with the certifying body. The duration of a Primary Stroke Center designation shall coincide with the duration of its Primary Stroke Center certification. Each designated Primary Stroke Center shall have its designation automatically renewed upon the Department's receipt of a copy of the accrediting body's certification renewal. (5) A hospital that no longer meets nationally recognized, evidence-based standards for Primary Stroke Centers, or loses its Primary Stroke Center certification, shall notify the Department and the Regional EMS Advisory Committee within 5 business days. (a-5) The Department shall attempt to designate Comprehensive Stroke Centers in all areas of the State. (1) The Department shall designate as many certified Comprehensive Stroke Centers as apply for that designation, provided that the Comprehensive Stroke Centers are certified by a nationally recognized certifying body approved by the Department, and provided that the certifying body's certification criteria are consistent with the most current nationally recognized and evidence-based stroke guidelines for reducing the occurrence of stroke and the disabilities and death associated with stroke. (2) A hospital certified as a Comprehensive Stroke Center shall send a copy of the Certificate and annual fee to the Department and shall be deemed, within 30 business days of its receipt by the Department, to be a State-designated Comprehensive Stroke Center. (3) A hospital designated as a Comprehensive Stroke Center shall pay an annual fee as determined by the Department that shall be no less than $100 and no greater than $500. All fees shall be deposited into the Stroke Data Collection Fund. (4) With respect to a hospital that is a designated Comprehensive Stroke Center, the Department shall have the authority and responsibility to do the following: (A) Suspend or revoke the hospital's Comprehensive Stroke Center designation upon receiving notice that the hospital's Comprehensive Stroke Center certification has lapsed or has been revoked by the State recognized certifying body. (B) Suspend the hospital's Comprehensive Stroke Center designation, in extreme circumstances in which patients may be at risk for immediate harm or death, until such time as the certifying body investigates and makes a final determination regarding certification. (C) Restore any previously suspended or revoked Department designation upon notice to the Department that the certifying body has confirmed or restored the Comprehensive Stroke Center certification of that previously designated hospital. (D) Suspend the hospital's Comprehensive Stroke Center designation at the request of a hospital seeking to suspend its own Department designation. (5) Comprehensive Stroke Center designation shall remain valid at all times while the hospital maintains its certification as a Comprehensive Stroke Center, in good standing, with the certifying body. The duration of a Comprehensive Stroke Center designation shall coincide with the duration of its Comprehensive Stroke Center certification. Each designated Comprehensive Stroke Center shall have its designation automatically renewed upon the Department's receipt of a copy of the certifying body's certification renewal. (6) A hospital that no longer meets nationally recognized, evidence-based standards for Comprehensive Stroke Centers, or loses its Comprehensive Stroke Center certification, shall notify the Department and the Regional EMS Advisory Committee within 5 business days. (a-7) The Department shall attempt to designate Thrombectomy Capable Stroke Centers, Thrombectomy Ready Stroke Centers, and Primary Stroke Centers Plus in all areas of the State according to the following requirements: (1) The Department shall designate as many certified Thrombectomy Capable Stroke Centers, Thrombectomy Ready Stroke Centers, and Primary Stroke Centers Plus as apply for that designation, provided that the body certifying the facility uses certification criteria consistent with the most current nationally recognized and evidence-based stroke guidelines for reducing the occurrence of strokes and the disabilities and death associated with strokes. (2) A Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus shall send a copy of the certificate of its designation and annual fee to the Department and shall be deemed, within 30 business days after its receipt by the Department, to be a State-designated Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus. (3) A Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus shall pay an annual fee as determined by the Department that shall be no less than $100 and no greater than $500. All fees collected under this paragraph shall be deposited into the Stroke Data Collection Fund. (4) With respect to a Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus, the Department shall: (A) suspend or revoke the Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus designation upon receiving notice that the Thrombectomy Capable Stroke Center's, Thrombectomy Ready Stroke Center's, or Primary Stroke Center Plus's certification has lapsed or has been revoked by its certifying body; (B) in extreme circumstances in which patients may be at risk for immediate harm or death, suspend the Thrombectomy Capable Stroke Center's, Thrombectomy Ready Stroke Center's, or Primary Stroke Center Plus's designation until its certifying body investigates the circumstances and makes a final determination regarding its certification; (C) restore any previously suspended or revoked Department designation upon notice to the Department that the certifying body has confirmed or restored the Thrombectomy Capable Stroke Center's, Thrombectomy Ready Stroke Center's, or Primary Stroke Center Plus's certification; and (D) suspend the Thrombectomy Capable Stroke Center's, Thrombectomy Ready Stroke Center's, or Primary Stroke Center Plus's designation at the request of a facility seeking to suspend its own Department designation. (5) A Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus designation shall remain valid at all times while the facility maintains its certification as a Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus and is in good standing with the certifying body. The duration of a Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus designation shall be the same as the duration of its Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus certification. Each designated Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus shall have its designation automatically renewed upon the Department's receipt of a copy of the certifying body's renewal of the certification. (6) A hospital that no longer meets the criteria for Thrombectomy Capable Stroke Centers, Thrombectomy Ready Stroke Centers, or Primary Stroke Centers Plus, or loses its Thrombectomy Capable Stroke Center, Thrombectomy Ready Stroke Center, or Primary Stroke Center Plus certification, shall notify the Department and the Regional EMS Advisory Committee of the situation within 5 business days after being made aware of it. (b) Beginning on the first day of the month that begins 12 months after the adoption of rules authorized by this subsection, the Department shall attempt to designate hospitals as Acute Stroke-Ready Hospitals in all areas of the State. Designation may be approved by the Department after a hospital has been certified as an Acute Stroke-Ready Hospital or through application and designation by the Department. For any hospital that is designated as an Emergent Stroke Ready Hospital at the time that the Department begins the designation of Acute Stroke-Ready Hospitals, the Emergent Stroke Ready designation shall remain intact for the duration of the 12-month period until that designation expires. Until the Department begins the designation of hospitals as Acute Stroke-Ready Hospitals, hospitals may achieve Emergent Stroke Ready Hospital designation utilizing the processes and criteria provided in Public Act 96-514. (1) (Blank). (2) Hospitals may apply for, and receive, Acute Stroke-Ready Hospital designation from the Department, provided that the hospital attests, on a form developed by the Department in consultation with the State Stroke Advisory Subcommittee, that it meets, and will continue to meet, the criteria for Acute Stroke-Ready Hospital designation and pays an annual fee. A hospital designated as an Acute Stroke-Ready Hospital shall pay an annual fee as determined by the Department that shall be no less than $100 and no greater than $500. All fees shall be deposited into the Stroke Data Collection Fund. (2.5) A hospital may apply for, and receive, Acute Stroke-Ready Hospital designation from the Department, provided that the hospital provides proof of current Acute Stroke-Ready Hospital certification and the hospital pays an annual fee. (A) Acute Stroke-Ready Hospital designation shall remain valid at all times while the hospital maintains its certification as an Acute Stroke-Ready Hospital, in good standing, with the certifying body. (B) The duration of an Acute Stroke-Ready Hospital designation shall coincide with the duration of its Acute Stroke-Ready Hospital certification. (C) Each designated Acute Stroke-Ready Hospital shall have its designation automatically renewed upon the Department's receipt of a copy of the certifying body's certification renewal and Application for Stroke Center Designation form. (D) A hospital must submit a copy of its certification renewal from the certifying body as soon as practical but no later than 30 business days after that certification is received by the hospital. Upon the Department's receipt of the renewal certification, the Department shall renew the hospital's Acute Stroke-Ready Hospital designation. (E) A hospital designated as an Acute Stroke-Ready Hospital shall pay an annual fee as determined by the Department that shall be no less than $100 and no greater than $500. All fees shall be deposited into the Stroke Data Collection Fund. (3) Hospitals seeking Acute Stroke-Ready Hospital designation that do not have certification shall develop policies and procedures that are consistent with nationally recognized, evidence-based protocols for the provision of emergent stroke care. Hospital policies relating to emergent stroke care and stroke patient outcomes shall be reviewed at least annually, or more often as needed, by a hospital committee that oversees quality improvement. Adjustments shall be made as necessary to advance the quality of stroke care delivered. Criteria for Acute Stroke-Ready Hospital designation of hospitals shall be limited to the ability of a hospital to: (A) create written acute care protocols related to emergent stroke care; (A-5) participate in the data collection system provided in Section 3.118, if available; (B) maintain a written transfer agreement with one or more hospitals that have neurosurgical expertise; (C) designate a Clinical Director of Stroke Care who shall be a clinical member of the hospital staff with training or experience, as defined by the facility, in the care of patients with cerebrovascular disease. This training or experience may include, but is not limited to, completion of a fellowship or other specialized training in the area of cerebrovascular disease, attendance at national courses, or prior experience in neuroscience intensive care units. The Clinical Director of Stroke Care may be a neurologist, neurosurgeon, emergency medicine physician, internist, radiologist, advanced practice registered nurse, or physician assistant; (C-5) provide rapid access to an acute stroke team, as defined by the facility, that considers and reflects nationally recognized, evidence-based protocols or guidelines; (D) administer thrombolytic therapy, or subsequently developed medical therapies that meet nationally recognized, evidence-based stroke guidelines; (E) conduct brain image tests at all times; (F) conduct blood coagulation studies at all times; (G) maintain a log of stroke patients, which shall be available for review upon request by the Department or any hospital that has a written transfer agreement with the Acute Stroke-Ready Hospital; (H) admit stroke patients to a unit that can provide appropriate care that considers and reflects nationally recognized, evidence-based protocols or guidelines or transfer stroke patients to an Acute Stroke-Ready Hospital, Primary Stroke Center, or Comprehensive Stroke Center, or another facility that can provide the appropriate care that considers and reflects nationally recognized, evidence-based protocols or guidelines; and (I) demonstrate compliance with nationally recognized quality indicators. (4) With respect to Acute Stroke-Ready Hospital designation, the Department shall have the authority and responsibility to do the following: (A) Require hospitals applying for Acute Stroke-Ready Hospital designation to attest, on a form developed by the Department in consultation with the State Stroke Advisory Subcommittee, that the hospital meets, and will continue to meet, the criteria for an Acute Stroke-Ready Hospital. (A-5) Require hospitals applying for Acute Stroke-Ready Hospital designation via national Acute Stroke-Ready Hospital certification to provide proof of current Acute Stroke-Ready Hospital certification, in good standing. The Department shall require a hospital that is already certified as an Acute Stroke-Ready Hospital to send a copy of the Certificate to the Department. Within 30 business days of the Department's receipt of a hospital's Acute Stroke-Ready Certificate and Application for Stroke Center Designation form that indicates that the hospital is a certified Acute Stroke-Ready Hospital, in good standing, the hospital shall be deemed a State-designated Acute Stroke-Ready Hospital. The Department shall send a designation notice to each hospital that it designates as an Acute Stroke-Ready Hospital and shall add the names of designated Acute Stroke-Ready Hospitals to the website listing immediately upon designation. The Department shall immediately remove the name of a hospital from the website listing when a hospital loses its designation after notice and, if requested by the hospital, a hearing. The Department shall develop an Application for Stroke Center Designation form that contains a statement that "The above named facility meets the requirements for Acute Stroke-Ready Hospital Designation as provided in Section 3.117 of the Emergency Medical Services (EMS) Systems Act" and shall instruct the applicant facility to provide: the hospital name and address; the hospital CEO or Administrator's typed name and signature; the hospital Clinical Director of Stroke Care's typed name and signature; and a contact person's typed name, email address, and phone number. The Application for Stroke Center Designation form shall contain a statement that instructs the hospital to "Provide proof of current Acute Stroke-Ready Hospital certification from a nationally recognized certifying body approved by the Department". (B) Designate a hospital as an Acute Stroke-Ready Hospital no more than 30 business days after receipt of an attestation that meets the requirements for attestation, unless the Department, within 30 days of receipt of the attestation, chooses to conduct an onsite survey prior to designation. If the Department chooses to conduct an onsite survey prior to designation, then the onsite survey shall be conducted within 90 days of receipt of the attestation. (C) Require annual written attestation, on a form developed by the Department in consultation with the State Stroke Advisory Subcommittee, by Acute Stroke-Ready Hospitals to indicate compliance with Acute Stroke-Ready Hospital criteria, as described in this Section, and automatically renew Acute Stroke-Ready Hospital designation of the hospital. (D) Issue an Emergency Suspension of Acute Stroke-Ready Hospital designation when the Director, or his or her designee, has determined that the hospital no longer meets the Acute Stroke-Ready Hospital criteria and an immediate and serious danger to the public health, safety, and welfare exists. If the Acute Stroke-Ready Hospital fails to eliminate the violation immediately or within a fixed period of time, not exceeding 10 days, as determined by the Director, the Director may immediately revoke the Acute Stroke-Ready Hospital designation. The Acute Stroke-Ready Hospital may appeal the revocation within 15 business days after receiving the Director's revocation order, by requesting an administrative hearing. (E) After notice and an opportunity for an administrative hearing, suspend, revoke, or refuse to renew an Acute Stroke-Ready Hospital designation, when the Department finds the hospital is not in substantial compliance with current Acute Stroke-Ready Hospital criteria. (c) The Department shall consult with the State Stroke Advisory Subcommittee for developing the designation, re-designation, and de-designation processes for Comprehensive Stroke Centers, Thrombectomy Capable Stroke Centers, Thrombectomy Ready Stroke Centers, Primary Stroke Centers Plus, Primary Stroke Centers, and Acute Stroke-Ready Hospitals. (d) The Department shall consult with the State Stroke Advisory Subcommittee as subject matter experts at least annually regarding stroke standards of care.

Legislative History

(Source: P.A. 103-149, eff. 1-1-24; 104-417, eff. 8-15-25.)