Section 545.67  Compliance Review

a)         The Department will accept complaints from the Office of the Illinois Attorney General related to allegations of violations to the Act and this Part, as set forth in Section 7.5 of the Act.

b)         After receiving a complaint, the Department will determine whether the hospital or approved pediatric health care facility is not in compliance with its approved plan, or if a violation of any provision of the Act or this Part has occurred.  (Section 8(a) of the Act)

c)         The Department will conduct on-site reviews of approved sexual assault treatment plans with hospital and approved pediatric health care facility personnel at least once during each 3-year approval period to ensure that the established procedures are being followed.  (Section 2.05(a) of the Act)

d)         Upon determining a violation of any provision of the Act or this Part has occurred, the Department will issue a written notice of violation that includes the specific items of noncompliance to the hospital or approved pediatric health care facility.  (Section 8(c) of the Act)  The Department's notice of violation will include, at a minimum, the following:

1)         The hospital or approved pediatric health care facility's right to request an administrative hearing to contest the Department's notice of violation;

2)         An opportunity to present evidence, orally, in writing, or both, on the question of the alleged violation before an administrative law judge; and

3)         An opportunity to file an answer responding to the Department's notice of violation.  (Section 8(g) of the Act)

e)         The hospital shall have 10 business days after receipt of the Department's written notice of violation to submit to the Department a plan of correction that contains the hospital's or approved pediatric health care facility's specific proposals for correcting the items of noncompliance.  The Department will review the plan of correction and notify the hospital in writing within 10 business days as to whether the plan is acceptable or unacceptable.  (Section 8(d) of the Act)

f)         The plan of correction shall include the following specific proposals for correcting items of noncompliance:

1)         A time frame for implementing corrections;

2)         A description of the activity that will be undertaken to correct the items of noncompliance;

3)         Identification of the person or persons responsible for implementing the corrections; and

4)         A description of how the requirements of the Act and this Part will be met.

g)         If the Department finds the plan of correction unacceptable, the hospital or approved pediatric health care facility shall have 10 business days to resubmit an acceptable plan of correction.  Upon notification that its plan of correction is acceptable, a hospital or approved pediatric health care facility shall implement the plan of correction within 60 days.  (Section 8(d) of the Act)

h)         The Department will conduct additional surveys or request documentation from the hospital or approved pediatric health care facility, as necessary, to ensure compliance with the accepted plan of correction.  (Section 8(d) of the Act)

i)          If the hospital or approved pediatric health care facility fails to submit an acceptable plan of correction or implement an accepted plan of correction within the time frames required in this Section, the Department will impose a fine as follows:

1)         At least $1,500 but less than $3,000 for a first violation; and

2)         At least $3,000 but less than $5,000 for a second or subsequent violation.  (Section 8(e) of the Act)

j)          In imposing a fine, the Department will consider the following factors:

1)         The alleged violation or violations and the adequacy of the response by the hospital or pediatric facility;

2)         Any historical pattern or practice of noncompliance with this Act; and

3)         The number of patients seeking treatment and support from the hospital or pediatric facility affected by the violation.  (Section 8(f) of the Act)

k)         All hearings will be conducted in accordance with the Department's rules, Practice and Procedure in Administrative Hearings, pursuant to 77 Ill Adm Code 100.

l)          The Department will maintain the confidentiality of all patient identities and medical information provided during a site survey or otherwise received by the Department pursuant to this Part. 

m)        The Department will comply with the patient record confidentiality requirements set out in Section 6.14b of the Hospital Licensing Act.  (Section 2.06 of the Act)

(Source:  Amended at 50 Ill. Reg. 11178, effective July 17, 2026)