Ill. Admin. Code tit. 77, pt. 515, subpt. K, app N
Application Instructions
Follow these instructions to initiate the process to request recognition as a Pediatric Critical Care Center (PCCC) and Emergency Department Approved for Pediatrics (EDAP). The Pediatric Plan shall be developed through interaction and collaboration with all appropriate disciplines:
1. Complete the Request for Recognition of Pediatric Critical Care Center and Emergency Department Approved for Pediatrics Status Application Form and obtain the appropriate signatures.
2. Using the Pediatric Critical Care Center Plan Application Guideline and the PCCC/EDAP requirements, complete a PCCC and EDAP Pediatric Plan. The Pediatric Plan should follow the Pediatric Critical Care Center Plan Application Guideline checklist format provided in this application and include all requested supporting documentation, including, but not limited to, scope of services/care, credentialing forms, policies (both administrative and department specific), procedures, protocols, guidelines, flow charts, rosters, calendars, schedules, etc.
3. Complete and obtain signatures on the Department-approved physician, nurse practitioner, clinical nurse specialist, physician assistant, and nursing credentialing forms.
4. Complete the EDAP, PICU and Pediatric Unit Equipment Checklists.
5. Submit four copies of the hospital's Pediatric Plan (an original signed copy plus three additional copies) that each contain the following:
a. Signed Request for Recognition of Pediatric Critical Care Center and Emergency Department Approved for Pediatrics Status Application Form;
b. Completed PCCC Plan and EDAP Plan (including supporting documentation);
c. Completed physician, nurse practitioner, clinical nurse specialist, physician assistant, and nursing credentialing forms;
d. Completed EDAP, PICU and Pediatric Inpatient Unit Equipment Checklists.
6. Submit these documents (including all supporting documentation) in the order listed in this application to: Division of EMS & Highway Safety, Illinois Department of Public Health, 422 S. 5th Street, Springfield IL 62701.
7. The Pediatric Plan shall be submitted in a single-sided format and unstapled.
8. Any submitted requests to waive any of the EDAP or PCCC equipment requirements shall include the criteria by which compliance is considered to be a hardship and shall demonstrate that there will be no reduction in the provision of medical care.
Site Survey Procedure
1. Within four to six weeks following the Department's receipt of the PCCC Pediatric Plan and supporting documents, the hospital will be informed as to the status of the application. If all documentation is in order, a site visit will be scheduled.
2. In preparation for the site visit, hospital personnel shall prepare evidence to verify adherence to the facility recognition requirements.
3. The site visit will include a survey of the Emergency Department, Pediatric Intensive Care Unit, Pediatric Units and a meeting with the following individuals:
a. chief administrative/executive officer or designee
b. chief of pediatrics
c. medical director of the pediatric intensive care services
d. medical directors of the pediatric units
e. medical director of pediatric ambulatory care
f. nursing director or nurse manager of the pediatric intensive care services
g. nursing director or nurse manager of the pediatric units
h. administrator of pediatric services
i. administrator of emergency services
j. pediatric quality coordinator
k. hospital quality improvement department director or designee
l. emergency department medical director and the pediatric emergency department medical director
m. emergency department nurse manager and the pediatric emergency department nurse manager
n. hospital emergency management/disaster preparedness coordinator
o. transport team medical director
p. transport team nurse coordinator
q. Clinical nurse specialist, nurse practitioner or physician assistant for those facilities that use these clinicians
r. For EMS Resource or Associate Hospitals: The EMS MD and EMS coordinator
Site Survey Team
The EMSC program within the Division of EMS & Highway Safety will appoint the site survey team. Site survey teams will be composed of a physician/nurse team along with a representative from the Illinois Department of Public Health. All team members will attend formal training in the site survey responsibilities, expectations and process.
Following the Site Survey
1. Within four to six weeks following the site visit, the hospital shall receive the results of the survey from the Department. Those hospitals meeting all requirements will receive a formal recognition of their Pediatric Critical Care capabilities.
2. Hospitals that do not meet the requirements will receive a letter from the Illinois Department of Public Health outlining the areas of non-compliance. The Department shall deny a request for recognition if findings show failure to substantially comply with the EDAP and PCCC requirements. Hospitals may appeal the denial by submitting a written request to the Illinois Department of Public Health, Division of EMS & Highway Safety.
3. Re-recognition shall occur every three years, with site visits scheduled as necessary.
ILLINOIS EMSC
FACILITY RECOGNITION
Request for Recognition of Pediatric Critical Care Center (PCCC) and Emergency Department Approved for Pediatrics (EDAP) Status
Application Form
Name of hospital and address (typed)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
The above-named hospital is requesting PCCC and EDAP recognition. In addition, the above-named hospital certifies that each requirement in this Request for Recognition is met.
______________________________________________________________________
Typed name - CEO/Administrator
______________________________________________________________________
Signature - CEO/AdministratorDate
______________________________________________________________________
Typed name - Chairman of the Department of Pediatrics
______________________________________________________________________
Signature - Chairman of the Department of PediatricsDate
______________________________________________________________________
Typed name - Medical Director of Emergency Services
______________________________________________________________________
Signature - Medical Director of Emergency ServicesDate
______________________________________________________________________
Contact Person - Typed name, credentials and title
______________________________________________________________________
Contact Person - Phone number, fax number and email
Ill. Admin. Code tit. 77, pt. 515, subpt. K, app N