1. a) Policy on Patients' Rights

   1. 1) Hospitals shall adopt a written policy on patients' rights.
   2. 2) This policy shall be available to all patients and personnel upon request.

2. b) Patient Morale

   1. 1) Emotional and Attitudinal Support

      Hospitals shall have a written plan for the provision of those components of total patient care that relate to the spiritual, emotional and attitudinal health of the patient, patients' families and hospital personnel.

   2. 2) Social Services

      1. A) An organized social service within the hospital; or
      2. B) A social worker employed on a part-time basis; or
      3. C) Social work consultant services from a community agency.

      Hospitals shall have a written plan for providing social services. This service may be provided through:

3. c) Patient Protection from Abuse

4. 1) For purposes of this subsection (c):

   1. 2) No administrator, agent, or employee of a hospital or a hospital affiliate or a member of a hospitals' medical staff may abuse a patient in the hospital or in a facility operated by a hospital affiliate.
   2. 3) Any hospital administrator, agent, employee, or medical staff member, or an administrator, employee, or physician employed by a hospital affiliate, who has reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital or hospital affiliate shall promptly report or cause a report to be made to a designated hospital administrator responsible for providing such reports to the Department as required by this subsection (c).
   3. 4) Retaliation against a person who lawfully and in good faith makes a report under this subsection (c) is prohibited.
   4. 5) Upon receiving a report under subsection (c)(3), the hospital or hospital affiliate shall submit the report to the Department within 24 hours after obtaining such report. In the event that the hospital receives multiple reports involving a single alleged instance of abuse, the hospital shall submit one report to the Department.
   5. 6) Upon receiving a report under this subsection (c), the hospital or hospital affiliate shall promptly conduct an internal review to ensure the alleged victim's safety. Measures to protect the alleged victim shall be taken as deemed necessary by the hospital's administrator and shall include, but are not limited to, removing suspected violators from further patient contact during the hospital's or hospital affiliate's internal review. If the alleged victim lacks decision-making capacity under the Health Care Surrogate Act and no health care surrogate is available, the hospital or hospital affiliate may contact the Illinois Guardianship and Advocacy Commission to determine the need for a temporary guardian of that person.
   6. 7) All internal hospital and hospital affiliate reviews shall be conducted by a designated employee or agent who is qualified to detect abuse and is not involved in the alleged victim's treatment. All internal review findings shall be documented and filed according to hospital or hospital affiliate procedures and shall be made available to the Department upon request.
   7. 8) Any other person may make a report of patient abuse to the Department if that person has reasonable cause to believe that a patient has been abused in the hospital or hospital affiliate.

   8. 9) The report required under this subsection (c) shall include:

      1. A) The name of the patient;
      2. B) The name and address of the hospital or hospital affiliate treating the patient;
      3. C) The age of the patient;
      4. D) The nature of the patient's condition, including any evidence of previous injuries or disabilities;
      5. E) Any other information that the reporter believes might be helpful in establishing the cause of the reported abuse and the identity of the person believed to have caused the abuse;
      6. F) The date of the alleged abuse incident and the date the hospital or hospital affiliate was notified; and
      7. G) A description of the alleged abuse.
   9. 10) Except for willful or wanton misconduct, any individual, person, institution, or agency participating in good faith in making a report under this subsection (c), or in the investigation of such a report or in making a disclosure of information concerning reports of abuse under this subsection (c), shall have immunity from any liability, whether civil, professional, or criminal, that otherwise might result by reason of such actions. For the purpose of any proceedings, whether civil, professional, or criminal, the good faith of any persons required to report cases of suspected abuse under this subsection (c) or who disclose information concerning reports of abuse in compliance with this subsection (c) shall be presumed.
   10. 11) No administrator, agent, or employee of a hospital or hospital affiliate shall adopt or employ practices or procedures designed to discourage or having the effect of discouraging good faith reporting of patient abuse under this subsection (c).
   11. 12) Every hospital or hospital affiliate shall ensure that all new and existing employees are trained in the detection and reporting of abuse of patients and retrained at least every 2 years thereafter.
   12. 13) The Department will investigate each report of patient abuse made under this subsection (c) according to the procedures of the Department, except that a report of abuse which indicates that a patient's life or safety is in imminent danger shall be investigated within 24 hours after such report. Under no circumstances may a hospital's or hospital affiliate's internal review of an allegation of abuse replace an investigation of the allegation by the Department.
   13. 14) The Department will keep a continuing record of all reports made pursuant to this subsection (c), including indications of the final determination of any investigation and the final disposition of all reports. The Department will inform the investigated hospital or hospital affiliate and any other person making a report under subsection (c)(8) of this Section of its final determination or disposition in writing.
   14. 15) All patient identifiable information in any report or investigation under this subsection (c) shall be confidential and shall not be disclosed except as authorized by the Act or other applicable law.
   15. 16) Nothing in this subsection (c) relieves a hospital or hospital affiliate administrator, employee, agent, or medical staff member from contacting appropriate law enforcement authorities as required by law.
   16. 17) Nothing in this subsection (c) shall be construed to mean that a patient is a victim of abuse because of health care services provided or not provided by health care professionals.
   17. 18) Nothing in this subsection (c) shall require a hospital or hospital affiliate, including its employees, agents, and medical staff members, to provide any services to a patient in contravention of his or her stated or implied objection thereto upon grounds that such services conflict with his or her religious beliefs or practices, nor shall such a patient be considered abused under this Section for the exercise of such beliefs or practices. (Section 9.6 of the Act)

   Abuse – means any physical or mental injury or sexual abuse intentionally inflicted by a hospital or hospital affiliate employee, agent, or medical staff member on a patient of the hospital or hospital affiliate and does not include any hospital or hospital affiliate, medical, health care, or other personal care services done in good faith in the interest of the patient according to established medical and clinical standards of care.

   Hospital affiliate – means a corporation, partnership, joint venture, limited liability company, or similar organization, other than a hospital, that is devoted primarily to the provision, management, or support of health care services and that directly or indirectly controls, is controlled by, or is under common control of the hospital. For the purposes of this definition, "control" means having at least an equal or a majority ownership or membership interest. A hospital affiliate shall be 100% owned or controlled by any combination of hospitals, their parent corporations, or physicians licensed to practice medicine in all its branches in Illinois. "Hospital affiliate" does not include a health maintenance organization regulated under the Health Maintenance Organization Act. (Section 10.8(b) of the Act)

   Mental Injury – means intentionally caused emotional distress in a patient from words or gestures that would be considered by a reasonable person to be humiliating, harassing, or threatening and which causes observable and substantial impairment.

   Sexual Abuse – means any intentional act of sexual contact or sexual penetration of a patient in the hospital.

   Substantiated – with respect to a report of abuse, means that a preponderance of the evidence indicates that abuse occurred.

5. d) Patient Discrimination

   1. 1) Discrimination Grievance Procedures. Upon receipt of a grievance alleging unlawful discrimination on the basis of race, color, or national origin, the hospital must investigate the claim and work with the patient to address valid or proven concerns in accordance with the hospital's grievance process. At the conclusion of the hospital's grievance process, the hospital shall inform the patient that such grievances may be reported to the Department if not resolved to the patient's satisfaction at the hospital level. (Section 5.1 of the Medical Patient Rights Act)
   2. 2) Emergency Room Anti-discrimination Notice. Every hospital shall post, either by physical or electronic means, a sign next to or in close proximity of its sign required by 42 CFR 489.20(q)(1) stating the following: "You have the right not to be discriminated against by the hospital due to your race, color, or national origin if these characteristics are unrelated to your diagnosis or treatment. If you believe this right has been violated, please call the Illinois Department of Public Health Central Complaint Registry, 1-800-252-4343." (Section 5.2 of the Medical Patient Rights Act)
6. e) In compliance with Section 3.4 of the Medical Patient Rights Act, every hospital shall post information about the rights listed in Section 3.4 of the Medical Patient Rights Act in a prominent place (physical or electronic) and on their websites. The postings in the hospital and on the hospital's website shall include the web address of the Department's posting of this information, http://www.dph.illinois.gov/topics-services/health-care-regulation/facilities/hospitals. (Section 3.4(b) of the Medical Patient Rights Act)

(Source: Amended at 49 Ill. Reg. 11475, effective August 26, 2025)