Ill. Admin. Code tit. 68 § 1285.235

Current through Register Vol. 48, No. 45, November 8, 2024

Section 1285.235 - Mandatory Reporting of Impaired Physicians by Health Care Institutions

a) Section 23 of the Act requires that the chief administrator or executive officer of any health care institution licensed by the Department of Public Health report to the Disciplinary Board concerning impaired persons. All instances in which a person licensed under the Medical Practice Act of 1987 is impaired by reason of age, drug, or alcohol abuse or physical or mental impairment, is under supervision and, where appropriate, is in a program of rehabilitation, must be reported to the Disciplinary Board. The reports must contain sufficient current information to enable the Disciplinary Board to evaluate the impairment and determine the appropriateness of the supervision of the program of rehabilitation. If the Board finds the supervision or treatment plan submitted by the institution is not sufficient to meet the needs of the individual, the Board may direct the facility to work with the Medical Coordinators to revise the plan or treatment to meet the specific objections.

b) Contents of Reports. Reports of impaired persons shall be submitted in writing, on forms provided by the Division, that shall include but not be limited to the following information:

1) The name, address, telephone number and title of the person making the report;

2) The name, address, telephone number and type of health care institution where the maker of the report is employed;

3) The name, address, telephone number, and professional license number of the person who is the subject of the report;

4) The means of identification used by the institution of any patient or patients whose treatment is a subject of the report; provide, however, no medical records may be revealed without the written consent of the patient or patients; and further provided that the Disciplinary Board may require disclosure of the name, address and telephone number of any patient if it deems the information necessary to an evaluation of the impairment or a determination of the appropriateness of the supervision or program of rehabilitation;

5) The nature of the impairment and brief description of the facts that gave rise to the issuance of the report, including the dates of any occurrences deemed to necessitate the filing of the report;

6) The terms and conditions of the supervision under which the subject of the report is conducting activities or practice, including the date supervision commenced; the term of the supervision; the name, address and telephone number of the person in charge of the subject's supervision; and a written consent executed by the subject of the report authorizing the Disciplinary Board, the Medical Coordinators or other designated representative of the Disciplinary Board to contact the person in charge of the subject's supervision for information, including written documentation, in order to evaluate the progress of the subject's supervision (pursuant to subsection (g)(2));

7) If the subject of the report is in a program of rehabilitation, the name, address, and telephone number of the program and the name and position of any individual in charge of the program; and

8) Any other information deemed by the reporting person to be of assistance to the Disciplinary Board and the Medical Coordinators in evaluating the report, including but not limited to the following items: drug screens being used and their status; relapses and actions taken; attendance at work; observations of recovery status and level of cooperation in recovery; other psychopathology, known and related physical and mental illnesses; involvement of the family and others in treatment or supervision; and a copy of the aftercare agreement.

c) Reports of impaired persons shall be submitted to the Disciplinary Board in a timely manner. The initial report shall be submitted on forms provided by the Division within 60 days after it is determined that a report is necessary under the Act and this Part. Periodic reports that evidence written documentation of the progress of suspension or rehabilitation shall be submitted to the Disciplinary Board every 6 months, commencing with the time of the filing of the initial report. A copy of each report shall be sent by the person making the report to the impaired person.

d) Confidentiality

1) The contents of any report shall be strictly confidential, except as otherwise provided in this subsection (d), and exempt from public disclosure, but may be reviewed by:

A) Members of the Disciplinary Board or their designees;

B) The Disciplinary Board's designated attorneys;

C) The Medical Coordinators or their designees;

D) Administrative personnel assigned to open mail containing reports and to process and distribute reports to authorized persons, and to communicate with senders of reports; and

E) The person who is the subject of the report or that person's attorney or authorized representative (as evidenced by a written authorization signed by the person who is the subject of the report).

2) The reports may also be handled or processed by other designated persons in a limited manner necessary to implement reports required under the Act by computer, word processing equipment or other mechanical means. The data record shall be limited to the name and address of the originator of the report, the date the initial report was received, the date of the most recent report and the professional license number of the subject of the report.

3) The contents of the confidential reports relating to impaired persons shall not be used or made available in any other administrative proceedings before the Division or any other department; however, violations of the treatment or supervision plan will result in a review of the person's status by the Disciplinary Board, the Medical Coordinators or their designees for possible discipline or revision in the treatment or supervision plan. Reports shall not be disclosed, made available or subject to subpoena or discovery proceedings in any civil or criminal court proceedings.

e) Upon a determination by the Disciplinary Board that reports on an impaired person no longer require review and consideration, the Disciplinary Board shall notify the maker of the reports to cease sending the reports and the Board and Division records shall be purged of information contained in the reports. These determinations shall be based on, but not be limited to: the type of impairment and the type of rehabilitation program, length of supervision, occurrence of any relapses and present status of license.

f) Whenever any chief administrative or chief executive officer of any health care institution makes a report or provides other information to the Disciplinary Board, or assists the Disciplinary Board concerning an impaired person, acts in good faith, and not in a willful and wanton manner, the chief administrative or chief executive officer, and the health care institution employing him, shall not, as a result of such actions, be subject to criminal prosecution or civil damages (Section 23(c) of the Act).

g) The following definitions shall apply to this Section:

1) "Impaired" means the inability to practice medicine with reasonable skill and safety due to physical and mental disabilities as evidenced by a written evaluation or clinical evidence that reveals a deterioration of the physician's ability to deliver competent care, due to problems related to aging, loss of motor skill, abuse of drugs or alcohol, or mental illness.

2) "Under supervision" means that the performance of the impaired person's clinical privileges and status of the person's impairment is being observed and monitored under the authority of a written directive issued in accordance with a health care institution's or medical staff's bylaws or rules and regulations.

Ill. Admin. Code tit. 68, § 1285.235

Amended at 29 Ill. Reg. 18823, effective November 4, 2005