AUTHORITY: Implementing Section 3 of the Community Services Act [405 ILCS 30/3] and Sections 5-1 through 5-11 of the Public Aid Code [305 ILCS 5/5-1 through 5-11] and authorized by Section 5-104 of the Mental Health and Developmental Disabilities Code [405 ILCS 5/5-104] and Section 5 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705/5].

SOURCE: Adopted and codified at 7 Ill. Reg. 15630, effective November 9, 1983; emergency amendment at 16 Ill. Reg. 2652, effective February 1, 1992, for a maximum of 150 days; emergency expired June 30, 1992; amended at 18 Ill. Reg. 15600, effective October 5, 1994; amended at 20 Ill. Reg. 4762, effective March 8, 1996; recodified from the Department of Mental Health and Developmental Disabilities to the Department of Human Services at 21 Ill. Reg. 9321; emergency amendment at 22 Ill. Reg. 12185, effective June 24, 1998, for a maximum of 150 days; emergency expired November 21, 1998; amended at 22 Ill. Reg. 22399, effective December 8, 1998; amended at 48 Ill. Reg. 5279, effective March 21, 2024.

SUBPART A: GENERAL PROVISIONS

 

Section 120.10  Definitions

 

For the purposes of this Part, the following terms are defined:

 

"Abuse."  See full definitions for physical abuse, sexual abuse, mental abuse, and financial exploitation in 59 Ill. Adm. Code 50.10.

 

"Adult." An individual aged eighteen (18) or older.

 

"Children's Group Home (CGH)."  A residential service within the DD Children's Residential Waiver, for children and adolescents (ages 3-21) with developmental disabilities, that is designed to provide a structured environment to children and adolescents who cannot reside in their own home.  These settings are licensed by DCFS under Title 89, Chapter III, Subchapter e.

 

"Code."  The Mental Health and Development Disabilities Code [405 ILCS 5].

 

"Coercion."  Occurs when an Individual, guardian, or family member is compelled by force, intimidation, or threat to act in a manner contrary to how that person would have acted if permitted to act in accordance with their free and informed choice.

 

"Community Day Service (CDS)."  A Home and Community-Based certified day program that provides assistance with gaining, maintaining, and/or improving skills and functioning to Individuals with developmental disabilities.  Services can reinforce skills or strategies taught in other settings and may include training and supports to help prevent or slow the loss of skills. CDS takes place in a non-residential setting, separate from the participant's residential setting, whether individually-owned, controlled or other. CDS can be provided in a site certified by the Department (site-based CDS) or in community locations where members of the general community typically congregate (non-site-based CDS). CDS activities shall promote greater independence and support full access to the general community to the same degree as persons not receiving HCBS Waiver services.

 

"Community Integrated Living Arrangement (CILA)."  A living arrangement certified by the Department where eight or fewer Individuals with a developmental disability reside together in a home under the supervision of the agency and are provided with an array of services. [210 ILCS 135/3(d)]

 

"Community living facility (CLF)."  A transitional residential setting licensed by the Department of Public Health (77 Ill. Adm. Code 370.240) that serves individuals with developmental disabilities in skill training programs that provide guidance, supervision, training and other assistance, with the goal of eventually assisting individuals in moving to independent living. Individuals are encouraged to participate in day activities, Community Day Services, Supported Employment, or regular employment. A CLF shall not be a nursing or medical facility and shall serve no more than 20 Individuals [210 ILCS 35/3]. CLFs that serve 16 or fewer Individuals are a part of the Adults with Developmental Disabilities Waiver.

 

"Confidentiality Act."  The Mental Health and Developmental Disabilities Confidentiality Act [740 ILCS 110].

 

"Conflict of interest free case management."  Separation of entities that provide HCBS Waiver services and those that conduct activities that include, but are not limited to determining eligibility for HCBS Waiver services, helping individuals gain access to HCBS Waiver services, developing and/or monitoring the person-centered plan (case management activities).  Case management activities cannot be conducted by a relative of the person served, a direct provider of service, someone who has a financial interest in a provider or who is employed by a provider (42 CFR 441.301(c)(1)(vi)).

 

"Day."  A calendar day, unless otherwise indicated.

 

"Department." The Department of Human Services (DHS).

 

"Developmental disability (DD)."  An intellectual disability or other severe, chronic disability, other than mental illness, found to be closely related to an intellectual disability (ID) because this condition results in an impairment of general intellectual functioning or adaptive behavior similar to that of persons with ID and requires services similar to those required for a person with an ID. In addition, a developmental disability is manifested before the person reaches 22 years of age, is likely to continue indefinitely, results in substantial functional limitations in three or more of the following areas of major life activity:  self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, or economic self-sufficiency; and reflects the person's need for a combination and sequence of special interdisciplinary or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

 

"Division of Developmental Disabilities (DDD)" or "Division."  The Department's Division of Developmental Disabilities.

 

"Grant agreement." When fully executed the obligating instrument providing the basis for Departmental financial participation in grant-in-aid programs and which formalizes the written relationship between the Department and the provider, indicating the amount of Department funds which may be paid to the provider for the provision of services as described in the grant agreement and the agency plan. Requirements for grant-in-aid funded providers are contained in the Department's rules at 59 Ill. Adm. Code 103.

 

"Guardian."  The plenary or limited guardian or conservator of the Individual appointed by the court for an Individual over age 18 (when the limited guardian's duties encompass concerns related to service requirements), the natural or adoptive parent of a minor, or a person acting as a parent of a minor.  All references in this Part to an "Individual and/or guardian" include the guardian only if applicable.

 

"Habilitation."  An effort directed toward increasing the level of physical, mental, social or economic functioning of an Individual with a developmental disability. Additionally, habilitation may include efforts to prevent loss of skills or to decelerate loss of function. Habilitation may also include, but is not limited to, diagnosis, evaluation, medical services, personal care, day care, special living arrangements, training, education, employment-related services, supported employment, protective services, counseling and other services provided to Individuals with developmental disabilities by developmental disabilities programs. [405 ILCS 5/1-111]

 

"HFS."  The Illinois Department of Healthcare and Family Services.

 

"Home and Community-Based Services (HCBS) Waiver."  A federally-approved Medicaid program which allows services that support Individuals to remain in their own homes or live in a community setting, instead of an institution. HCBS is person-centered care which is delivered in the home and community.

 

"Individual." A person with developmental disabilities who is requesting, is receiving, or has received services under this Part.

 

"Implementation Strategy."  A document developed by a licensed or certified provider agency, in conjunction with the Individual and the Individual's guardian, that describes and directs the activities and methods used to provide services and supports for the areas of an Individual's Personal Plan for which the provider agency has agreed to be responsible. The priorities, strengths, support needs, and risk factors identified in the Personal Plan must be addressed and accounted for in the Implementation Strategy for those areas of the provider agency's responsibility. The document must describe how the provider agency will support the Individual to pursue the outcomes included in the Personal Plan and be approved by the Individual and/or guardian.

 

"Independent Service Coordination (ISC) agency."  An entity designated by DDD to carry out federal and State requirements related to assessment, determination of eligibility, and service coordination for Individuals with a developmental disability. This entity provides conflict of interest-free case management, including development and monitoring of an Individual's Personal Plan, to DD Medicaid HCBS Waiver participants. They also serve as the front line for information and assistance to help Individuals and families navigate the system, ensure informed choice, link Individuals to services, and address problems related to outcomes and quality.

 

"Individually-owned or -controlled."  A physical setting in which the Individual resides that is owned, co-owned, leased, or rented by the Individual. This setting is not provider-owned or -controlled.

 

"Intellectual disability."  A disorder with onset during the developmental period (before the person reaches age 22), that includes both intellectual and adaptive deficits in conceptual, social, and practical domains. The following three criteria must be present:

 

Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience confirmed by both clinical assessment and individualized, standardized intelligence testing (generally indicated with an IQ score of 70 or below);

 

Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community; and

 

Onset of intellectual and adaptive deficits during the developmental period.

 

"Intermediate care facility for individuals with Intellectual Disabilities (ICF/DD)."  A facility that meets the standards specified in 42 CFR 483, Subpart I.

 

"Modification."  Altering or limiting the conditions in a provider-owned or -controlled residential setting as specified in 42 CFR 441.301(c)(2)(xiii) and Section 120.70(d)(6)(A) through (E).  Modifications must be supported by a specific assessed need and justified in the Personal Plan.

 

"Natural supports."  Unpaid assistance provided to a person with a mental illness or developmental disability, typically by a person who has some type of friendship, kinship, or other relationship (e.g., co-worker, member of the same social group) with the person, whom the person accepts into their life and with whom the person has chosen to spend time. A natural support includes an informal agreement to assist in a particular way for some duration of time and not just a one-time action done out of courtesy.

 

"Neglect."  See full definition of neglect found in 59 Ill. Adm. Code 50.10.

 

"Person-centered planning."  A process that addresses health and long-term services and support needs in a manner that reflects Individual preferences and outcomes. The planning process, and the resulting Personal Plan, will assist the Individual in achieving personally-defined outcomes in the most integrated community setting, ensure delivery of services in a manner that reflects personal preferences and choices, and contribute to the assurance of health and welfare.

 

"Personal Plan."  A written document developed by an ISC agency in conjunction with the Individual and guardian, as well as family members, providers of services, and others (e.g., friends or Individual's representatives) as chosen by the Individual and guardian, that includes an assessment of the Individual's strengths, preferences, needs, and desired outcomes. The document describes what is important to the Individual regarding delivery of services in a manner which ensures both personal preferences and health and welfare, including risk factors and means to minimize them. It includes the services that are to be furnished to the Individual, the amount and frequency of each service, and the type of provider to furnish each service.

 

"Program."  The Medicaid Home and Community-Based Services Waiver Programs implemented in this Part.

 

"Provider."  A community developmental services organization in accordance with Chapter 805 of the Illinois Compiled Statutes, that is under an agreement with the Department to provide HCBS Waiver services for Individuals with a developmental disability.

 

"Provider-owned or -controlled."  A physical setting in which the Individual resides that is owned, co-owned, leased, or rented by a provider of HCBS or is owned, co-owned, leased, or rented by a third party that has a direct or indirect financial relationship with a provider of HCBS.

 

"PUNS."  A database of Illinois children, adolescents, and adults who are presumed to have a developmental disability and want or need services in a developmental disability Home and Community Based Services Waiver program.

 

"Qualified Intellectual Disabilities Professional (QIDP)."  A QIDP must have at least one year of experience working directly with Individuals with intellectual disabilities or other developmental disabilities (including individuals who are dually diagnosed with an ID/DD and mental illness or other diagnosis) and be one of the following:

 

A doctor of medicine or osteopathy licensed pursuant to the Medical Practice Act of 1987 [225 ILCS 60].

 

A registered professional nurse licensed pursuant to the Nurse Practice Act [225 ILCS 65].

 

An occupational therapist or occupational therapist assistant certified by the American Occupational Therapy Association or other comparable body (Illinois Occupational Therapy Practice Act [225 ILCS 75]).

 

A physical therapist certified by the American Physical Therapy Association or other comparable body (Illinois Physical Therapy Act [225 ILCS 90]).

 

A physical therapist assistant registered by the American Physical Therapy Association or a graduate of a two-year college-level program approved by the American Physical Therapy Association or comparable body.

 

A psychologist with at least a master's degree in psychology from an accredited school (Clinical Psychologist Licensing Act [225 ILCS 15]).

 

A social worker with a bachelor's degree from a college or university or graduate degree from a school of social work accredited or approved by the Council on Social Work Education or another comparable body (the Clinical Social Work and Social Work Practice Act [225 ILCS 20]).

 

A speech-language pathologist or audiologist with a certificate of Clinical Competence in Speech-Language Pathology or Audiology granted by the American Speech Language Hearing Association or comparable body or who meets the education requirements for licensure and is in the process of accumulating the supervised experience required for licensure (the Illinois Speech-Language Pathology and Audiology Practice Act [225 ILCS 110]).

 

A professional recreation staff person with a bachelor's degree in recreation or in a specialty area such as art, dance, music, or physical therapy.

 

A professional dietitian registered with the Commission on Dietetic Registration (Dietitian Nutritionist Practice Act [225 ILCS 30]); or

 

A human services professional with a bachelor's degree in a human services field, including, but not limited to sociology, special education, rehabilitation counseling, or psychology.

 

"Quality assurance review."  The Division's Bureau of Quality Management's (BQM) process to determine the degree of compliance with quality assurance requirements in this Part that a provider agency has maintained. This can include reviewer observation and an on-site examination, desk audit, remote or virtual form of examination of the following:  policies, procedures, records of Individuals, written Personal Plan, and Implementation Strategies. Reviewers shall use an instrument containing standard indicators to interview Individuals and employees. Observation of a sample of Individuals, drawn from across provider agency sites statewide, is also a part of the review.

 

"Restraint."  The direct restriction through mechanical means or personal physical force of the limbs, head or body of an Individual except as part of a medically prescribed procedure for the treatment of an existing physical disorder or the amelioration of a physical disability. The partial or total immobilization of an Individual for the purpose of performing a medical or surgical procedure shall not constitute restraint. Momentary periods of physical restriction by direct person-to-person contact, without the aid of material or mechanical devices, accomplished with limited force, and that are designed to prevent a recipient from completing an act that would result in potential physical harm to themselves or another shall not constitute restraint, but shall be documented in the Individual's record [405 ILCS 5/1-125]

 

"Restriction."  Altering or limiting an Individual's rights outlined in Section 120.100.

 

"Seclusion."  Sequestration by placement of an Individual alone in a room from which the Individual has no means of leaving; seclusion is prohibited. [405 ILCS 5/1-126]

 

"Secretary."  The Secretary of the Department of Human Services or their designee.

 

"Service coordination."  The coordination and monitoring of supports to assist an Individual in planning and evaluating necessary services to ensure a comprehensive array of supports and services to meet an Individual's needs, personal goals, and choices, as defined in the Individual's Personal Plan.

 

"Supported employment program (SEP)."  Intensive supports provided to Individuals with developmental disabilities to obtain and sustain full-time or part-time paid work (at or above minimum wage) in an integrated business, industry, or community setting. Individuals participating in SEP shall be provided opportunities for advancement similar to those employees without disabilities who have similar positions. Supports shall occur at locations where the Individual interacts with employees without disabilities, as well as regular interaction with persons who are not paid caregivers or service providers. Supports may be provided individually or in group settings of no more than six Individuals with disabilities. Individuals in SEP shall not be isolated from individuals who do not have disabilities.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.20  Purpose

 

a)         The intent of this Part is to provide uniform direction for providers, Individuals, and guardians enrolled in one of the following Medicaid Home and Community-Based Services (HCBS) Waiver Programs:

 

1)         Adults with Developmental Disabilities Waiver;

 

2)         The Children's Residential Waiver; or

 

3)         The Children's Support Waiver.

 

b)         This Part also provides direction to Independent Service Coordination (ISC) agencies regarding case management activities.

 

c)         The Illinois Department of Healthcare and Family Services (HFS) is the single State Medicaid Agency designated to administer and oversee the administration of the Medicaid program under Title XIX, Medical Assistance, of the Social Security Act (42 U.S.C. 1395a (2018) and 42 CFR 431 (2017)) and the Illinois Public Aid Code [305 ILCS 5].

 

d)         The Department is designated as a State Operating Agency having primary responsibility for administering the delivery of HCBS Waiver programs for Individuals with developmental disabilities under the Code.

 

e)         HFS and the Department have entered into an interagency agreement to specify their respective roles and responsibilities regarding the HCBS Waiver Program for Individuals with developmental disabilities.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.25  Incorporation by reference

 

Any rules of an agency of the United States or of a nationally-recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified and do not include any later amendments or editions.

 

(Source:  Added at 20 Ill. Reg. 4762, effective March 8, 1996)

 

Section 120.30  Program description (Repealed)

 

(Source:  Repealed at 20 Ill. Reg. 4762, effective March 8, 1996)

 

Section 120.40  Service descriptions

 

a)         The services covered under the Medicaid HCBS Waiver Programs shall be rendered as specified by the Division, in accordance with a written Personal Plan and Implementation Strategy and shall be designed to ensure the continuity of supports and services for Individuals. HCBS Waiver services, for the purpose of this Part, do not include:

 

1)         Special education and related services (as defined in Section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C.A. 1400 (2015)) which otherwise are available to the Individual through a local education agency; or

 

2)         Vocational rehabilitation services which otherwise are available to the Individual though a program funded under Section 110 of the Rehabilitation Act of 1973 (20 U.S.C.A. 794 (2018)).

 

b)         HCBS residential habilitation services shall promote the health, safety, and well-being of Individuals receiving such services.  These services are designed to assist children/adolescents and adults in acquiring, retaining, and improving skills related to living in the community. These services include, but are not limited to, self-help, socialization, community inclusion, daily living, and adaptive skills necessary to reside successfully in HCBS Waiver settings.

 

c)         Day and employment services are provided to adults enrolled in the Adults with Developmental Disabilities Waiver program and are intended to enhance Individual life skills, community and social skills, work-related activities, and employment skills.

 

d)         HCBS Home Based Support Services (HBS) is an individually designed program of separately-covered services, or assessment of the need for these services, to assist Individuals to live in a private family home or an individually-owned or -controlled home. HBS has a monthly dollar cost maximum set by the Department that will be communicated by an award letter at the time of program enrollment. All services provided must be for the direct benefit of the Individual and must be directly related to their disability. HBS, and the services available within the program, are further detailed at 59 Ill. Adm. Code 117.

 

e)         HCBS Waivers provide a variety of other services and supports to address an Individual's habilitation, mobility, emotional, cognitive, or behavioral needs. The services must be included in the Personal Plan and can be provided in a variety of ways including, but not limited to, direct support and/or treatment, evaluations, intervention strategies, staff training, equipment, environmental changes, and emergency supports. HCBS Waiver services can be combined with State Medicaid Plan services to support an Individual's needs.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.50  Target population

 

Individuals to be served under this Part are Medicaid-eligible Illinois adults and children with developmental disabilities who otherwise would require ICF/DD (42 CFR 440.150) level of care.  Adults entering the Adults with Developmental Disabilities Waiver must be at least age 18 years or older. Children entering the Children's Residential or Children's Support Waiver must be at least age 3 years old and can remain through age 21. Individuals served shall meet Illinois Medicaid eligibility standards, non-financial eligibility criteria under this Part, and be:

 

a)         Residents of State-operated facilities who are able to live in the community and/or who prefer services in an HCBS Waiver;

 

b)         On PUNS, including Individuals currently living at home, living in private ICF/DDs and living in Medically Complex facilities for persons with Developmental Disabilities;

 

c)         Individuals being subjected to abuse, neglect, homelessness; or

 

d)         Youth who are 18 years or older, but prior to their 22^nd birthday, residing as an adult in a DDD child group home;

 

e)         Illinois Department of Children and Family Services youth in care who are 18 years or older, but prior to their 22^nd birthday;

 

f)         A Bogard class member, i.e., certain Individuals with developmental disabilities who currently reside or previously resided in a nursing facility; or

 

g)         Part of a DHS Intermediate Care Facility for Individuals with Developmental Disabilities (ICF/DD) Downsizing.  The ICF/DD must have an agreement with the Division.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

SUBPART B: SYSTEM COMPONENTS

 

Section 120.60  Overview (Repealed)

 

(Source:  Repealed at 20 Ill. Reg. 4762, effective March 8, 1996)

 

Section 120.65  Conflict of interest-free case management

 

a)         The Department shall contract ISC agencies to provide conflict of interest-free case management, as described in 42 CFR 441.301(c)(1)(vi).

 

b)         Case management shall include, but not be limited to: 

 

1)         Determination of eligibility. In accordance with Section 120.140, the Department has the responsibility to oversee the accuracy, quality, and appropriateness of functions provided by ISC agencies and reserves the right to review and approve or reject determinations of eligibility made by ISC agencies.

 

2)         Development and annual update of the Personal Plan as described in 42 CFR 441.301(c)(1)(vi) and Section 120.160(b).

 

3)         Enrolling and maintaining Individuals in PUNS.

 

4)         Ensuring the provision of informed choice of all services (including State Plan, entitlement services, unpaid, and natural supports) and providers.

 

5)         Collaboration with service providers to ensure Individual's health, safety, welfare, well-being, and satisfaction with services funded by DDD, and as such, addressing problems related to outcomes and quality.

 

6)         Supporting Individuals, including but not limited to, advocacy, exercising rights, and securing and maintaining services.

 

c)         Conflict of interest occurs when the entity providing case management is:

 

1)         A provider agency or a person who has an interest in, or who is employed by, a provider.

 

2)         A person who is related by blood or marriage to the Individual or to any paid caregiver of the Individual.

 

3)         A person who is financially responsible for the Individual.

 

4)         A person who is empowered to make financial or health-related decisions for the Individual.

 

(Source:  Added at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.70  Service provider requirements

 

a)         New and current provider agencies must be enrolled as a Medicaid provider in the Illinois Medical Program Advanced Cloud Technology (IMPACT) system with HFS.

 

b)         The provider shall meet Department standards applicable to the specific services to be provided and shall demonstrate competency to provide services.

 

c)         Service providers shall:

 

1)         Meet the fiscal, program, and reporting requirements of the Medicaid HCBS Waiver programs

 

2)         Be willing to serve eligible individuals from a variety of backgrounds including, but not limited to, former or potential residents of State-operated facilities or ICF/DDs; 

 

3)         Comply with applicable Medicaid provider requirements, appropriate licensure procedures, and/or standards, as well as Department operational procedures for purchase of service or grant programs (see the Department's Rules at 59 Ill. Adm. Code 103, 113, 115 and 119); and

 

4)         Comply with intake, assessment, monitoring, and billing procedures established for services under this Part.

 

d)         Provider-owned or -controlled residential and non-residential settings must have all of the following qualities, and other qualities as determined to be appropriate, based on the needs of the Individual as indicated in their Personal Plan (42 CFR 441.301(c)(4)): 

 

1)         Be integrated in and support full access of Individuals receiving Medicaid HCBS to the greater community, including opportunities to: 

 

A)        Seek employment and work in competitive integrated settings;

 

B)        Engage in community life, to the extent chosen by the Individual;

 

C)        Control personal resources; and

 

D)        Receive services in the community, to the same degree of access as Individuals not receiving Medicaid HCBS.

 

2)         Be selected, with the assistance of the ISC agency, by the Individual from among setting options including non-disability specific settings and an option for a private bedroom or unit in a residential setting. The setting options are identified and documented by the ISC agency in the Personal Plan and are based on the Individual's needs, preferences, and, for residential settings, resources available for room and board.  When feasible, the provider agency should offer the option for a private bedroom or unit in a residential setting.

 

3)         Ensure an Individual's rights to privacy, dignity and respect, and freedom from coercion and restraint.

 

4)         Optimize, but not regiment, Individual initiative, autonomy, and independence in making life choices, including, but not limited to, daily activities, physical environment, and with whom to interact.

 

5)         Facilitate Individual choice regarding services and supports and who provides them.

 

6)         Provider-owned or -controlled residential settings, in addition to the qualities described in subsections (d)(1) through (d)(5), must meet the following additional conditions:

 

A)        The residential setting is a specific physical place that can be owned, rented, or occupied under a legally-enforceable agreement (consistent with the guidelines issued by the Department) by the Individual receiving services, and the Individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the State, county, city, and/or other designated entity. For settings in which landlord/tenant laws do not apply, the State must ensure that a lease, residency agreement, or other form of written agreement, as determined by the Department, will be in place for each HCBS participant, and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord/tenant law.

 

B)        Each Individual has privacy in their residential setting.

 

i)          Residential settings shall have entrance doors lockable by the Individual, with only appropriate staff having keys to doors.

 

ii)         Individuals sharing a residential setting shall have a choice of roommates in that setting.

 

iii)        Individuals shall have the freedom to furnish and decorate their residential setting within the lease or other agreement.

 

C)        Individuals have the freedom and support to control their own schedules and activities and have access to food at any time.

 

D)        Individuals can have visitors of their choosing at any time.

 

E)        The setting is physically accessible if required by the needs of any Individuals served in the setting.  Providers should access all available resources, through the Division and community, to accommodate accessibility needs. All communal areas must meet standards set forth by the ADA and other federal, State, or municipal regulations. Providers must ensure sites are certified and have capacity for a non-ambulatory Individual before offering placement. The non-ambulatory capacity is indicated in the certification letter given to each provider by the Department for every site.

 

F)         Any modification of the additional conditions, under subsections (d)(6)(A) through (E), must be supported by a specific assessed need and justified in the Personal Plan. The following requirements must be documented in the Personal Plan and Implementation Strategy:

 

i)          Identify a specific and individualized assessed need.

 

ii)         Document the positive interventions and supports used prior to any modifications to the Personal Plan.

 

iii)        Document less intrusive methods of meeting the need that have been tried but did not work.

 

iv)        Include a clear description of the condition that is directly proportionate to the specific assessed need.

 

v)         Include regular collection and review of data to measure the ongoing effectiveness of the modification.

 

vi)        Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.

 

vii)       Include the informed consent of the Individual and guardian.

 

viii)      Include an assurance that interventions and supports will cause no harm to the Individual.

 

e)         Providers who deliver authorized services to Individuals determined eligible under the Medicaid HCBS Waiver Programs shall be paid by the Department on a monthly basis on submission of service reports/billing statements.

 

f)         Providers shall cooperate with:

 

1)         Quality assurance reviews, monitoring, evaluations, information requests (conducted by the Department, HFS, or by other entities that are authorized by the Department or HFS, such as ISC agencies, auditors, or evaluators) and when necessary, sanctions.  Prior to initiating formal action to sanction a provider agency, the Department will allow the provider an opportunity to take corrective action to eliminate or ameliorate a deficiency except in cases in which the Department determines that emergency action is necessary to protect the public or individual interest, safety, or welfare.

 

2)         Licensure and certification surveys, monitoring, evaluations and information requests, (conducted by the Department) and when necessary, sanctions.  The Department will conduct onsite surveys of providers to ensure that they maintain compliance with established rules, regulations, and standards. Providers who fail to comply with the established rules, regulations, and standards set forth by the Department shall receive sanctions that include hold on admissions or payment, decertification of a site, and licensure revocation. Once a provider comes into compliance, the sanction shall be lifted, and the Department will proceed with the required survey process unless the Department has decertified a site or revoked the license in which case the sanction will not be lifted.

 

g)         Provider agencies shall only use Restraint as allowed and directed pursuant to statutes and administrative rules applicable to the program (i.e., 59 Ill. Adm. Code 115, 59 Ill. Adm. Code 119, 77 Ill. Adm. Code 370, 89 Ill. Adm. Code 384, 89 Ill. Adm. Code 401, 89 Ill. Adm. Code 403, 210 ILCS 35/18, and 405 ILCS 5). If any type of Restraint not allowed and/or directed by administrative rule applicable to the program is utilized by an Agency employee, the incident must be reported via the Critical Incident Reporting and Analysis System (CIRAS) as well as reported to the Office of the Inspector General.

 

h)         When a provider determines it will reduce, suspend, or terminate services to an Individual in an HCBS Waiver Program, the agency must do so according to the following, unless specified otherwise in the statutes or administrative rules applicable to the program (i.e., 59 Ill. Adm. Code 115, 59 Ill. Adm. Code 119, 77 Ill. Adm. Code 370, 89 Ill. Adm. Code 384, 89 Ill. Adm. Code 401, 89 Ill. Adm. Code 403, 210 ILCS 35/18, and 405 ILCS 5): 

 

1)         A provider agency shall terminate its services if an Individual or guardian chooses either of the following actions, both of which are considered voluntary, and the termination is not appealable: 

 

A)        An Individual transfers to another qualified provider; or

 

B)        An Individual or Individual's guardian withdraws the Individual from the provider agency's services (with no intention of returning).

 

2)         A provider agency may involuntarily reduce, suspend, or terminate services to an Individual for the following reasons: 

 

A)        The medical needs of the Individual cannot be met by the provider agency as documented in the Individual's record.

 

B)        The behavioral needs of an Individual cannot be met by the provider agency to ensure the physical safety of the Individual and/or others as documented in the Individual's record.

 

3)         A notice of reduction, suspension, or termination issued by a provider agency, must:

 

A)        Be in writing.

 

B)        Be sent to the Individual, guardian, and ISC agency.

 

C)        Include a time frame for the action. For involuntary terminations, the provider shall issue the Individual and guardian at least a 30-day notice, except in emergency situations as described in Section 120.110(i).

 

D)        Provide a clear statement of the action to be taken.

 

E)        Provide a clear statement of the reason for the action.

 

F)         Include a complete statement of the Individual's right to appeal, including the provider's grievance process; it must also include the Department's informal review process and HFS' hearing process as described in Section 120.110.

 

i)          Appeals by providers.  Provider agencies may appeal the Department's administrative decisions (i.e., licensure or certification denial, notice of deficiencies), and request an administrative hearing as outlined in 89 Ill. Adm. Code 508.  Providers may not appeal the Department's decisions related to discharge, termination, or reduction of services to an Individual.

 

1)         As the single State Medicaid agency, HFS is responsible for conducting all provider administrative hearings and rendering the final administrative decision.  The appeal requirements and process are contained in HFS's rules at 89 Ill. Adm. Code 104.200 through 104.210.

 

2)         The Department shall conduct informal reviews of provider appeals to attempt to resolve issues without a formal administrative hearing.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.80  Program assurances

 

In addition to program requirements specified in other Sections of this Part, assurances for the Medicaid HCBS Waiver Program will include:

 

a)         Level of care determination

An evaluation and periodic (at least annual) reevaluations of the Individual's need for the level of care provided in an ICF/DD, as defined by 42 CFR 483.400 through 483.480, shall be conducted for an Individual when there are indications (see 42 CFR 483.440 (a)) that the Individual might need such services in the near future.

 

b)         Informing Individuals of choice

All Individuals participating in HCBS Waivers must have a Personal Plan (see Section 120.160) which facilitates Individual choice regarding services and supports, and who provides them, per 42 CFR 441.301(c)(4)(v).

 

c)         Average per capita expenditures

The average per capita Medicaid expenditures, including HCBS Waiver services, will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State Plan for the levels of care specified for this waiver had the waiver not been granted. The State must therefore limit participating Individuals and expenditures under this program to meet the per capita cost requirements.

 

d)         Rate methodology

Rates for reimbursement of program services shall be established by the Department and approved by HFS. Rate levels shall be determined for each type of Medicaid HCBS Waiver service by unit of service provided, e.g., per hour, per day. Providers shall receive written notification of rates and rate changes at least annually.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.90  Department audit

 

The Department requirements for service providers annual audits are found in 89 Ill. Adm. Code 507 Section.

 

(Source:  Amended at 22 Ill. Reg. 22399, effective December 8, 1998)

 

Section 120.95  Electronic Signatures

 

a)         Electronic signature or computer-generated signature codes are acceptable as authentication of record content.

 

b)         In order for a provider or ISC agency to employ electronic signatures or computer-generated signature codes for authentication purposes, the provider or ISC agency must adopt a policy that permits authentication by electronic or computer-generated signature.

 

c)         At a minimum, the electronic or computer-generated signature policy shall include adequate safeguards to ensure confidentiality of the codes, including, but not limited to, the following:

 

1)         Each user must be assigned a unique identifier that is generated through a confidential access code.

 

2)         The provider or ISC agency must certify in writing that each identifier is kept strictly confidential.  This certification must include a commitment to terminate a user's use of a particular identifier if it is found that the identifier has been misused.  "Misused" shall mean that the user has allowed another person or persons to use their personally assigned identifier, or that the identifier has otherwise been inappropriately used.

 

3)         The user must certify in writing that the user is the only person with user access to the identifier and the only person authorized to use the signature code.

 

4)         The provider or ISC agency must monitor the use of identifiers periodically and take corrective action as needed.  The process by which the provider or ISC agency will conduct monitoring shall be described in the electronic or computer-generated signature policy.

 

d)         A system employing the use of electronic signatures or computer-generated signature codes for authentication shall include a verification process to ensure that the content of authenticated entries is accurate.  The verification process shall include, at a minimum, the following provisions:

 

1)         The system shall require completion of certain designated fields for each type of document before the document may be authenticated, with no blanks, gaps, or obvious contradictory statements appearing within those designated fields.  The system shall also require that correction or supplementation of previously authenticated entries shall be made by additional entries, separately authenticated, and made subsequent in time to the original entry.

 

2)         The system must make an opportunity available to the user to verify that the document is accurate and the signature has been properly recorded.

 

3)         The provider or ISC agency must periodically sample records generated by the system to verify the accuracy and integrity of the system.

 

e)         Each document generated by a user must be separately authenticated.

 

(Source:  Added at 48 Ill. Reg. 5279, effective March 21, 2024)

SUBPART C: INDIVIDUAL RIGHTS AND RESPONSIBILITIES

 

Section 120.100  Overview of rights

 

a)         Observation and protection of rights of Individuals

 

1)         The observation and protection of rights of Individuals receiving developmental disability services in the public and the private sector as set forth in Chapter 2 of the Code, except that the use of Seclusion will not be permitted, are applicable to all Sections of this Part.

 

2)         Individuals receiving HCBS Waiver services must be free from:

 

A)        Abuse, neglect, and financial exploitation, pursuant to 59 Ill. Adm. Code 50.10.

 

B)        Seclusion and coercion.

 

C)        Restraint (other than what is allowed and directed pursuant to statutes and administrative rules applicable to the program (i.e., 59 Ill. Adm. Code 115, 59 Ill. Adm. Code 119, 89 Ill. Adm. Code 401, 89 Ill. Adm. Code 403, 89 Ill. Adm. Code 384, 210 ILCS 35/18, and 77 Ill. Adm. Code 370).

 

3)         Service providers shall ensure that Individuals, guardians, and others designated by the Individual receive a complete explanation of their rights, as documented in the IL 462-1201 form, and responsibilities at the time of service initiation, annually thereafter, and on request.

 

4)         The ISC shall complete the Rights of Individuals form (IL 462-1201) with Individual and/or guardian signing the document at the time of service initiation, annually thereafter, and on request.

 

5)         The justification for any restriction of Individual's HCBS Waiver rights, as indicated in Section 120.70(e)(6)(A) through (E), shall be: 

 

A)        Documented in the Individual's Personal Plan and Implementation Strategy pursuant to Section 120.160.

 

B)        Reviewed and approved by the provider agency's Human Rights Committee before the restriction is implemented.

 

6)         An Individual's confidentiality shall be governed by the Mental Health and Developmental Disabilities Confidentiality Act [740 ILCS 110].

 

b)         Non-discrimination

In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d (2009)), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794 (2015)), the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 through 12213 (2008) and 47 U.S.C. 225 and 611 (2010)) and the regulations at 45 CFR 80 (2005) and 45 CFR 84 (2010), the Department assures that no Individual shall be subjected to discrimination under this Part on the grounds of race, color, sex, religion (creed), gender identity, gender expression, age, national origin (ancestry), ethnicity, disability, marital status, sexual orientation, or military status.

 

c)         Confidentiality of case information

For the protection of Individuals, any information about an Individual or case is confidential and may be used only for purposes directly related to the administration of the Medicaid HCBS Waiver Programs. The Department and service providers shall inform all entities to whom information is furnished that this material is confidential, subject to the provisions of the Confidentiality Act, and shall be so considered by the entity. An authorization for release of information shall be used to secure the Individual's or guardian's consent to share information.

 

d)         Notice of action.  Individuals requesting or receiving HCBS Waiver services have the right to:

 

1)         A written notice of:

 

A)        Denial of clinical eligibility by the Division or an ISC agency;

 

B)        Denial of service(s) by the Division; and

 

C)        Reduction, suspension, or termination of HCBS Waiver services by the Division or a provider agency.

 

2)         Appeal the decision disposition (reduction, suspension, termination, or denial of HCBS services) pursuant to Section 120.110.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.110  Appeals and fair hearings

 

a)         The Individual, parents, guardian, or the Individual's representative may appeal the following actions:

 

1)         Refusal of the Division or ISC agency to accept a request for Waiver program enrollment.

 

2)         Failure of the Division or ISC agency to act on a request for services within the mandated time period.

 

3)         Denial of a requested Waiver service by the Division or ISC agency (i.e., Individual in Home-Based Supports and is now requesting Assistive Technology).

 

4)         Denial of clinical eligibility by the Division or an ISC agency.

 

5)         Suspension, termination, or reduction of services by the Division or a provider agency.

 

b)         The desire to appeal any action listed under subsection (a) shall be communicated to the ISC within 10 working days after the date the Individual or guardian receives the notice of action from the provider.  The communication shall be followed by a written request to appeal signed by the Individual, parent, guardian, or Individual's representative.

 

c)         Within 45 days after receiving notification to appeal, the ISC must:

 

1)         Gather the following:

 

A)        The written request to appeal signed by the Individual, parent, guardian, or Individual's representative.

 

B)        A complete appeal checklist.

 

C)        A complete Documentation for Medicaid Waiver Appeals form (IL444-0171) and supporting documents as indicated in the form.

 

D)        Documents from the provider agency to support its decision to suspend, terminate, or reduce services.

 

E)        Any additional documentation relevant to the appeal.

 

2)         Submit the documents pursuant to subsections (c)(1)(A) through (E) to DDD's Appeals Unit by:

 

A)        Secure email.  Emails should be directed to DHS.DDDAppeals@illinois.gov;

 

B)        Fax to 217-558-2799 Attn:  Appeals Unit supervisor; or

 

C)        Mail to: 

 

DHS/DDD – Program Development

Attn:  Appeals Unit Supervisor

600 East Ash Street Building 400, 3^rd Floor South

Springfield, IL  62703

 

d)         Within 30 working days after the appeal and supporting documents indicated in subsection (c)(1) are received, DDD shall conduct an informal review of the appealed action listed in subsection (a) and either uphold or not uphold the appealed action.  The Individual, parent, guardian, or Individual's representative (if any), and the service providers shall be notified in writing of DDD's decision within 10 working days after the informal review is complete.  The written notification shall include:

 

1)         A clear statement of the action to be taken;

 

2)         A clear statement of the reason for the action;

 

3)         A specific policy reference which supports such action; and

 

4)         A complete statement of the Individual's right to continue the appeal and have an Administrative Hearing with HFS.  When DDD's Informal Review decision does not support the Individual's appeal, the Individual, parent, guardian, the Individual's representative, and provider, if applicable, will be notified that the appeal will continue to HFS for an Administrative Hearing.

 

e)         When DDD's informal review decision does not support the Individual's appeal, within 10 working days after the decision, DDD shall forward the appeal and all documents reviewed to HFS for an administrative hearing to be scheduled by HFS.

 

f)         The hearing shall be conducted by an impartial hearing officer appointed by HFS.

 

g)         The hearing may be held by telephone.

 

h)         HFS' hearing rules for assistance appeals, as set forth at 89 Ill. Adm. Code 104, shall apply, except that subsection (d) shall apply rather than any similar HFS rule.

 

i)          Following the hearing, the Director of HFS shall issue a final administrative decision in accordance with 89 Ill. Adm. Code 104.70.  Copies of the decision shall be mailed to the Individual, guardian, parent, the Individual’s representative (if any), the provider, and the Supervisor of DDD's Appeals Unit.

 

j)          The receipt of the appeal shall stay the decision pending the final administrative decision or the withdrawal of the appeal.  If the decision being appealed is regarding suspension, termination, or reduction of services, services shall not be suspended, terminated, or reduced until the appeal is resolved, except as described below.

 

1)         Services may be suspended, terminated, or reduced before the final administrative decision when:

 

A)        The physical safety or health of the Individual or others is in extreme risk of harm; or

 

B)        Appropriate medical services are not available at the provider agency thereby jeopardizing the health of the Individual; and

 

C)        The ISC agency has:

 

i)          Reviewed the Individual's record and clinical information;

 

ii)         Reviewed the actions, including the supports implemented, of the provider;

 

iii)        Discussed the current situation and alternatives available with the Individual and guardian;

 

iv)        Determined that a delay in termination, suspension, or reduction in services would put the safety of the Individual or others in extreme risk of harm and has documented that fact in the Individual's record; and

 

v)         Consulted with the Division of Developmental Disabilities.

 

2)         If the conditions of subsection (j)(1) are met, services to the Individual may be terminated, suspended, or reduced and the notice of action shall be given in accordance with Section 120.70(h) as soon as possible, but in no case later than 48 hours before the termination, suspension, or reduction in services.

 

3)         The provider shall continue to provide services until the appeal is resolved except as described in subsection (j)(l).

 

4)         If the conditions of subsections (j)(l)(A) or (B) exist, the Individual (if possible), the guardian, the ISC agency, and a Department representative will work together to secure alternative services.  The provider agency (including the QIDP) shall work cooperatively with the Individual, the guardian, the ISC agency and the Department in effort to secure and transition Individuals to alternative services.  This includes, but is not limited to, supplying records and other documents, supplying the Individual's personal items, and conferencing with prospective agencies regarding the Individual's care.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.120  Individual's responsibilities

 

a)         Information to establish eligibility

The Individual shall provide, as able, the factual information necessary to establish eligibility, including the consent to release information as provided for in Section 120.100(c). The ISC agency or service provider, with the consent of the Individual, may assist in obtaining such information.

 

b)         Reporting changes in personal information and services

 

1)         It is the responsibility of the Individual or guardian to report all changes in circumstances (including change in address, housing arrangements, income or assets, or eligibility for other benefits or programs) to the Department and to the provider within five working days after the change.

 

2)         It is the responsibility of the Individual or guardian to report changes in services currently provided by other entities which might affect the extent of supports or services provided through the Medicaid HCBS Waiver Program. Such information shall be reported to the provider.

 

c)         Application for other benefits

Individuals are required to apply for all other financial benefits, such as Supplemental Security Income, public assistance (the Illinois Public Aid Code [305 ILCS 5]), veterans benefits (38 U.S.C. 521, 541, and 542 (2011)), unemployment compensation (the Unemployment Insurance Act [820 ILCS 405]), Social Security retirement and disability benefits (Title II of the Social Security Act, 42 U.S.C. 401 (2011)), Worker's Compensation (Workers' Compensation Act [820 ILCS 305]), and Supplemental Nutritional Assistance Program (SNAP), for which they may qualify and to avail themselves of such benefits at the earliest possible date.

 

d)         Social security number

The Department, in compliance with the Identity Protection Act [5 ILCS 179], may request Individuals receiving program services to supply a social security number for program administration purposes. The service coordinator or provider can assist the Individual in applying for a social security number if the Individual so wishes.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

SUBPART D: OPERATIONAL PROCEDURES

 

Section 120.130  Filing an application (Repealed)

 

(Source:  Repealed at 20 Ill. Reg. 4762, effective March 8, 1996)

 

Section 120.140  Eligibility criteria

 

a)         The Individual's age shall be within guidelines set forth by the Adults with Developmental Disabilities Waiver, Children's Residential Waiver, or the Children's Support Waiver at the time services are initiated.

 

b)         The Individual shall be a resident of Illinois.

 

c)         Prior to Medicaid waiver enrollment, an ISC agency shall assess the Individual and determine that a developmental disability is present, that the Individual could benefit from active treatment, and that the Individual does not require 24-hour nursing care.

 

1)         Individuals shall be given a choice of alternative services through the pre-admission screening process. The choice shall include both ICF/DD and Home and Community-Based Waiver services, which are an alternative to ICF/DD placement.

 

2)         The criteria for this determination are contained in HFS' rule at 89 Ill. Adm. Code 140.642.

 

d)         The Individual shall meet all financial and non-financial Medicaid eligibility criteria as specified in the approved State Medicaid Plan.

 

e)         The Individual shall not be receiving services in a nursing facility, Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), Intermediate Care Facility for Developmental Disabilities (ICF/DD), State-Operated Facility, Medically Complex facility for persons with Developmental Disabilities (MC/DD), hospital, or another Medicaid Waiver program (without direct approval from the Secretary of the Department) at the time HCBS Waiver services are being delivered.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.150  Eligibility determination

 

a)         HFS shall determine the Individual's financial eligibility per 89 Ill. Adm. Code 120.

 

b)         Individuals shall be served by the ISC agency that is located in the geographic area where the person resides. The ISC agency shall be responsible for:

 

1)         Compiling information as needed for the determination of clinical eligibility pursuant to Section 120.140; and

 

2)         Completing a determination of HCBS Waiver eligibility pursuant to the criteria in Section 120.140.

 

c)         Eligibility for services under this Part may be denied for the following reasons:

 

1)         An Individual fails to meet the eligibility criteria specified in Section 120.140 of this Part.

 

2)         The applicant does not supply needed information to complete the eligibility determination.

 

3)         The Individual's Personal Plan cannot be designed to adequately meet the Individual's needs within the program limits.  In the case of HBS, the services must be within the service cost limitations.

 

4)         Individuals and expenditures under this program do not meet the average per capita cost.

 

d)         The ISC agency shall conduct a redetermination of Medicaid HCBS Waiver program eligibility within 12 months after the last eligibility determination or redetermination.  A redetermination shall also be conducted if, before 12 months have elapsed, there is a change in circumstances affecting eligibility (see Section 120.120(b)). A redetermination shall include an examination of criteria identified in Section 120.140. A redetermination of the presence of developmental disability is not required.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)

 

Section 120.160  Person-Centered Planning

 

a)         Individuals who are or who will be enrolled in an HCBS Waiver Program, guardians, ISC agencies, and provider agencies shall comply with Person-Centered Planning requirements pursuant to 42 CFR 441.301(c)(1) through (c)(3) and as set forth by the Department. The Person-Centered Planning process:

 

1)         Must be driven by the Individual who is or who will be enrolled in an HCBS Waiver Program. The ISC agency shall facilitate the process and the guardian must be included. Other persons invited by the Individual and agencies currently providing services shall be invited to contribute to the process.

 

2)         Provides necessary information and support to ensure that the Individual directs the process to the maximum extent possible and is enabled to make informed choices and decisions.

 

3)         Is timely and occurs at times and locations of convenience to the Individual.

 

4)         Reflects cultural considerations of the Individual and is conducted by providing information in plain language and in a manner that is accessible to Individuals with disabilities and persons who have limited English proficiency.

 

5)         Includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants.

 

6)         Is initiated and overseen by a conflict of interest-free case management entity as indicated in Section 120.65. Providers of HCBS Waiver services, or those who have an interest in or are employed by a provider of HCBS Waiver services must not provide case management or develop the Personal Plan.

 

7)         Offers informed choices to the Individual regarding the services and supports that they receive and from whom.

 

8)         Includes a method for the Individual to request updates to the plan as needed.

 

9)         Records the alternative home and community-based settings that were considered by the Individual.

 

b)         ISC agencies shall initiate the Person-Centered Planning process for each Individual who is or who will be enrolled in an HCBS Waiver Program by conducting a discovery process designed to gather information about an Individual's preferences, interests, abilities, preferred environments, activities, and supports needed.

 

1)         The ISC agencies will be responsible for facilitating the discovery process, as outlined by the Department, and for documenting what they gather.

 

2)         This process should begin with the Individual and then include the guardian, advocate, family, and others chosen by the Individual. It must also include information from current providers.

 

3)         The information captured during this process is used to develop the Personal Plan, which summarizes key and critical areas of the Individual's life.

 

c)         After the discovery process is complete, the ISC agency shall develop the Personal Plan. The Personal Plan must reflect the services and supports that are important for the Individual to meet the needs identified through the discovery process, as well as what is important to the Individual with regard to preferences for the delivery of such services and supports. The written plan must: 

 

1)         Reflect that the setting in which the Individual resides is chosen by the Individual. The State must ensure that the setting chosen by the Individual is integrated in, and supports full access of, Individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree of access as Individuals not receiving Medicaid HCBS.

 

2)         Reflect the Individual's strengths and preferences.

 

3)         Reflect clinical and support needs, as identified through the discovery process.

 

4)         Include individually-identified and -desired outcomes.

 

5)         Reflect the services and supports (paid and unpaid) that will assist the Individual to achieve identified outcomes, and the providers of those services and supports, including natural supports.

 

6)         Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies, when needed.

 

7)         Be understandable to the Individual receiving services and supports, and to those who are important in supporting the Individual. At a minimum, for the written plan to be understandable, it must be written in plain language and in a manner that is accessible to Individuals with disabilities and to persons who have limited English proficiency.

 

8)         Identify the person and/or entity responsible for monitoring the plan.

 

9)         Be finalized and agreed to, with the informed consent of the Individual in writing. The persons and providers responsible for its implementation shall sign the completed plan.

 

10)       Be distributed to the Individual and other people involved in the plan.

 

11)       Include those services which the Individual elects to self-direct.

 

12)       Prevent the provision of unnecessary or inappropriate services and supports.

 

13)       Include any modification of the conditions in Section 120.70(d)(6)(A) through (d)(6)(E). Modifications of these conditions must be supported by a specific assessed need and justified in the Personal Plan. The following requirements must be documented in the Personal Plan: 

 

A)        Identify a specific and individualized assessed need.

 

B)        Document the positive interventions and supports used prior to any modifications to the Personal Plan.

 

C)        Document less intrusive methods of meeting the need that have been tried but did not work.

 

D)        Include a clear description of the condition that is directly proportionate to the specific assessed need.

 

E)        Include a regular collection and review of data to measure the ongoing effectiveness of the modification.

 

F)         Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.

 

G)        Include informed consent of the Individual.

 

H)        Include an assurance that interventions and supports will cause no harm to the Individual.

 

d)         The Personal Plan must be reviewed and revised upon reassessment of functional need, as required by 42 CFR 441.365(e), at least every 12 months, when the Individual's circumstances or needs change significantly, or at the request of the Individual.

 

e)         Provider agencies must comprehensively address the needs of Individuals enrolled in an HCBS Waiver and for whom they have signed a Personal Plan through the development of an Implementation Strategy as it relates to their Personal Plan.

 

1)         Within 20 calendar days of the provider's signature on the Personal Plan, an Implementation Strategy shall be developed that:

 

A)        Is based on the Personal Plan developed by the ISC agency and on the assessment results.

 

B)        Includes the participation of the Individual and guardian, and the ISC as necessary.

 

C)        Reflects the Individual's and guardian's agreement, as indicated by a signature on the Implementation Strategy or staff notes indicating why there is no signature and why the Individual's and guardian's agreement is not reflected.

 

D)        Describes and directs the activities and methods used to provide services and supports the areas of an Individual's Personal Plan for which the provider is responsible.

 

E)        Addresses and accounts for the priorities, strengths, support needs, and risk factors identified in the Personal Plan for those areas of the provider's responsibility.

 

F)         Justify and document the restriction of an Individual's HCBS Waiver rights, which are outlined in Section 120.70(d)(6)(A) through (E)

 

G)        Addresses outcomes identified in the Personal Plan that the provider agency agreed to support the Individual in.

 

H)        Identifies the agencies' services to support the Individual in attaining skills or achieving outcomes identified in the Personal Plan, detailing timeframes for completion, staff positions assigned responsibility, and benchmarks for determining the success of the strategies.

 

I)         Identifies the services chosen by the Individual and guardian and indicates the type and the amount of supervision provided to the Individual.

 

J)         Includes the names and titles of all employees and other persons contributing to the Implementation Strategy.

 

K)        Is signed by the Individual, guardian, and provider agency representatives.

 

2)         The Individual, guardian and ISC shall be given a copy of the Implementation Strategy and subsequent updates.

 

3)         The Implementation Strategy and subsequent updates shall become a part of the Individual's record.

 

4)         At least monthly, the QIDP shall review the Implementation Strategy and shall document, sign, and date in the Individual's monthly summary that:

 

A)        Services are being implemented, as identified in the Implementation Strategy.

 

B)        Services identified in the Implementation Strategy continue to meet the Individual's needs or require modification to better meet the Individual's needs.

 

C)        Outcomes are being supported as specified in the Personal Plan and Implementation Strategy.

 

D)        Progress is being made toward outcomes, as identified in the Personal Plan and Implementation Strategy. In situations when there is no progress made, provider agencies must document barriers and/or reasons why progress was not made.

 

5)         Updates shall be made to the Implementation Strategy as the Personal Plan is modified, or more often if warranted by a change in functional status or at the request of the Individual or guardian.

 

6)         All services specified in the Implementation Strategy, whether provided by an employee of the agency, consultants, or sub-contractors, shall be provided by or under the supervision of a QIDP.

 

7)         The provider agency must ensure that current copies (digital or paper) of Individuals' Personal Plans and Implementation Strategies are kept at the provider agency.

 

8)         The provider agency must also ensure that direct care workers (including employees, contractual persons, and host family members) are knowledgeable about the Individuals' Personal Plans and Implementation Strategies, are trained in their implementation, and maintain records regarding the Individuals' progress toward the outcomes of the Personal Plans and Implementation Strategies.

 

(Source:  Amended at 48 Ill. Reg. 5279, effective March 21, 2024)