AUTHORITY: Implementing and authorized by the Community Services Act [405 ILCS 30] and Section 15.3 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705].

SOURCE: Emergency rules adopted at 16 Ill. Reg. 211, effective December 31, 1991, for a maximum of 150 days; new rules adopted at 16 Ill. Reg. 9006, effective May 29, 1992; amended at 18 Ill. Reg. 15593, effective October 5, 1994; emergency amendment at 19 Ill. Reg. 9200, effective July 1, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 16178, effective November 28, 1995; amended at 21 Ill. Reg. 8292, effective June 25, 1997; recodified from the Department of Mental Health and Developmental Disabilities to the Department of Human Services at 21 Ill. Reg. 9321; amended at 22 Ill. Reg. 21870, effective December 1, 1998; emergency amendment at 23 Ill. Reg. 4497, effective April 1, 1999, for a maximum of 150 days; amended at 23 Ill. Reg. 10205, effective August 23, 1999; amended at 24 Ill. Reg. 17737, effective November 27, 2000; amended at 26 Ill. Reg. 13213, effective August 20, 2002; amended at 28 Ill. Reg. 11723, effective August 1, 2004; amended at 31 Ill. Reg. 9097, effective July 1, 2007; emergency amendments at 31 Ill. Reg. 10159, effective July 1, 2007, for a maximum of 150 days; amended at 31 Ill. Reg. 15805, effective November 8, 2007; amended at 32 Ill. Reg. 9981, effective July 1, 2008; emergency amendment at 35 Ill. Reg. 1128, effective January 1, 2011, for a maximum of 150 days; emergency amendment repealed by emergency rulemaking at 35 Ill. Reg. 7719, effective April 28, 2011; amended at 35 Ill. Reg. 8860, effective May 26, 2011; amended at 36 Ill. Reg. 18582, effective December 13, 2012; amended at 38 Ill. Reg. 15550, effective July 1, 2014; amended at 39 Ill. Reg. 13684, effective October 1, 2015; former Part repealed at 43 Ill. Reg. 1046, and new Part adopted at 43 Ill. Reg. 1049, effective January 1, 2019; emergency amendment at 45 Ill. Reg. 11877, effective September 16, 2021, for a maximum of 150 days; amended at 46 Ill. Reg. 2937, effective February 4, 2022; emergency amendment at 47 Ill. Reg. 12785, effective August 11, 2023, for a maximum of 150 days; amended at 48 Ill. Reg. 918, effective December 29, 2023; emergency amendment at 48 Ill. Reg. 5799, effective March 28, 2024, for a maximum of 150 days; amended at 48 Ill. Reg. 12012, effective July 25, 2024.

SUBPART A: GENERAL PROVISIONS

Section 132.5  COVID-19 Vaccination of Entity Staff (Repealed)

 

(Source:  Repealed at 48 Ill. Reg. 918, effective December 29, 2023)

 

Section 132.10  Purpose

 

a)         To facilitate the establishment of a comprehensive and coordinated continuum of community-based programs, sensitive to the needs of local communities, for persons with or at risk for a diagnosis of mental illness.

 

b)         To effectuate the Division of Mental Health's role as the federally-recognized State Mental Health Authority with statutory mandates to plan, fund and monitor community-based mental health programs.

 

c)         To promote the availability of culturally relevant, evidence-based, developmentally appropriate, trauma-informed mental health programs across the lifespan.

 

d)         To maximize the effectiveness and quality of programs to ensure cost efficiency and best possible outcomes in natural settings that reduce the use of institutional care.

 

e)         To establish criteria for certification and recertification of Comprehensive Community Mental Health Centers (CMHC) and other entities seeking to offer programs directly funded by DHS-DMH and DCFS.

 

Section 132.15  Incorporation by Reference

 

Any rules or standards 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.

 

Section 132.25  Definitions

 

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

 

Accessibility – Compliance with all appropriate provisions of the Americans With Disabilities Act (ADA) of 1990 (42 USC 12101 et seq.), as amended, and section 504 of the Rehabilitation Act of 1973 (29 USC 794), and the most recent standards identified in the Illinois Accessibility Code (71 Ill. Adm. Code 400) and/or ADA Accessibility Guidelines, whichever standard is more stringent.

 

Assertive Community Treatment Program or ACT Program – An evidence-based program that includes all components necessary to provide the assertive community treatment model. 

 

Applicant −An entity that seeks certification as a Certified Specialty Provider (CSP) or CMHC under this Part

 

Centers for Medicare and Medicaid Services or CMMS – A federal agency within the U.S. Department of Health and Human Services with responsibility for Medicare, Medicaid, State Children's Health Insurance (SCHIP), Health Insurance Portability and Accountability Act (HIPAA), and Clinical Laboratory Improvement Amendments (CLIA).

 

Certifying State Agency or CSA − Departments responsible for determining and monitoring compliance with this Part, i.e., Department of Human Services or Department of Children and Family Services.

 

Client − An individual who is receiving community mental health services eligible for Medical Assistance funding.

 

Certified Comprehensive Community Mental Health Center or CMHC – An entity that meets the requirements of Subparts C and D and has been certified by a Certifying State Agency. Any entity certified as a CMHC under this Part shall be designated as an Essential Community Behavioral Health Center by the Division of Mental Health.

 

Certified Specialty Provider or CSP – An entity that has chosen to meet the requirements set forth in Subpart B to be eligible to provide specialty programs directly funded by DHS-DMH and/or DCFS.

 

Community Support Team Program – A program designed with the infrastructure and supports necessary to provide team-based care consistent with DHS-DMH certification requirements.

 

Day − A calendar day unless otherwise indicated.

 

Department – The Illinois Department of Human Services (DHS)

 

Department of Children and Family Services or DCFS – The State child welfare agency responsible for:

 

protecting children who are reported to be abused or neglected and to increase their families' capacity to safely care for them;

 

providing for the well-being of children in care; providing appropriate, permanent families as quickly as possible for those children who cannot safely return home;

 

supporting early intervention and child abuse prevention activities and working in partnerships with communities to fulfill this mission.

 

Department of Human Services or DHS − The State agency responsible for providing a wide variety of safety net services to Illinois residents in poverty who are facing other economic challenges or who have any of a variety of disabilities or health challenges.

 

Department of Human Services-Division of Mental Health or DHS-DMH – A program division of DHS that, as the State Mental Health Authority pursuant to Department of Human Services (Mental Health and Developmental Disabilities) Law [20 ILCS 1710], is responsible for assuring that children, adolescents and adults throughout Illinois have the availability of and access to public-funded mental health services.

 

Emotional Disturbance – For clients under age 21, symptoms of an emotional disorder contained in the DSM-5 and ICD-10-CM that is the condition that will be the main focus of treatment.  For clients under age 6, DC 0-5 may be utilized to develop an age appropriate diagnosis, then the crosswalk between the DSM 5/ICD -10/DC 0-5 shall be used to identify which DSM-5/ICD-10 condition will be the main focus of treatment.  Emotional disturbance does not include organic disorders such as dementia and those associated with known or unknown physical conditions such as hallucinations, amnestic disorder and delirium; psychoactive substance induced organic mental disorders; and intellectual disabilities, autism spectrum disorders or psychoactive substance use disorders.

 

Enrollment −The official act of registering an entity or an individual as a provider in the Illinois Medical Assistance Program.

 

Guardian − The court-appointed guardian or conservator of the person under the Probate Act of 1975 [755 ILCS 5] or a temporary custodian or guardian of the person of a child appointed by an Illinois juvenile court or a legally-appointed guardian or custodian or other party granted legal care, custody and control over a minor child by a juvenile court of competent jurisdiction located in another state whose jurisdiction has been extended into Illinois via the child's legally authorized placement in accordance with the applicable interstate compact.  (See the Juvenile Court Act of 1987 [705 ILCS 405] and the Interstate Compact on the Placement of Children [45 ILCS 15].)

 

Healthcare and Family Services or HFS − The State agency responsible for administering Medicaid for Illinois.

 

Health Information Technology for Economic and Clinical Health (HITECH) Act – Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 (ARRA), P.L. 111-5 (Feb. 17, 2009).

 

Health Insurance Portability and Accountability Act or HIPAA − 42 USC 1320 et seq. and 45 CFR 160 and 164 (2003).

 

Illinois Medicaid Program Advanced Cloud Technology or IMPACT – The HFS web-based Medicaid Management Information System platform.

 

Intensive Outpatient Program − A program designed with the infrastructure and supports necessary to provide group therapeutic sessions consistent with the clinical standards set forth in Subpart E.

 

Interdisciplinary Care − Professionals from a range of disciplines working together to deliver comprehensive services and supports that address as many of the client's needs as possible. This can be delivered by a range of professionals and paraprofessionals functioning as a team under one organizational umbrella or from a range of organizations, including private practice, brought together as a unique team. As a client's condition changes over time, the composition of the team may change to reflect the changing clinical and psychosocial needs of the client.

 

Licensed Clinician – An individual who is:

 

A licensed practitioner of the healing arts (LPHA);

 

A licensed social worker (LSW) possessing at least a master's degree in social work and licensed under the Clinical Social Work and Social Work Practice Act [225 ILCS 20] with specialized training in mental health services or with at least two years' experience in mental health services;

 

A licensed professional counselor (LPC) possessing at least a master's degree and licensed under the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107] with specialized training in mental health services or with at least two years' experience in mental health services;

 

A registered professional nurse (RPN) licensed under the Nurse Practice Act [225 ILCS 65] with at least one year of clinical experience in a mental health setting or who possesses a master's degree in psychiatric nursing; or

 

An occupational therapist (OT) licensed under the Illinois Occupational Therapy Practice Act [225 ILCS 75] with at least one year of clinical experience in a mental health setting.

 

Licensed Practitioner of the Healing Arts or LPHA − A LPHA is defined as one of the following (additional information can be found in 89 Ill. Adm. Code 140.453):

 

Physician;

 

Licensed advanced practice registered nurse with psychiatric specialty;

 

Licensed clinical psychologist;

 

Licensed clinical professional counselor;

 

Licensed marriage and family therapist; or

 

Licensed clinical social worker. 

 

Medical Assistance − Health care benefits authorized by HFS under Article V of the Illinois Public Aid Code [305 ILCS 5].

 

Mental Health Professional or MHP − An individual who provides services under the supervision of a Qualified Mental Health Professional (additional information can be found in 89 Ill. Adm. Code 140.453) and who possesses:

 

A bachelor's degree in counseling and guidance, rehabilitation counseling, social work, education, vocational counseling, psychology, pastoral counseling, family therapy, or a related human service field;

 

A bachelor's degree in any other field with two years of supervised clinical experience in a mental health setting;

 

A practical nurse license under the Illinois Nurse Practice Act [225 ILCS 65];

 

A certificate of psychiatric rehabilitation from a DHS-approved program, plus a high school diploma or GED, plus 2 years of experience in providing mental health services;

 

A recovery support specialist certified by, and in good standing with, the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.;

 

A family partnership professional certificate from and in good standing with the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.;

 

An occupational therapy assistant licensed under the Illinois Occupational Therapy Practice Act [225 ILCS 75] with at least one year of experience in a mental health setting;

 

A minimum of a high school diploma or GED and 5 years supervised clinical experience in mental health or human services; or 

 

Any individual employed as an MHP prior to July 1, 2013 may continue to be so designated unless employment changes.

 

Mental Health Setting – A location, public or private, in a group or individual practice, in a mental health center, hospital or clinic where services intended to reduce symptoms of mental illness are provided to persons with mental illness.

 

Mental Illness − For clients age 18 and older, a mental disorder diagnosis contained in the DSM-5 and ICD-10-CM. Mental illness does not include organic disorders such as dementia and those associated with known or unknown physical conditions such as hallucinations, amnestic disorder and delirium; psychoactive substance induced organic mental disorders; and intellectual disabilities, autism spectrum disorders or psychoactive substance use disorders.

 

Natural Setting − A setting where an individual who has not been diagnosed with a mental illness typically spends time, including home, work, churches, community centers, libraries, parks, recreation centers, educational settings, courthouses, jails or other public buildings.  These sites are not licensed, certified or accredited as a treatment setting nor typically identified as treatment sites.

 

Natural Support – Persons identified by the client who are not paid to provide support, e.g., family, friends, pastor, colleague, landlord.

 

Notice of Violation or NOV – A written document that specifies the standards within this Part with which the entity/CMHC is not compliant.

 

Psychiatric Resource −

 

A physician licensed under the Medical Practice Act of l987 [225 ILCS 60] to practice medicine or osteopathy with training in mental health services or one year of clinical experience, under supervision, in treating problems related to mental illness, or specialized training (i.e., the treatment of children and adolescents);

 

A psychiatrist (a physician licensed under the Medical Practice Act of l987 [225 ILCS 60]) who has successfully completed a training program in psychiatry approved by the American Medical Association, the American Osteopathic Association or other training program identified as equivalent by the Department;

 

An advanced practice registered nurse (APRN) with a psychiatric specialty licensed in Illinois under Article 65 of the Nurse Practice Act [225 ILCS 65]; or

 

A prescribing psychologist licensed in Illinois pursuant to the Clinical Psychologist Licensing Act [225 ILCS 15], practicing within his or her scope of practice and adhering to all applicable federal and State administrative rules and policies, with sufficient credentials to prescribe psychotropic medications in Illinois.

 

Psychosocial Rehabilitation Program or PSR − A facility-based program designed with the infrastructure and supports necessary to provide intensive skill development in a classroom-based setting, consistent with clinical standards set forth in Subpart E.

 

Public Payer − A State agency or a unit of local government that is responsible for payment for services provided to a client.

 

"Qualified Mental Health Professional" or "QMHP" means one of the following:

 

Any individual identified as an LPHA.

 

A registered professional nurse who holds a valid license in the state of practice, is legally authorized under state law or rule to practice as registered nurse or registered professional nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act, and has training in mental health services or one year of clinical experience, under supervision, in treating problems related to mental illness, or specialized training in the treatment of children and adolescents.

 

An occupational therapist who holds a valid license in the state of practice and is authorized under state law or rule to practice as an occupational therapist, so long as that practice is not in conflict with the Illinois Occupational Therapy Practice Act, with at least one year of clinical experience in a mental health setting.  If the state of practice does not provide a legal authority for licensure, the individual must meet the requirements of 42 CFR 484.4 for an occupational therapist.

 

An individual who possesses a master's or doctoral degree in counseling and guidance, rehabilitation counseling, social work, psychology, pastoral counseling, family therapy, or a related field and has:

 

Successfully completed 1,000 hours of practicum and/or internship under clinical and educational supervision; or

 

One year of documented clinical experience under the supervision of a QMHP.

 

Rehabilitative Services Associate or RSA − An RSA assists in the provision of rehabilitative services under the supervision of a QMHP (additional information can be found in 89 Ill. Adm. Code 140.453) and must:

 

Be at least 21 years of age;

 

Have demonstrated skills in the field of services to adults or children;

 

Have demonstrated the ability to work within agency structure and accept supervision; and

 

Have demonstrated the ability to work constructively with clients, other providers and the community. 

 

SAMHSA − The federal Substance Abuse and Mental Health Services Administration responsible for guidance to the State Mental Health Authorities, including administration of the federal block grant, defining and identifying evidence-based practices, and translation of research to practice.

 

Safety Net – A collection of services provided, in collaboration with health care and social service providers throughout the community, to the uninsured and other vulnerable populations. The collection of services is designed to help prevent individuals from further emotional, mental, physical and economic decompensation, while promoting stability and empowerment.

 

Specialty Certification – The confirmation from DHS-DMH, the Illinois State Mental Health Authority, that a program meets the required clinical standards set forth in Subpart E.

 

State Mental Health Authority or SMHA – The entity within a state with federal and state statutorily assigned responsibility for planning, organizing, delivering and monitoring the programs that provide critical mental health services, through the development of safety net programs that provide critical care to individuals with serious mental illnesses who lack insurance and/or have high levels of service needs.  In Illinois, DHS-DMH is charged with this responsibility, which includes the development and implementation of a plan for comprehensive community mental health systems and reporting a set of standardized utilization and outcome measures.

 

Supervision of Treatment Services – The dedicated time an LPHA or QMHP spends with his or her supervisees discussing the supervisees' work.  This may include reviewing individual cases, treatment plans, group counseling, individual counseling, progress made by clients, or problem solving when progress is not occurring or when individuals are not engaged in the therapeutic process.  Supervision may be done individually or in groups.

 

Treatment, Habilitation and Support Services – Services designed to:

 

help individuals develop skills that promote independence and improved levels of social and vocational functioning and personal growth; and

 

provide nontreatment support services necessary for successful community living [405 ILCS 30/2(e)].

 

Section 132.30  Client Rights

 

To assure that a client's rights are protected and that all services provided to clients comply with the law, all providers under this Part shall ensure that:

 

a)         A client's rights shall be protected in accordance with Chapter 2 of the Mental Health and Developmental Disabilities Code [405 ILCS 5].

 

b)         The right of a client to confidentiality shall be governed by the Mental Health and Developmental Disabilities Confidentiality Act and the federal Health Insurance Portability and Accountability Act of 1996.

 

c)         Staff shall inform the client upon intake and annually of the following:

 

1)         The rights in accordance with subsections (a) and (b);

 

2)         The right to contact the Illinois Guardianship and Advocacy Commission and Equip for Equality, Inc.  The provider shall offer assistance to a client in contacting these groups, giving each client the address and telephone number of the Guardianship and Advocacy Commission and Equip for Equality, Inc.;

 

3)         The right to be free from abuse, neglect and exploitation;

 

4)         The right to be provided mental health services in the least restrictive setting;

 

5)         The client's right or the guardian's right to present grievances up to and including the provider's Executive Director or comparable position.  The client or guardian will be informed of how his or her grievances will be handled at the provider level.  A record of, and the response to, those grievances shall be maintained by the provider.  The Executive Director's decision on the grievance shall constitute a final administrative decision (except when the decisions are reviewable by the provider's governing board, in which case the governing board's decision is the final authority at the provider level);

 

6)         The right not to have services reduced, denied, suspended or terminated for exercising any rights;

 

7)         The right to contact the public payer or its designee and to be informed of the public payer's process for reviewing grievances;

 

8)         The right to have disabilities accommodated as required by the Americans With Disabilities Act, section 504 of the Rehabilitation Act and the Human Rights Act [775 ILCS 5]; and

 

9)         The right to contact HFS or its designee and to be informed by HFS or its designee of the client's healthcare benefit and the process for reviewing grievances.

 

d)         The sharing of information consistent with this Section shall be communicated in a language or a method of communication that the client understands.  Documentation that this information was shared in that manner shall be noted in the clinical record.

 

Section 132.35  Inter-Departmental Administration and Coordination of Services 

 

a)         DHS-DMH and DCFS, pursuant to an executed interagency agreement with the Department, shall ensure the administration and coordination of mental health services.

 

b)         Specific service details of Medicaid Rehabilitation Option (MRO) qualified mental health services pursuant to section 1905(a)(13)(C) of the Social Security Act are found in 89 Ill. Adm. Code 140.453(e) and (f). 

SUBPART B: CERTIFIED SPECIALTY PROVIDER (CSP)

 

Section 132.40  Definition and Characteristics

 

a)         The Department shall make CSP certification available on a voluntary basis to entities seeking CSP designation.  CSP certification may be required for receipt of DHS-DMH and DCFS funding.

 

b)         A CSP is an entity providing community-based mental health services under the direction of an LPHA in a specific geographic area or to a specialized population.  At a minimum, a CSP:

 

1)         Provides services necessary to prevent unnecessary institutionalization.

 

2)         Collaborates with other entities supporting the needs of individuals, including, but not limited to, primary care providers, coordination entities and/or managed care entities.

 

3)         Meets all of the requirements outlined in Subpart D, as demonstrated by having been issued a certificate by a CSA in accordance with the requirements set forth in this Part.

 

Section 132.45  General Requirements

 

a)         The CSP shall operate in a manner compliant with all applicable State and federal laws, regulations, and adopted policies and procedures.

 

b)         The CSP shall establish and maintain policies and procedures to be used by all CSP staff in the administration of programs and the delivery of services from any CSP site or location.

 

Section 132.50  Quality Systems Requirements

 

a)         The CSP shall establish and maintain continuous quality improvement systems to ensure quality of care provided in the least restrictive setting supporting the ongoing purchase of services.

 

b)         The CSP shall establish and maintain a Utilization Review Plan for the ongoing review and assessment of delivered services and client outcomes to ensure services are cost effective and result in the expected outcomes.

 

c)         The CSP shall establish and maintain a system for obtaining feedback from individuals served and community stakeholders.

 

Section 132.55  Personnel and Staffing Requirements

 

The CSP shall:

 

a)         Establish and maintain a comprehensive set of personnel policies and procedures, minimally addressing hiring, training, evaluation, disciplining, termination, and other personnel matters related to staffing. Establish and maintain job descriptions detailing the duties and qualifications for all positions, including volunteers, interns and unpaid personnel. Establish and maintain individual personnel records for all personnel, paid and unpaid, minimally including the following components:

 

1)         Documentation of current education, experience, licensure and certification;

 

2)         Employment status of the individual (e.g., hire date, employee/contractor, termination date, etc.);

 

3)         Review of individual employee's performance within the last 12 months; and

 

4)         Documentation of training and continuing education units, as applicable.

 

b)         Upon hire, perform sufficient background checks for all employees, volunteers, interns, unpaid personnel, or other individuals who are agents of the CSP or CMHC.  At a minimum, the review shall include:

 

1)         Searching the Illinois Department of Public Health's (DPH) Health Care Worker Registry concerning the person.  If the Registry has information substantiating a finding of abuse or neglect against the person, the provider shall not employ them in any capacity.

 

2)         Performing background checks in compliance with requirements set forth in the Health Care Worker Background Check Act [225 ILCS 46] and in DPH rules at 77 Ill. Adm. Code 955.

 

3)         Reviewing the Provider Sanctions List, provided by the HFS Office of Inspector General (HFS-OIG), to ensure the provider is not on the list of sanctioned providers.  The CSP/CMHC shall not employ or contract with any provider found on the List.

 

c)         The provisions of Section 132.55(b), except for subsection (b)(3), do not apply to Peer Support Workers (PSWs) providing services as part of a Violence Prevention Community Support Team (VP-CST) pursuant to 89 Ill. Adm. Code 140.453.  PSWs delivering VP-CST must meet the background check requirements outlined in 89 Ill. Adm. Code 140.TABLE P.

 

d)         Annually, at a minimum, comply with all requirements set forth in the Health Care Worker Background Check Act and in DPH rules.

 

e)         Ensure that all assessment activities and subsequent individual treatment plans are developed with the active involvement of a QMHP and the clinical review of an LPHA.

 

f)         Ensure management and oversight of all treatment staff by a QMHP.  Management and oversight may be face to face or virtual, to include group supervision as well as supervision by teleconference and videoconference.  All treatment staff must have access to a QMHP who is available for immediate consultation and supervision of treatment services.

 

g)         All staff shall receive, at a minimum, one hour of supervision per month delivered face to face, or by teleconference or videoconference.

 

1)         Group supervision is acceptable and the size of the group shall be conducive to the topic being discussed.

 

2)         Supervision must be documented in a written record.

 

3)         LPHAs are not required to have supervision under this Section.

 

4)         QMHPs must be supervised by an LPHA. MHPs and RSAs must be supervised by, at a minimum, a QMHP.

 

(Source:  Amended at 48 Ill. Reg. 12012, effective July 25, 2024)

 

Section 132.60  Recordkeeping Requirements

 

a)         The CSP shall maintain records, including but not limited to the following:

 

1)         Clinical records;

 

2)         Service billing files;

 

3)         Organizational records, including policies and procedures;

 

4)         Personnel records; and

 

5)         All other documents required in this Part.

 

b)         Required records shall be retained for a period of not less than 10 calendar years from the date of service, or origin of the record, except that, if an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every exception resolved.  This provision is not to be construed as a statute of limitations.

 

c)         Required records shall be readily available for inspection, audit and copying during normal business hours by personnel representing the CSA, the public payer, HFS, CMMS, or U.S. Department of Health and Human Services, as applicable.

 

d)         The compilation, storage of, and accessibility to records, including electronic records, shall be governed by written policies and procedures, in accordance with the Confidentiality Act, HIPAA, HITECH, and all other applicable State and federal laws.

 

e)         Clinical records and other client information, regardless of format, shall be secured from theft, loss or fire.

 

f)         Electronic or digital signature of records is acceptable when the CSP has established the necessary policies and procedures to:

 

1)         safeguard the issuance and identity of users;

 

2)         ensure uniqueness in issuance of signature;

 

3)         regularly review the usage of signature;

 

4)         ensure adequate safeguards within the system upon application of signature to documents; and

 

5)         audit users to remove unnecessary, unused, and abuses on a regular frequency.

 

Section 132.65  Physical Plant Location Requirements

 

a)         At a minimum, a CSP shall have a single discrete physical location, owned, leased or controlled by the entity seeking certification.

 

b)         All additional locations where treatment services occur, if owned, leased or controlled by the CSP, must be certified.  Locations meeting the definition of natural settings do not need to be certified.

 

c)         All locations must meet the following physical plant requirements for certification:

 

1)         Provide a safe, functional, sanitary and comfortable environment for clients and staff that is conducive to the provision of behavioral health services.

 

A)        A safe, functional and sanitary environment includes the establishment and maintenance of policies and procedures specific to the operation of each specific physical plant, including an emergency disaster plan, fire evacuation plan, and procedures for managing the basic mechanics of the site.

 

B)        A comfortable environment shall be reflective of trauma informed care, ensuring that the interventions being provided and the populations being served have access to an environment that ensures the physical, psychological and emotional safety of both employees and populations being served;

 

2)         Meet health and safety standards and State health care occupancy regulations as applicable;

 

3)         Be deemed accessible in accordance with the ADA, the Illinois Accessibility Code, and the ADA Accessibility Guidelines, whichever is more stringent.  Providers must maintain a written policy for reasonable accommodations for the provision of services to clients unable to access the provider's sites due to physical inaccessibility;

 

4)         Be in compliance with approved State and local building and fire ordinances and codes as follows:

 

A)        Fire safety in accordance with rules of the Office of the State Fire Marshal at 41 Ill. Adm. Code 100.

 

B)        Building requirements in compliance with the uniform or national building code adopted by local or county ordinance.

SUBPART C: CERTIFIED COMPREHENSIVE COMMUNITY MENTAL HEALTH CENTER (CMHC)

 

Section 132.70  Definition, Characteristics and Incentives

 

a)         Certified Comprehensive Community Mental Health Centers are a specialty service provider type embedded in the community with knowledge and expertise in providing services to adults with or at risk of serious mental illnesses (SMI) and/or children and youth with or at risk of serious emotional disturbances (SED.  CMHCs respond to the unique mental health needs of the community with a continuum of services ranging from prevention/promotion through treatment and recovery.  CMHCs collaborate with other social service and health care providers to deliver integrated care to individuals in the identified geographic service area.  CMHCs must be nonprofit or local government entities.

 

b)         CMHCs shall:

 

1)         Comply with all requirements of a CSP as articulated in Subpart B, in addition to the requirements set forth in this Subpart C.

 

2)         Operate within a system of care that provides treatment, habilitation and support services.

 

3)         Provide a comprehensive strengths-based array of mental health services within an identified geographic service area.

 

4)         Provide care to individuals with or at risk for SMI/SED by using a person-centered approach to care performed by an interdisciplinary team.

 

5)         Serve individuals who have complex needs as a result of child welfare, justice or multisystem involvement, medical co-morbidity, homelessness, dual disorders, etc.

 

6)         Ensure the connectability of services in the service area for individuals across the life span.

 

7)         Provide services in the client's natural settings.

 

8)         Provide a safety net for individuals with SMI/SED who are indigent.

 

9)         Provide outreach and engagement to individuals in need of mental health services.

 

10)         Provide evidence-based and evidence-informed developmentally appropriate practices in a proficient manner.

 

11)         Provide for a screening prior to a referral to a more intensive level of care.

 

12)         Provide education and resources to the public on mental health issues, including suicide prevention and wellness.

 

13)         Prioritize principles of recovery, system of care, trauma informed care, and culturally relevant practices.

 

14)         Provide access or linkage to psychiatric services and other health and social services.

 

c)         CMHCs are the only entities that may pursue certifications of the following programs:

 

1)         Assertive Community Treatment Programs; and

 

2)         Psychosocial Rehabilitation Programs.

 

d)         DHS-DMH will recognize certified CMHCs as preferred provider types when awarding State grant funds to support mental health treatment programs and services as State laws permit.

 

e)         DHS-DMH will recognize certified CMHCs as preferred provider types when pursuing federal or other grants within DMH or when awarding federal pass-through funds as federal and State laws permit.

 

f)         DHS-DMH will recognize certified CMHCs as preferred provider types when establishing technical assistance and training programs.

 

Section 132.75  General Requirements

 

a)         Establish and maintain policies and procedures to be used by all CMHC staff in the administration of CMHC programs and the delivery of services from any CMHC site or location.

 

1)         Policies detailing the organization's clear commitment to person-centered recovery and resilience principles and the empowerment of families and individuals served.  Programs and services should promote personal choice, self-help measures, the strengthening of natural supports, the use of education and interventions in natural settings, and the reduction of the utilization of institutional levels of care.

 

2)         Policies detailing how clients will actively participate in the development, planning and oversight of programs and services.

 

3)         Policies and procedures to ensure co-morbid physical healthcare needs are addressed for clients as needed. A CMHC that is not licensed to provide Level 1 and Level 2 Substance Use services and enrolled to participate in the Illinois Medical Assistance Program shall develop policies and procedures to ensure clients receive referrals for services as needed.

 

4)         Policies and procedures to ensure SAMHSA's principles of trauma informed approaches are embedded into the organizational structure and clinical practices of the CMHC.

 

b)         Ensure the availability of services that are culturally and linguistically appropriate and responsive to the needs of clients served, including but not limited to children/youth, military families, those in the criminal justice system, and the LGBTQ population.

 

c)         Ensure the availability of and/or linkage to a psychiatric resource for the purpose of consultation, evaluation, prescription and management of medication as needed by clients served by the CMHC.  This may be secured through various arrangements, including but not limited to employment, contractual relationship or mutual agreement.

 

d)         Identify a specific geographic service area in which the CMHC will operate and organize the delivery of services and programs and provide interventions to clients.

 

e)         Maintain insurance against professional and physical liabilities.

 

f)         Ensure the estimated incidence and prevalence of serious mental illness and severe emotional disturbance are collected. Providers must participate in DHS-DMH surveys to collect data to meet federal reporting requirements via registration information and/or ad hoc surveys.

 

Section 132.80  Personnel and Staffing Requirements

 

Establish and maintain an organizational structure that includes a staffing structure and management system consistent with the following:

 

a)         Employ a full-time LPHA to oversee and direct the clinical functions of the CMHC;

 

b)         Maintain staff with training and credentialing to provide interdisciplinary person-centered care, evidence based/informed practices, developmentally appropriate trauma informed care, and culturally and linguistically responsive services. 

 

c)         When good cause is established by the organization, an exception to the full-time status of the LPHA may be granted by the Department in accordance with the process and criteria outlined in this subsection (c).

 

1)         The organization shall submit a request for consideration of waiver to the Department detailing the reasons for the request.

 

2)         The organization shall provide a detailed staffing plan that includes the number and credential levels of all staff providing direct services that include a calculation of the hours of clinical supervision necessary to meet the requirements of Section 132.55(g)(4).

 

3)         The organization shall provide a projected number of individuals to be served on annual basis and calculation of the hours required for provision of clinical oversight and direction of all clinical functions related to those services.  This calculation shall be based on a needs assessment of the service area completed by the organization.

 

4)         The organization shall propose a staffing equivalency for clinical oversight and direction by the LPHA that is sufficient to meet the needs identified in Section 132.80(c)(2) and (3).

 

5)         The organization shall describe a plan to ensure access to clinical direction and oversight of an LPHA by less-credentialed staff in the event of emergent situations.

 

6)         Request for an exception must be submitted to the Department for consideration at least 30 calendar days prior to the anticipated need for the exception.

 

(Source:  Amended at 48 Ill. Reg. 12012, effective July 25, 2024)

 

Section 132.85  Addition and Removal of Physical Plant Locations

 

a)         Upon enrollment and establishment of the CMHC, the entity may seek to add additional physical plant locations to operate as part of the CMHC, pursuant to Section 132.65.  All CMHC requirement documentation and plans must be updated to reflect the addition of the physical plant location and must meet standards established in Subparts B and C.

 

b)         The CMHC must notify the CSA and HFS of a change in status if any physical plant location is removed from the CMHC or becomes inactive.  Furthermore, such a change must note if the removal or inactive status impacts the CMHC's ability to meet the standards detailed in Subparts B and C.

 

c)         The addition, removal or other potential changes in status reported by the CMHC to the CSA and HFS may result in a review of documents and plans consistent with Subparts B, C and D, resulting in certification, compliance review, or failure of the CMHC to retain status as a CMHC.

SUBPART D: ENROLLMENT AND CERTIFICATION REQUIREMENTS OF CERTIFIED COMPREHENSIVE COMMUNITY MENTAL HEALTH CENTERS AND CERTIFIED SPECIALTY PROGRAMS

 

Section 132.95  Certified Specialty Providers (CSP) and Certified Comprehensive Community Mental Health Center (CMHC) Certification Process

 

a)         The IMPACT portal is the enrollment site for the HFS Provider Participation Unit.  Entities seeking certification as a CMHC shall request enrollment through the IMPACT portal. Any entity enrolled through the IMPACT portal may request certification from a CSA as a CSP or CMHC.

 

b)         During the IMPACT application process, entities shall determine what population they will be serving and will be directed to the appropriate CSA to complete the certification process. 

 

1)         If an entity intends to contract for services with more than one CSA, it shall submit its certification application to the State agency that provides the most funding for community mental health services.

 

2)         If the funding from both CSAs is equal, the provider shall submit the application to DHS.

 

c)         The entity shall contact the CSA in writing to request the application packet.

 

DHS-BALC:

401 S. Clinton, 7^th Floor

Chicago IL 60627

DHS.BALC@illinois.gov

 

DCFS:

DCFS.Medicaid@illinois.gov

 

d)         IMPACT will issue notice of initial enrollment to the provider and the CSAs within 10 days.  The CSA shall review the provider information provided through the IMPACT portal.

 

e)         Upon review of all submitted materials, the CSA shall determine that:

 

1)         The submitted materials meet the standards of a CSP or CMHC established in Subparts B and C; or

 

2)         The submitted materials do not meet the standards established in Subparts B and C.

 

f)         If the CSA determines that the submitted materials meet the standards established in Subparts B and C, the CSA shall issue a provisional certification determination to HFS, if applicable, and the entity within 30 days after reviewing materials and reaching a determination.

 

1)         The effective date of provisional certification shall indicate the type of certification awarded and the date that the application was approved.

 

2)         A provisional certificate shall be in effect for 12 months, unless extended by the CSA.

 

3)         An entity issued a provisional certificate shall enroll in any information system required by the CSA.

 

g)         If the CSA determines that the submitted materials do not meet the standards established in Subparts B and C, the CSA shall issue the applicant a Notice of Violation within 30 days after the review.  The NOV shall provide the entity 30 days to remedy the violations.

 

1)         If the entity intends to proceed with certification as a CSP or CMHC, the entity may submit notice and documentation of corrections to the CSA to address all identified violations by the due date indicated on the NOV.

 

2)         If the notice and documentation of corrections is found to address all of the identified violations included in the NOV, then the CSA shall continue with the certification process outlined in this Part.

 

3)         If the entity pursuing CMHC certification fails to supply the necessary materials or the supplied materials fail to meet the standards detailed in this Part, the CSA shall notify HFS and the entity in writing of the entity's failure to obtain certification as a CMHC and right to appeal pursuant to Section 132.110.

 

4)         If the entity pursing CSP certification fails to supply the necessary materials or the supplied materials fail to meet the standards detailed in this Part, the CSA shall notify the entity in writing of the entity's failure to obtain certification as a CSP and right to appeal pursuant to Section 132.110.

 

h)         The CSA may supply technical assistance through the certification process as deemed necessary.

 

Section 132.100  Initial On-site Certification

 

a)         The CSA shall be granted access to all physical plant locations. 

 

b)         The CSA shall be granted access to all records, upon request, during any certification or other compliance review activities.

 

c)         On-site Certification 

 

1)         The CSA shall perform an on-site review within the provisional certification period outlined in Section 132.95(f) to confirm the findings of the provisional certification determination.  If the CSA determines the CSP or CMHC to be:

 

A)        In compliance, the CSA shall notify the CSP or CMHC.  For providers enrolled in the IMPACT system, the CSA shall notify HFS of the change in certification status from provisional to full certification.

 

B)        Not in compliance, the CSA shall issue the CSP or CMHC a Notice of Violation within 15 days after the on-site review.  The entity shall respond to the NOV by the due date indicated on the NOV, which shall be approximately 30 days after the date of the NOV.

 

2)         The CSP or CMHC shall submit notice and a Plan of Correction to the CSA to address all identified violations by the due date indicated on the NOV.

 

3)         If the notice and Plan of Correction is found to address all of the identified violations, the CSA shall assure implementation of the Plan of Correction.  The program certification status must be in "good standing" with the CSA.  The CSA shall notify the CSP or CMHC of the change in certification status from provisional to full certification.  For entities enrolled in the IMPACT Portal, the CSA shall notify HFS of the change in certification status from provisional to full certification.

 

4)         If the CSP or CMHC fails to supply a Plan of Correction or fails to implement its approved Plan of Correction and is "not in good standing" with the CSA, as detailed in this Part, the CSA shall notify the entity in writing of its failure to retain certification and right to appeal pursuant to Section 132.100.  For entities enrolled in IMPACT, the CSA shall also notify HFS of the entity's failure to retain certification.

 

5)         If the CSA finds evidence of suspected fraud or abuse relating to Medical Assistance, the CSA shall refer that evidence to HFS-OIG for further action.

 

Section 132.105  Certification Review Cycle

 

a)         The CSA may perform a review for compliance with the standards of this Part at any CSP or CMHC, at will, regardless of deemed status and without prior notice to the entity.

 

b)         The CSAs shall, at a minimum, review one-third of all CSPs and CMHCs on an annual basis, ensuring that all CSPs and CMHCs are reviewed within a three year period. If the CSA determines the entity to be:

 

1)         In compliance with Subparts B, C and D, the CSA shall notify the entity of retention of certification.  For entities enrolled in the IMPACT system, the CSA shall notify HFS of retention of certification.

 

2)         Not in compliance, the CSA shall issue the entity a Notice of Violation within 15 days after the on-site review.  The entity shall respond to the NOV by the due date indicated on the NOV, which shall be approximately 30 days after the date of the NOV.

 

A)        The entity shall submit a Plan of Correction to the CSA to address all identified violations by the due date indicated on the NOV.

 

B)        If the Plan of Correction is found to address all of the identified violations included in the NOV, the CSA shall assure implementation of the Plan of Correction, which will determine the certification status.  The program certification status must be in "good standing" with the CSA.  The CSA shall notify the entity of retention of certification.  For an entity enrolled in IMPACT, the CSA shall also notify HFS of the entity's retention of certification.

 

c)         If the entity fails to supply the necessary materials or the supplied materials fail to meet the standards detailed in Subparts B, C and D, the CSA shall notify the entity of its failure to retain certification and the right to appeal pursuant to Section 132.340.  For entities enrolled in IMPACT, the CSA shall also notify HFS in writing of the entity's failure to retain certification.

 

d)         If the CSA finds evidence of suspected fraud or abuse relating to Medical Assistance, the CSA shall refer that evidence to HFS Office of Inspector General for further action.

 

e)         Revocation of Certification

 

1)         The CSA may revoke an entity's certification at any time for any of the following reasons:

 

A)        The entity meets any of the grounds for termination set forth in 89 Ill. Adm. Code 140.16;

 

B)        The entity is convicted of defrauding the Medical Assistance Program under Article VIIIA of the Illinois Public Aid Code; or

 

C)        The entity fails to comply with the requirements of Subpart B, C or D.

 

2)         The CSA shall notify the entity in writing of the entity's revocation of certification and right to appeal pursuant to Section 132.110.  For providers enrolled in the IMPACT system, the CSA shall notify HFS.

 

Section 132.110  Appeal of Certification Determination

 

a)         An entity may appeal the following actions detailed in this Part:

 

1)         Refusal to issue a provisional certification;

 

2)         Refusal to issue full certification;

 

3)         Refusal to retain certification; or

 

4)         Revocation of certification.

 

b)         If the CSA determines that provisional certification or certification shall not be issued, that certification shall not be retained, or that an entity's certification shall be revoked, the CSA shall send written notice to DHS and the entity within 30 days after that determination.  The notice shall contain the specific requirements with which the entity has not complied, the CSA's proposed action, and the entity's rights as follows:

 

1)         If the entity chooses to appeal the CSA's decision, the entity shall submit a written request for a hearing to the DHS Bureau of Hearings, within 20 days after the date of the notice.

 

2)         If an appeal is initiated by a CMHC with provisional certification or certification, the entity may continue to provide services pending a final administrative decision unless the entity's continued provision of services would present an imminent risk of harm.

 

3)         Hearing Process

 

A)        The DHS rules at 89 Ill. Adm. Code 508 (Administrative Hearings) shall apply.

 

B)        The sole issue at the hearing shall be whether the provider is in compliance with certification requirements set forth in this Part or meets the criteria for revocation of certification set forth in this Part.

 

C)        The burden of proof in hearings conducted pursuant to this Section shall be on the appealing entity.

 

4)         If the final administrative decision pursuant to appeal is that certification shall not be issued or retained, or that an entity's certification shall be revoked, the notice shall specify that the decision shall take effect upon receipt by the entity and that the entity shall not be certified as a CMHC during the pendency of any proceeding for judicial review of the hearing decision, except by court order.

 

Section 132.115  Nontransferability

 

a)         CMHC certification is assignable or transferable consistent with the policies and procedures established by the HFS Provider Participation Unit related to the assignment and transferability of an entity's enrollment status with HFS.

 

b)         CMHC certification is not assignable or transferable between or among entity-owned or leased physical plant locations without an on-site review of the location to ensure compliance with this Part.

 

Section 132.120  Deemed Status

 

a)         The CSA, in qualifying an entity as a CMHC for participation and enrollment in the Illinois Medical Assistance Program as governed by the Social Security Act and all applicable federal regulations, shall grant deemed status to accredited CMHCs, pursuant to Section 3 of the Community Services Act [405 ILCS 30] and this Section.

 

1)         "Deemed status" means that, if an entity is actively accredited by an Acknowledged Accrediting Organization (AAO) or Standard identified in subsection (a)(2), the CSA shall deem the entity to meet all qualifying requirements of this Part covered by the AAO, as determined by DHS in collaboration with the AAOs, consistent with subsection (b).

 

2)         Acknowledged Accrediting Organizations and Standards

 

A)        The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace IL 60181; Standards for Behavioral Health Care Accreditation;            Standards for Hospital Accreditation

 

B)        Council on Accreditation (COA), 45 Broadway, 29^th Floor, New York NY 10006; Standards for Private Organization/Behavioral Health Services Accreditation; Standards for Public Agency/Behavioral Health Services Accreditation

 

C)        The Council on Quality and Leadership, 100 West Road, Suite 300, Towson MD 21204; Standards for Quality Assurances Accreditation; Standards for Person-Centered Excellence Accreditation; Standards for Person-Centered Excellence Accreditation with Distinction

 

D)        Commission on Accreditation of Rehabilitation Facilities (CARF), 6951 East Southpoint Road, Tucson AZ 85756-9407; Standards for Behavioral Health Accreditation

 

E)        Healthcare Facilities Accreditation Program (HFAP), 142 E. Ontario Street, Chicago IL 60611; Standards for Behavioral Health Accreditation

 

b)         Determination of Covered Standards.  In an effort to afford entities and CMHCs a streamlined certification process, DHS shall complete a process to determine covered standards pursuant to Section 3(d-10) of the Community Services Act;

 

1)         Due to the proprietary nature of the intellectual property retained by the AAO within its standards, DHS shall require the AAO to complete the following documents:

 

A)        Crosswalk of Standards.  On and after January 1, 2019, and upon any material changes to any standard, the Crosswalk of Standards shall be completed and submitted by the AAOs with their Attestation of Accrediting Standards.  The AAO can provide an updated Crosswalk of Standards, including new standards, at any time.  The standards received by the CSA by January 31 of any given year will be considered for deeming at the start of the next State Fiscal Year.

 

B)        Attestation of Accrediting Standards.  The Attestation of Accrediting Standards shall be completed, signed and submitted to DHS prior to May 30 of any given year when material changes to the standards that are matched to requirements in this Part are made, in attestation for the following State Fiscal Year to begin on July 1.

 

C)        The Crosswalk of Standards and Attestation of Accrediting Standards shall be submitted to:

 

DHS Bureau of Accreditation, Licensure and Certification

401 S. Clinton Street, 7^th Floor

Chicago IL 60607

 

2)         The CSAs reserve the right to request additional detail regarding any submitted Crosswalk of Standards or Attestation of Accrediting Standards.

 

3)         Entities and CMHCs accredited by an AAO or Standard shall be deemed to have met any certification requirements of this Part that are determined by DHS pursuant to this Section to be covered by the accreditation standards of that AAO.

 

4)         Non-deemed requirements and applicable violations identified in the AAO report shall be reviewed for compliance by the CSA.

 

c)         The CMHC shall demonstrate current accreditation status by submission to the CSA of a certificate of accreditation and the most recent accreditation report.

 

d)         If the CMHC's accreditation is suspended, lost or discontinued, the CMHC shall notify the CSA of that change within 30 days after the effective date of the change. 

 

e)         The CMHC shall submit its complete accreditation report to the CSA within 30 days after receipt from the AAO.

 

f)         Deemed status may be nullified in part or in whole by a complaint or report to the CSA that the CMHC is noncompliant with Subpart B, C or D.

 

g)         Upon notification of loss or discontinuance of accreditation or nullification of deemed status, the CSA shall prepare to review the CMHC pursuant to Section 132, applying all of the standards of Subparts B, C and D.

SUBPART E: SPECIALTY PROGRAM CERTIFICATION AND COMPETENCY