AUTHORITY: Implementing and authorized by Articles III, IV, V, VI and Section 12-13 of the Illinois Public Aid Code [305 ILCS 5].
SOURCE: Old Part repealed at 14 Ill. Reg. 13800, effective August 15, 1990; new Part adopted at 20 Ill. Reg. 4419, effective February 29, 1996; emergency amendment at 21 Ill. Reg. 13875, effective October 1, 1997, for a maximum of 150 days; amended at 22 Ill. Reg. 4430, effective February 27, 1998; emergency amendment at 22 Ill. Reg. 13146, effective July 1, 1998, for a maximum of 150 days; amended at 22 Ill. Reg. 19914, effective October 30, 1998; amended at 23 Ill. Reg. 5819, effective April 30, 1999; emergency amendment at 23 Ill. Reg. 8256, effective July 1, 1999, for a maximum of 150 days; amended at 23 Ill. Reg. 13663, effective November 1, 1999; amended at 24 Ill. Reg. 8353, effective June 1, 2000; emergency amendment at 26 Ill. Reg. 14882, effective October 1, 2002, for a maximum of 150 days; amended at 27 Ill. Reg. 2176, effective February 1, 2003; emergency amendment at 27 Ill. Reg. 10854, effective July 1, 2003, for a maximum of 150 days; amended at 27 Ill. Reg. 18671, effective November 26, 2003; emergency amendment at 28 Ill. Reg. 12218, effective August 11, 2004, for a maximum of 150 days; emergency amendment at 28 Ill. Reg. 14214, effective October 18, 2004, for a maximum of 150 days; amended at 29 Ill. Reg. 852, effective January 1, 2005; emergency amendment at 29 Ill. Reg. 2014, effective January 21, 2005, for a maximum of 150 days; amended at 29 Ill. Reg. 4360, effective March 7, 2005; expedited correction at 29 Ill. Reg. 14127, effective March 7, 2005; amended at 29 Ill. Reg. 6967, effective May 1, 2005; amended at 29 Ill. Reg. 14987, effective September 30, 2005; amended at 30 Ill. Reg. 8845, effective May 1, 2006; amended at 31 Ill. Reg. 5589, effective April 1, 2007; emergency amendment at 31 Ill. Reg. 5876, effective April 1, 2007, for a maximum of 150 days; amended at 31 Ill. Reg. 11681, effective August 1, 2007; amended at 33 Ill. Reg. 11803, effective August 1, 2009; emergency amendment at 36 Ill. Reg. 6751, effective April 13, 2012, for a maximum of 150 days; amended at 36 Ill. Reg. 13885, effective August 27, 2012; amended at 37 Ill. Reg. 17624, effective October 28, 2013; expedited correction at 38 Ill. Reg. 4518, effective October 28, 2013; amended at 38 Ill. Reg. 13255, effective June 11, 2014; amended at 38 Ill. Reg. 13893, effective June 23, 2014; amended at 38 Ill. Reg. 15152, effective July 2, 2014; emergency amendment at 38 Ill. Reg. 15713, effective July 7, 2014, for a maximum of 150 days; amended at 38 Ill. Reg. 23768, effective December 2, 2014; emergency amendment at 39 Ill. Reg. 6945, effective May 1, 2015 through June 30, 2015; emergency amendment at 42 Ill. Reg. 13733, effective July 2, 2018, for a maximum of 150 days; emergency amendment to emergency rule at 42 Ill. Reg. 16311, effective August 13, 2018, for the remainder of the 150 days; emergency expired November 28, 2018; amended at 42 Ill. Reg. 16731, effective August 28, 2018; emergency amendment at 42 Ill. Reg. 17935, effective September 24, 2018, for a maximum of 150 days; emergency expired February 20, 2019; amended at 43 Ill. Reg. 6803, effective May 28, 2019; Subpart B and Subpart E recodified at 43 Ill. Reg. 7014; amended at 44 Ill. Reg. 2331, effective January 15, 2020; emergency amendment at 44 Ill. Reg. 12825, effective July 17, 2020, for a maximum of 150 days; amended at 44 Ill. Reg. 19760, effective December 11, 2020; amended at 45 Ill. Reg. 5877, effective April 26, 2021; amended at 45 Ill. Reg. 8319, effective June 28, 2021; amended at 45 Ill. Reg. 10015, effective July 26, 2021; amended at 47 Ill. Reg. 18051, effective November 21, 2023; amended at 48 Ill. Reg. 895, effective December 27, 2023.
SUBPART A: AMBULATORY SURGICAL TREATMENT CENTERS
Section 146.100 General Description
This Part sets forth the conditions that an ambulatory surgical treatment center must meet in order to participate in the Medical Assistance Program.
(Source: Amended at 38 Ill. Reg. 15152, effective July 2, 2014)
Section 146.105 Definitions
For purposes of this Part, the following terms shall be defined as follows:
a) "Ambulatory Surgical Treatment Center" or "ASTC". Any distinct entity that operates primarily for the purpose of providing surgical services to patients not requiring hospitalization. Such facilities shall not provide beds or other accommodations for the overnight stay of patients; however, facilities devoted exclusively to the treatment of children may provide accommodations and beds for their patients for up to 23 hours following admission. Individual patients shall be discharged in an ambulatory condition without danger to the continued well-being of the patients or shall be transferred to a hospital or other similar environment. This provision shall include any place which meets the definition of an ambulatory surgical treatment center under the regulations of the Centers for Medicare and Medicaid Services (42 CFR 416). The term "ambulatory surgical treatment center" does not include:
1) Any institution, place, building or agency required to be licensed pursuant to the Hospital Licensing Act [210 ILCS 85].
2) Any person or institution required to be licensed pursuant to the Nursing Home Care Act [210 ILCS 45], the ID/DD Community Care Act [210 ILCS 47], or the Specialized Mental Health Rehabilitation Act of 2013 [210 ILCS 49].
3) Hospitals or ambulatory surgical treatment centers maintained by the State or any department or agency thereof, where such department or agency has authority under law to establish and enforce standards for the hospitals or ambulatory surgical treatment centers under its management and control.
4) Hospitals or ambulatory surgical treatment centers maintained by the federal government or agencies thereof.
5) Any place, agency, clinic or practice, public or private, whether organized for profit or not, devoted exclusively to the performance of dental or oral surgical procedures.
b) "Ambulatory Surgical Treatment Center Services." Facility services that are furnished in an ambulatory surgical treatment center.
c) "Department." The Illinois Department of Healthcare and Family Services .
d) "Facility Services." Services that are furnished in connection with covered surgical procedures performed in an ambulatory surgical treatment center.
(Source: Amended at 38 Ill. Reg. 15152, effective July 2, 2014)
Section 146.110 Participation Requirements
To participate in the Medical Assistance Program, an ambulatory surgical treatment center (ASTC) must, in addition to any other Department requirements:
a) Be licensed by the Illinois Department of Public Health pursuant to 77 Ill. Adm. Code 205.
b) In the case of an out-of-state ASTC, be licensed by the state in which it is located or, where a state does not license ASTCs, be accredited by a national accrediting body.
c) Meet the requirements in 42 CFR 416.
d) Maintain a contractual relationship, including a transfer and referral plan with a hospital. Such a plan shall include procedures for effecting transfer of the patient from the ASTC to a hospital.
1) The contracting hospital must be within 15 minutes of the ASTC.
2) Have an effective procedure for the immediate transfer to a hospital of patients requiring emergency medical care beyond the capabilities of the ASTC.
e) Ensure that a qualified physician shall be present at the facility at all times during the operative and postoperative period for all patients.
f) Must perform surgical procedures in a safe manner using qualified physicians or dentists who have been granted clinical privileges by the governing body of the ASTC. These providers must be licensed in the State of Illinois or, for an out-of-state ASTC, licensed by the state in which they practice and have skilled equivalent practice privileges at a licensed hospital.
(Source: Amended at 38 Ill. Reg. 15152, effective July 2, 2014)
Section 146.115 Records and Data Reporting Requirements
a) In addition to any other Department record requirements, the ambulatory surgical treatment center (ASTC) must maintain complete, comprehensive and accurate medical records to ensure adequate patient care that includes, but is not limited to, the following:
1) Patient identification.
2) Significant medical history and results of physical examination.
3) Preoperative diagnostic studies (entered before surgery), if performed.
4) Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body of the ASTC or State law.
5) Any known allergies and abnormal drug reactions.
6) Entries related to anesthesia administration.
7) Documentation of properly executed informed patient consent.
8) Discharge diagnosis.
9) Medications ordered and administered.
b) ASTC medical records must contain the dates of service and the name of the medical practitioner seeing the patient at the time of each center visit.
c) Medical records for Medical Assistance patients must be made available to the Department or its designated representative in the performance of utilization review.
d) The ASTC agrees to furnish to the Department, if requested, information necessary to establish payment rates in the form and manner that the Department requires.
e) Services provided in an ASTC may be subject to prepayment and post-payment review to assess medical care, coding validation and quality of care.
(Source: Amended at 38 Ill. Reg. 15152, effective July 2, 2014)
Section 146.125 Covered Ambulatory Surgical Treatment Center Services
Effective for dates of service on or after July 1, 2014:
a) The Department of Healthcare and Family Services will reimburse ambulatory surgical treatment centers (ASTCs) for facility services in accordance with covered enhanced ambulatory patient group (EAPG) services as defined in 89 Ill. Adm. Code 148.140(b)(1). The Department may exclude from coverage in an ASTC any procedure identified as only appropriate for coverage in a hospital setting.
b) Facility services furnished by an ASTC include, but are not limited to:
1) Nursing, technician and related services.
2) Use of the ASTC facilities.
3) Supplies (such as drugs, biological products (e.g., blood)), surgical dressings, splints, casts and appliances, and equipment directly related to the provision of surgical procedures.
4) Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure.
5) Administrative, record keeping, and housekeeping items and services.
6) Materials for anesthesia.
c) Facility services do not include items and services for which payment may be made under other provisions of this Section such as physicians' or dentists' services, laboratory, x-ray or diagnostic procedures performed by independent facilities or practitioners on the day of surgery (other than those directly related to performance of the surgical procedure), prosthetic devices, ambulance services, leg, arm, back and neck braces, artificial limbs, and durable medical equipment for use in the patient's home. In addition, they do not include anesthetist services.
(Source: Amended at 44 Ill. Reg. 19760, effective December 11, 2020)
Section 146.130 Reimbursement for Services
Effective for dates of service on or after July 1, 2014:
a) With respect to all non-EAPG procedures, reimbursement levels shall be at the lower of the ASTC's usual and customary charge to the public or the Department's Statewide maximum reimbursement screen.
b) With respect to EAPG procedures described in 89 Ill. Adm. Code 148.140(b)(1), reimbursement for those services shall be in accordance with 89 Ill. Adm. Code 148.140(d)(7).
c) Laboratory, x-ray, prescription, physician or dental services, provided in connection with a covered surgical procedure, must be billed by the providers rendering those services. If the ASTC provides the laboratory or x-ray service, then:
1) Separate billing is NOT allowed if provided on the day of surgery; or
2) Separate billing IS allowed if provided on other than the day of surgery.
d) The providers described in subsection (c) must meet all applicable license, enrollment and reimbursement conditions of the Department of Healthcare and Family Services, the Department of Public Health and the Department of Financial and Professional Regulation-Division of Professional Regulation.
(Source: Amended at 38 Ill. Reg. 15152, effective July 2, 2014)
SUBPART B: SUPPORTIVE LIVING PROGRAM (SLP) SETTINGS
Section 146.200 General Description
a) The Public Aid Code [305 ILCS 5/5-5.01a] calls for the Department to establish and provide oversight for a program of supportive living facilities (SLFs) that seeks to promote independence, dignity, respect and well-being for residents in the most cost effective manner. When submitting an application for participation in the Supportive Living Program, each SLF shall designate which population it will serve, either:
1) persons with a disability who are 22 to 64 years of age; or
2) persons who are 65 years of age and over who meet the requirements described in Section 146.220.
b) An SLF is a residential setting in Illinois that provides or coordinates flexible personal care services, 24 hour supervision and assistance (scheduled and unscheduled), activities, and health related services with a service program and physical environment designed to minimize the need for residents to move within or from the setting to accommodate changing needs and preferences; has an organizational mission, service programs and a physical environment designed to maximize residents' dignity, autonomy, privacy and independence; and encourages family and community involvement.
(Source: Amended at 30 Ill. Reg. 8845, effective May 1, 2006)
Section 146.205 Definitions
For purposes of this Part, the following terms shall be defined as follows:
"Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (42 CFR 488.301).
"Activities of Daily Living" or "ADL" means eating, bathing, dressing, transferring, toileting, walking and grooming.
"Advance Directive" means a power of attorney that gives a designated individual decision-making powers upon a person's incompetence. The Department of Public Health is required to make available a Uniform Do Not Resuscitate Advance Directive that may be used in all settings, the Statutory Will Declaration form, the Illinois Statutory Short Form Power of Attorney for Health Care, the statutory Declaration of Mental Health Treatment Form, and the summary of advance directives law in Illinois (Section 2310-600 of the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois [20 ILCS 2310-600].
"Bank Nursing Facility Beds" means a choice by SLP providers to participate by converting a distinct part of a nursing facility. Such facilities shall be allowed to retain the Certificate of Need for nursing beds that were converted.
"Complaint" means a phone call, letter or personal contact to the Department from a resident, family member, resident representative or any other interested person expressing a concern related to the health, safety or well-being of one or more SLP residents.
"Comprehensive Resident Assessment Instrument" or "RAI" means the Department designated resident assessment instrument designed for use in SLP settings.
"Declaration of Mental Health Treatment" means a document that lets a person state he or she wants to receive electroconvulsive treatment (ECT) or psychotropic medicine when the person has a mental illness and is unable to make decisions for himself or herself. It also allows a person to say whether he or she wishes to be admitted to a mental health facility if unable to make that decision.
"Department" means the Illinois Department of Healthcare and Family Services.
"Determination of Need" or "DON" means the assessment tool used by the Department or the Department's authorized representative to determine functional needs of a resident or prospective resident of the SLP in which the resident or prospective resident has been found to be in need of a nursing facility level of care. A minimum score of 29 is required on the DON, which indicates a nursing facility level of care, before payment may be authorized for the SLP resident.
"Developmental Disability" or "DD" means a disability that is attributable to a diagnosis of mental retardation or related condition such as cerebral palsy or epilepsy that results in impairment of general intellectual functioning or adaptive behavior. This condition is manifested before the age of 22 and is likely to continue indefinitely. It results in substantial functional limitations in three or more areas of major life activities, such as self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living.
"Direct Care Staff" means staff that provides professional nursing services, assistance with activities of daily living or other personal needs or maintenance, or general supervision and oversight of the physical and mental well being of an individual.
"Distinct Part" means a separate building or an entire wing or other physically identifiable space of an existing nursing facility licensed under the Nursing Home Care Act or the Hospital Licensing Act that is operated as an SLP setting distinguishable from the rest of the facility. The distinct part of a nursing facility will not be subject to provisions of the Nursing Home Care Act. The distinct part of a hospital will be subject to provisions of the Hospital Licensing Act while complying with provisions of this Subpart B. Distinct part does not include the conversion of an entire nursing facility or hospital.
"Do Not Resuscitate" or "DNR" means a medical treatment order that says cardiopulmonary resuscitation (CPR) will not be attempted if a person's heart and/or breathing stops.
"Durable Power of Attorney" means power of attorney given to a person designated as another person's agent giving broad powers to make health care decisions, including power to require, consent to or withdraw any type of personal care or medical treatment for any physical or mental condition, and to admit or discharge a person from any hospital, home or other institution.
"Financial Exploitation" means the act of obtaining control over a resident or his or her property and/or resources through deception or intimidation to the disadvantage of the resident and/or the profit of another and/or the intent of depriving the resident of the use, benefit or possession of his or her property and/or resources.
"Follow-up Care" means the response to, and documentation of, the service plan that is discussed with, and agreed to by, the resident and/or the resident's guardian. It may include, but is not limited to, physician referrals, revision of the service plan to incorporate nursing services, health promotion counseling and teaching self care in meeting health needs.
"Freestanding Facility" means a separate building that is not part of an existing nursing facility or hospital. Freestanding facility includes new construction, an existing building or conversion of an entire nursing facility or hospital into an SLP setting.
"Immediate Jeopardy" means a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident (42 CFR 488.301).
"Instrumental Activities of Daily Living" or "IADL" means activities related to independent living and includes preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone.
"Licensed Nurse" means a person whose services are paid for by an SLP and who is licensed as a registered nurse, registered professional nurse, practical nurse or licensed practical nurse under the Nurse Practice Act [225 ILCS 65].
"Living Will" means a document that tells a person's health care professional whether the person wants death-delaying procedures used if the person has a terminal condition, and the person is unable to state his or her wishes. A terminal condition means an incurable and irreversible condition such that death is imminent, and the application of any death delaying procedures serves only to prolong the dying process. A living will allows for the administration of medication, sustenance, or the performance of any medical procedure deemed necessary by the person's attending physician to provide the person with comfort care.
"Mandated Reporter" is anyone identified in the Elder Abuse and Neglect Act [320 ILCS 20] that shall report suspected abuse while engaged in carrying out professional duties. A mandated reporter includes, but is not limited to, a professional or professional's designee while engaged in social services and the care of an adult age 60 and over. It also includes, but is not limited to, any occupation required to be licensed under the Dietetic and Nutrition Services Practice Act [225 ILCS 30], Nurse Practice Act, and Nursing Home Administrator Licensing and Disciplinary Act [225 ILCS 70], and field personnel of the Departments of Healthcare and Family Services, Public Health and Human Services and any county or municipal health department.
"Medicaid" means the Department's Medical Assistance Program.
"Medicaid Resident" means a person with a physical disability (as determined by the Social Security Administration) age 22 years and over or a person who is age 65 years and over, who has been determined eligible for Medicaid payment for SLP services. Eligibility for a person residing in an SLP setting shall be determined in accordance with 89 Ill. Adm. Code 120.10 and 120.61 (excluding subsection (f) of Section 120.61). Provisions for property transfers as described at 89 Ill. Adm. Code 120.387 shall apply to a person residing in an SLP setting. Provisions for the prevention of spousal impoverishment as described at 89 Ill. Adm. Code 120.379 shall apply to a person residing in an SLP setting.
"Medical Assistance Program" means the program administered under Article V of the Illinois Public Aid Code [305 ILCS 5/Art. V] or successor programs and Title XIX of the Social Security Act (42 USC 1396) and related federal and State rules and regulations.
"Medication Error" includes, but is not limited to, incorrect dosage, medication given at incorrect time, wrong medication given, wrong route used or missed medication.
"Neglect" means a failure by the SLP provider to notify the appropriate health care professional, to provide or arrange necessary services to avoid physical or psychological harm to a resident, or to terminate the residency of a resident whose needs can no longer by met by the SLP provider, causing an avoidable decline in function. Neglect may be either passive (non-malicious) or willful.
"Personal Allowance" means the $90 minimum protected monthly amount of a Medicaid-eligible resident's income that is retained by Medicaid-eligible residents for their personal use.
"Progress Notes" means notes used to document the decline or improvement in a resident's status.
"Rehabilitated Nursing Facility" means the conversion of a distinct part of an existing nursing facility into an SLP setting.
"Related Parties" means affiliates of an SLP provider; entities for which investments are accounted for by the equity method by the entire enterprise; trusts for the benefit of employees, such as pensions and profit-sharing trusts that are managed by or under the trusteeship of management; any general partner; management of the SLP setting; members of the immediate families of principal owners of the SLP setting or its management; and other parties with which the SLP provider may deal if one party controls or can significantly influence management or operating policies of the other to an extent that one of the transacting parties might be prevented from fully pursuing its own separate interests. An entity or person shall be deemed by the Department to be a related party if it can significantly influence management or operating policies of the transacting parties or if it has an ownership interest in one of the transacting parties and can significantly influence the other to an extent that one or more of the transacting parties might be prevented from fully pursuing its own separate interests.
"Resident" means a person living in an SLP setting, including Medicaid residents as defined in this Section and individuals who are not eligible for Medicaid payment for SLP services.
"Resident Assessment Instrument" or "RAI" or "Comprehensive Resident Assessment Instrument" means the Department designated resident assessment instrument designed for use in SLP settings.
"Room and Board" means the housing, utilities and meals provided under the resident contract. Unless otherwise specified in the resident contract, room and board does not include phone or cable charges.
"Security Deposit" means a payment used to secure the payment of rent or compensation for damage to property for residential property containing 25 units or more (see Security Deposit Interest Act [765 ILCS 715]). A security deposit may also include a pet deposit to secure payment for damage to the residential property. Damage to property shall not include normal wear and tear to an apartment or any other part of the SLP setting.
"Serious Mental Illness" means:
A diagnosis of a major mental illness, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorders, obsessive compulsive disorder, and any other disorder that could lead to a chronic disability that is not a primary diagnosis of dementia. If the person has both a dementia diagnosis and another psychiatric condition, the symptoms of dementia must be significantly more progressed than symptoms of the co-occurring psychiatric condition;
A disorder for which the duration is a significant life disruption or that required major treatment episodes within the past two years. This does not necessarily mean that the individual was hospitalized; and
That the disability or Level of Impairment is characterized by active behavioral health symptoms, within the preceding six month period, that significantly interfere with the individual's ability to interact interpersonally, concentrate, follow through with goals or needs, and/or adapt effectively to change.
"Services" means the personal and health care related services provided by an SLP provider pursuant to Section 146.230.
"Service Plan" means the written plan of care on the Department designated form that is developed for each resident based upon the initial assessment, annual comprehensive resident assessment or quarterly evaluation.
"Significant Change" means that there has been a decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, and the decline or improvement impacts more than one area of the resident's health status and requires revision of the Service Plan.
"SSI" means Supplemental Security Income under Title XVI of the Social Security Act.
"Subcontractor" means any person who assumes any duties and responsibilities from an SLP provider for the performance of SLP services pursuant to Section 146.230.
"Supportive Living Program" or "SLP" means a residential setting that meets the requirements of this Subpart B or, for dementia care settings, the requirements of this Subpart B and Subpart E.
(Source: Amended at 44 Ill. Reg. 2331, effective January 15, 2020)
Section 146.210 Structural Requirements
a) Building Construction
1) An SLF's architectural plans shall conform to the current State building codes for the respective building type, local Fire and Life Safety Standards for health care occupancy or the 2000 National Fire Protection Association Life Safety Code (NFPA) 101, Chapter 32, Residential Board and Care Occupancies, National Fire Protection Association, 1 Batterymarch Park, Quincy MA 02269 (March 11, 2003, no later amendments or editions included) or local building codes if more stringent.
2) An SLF shall meet accessibility standards of the Americans With Disabilities Act of 1990 (42 USC 12101 et seq.). If the facility is subject to the requirements of the Illinois Accessibility Code (71 Ill. Adm. Code 400), it shall be deemed residential or multi-story housing for determining the requirements under that Code.
3) An SLF shall not have any apartments below grade level.
4) A freestanding facility consisting of two or more stories with 75 or fewer units shall have a minimum of one elevator available for resident use. A freestanding facility consisting of two or more stories with 76 or more units shall have a minimum of two elevators available for resident use.
b) Heating and Air Conditioning
1) All residential apartments shall have individually controlled systems to maintain comfortable temperatures.
2) Buildings shall provide a heating and air conditioning system in public areas to maintain comfortable temperatures.
c) Illumination
Illumination systems shall be installed and maintained to ensure sufficient lighting for general lighting, reading, night lighting for corridors, stairwells and emergency situations. There shall be adequate illumination for outdoor areas.
d) Resident Apartments General Requirements – Freestanding Facility
1) Each single occupancy SLF apartment shall have no less than 300 square feet of living space, including closets and the bathroom.
2) Each double occupancy SLF apartment shall have no less than 450 square feet of living space, including closets and the bathroom.
3) Each apartment shall be equipped at a minimum with:
A) A door that locks from the inside;
B) A full bathroom as defined in this Section;
C) An emergency call system as provided in Section 146.230(m);
D) Heating and cooling controls;
E) Wiring for private telephone lines;
F) Access to cable television, satellite dish or master antenna that receives at least ten channels;
G) A sink, microwave oven or stove, and refrigerator with a separate freezer compartment; and
H) A separate bedroom for each unrelated occupant for SLFs approved for participation on or after October 18, 2004. Unrelated occupants may share an apartment with a single bedroom if requested, and agreed upon by the occupants. An apartment shared by two occupants shall meet the minimum square footage required for double occupancy.
4) An SLF shall have individual locked mailboxes located inside the building for each apartment.
5) Each freestanding SLF shall consist of one building housing at least ten but no more than 150 apartments.
e) Resident Apartments General Requirements – Rehabilitated Nursing Facilities
1) Any nursing facility rehabilitating a portion of the facility to conform with SLF requirements shall convert a distinct part of existing facility space.
2) Each single occupancy SLF apartment shall have no less than 160 square feet of living space, including closets and the bathroom.
3) Each double occupancy SLF apartment shall have no less than 320 square feet of living space, including closets and the bathroom.
4) Each apartment shall be equipped at a minimum with:
A) A door that locks from the inside;
B) A full bathroom as defined in this Section that may be between and shared by the adjoining apartment;
C) An emergency call system as provided in Section 146.230(m);
D) Heating and cooling controls;
E) Wiring for private telephone lines;
F) Access to cable television, satellite dish or master antenna that receives at least ten channels; and
G) A sink, microwave oven or stove, and refrigerator with a separate freezer compartment.
5) An SLF shall have individual locked mailboxes located inside the building for each apartment.
6) Each rehabilitated nursing facility shall consist of a distinct part of an existing facility housing at least ten apartments but no more than 150 apartments.
f) Apartment Bathrooms
1) Each bathroom shall be equipped with:
A) A toilet with grab bars sufficient to meet the needs of the resident;
B) A sink;
C) A bathtub and/or shower stall with grab bars sufficient to meet the needs of the resident;
D) Hot and cold running water with faucets that meet all marking standards under residential building codes; and
E) An emergency call system pursuant to Section 146.230(m).
2) Each bathroom shall be a separate room and shall be designed to provide privacy.
g) Closet Space
1) Each apartment shall have minimum closet space of 90 cubic feet, or minimum floor dimensions of no less than 72 inches wide and 24 inches deep for each resident of the apartment.
2) Each closet shall be equipped with a door.
h) Doors
1) All doors in residential apartments, including entrance doors, shall be wheelchair accessible.
2) Entrance doors to apartments shall have locking devices that are accessible to the outside.
3) Entrance doors to residential apartments shall open onto a public corridor.
4) Entrance doors to each apartment shall be equipped with an "eye-view".
5) All shared apartment bedrooms shall have doors.
i) Windows
All apartment windows shall be of transparent glass (except bathrooms) and large enough to permit viewing to the outside of the building. Apartments shall have at least one window with a sill height that permits viewing from a seated position.
j) Common Areas
1) An SLF shall have a minimum of two common areas that provide residents with space for socialization. The dining room may be used as one of the common areas.
2) All common areas shall be accessible for wheelchair use and shall be designed and furnished to meet resident needs.
3) Common areas shall be available for resident use at any time, provided such use does not disturb the health, safety, and well-being of other residents. Access to private or public outdoor recreation areas shall be available to all residents.
4) No less than one common area shall have ice for resident use at no charge.
5) The SLF may have one common bathing room. The common bathing room shall contain a toilet with grab bars sufficient to meet the needs of the residents, bathtub and a roll-in shower that is wheelchair accessible to allow a five foot turning radius or utilize the American National Standards Institute T-shape or Y-shape, both of which have a non-skid surface, transfer seat and grab bars. Each bathing room shall have door locks to ensure privacy.
k) Public Restrooms
1) There shall be at least one public restroom that is handicapped accessible.
2) All public restrooms shall be clean.
3) All public restrooms shall contain toilet tissue, waste receptacles and hand drying means that cannot be reused. Soap shall be provided in a manner that minimizes contamination.
l) Public Telephone
The SLF shall make available a handicapped accessible telephone that allows residents and others to conduct private conversations.
m) Social and Recreational Areas
1) Handicapped accessible public areas shall be provided for residents' social and recreational use.
2) Social and recreational areas in rehabilitated nursing facilities shall be separate from those of the nursing facility. Rehabilitated nursing facilities may use the SLF dining room as a social and recreational area.
n) Kitchens
1) SLF kitchens in rehabilitated nursing facilities may be shared with the nursing facility.
2) Food shall be prepared on-site in a full service kitchen. The food shall be freshly prepared each day and served in a central dining area.
3) In addition to requirements found in any local health or food preparation ordinances, the SLF shall have a kitchen that provides:
A) Storage for non-perishable foods and perishable foods;
B) Food preparation areas with cleanable surfaces;
C) Capacity for resident food distribution at the appropriate temperature;
D) Kitchenware washing space as necessary to meet food service needs;
E) Hand washing areas separate from food washing areas; and
F) An area to store and clean garbage cans and carts.
o) Dining Areas
1) The SLF shall have handicapped accessible dining space to accommodate residents.
2) The dining area in rehabilitated nursing facilities shall be separate from the dining area of the nursing facility.
p) Laundry Rooms
1) Laundry rooms for residents' use:
A) In addition to laundry services provided under Section 146.230, at least one accessible washer and dryer shall be provided for resident use at no cost. The SLF shall be responsible for providing detergent and fabric softener at no cost to the residents.
B) There shall be a sink for hand washing in the laundry area.
C) Each laundry room shall contain an emergency call system as provided in Section 146.230(m).
2) Laundry rooms for SLFs:
A) For laundry done on-site by SLF staff, the laundry equipment shall be located in a separate room from that of the laundry room used by the residents.
B) The SLF shall have space for laundry soiled with body secretions to be processed separately from other soiled linens and laundry.
C) There shall be two sinks, one for hand washing that is separate from a sink that is to be used for laundry rinsing in the laundry area.
q) Housekeeping and Maintenance Areas
There shall be at least one lockable janitor closet in the building. All janitor closets shall have a source of hot and cold running water. Rehabilitated nursing facilities may use the same janitor closet as the nursing facility.
r) Water Services
1) The building water supply shall be taken from a water system that is constructed, protected, operated and maintained in conformance with State and local regulations.
2) Water temperatures in the central kitchen and laundry used for sanitizing shall meet the standards of the local and State health departments.
3) Hot and cold running water with adequate water pressure shall be maintained.
4) Drinking water shall be accessible to residents at all times in no fewer than one common area and all residential apartments.
5) The SLF shall maintain hot water temperatures between 95° and 120°F in resident rooms and any other areas of the SLF that are accessible to residents. The SLF shall maintain a log or checklist to show that water temperatures are being checked at least monthly. The SLF shall document steps taken to correct hot water temperatures found not to be within the required range. The log or checklist should include, but not be limited to, the following:
A) Areas of the SLF where water temperatures were checked. This shall include a random sample of resident rooms;
B) Date the checks were done; and
C) Temperature of the water in the areas of the SLF that were checked.
s) Waste Removal
1) Liquid wastes shall be collected, stored, and disposed of in accordance with State building and health regulations. Those liquid wastes resulting from compacting shall be disposed of as sewage.
2) Sewage disposal shall be operated in compliance with State and local building and health department regulations.
3) Solid waste containers for use inside and outside shall be insect-proof, rodent-proof, fire-proof, non-absorbent and water-tight containers with tight fitting lids.
4) Indoor garbage containers shall be cleaned frequently enough to minimize the transmission of infection and attraction of insects and rodents.
5) Garbage from the public areas of the building shall be collected daily, and garbage from the residential apartments shall be collected as needed. All garbage shall be held in receptacles outside the building for removal on a regular schedule. Garbage and trash shall be disposed of in accordance with local ordinances.
6) The disposal of sharps shall be handled as follows:
A) SLF staff shall not dispose of sharps in wastebaskets found in resident rooms.
B) Sharps shall be disposed of in containers that are rigid and leak-resistant. These include proper red biohazard containers, plastic laundry detergent containers, and metal coffee cans. The SLF shall provide a container for residents that are independent with medications.
C) If using a container other than the proper red biohazard container, the container shall be capped and taped prior to it being thrown in a garbage receptacle outside the SLF.
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.215 SLP Participation Requirements
a) Facilities or distinct parts of facilities that are certified in the SLP and are in good standing with provisions contained in this Subpart B and, when applicable, Subpart E are exempt from the provisions of the Nursing Home Care Act [210 ILCS 45], the Illinois Health Facilities Planning Act [20 ILCS 3960] and the Assisted Living and Shared Housing Act [210 ILCS 9]. Nursing facilities rehabilitating a portion of the facility to conform with this Subpart B shall be allowed to retain their Certificate of Need for the nursing facility beds that were converted until the conclusion of the project or until the facility wishes to withdraw from the project and convert the SLP setting beds back to NF beds.
b) An SLP setting does not include:
1) A home, institution, or other place operated by the federal government or agency thereof, or by the State of Illinois;
2) A "long term care facility" licensed by the Nursing Home Care Act or Hospital Licensing Act. However, a nursing facility licensed under the aforementioned Acts can convert a distinct part to an SLP setting;
3) Any "facility for child care" as defined in the Child Care Act of 1969 [225 ILCS 10];
4) Any "Community Living Facility" as defined in the Community Living Facilities Licensing Act [210 ILCS 35];
5) Any "community residential alternative" as defined in the Community Residential Alternatives Licensing Act [405 ILCS 30];
6) Any nursing home or sanitarium operated solely by and for persons who rely exclusively upon treatment by spiritual means through prayer, in accordance with the creed of any well recognized church or religious denomination;
7) Any facility licensed by the Department of Human Services as a community-integrated living arrangement as defined in the Community Integrated Living Arrangements Licensure and Certification Act [210 ILCS 135];
8) Any "Supportive Residence" licensed under the Supportive Residences Licensing Act [210 ILCS 65];
9) Any freestanding hospice facility [210 ILCS 60];
10) Any "life care facility" as defined in the Life Care Facilities Act [210 ILCS 40]; or
11) Any "assisted living and shared housing establishment" licensed under the Assisted Living and Shared Housing Act [210 ILCS 9].
c) In order to participate in the Supportive Living Program, the building structure must be certified by the Department. To become certified, an SLP provider shall:
1) Submit an application to proceed toward certification.
A) Except in the case of a rehabilitated nursing facility, the Department shall only accept applications for sites where all apartments are devoted to SLP residents.
B) The Department shall evaluate each application according to factors including, but not limited to, geographic distribution, waiver limits, market feasibility, the needs of the population being served, the compliance histories of other facilities owned or operated in the State of Illinois by the applicant or a related party, community support from local government, environmental issues, operational experience with assisted living and financial stability. Applications that are found to be incomplete or inaccurate shall be returned to the applicant for completion and/or correction and must be resubmitted before the Department will evaluate them. The Department shall notify the applicant in writing that the application has been approved.
C) Direct and indirect owners of five percent or more of the entity designated as the operator shall be disclosed to the Department.
D) A recognized environmental condition found as the result of a Phase 1 Environmental Site Assessment (ESA) report shall result in a Phase 2 ESA to determine if significant amounts and concentrations of contaminants exist on the property. If contamination is found in Phase 2, the Department, prior to certification, may request subsequent testing, feasibility studies, and/or remediation.
E) The Department may withdraw approval of any application if the SLP building fails to become operational (i.e., ready to admit residents) within 24 months after the Department's approval of the application. Prior to the operational deadline, the applicant may make a written request, including documentation justifying the need for an extension, that the Department grant an extension to the operational deadline. A request for an extension shall not exceed 12 months from the original operational deadline. The Department may grant an extension to the operational deadline. The Department shall not grant more than one extension to an approved SLP applicant when construction has not begun.
F) A phase-in for opening may be approved upon the written request of the SLP provider. The request shall include the anticipated completion date of the phase-in, a plan to ensure the safety of residents during the phase-in, and the floors and areas of the SLP setting impacted by the phase-in. Additionally, the SLP provider shall assure that all services continue to be available during the phase-in. The Department shall approve no more than a single phase-in.
G) At any time prior to or subsequent to certification, the applicant shall report to the Department in writing any change to the application, as soon as such change becomes known to the applicant. These changes are subject to Department approval.
2) Submit a certificate of compliance signed by an architect that certifies that the project complies with applicable codes and all structural requirements found in Section 146.210.
3) Submit for approval prior to use a model of every type of resident contract to be used by the SLP provider.
4) Submit for approval all policies that include, but are not limited to:
A) Waste removal plan pursuant to Section 146.210(t);
B) Participation criteria pursuant to Section 146.220;
C) Base rate services pursuant to Section 146.230;
D) Resident daily check plan pursuant to Section 146.230(n);
E) Employee hiring process pursuant to Section 146.235;
F) SLP setting manager experience pursuant to Section 146.235(b);
G) Staff training policy pursuant to Section 146.235(e);
H) Resident rights pursuant to Section 146.250;
I) Resident discharge policy pursuant to Section 146.255;
J) Grievance procedure pursuant to Section 146.260;
K) Quality assurance plan pursuant to Section 146.270;
L) Annual satisfaction survey policy pursuant to Section 146.270(a);
M) Emergency contingency plan pursuant to Section 146.295;
N) Prevention and reporting of abuse, neglect and financial exploitation policy pursuant to Section 146.305;
O) Staff and resident rules and responsibilities;
P) Infection control, including, but not limited to, hand-washing, proper handling and disposal of sharps, proper handling of linens soiled with body waste, and cleaning of floors that have been soiled;
Q) Water temperature plan pursuant to Section 146.210(s)(5);
R) Tuberculosis plan in accordance with the Control of Tuberculosis Code (77 Ill. Adm. Code 696);
S) Potential resident inquiry and application for admission policy pursuant to Section 146.220; and
T) Non-discrimination policy.
5) Pass an on-site review, conducted by the Department, that includes review of documentation that demonstrates physical plant, health and sanitation, and food preparation compliance with local and county ordinances and regulations; compliance with State building codes for the respective building type; and compliance with Section 146.210.
6) Enroll to participate in the Medical Assistance Program in accordance with 89 Ill. Adm. Code 140.11 and execute a provider agreement with the Department.
d) The SLP provider shall accept the SSI rate (less the personal allowance) for room and board for Medicaid residents. If the SLP provider charges a private pay rate higher than the Medicaid rate, the SLP provider shall reserve not less than 25 percent of its apartments for Medicaid-eligible residents. Those SLP settings that set a commensurate rate for both private pay and Medicaid-eligible residents are not required to reserve apartments for Medicaid-eligible residents but must accept Medicaid-eligible residents on a first come, first served basis.
e) SLP certification is not transferable or applicable to any location, provider, management agent or ownership other than that indicated on the provider agreement.
1) An SLP provider shall notify the Department no fewer than 60 days prior to a change of ownership or management. The new owner shall complete an application for the Department's approval prior to the effective date of the change of ownership.
2) Pursuant to 89 Ill. Adm. Code 140.11(f), an SLP provider whose investor ownership has changed by 50 percent or more shall be required to submit a new application for enrollment in the Medical Assistance Program.
3) Pursuant to 89 Ill. Adm. Code 140.12(k), a new owner assumes liability for repayment to the Department of any overpayment made to the SLP provider, regardless of whether the overpayment was incurred by a current or previous owner or operator.
4) The Department has the right to terminate the provider agreement with an SLP provider if a change of ownership involves a barred Medicaid provider.
5) The new owner shall comply with the applicable certification requirements found in subsection (c).
6) The Department shall conduct an on-site certification review no later than at the date of the next annual certification review or within three months after the effective date of the change of ownership, whichever is earlier.
7) SLP certification shall be deemed to extend to a new owner until the Department separately certifies the SLP setting under the approved new owner.
f) SLP applicants with an application approved by the Department to proceed toward certification shall not change ownership without the approval of the Department. The approved applicant shall notify the Department no fewer than 60 days prior to a change of ownership or management. Direct and indirect owners of five percent or more of the entity designated as the operator shall be disclosed to the Department. The new owner shall complete an application for the Department's approval prior to the effective date of the change of ownership.
g) A request for a change in the number of apartments in an operational or approved SLP setting shall be made with an application to the Department for approval. A change in the number of apartments includes both a decrease and increase. The Department shall conduct an on-site review prior to issuing a new certificate for the change in the number of apartments. In the case of an increase in apartments, residents shall not be admitted to the apartments until an on-site review is conducted and the Department issues a revised certificate.
h) The certificate issued by the Department shall include:
1) Name and address of the SLP setting;
2) Maximum number of residents to be served at any time; and
3) Number of apartments certified in the SLP setting.
i) Providers certified as an SLP provider shall not operate or maintain SLP housing and SLP setting services in combination with a home health, home care, nursing home, hospital, residential care setting, congregate care setting or other type of residence or service agency unless those settings and services are licensed, maintained and operated as separate and distinct entities.
j) At least annually, the Department shall conduct an on-site review to ensure that the SLP setting is in compliance with the requirements of certification, which includes review of:
1) Items listed in subsection (c)(5).
2) Comprehensive Resident Assessments, service plans and the provision of services required under Section 146.230.
3) Staff sufficient in number to meet the needs of residents. Staff shall demonstrate capacity, within their job responsibilities, to provide covered services and perform tasks.
4) Compliance with resident contracts and the Department's provider agreement.
5) Protection of individual resident rights and involvement in directing their own care.
6) Resident satisfaction surveys as defined in Section 146.270.
k) The SLP provider shall comply with all applicable enrollment and participation requirements set forth in Department rules, including, but not limited to, 89 Ill. Adm. Code 140.11 and 140.12.
l) The SLP provider shall comply with the Americans With Disabilities Act of 1990.
m) The SLP provider shall submit to the Department all marketing materials prior to their use. If the Department does not notify the SLP provider of approval or disapproval of submitted materials within 30 days after submission, the SLP provider may begin to use those materials. The Department reserves the right to disapprove any materials or require changes at any time, provided that any such changes are consistent with, or required by, applicable law.
n) The SLP provider shall ensure that limited English speaking residents have meaningful and equal access to benefits and services. Steps to ensure access may include, but are not limited to:
1) hiring bi-lingual staff;
2) hiring staff interpreters;
3) contracting for interpreter services;
4) engaging community volunteers;
5) contracting with a telephone interpreter service; and
6) hiring staff proficient in American Sign Language.
o) The SLP provider shall encourage families of residents with impairments that limit the resident's decision-making ability to arrange to have a responsible party or guardian represent the resident's interests. The SLP provider shall provide all residents with information about advance directives, including the Durable Power of Attorney for Health Care, Statement of Illinois Law on Advance Directives, Living Will, Declaration for Mental Health Treatment and Do Not Resuscitate Advance Directive. The SLP provider shall maintain in a resident's file any of these documents authorized by the resident.
p) Upon admission of a resident whose name appears on the United States Department of Justice Dru Sjodin National Offender Public Website, the Illinois State Police Sex Offender Registration website or the Illinois Department of Corrections registered sex offender database (see Section 146.220(a)(4)), the SLP provider shall:
1) inform the Department and appropriate county and local law enforcement offices of the identity of the identified offenders being admitted to the SLP setting;
2) notify every SLP resident and resident's guardian or family in writing that such offenders are residents of the SLP setting;
3) develop a service plan in accordance with Section 146.245; and
4) ensure that the SLP setting has qualified staff to meet the needs of the individual and required level of supervision at all times.
(Source: Amended at 44 Ill. Reg. 2331, effective January 15, 2020)
Section 146.220 Resident Participation Requirements
a) The SLP setting may admit or retain residents whose needs can be met through the services described in Section 146.230. The following criteria shall be met prior to admission to the SLP setting:
1) Be age 22 years or over with a physical disability (as determined by the Social Security Administration) or elderly (age 65 years or over);
2) Be screened by the appropriate Department on Aging contracted Care Coordination Unit (DoA CCU) or the Department of Human Services Division of Rehabilitation Services (DHS-DRS) screening agency and found to be in need of nursing facility level of care. A new Determination of Need (DON), or successor tool, screen is not needed for a resident who is transferring between SLP providers or comes from a nursing facility with no break in service. It is the admitting SLP provider's responsibility to ensure that a screening document is received from the transferring SLP setting or nursing facility. If the individual is transferring directly from a nursing facility and has a history of a developmental disability or serious mental illness, as evidenced in the medical history accompanying the individual, the SLP provider must submit a referral for a specialized evaluation to be completed by the DHS Division of Developmental Disabilities (DHS-DDD) Independent Service Coordination (ISC) agency or the Division of Mental Health (DHS-DMH) Preadmission Screening Resident Review (PASRR) agency to evaluate for need for active treatment or the existence of serious functional risks and needs associated with the diagnosis to determine if they exceed the capacity of the SLP setting. Private pay individuals may choose to be admitted into the SLP setting when the screening assessment does not justify nursing facility level of care;
3) If further evaluation is necessary due to the suspicion of a developmental disability or serious mental illness, the developmental disability or serious mental illness must be determined by a qualified DHS-DDD ISC agent or DHS-DMH preadmission screening (PAS) agent. The presence of a developmental disability does not automatically preclude admission to the SLP unless there is the need of continuous active treatment for which the individual should be considered for other DHS-DDD services not available through the SLP. The presence of a serious mental illness does not automatically preclude admission to the SLP unless the psychiatric symptoms, behavioral risk, and major treatment adherence/engagement problem persist at a sufficiently serious level that exceeds the service capabilities of the SLP provider. The evaluation and determination of whether the needs are within the SLP provider capability or beyond the SLP provider capacity is determined by the DHS-DDD ISC or DHS-DMH PAS agent; and
4) Have name checked against the United States Department of Justice Dru Sjodin National Offender Public Website at www.nsopr.gov, the Illinois Sex Offender Registration website at www.isp.state.il.us and the Illinois Department of Corrections registered sex offender database at www.idoc.state.il.us. Refer to Section 146.215 for facility requirements if a person whose name appears on either registry is admitted to an SLP setting.
b) The SLP provider's assessment to determine if a potential resident's needs can be met by the SLP provider shall not occur until after the DON, or successor tool, assessment and other required PAS have been completed and determinations provided to the SLP provider.
c) Private pay residents seeking to convert to Medicaid while residing in an SLP setting shall be screened by the Department using the DON or successor tool, prior to the point of conversion and must be found to be in need of nursing facility level of care before Medicaid payment may be authorized.
d) Each prospective resident shall have a tuberculin skin test in accordance with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).
e) A Medicaid resident of the SLP setting shall not participate in any other federal Home and Community-Based Waiver Program.
(Source: Amended at 44 Ill. Reg. 2331, effective January 15, 2020)
Section 146.225 Reimbursement for Medicaid Residents
Supportive Living Programs (SLPs) shall accept the reimbursement provided in this Section as payment in full for all services provided to Medicaid residents.
a) The Department has established the rate methodology for SLP providers as follows:
1) Prior to July 1, 2014, the Department shall establish its portion of the reimbursement for Medicaid residents by calculating 60 percent of the weighted average (weighted by Medicaid patient days) nursing facility rates for the geographic grouping as defined in Section 146.290. Each SLP shall be paid 60 percent of the weighted average nursing facility geographic group rate, based upon the nursing facility geographic group in which it is located. The rates paid to SLPs shall be updated semi-annually on April 1 and on October 1 to assure that the rates coincide with 60 percent of weighted average nursing facility geographic group rates. Notwithstanding the provisions of this subsection, the supportive living program rates shall remain at the level in effect on April 30, 2011.
2) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, and subject to federal CMS approval, as of July 1, 2014, supportive living program rates shall no longer be 60 percent of the weighted average nursing facility rates for the geographic group rate, based upon the nursing facility geographic group in which it is located.
3) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, and subject to federal CMS approval, for dates of service on or after July 1, 2014, rates effective on June 30, 2014 shall be increased 8.85 percent.
4) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, and subject to federal CMS approval of the imposition of the assessment in 89 Ill. Adm. Code 140.86, for dates of service on or after July 1, 2014, rates effective July 1, 2014 shall be increased an additional 9.09 percent.
5) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, for dates of service on or after July 1, 2017, rates effective on June 30, 2017 shall be increased by 2.8 percent.
b) The payment rate received by the SLP from the Department for services, with the exception of meals, provided in accordance with Section 146.230 shall constitute the full and complete charge for services rendered. Additional payment, other than patient credits authorized by the Department, may not be accepted. Meals are included in the room and board amount paid by the resident.
c) Single Occupancy: Each Medicaid resident of an SLP shall be allotted a minimum of $90 per month as a deduction from his or her income as a protected amount for personal use. The SLP may charge each Medicaid resident no more than the current SSI rate for a single individual less a minimum of $90 for room and board charges. Any income remaining after deduction of the protected minimum of $90 and room and board charges shall be applied first towards medical expenses not covered under the Department's Medical Assistance Program. Any income remaining after that shall be applied to the charges for SLP services paid by the Department.
d) Double Occupancy: In the event a Medicaid eligible resident chooses to share an apartment, the Medicaid resident of an SLP shall be allotted a minimum of $90 per month as a deduction from his or her income as a protected amount for personal use. The SLP may charge each Medicaid resident no more than the resident's share of the current SSI rate for a couple less a minimum of $90 for room and board charges. The room and board rate for two Medicaid eligible individuals sharing an apartment cannot exceed the SSI rate for a married couple even if the two individuals sharing an apartment are unrelated. Any income of an individual remaining after deduction of the protected minimum of $90 and room and board charges shall be applied first towards that individual's medical expenses not covered under the Department's Medical Assistance Program. Any income of an individual remaining after that shall be applied to that individual's charges for SLP services paid by the Department. If one, or both, of the individuals sharing an apartment is not Medicaid eligible, the SLP may negotiate its own rate with the non-Medicaid individual or individuals.
e) The room and board charge for Medicaid residents shall only be increased when the SSI amount is increased. Any room and board charge increase shall not exceed the amount of the SSI increase.
f) Payment shall be made by the Department for up to 30 days per State fiscal year during a Medicaid resident's temporary absence from the SLP when the absence is due to situations such as hospitalizations or vacations. The resident shall continue to be responsible for room and board charges during any absence. Involuntary discharge criteria relating to temporary absence are found at Section 146.255(b) and (d)(7). Nursing facilities that have a distinct part certified as an SLP shall consider converted beds in the nursing facility's licensed capacity when calculating the 93 percent occupancy level for bed reserve payments pursuant to 89 Ill. Adm. Code 140.523.
1) The day a resident is transferred to the hospital is the first day of the temporary absence.
2) For all other temporary absences, except a long-term care admission, the day after resident leaves the SLP is the first day of the temporary absence.
3) The day before resident returns to the SLP is the last day of the temporary absence.
4) The Department does not pay for temporary absence due to admission to a long-term care facility. In this instance, an SLP shall discharge the resident from the Department's database. An SLP may choose to hold an apartment while a resident is in a long-term care facility.
5) By agreement between the SLP and a resident, an SLP may continue to hold an apartment when a resident has exceeded the 30 days payable by the Department.
(Source: Amended at 42 Ill. Reg. 16731, effective August 28, 2018)
Section 146.230 Services
a) An SLF must combine housing, personal and health related services in response to the individual needs of residents who need help in activities of daily living. Supportive services shall be available 24 hours per day to meet scheduled and unscheduled needs in a way that promotes resident self-direction and participation in decisions that emphasize independence, individuality, privacy, dignity and autonomy in a residential setting.
b) Nursing Services
1) The SLF shall conduct a comprehensive resident assessment and service plan for each SLF resident as required under Section 146.245.
2) When a resident is unable to administer his or her own medications, a licensed nurse shall administer the medications.
3) Nursing services shall include medication set-up (such as preparing weekly pill caddies with that week's medication) and follow-up care, and shall be conducted by a licensed nurse.
4) Other nursing services include episodic and intermittent health promotion or disease prevention counseling and teaching self-care in meeting routine and special health care needs that can be done by other staff under the supervision of a registered nurse.
5) All nursing services shall be provided in accordance with the Nurse Practice Act [225 ILCS 65].
c) Personal Care
1) The SLF shall provide personal care services for residents, including but not limited to assistance with bathing, eating, dressing, personal hygiene, grooming, toileting, ambulation and transfer.
2) Personal care services shall be delivered by certified nursing assistants who meet the qualifications described in Section 146.235(f)(1).
d) Medication Administration, Oversight and Assistance in Self-Administration
1) The SLF shall provide the following:
A) Reminding the resident to take his or her medications;
B) Taking medication from where it is stored in the apartment and handing it to the resident when requested to do so by the resident;
C) Opening or uncapping medication containers for residents; and
D) Assisting residents in the removal of the medication from the container and assisting the resident in consuming or applying the medication when requested to do so by the resident (i.e., placing a dose in a container and placing the container to the mouth of the resident).
2) The services identified in subsection (d)(1)(D) shall only be delivered by a licensed nurse.
3) Medication administration shall be documented according to the needs of each resident. Documentation for medication administration shall include, but not be limited to, the following:
A) Name of resident;
B) Name of medication, dosage, directions and route of administration;
C) Date and time medication is scheduled to be administered;
D) Date and time medication was administered; and
E) Signature or initials of employee administering the medication.
4) Medication oversight shall be documented according to the needs of each resident. Documentation for medication oversight shall include, but not be limited to, the following:
A) Name of resident;
B) Name of medication, dosage, directions and route of administration;
C) Type of oversight needed; i.e., reminders, assisting with opening container, etc.;
D) Date and time medication is scheduled to be taken;
E) Documentation showing that resident has taken, or refused to take, the medication; and
F) Signature or initials of employee providing oversight.
e) Meals
1) The SLF shall provide three meals per day, or two meals per day (noon and evening meals) and a breakfast bar. The menu shall include food choices that allow a resident to choose foods that will meet the requirements of a therapeutic diet as ordered by a resident's physician. The menu for each resident shall meet the basic food pattern for a general diet for an adult following the recommendations of the Food and Nutrition Board, National Academy of Sciences.
2) The SLF shall make available beverages, including coffee, fruit juice and snack foods, at no cost to the residents.
3) The SLF shall offer the same menu options to all residents regardless of payment source.
4) The SLF shall keep all menus served on file for not less than six months.
5) The SLF shall maintain on the premises supplies of staple foods for a minimum of a one week period and of perishable foods for a minimum of a two day period. Supplies shall be appropriate to meet the requirements of the menu.
6) The SLF shall keep records of all food purchased on file for not less than six months.
7) The SLF shall store, prepare, distribute and serve food in a manner to protect against contaminants and spoilage and to insure the preparation and serving of food at safe and palatable temperatures.
8) The SLF shall provide and maintain clean and sanitary central kitchen and dining areas. The SLF shall ensure a sanitary and adequate supply of eating and drinking utensils and pots and pans for preparing food in the central kitchen and dining areas.
9) The SLF shall provide residents with written information about menu plans. Menu cycles shall not be repeated within a one week time frame. There shall be an established mechanism for residents to provide input into the selection and preparation of food served.
10) The SLF shall allow residents to obtain, prepare and store food in residential apartments if doing so does not represent a health or safety hazard to others.
11) The SLF shall provide residents with meal service in their apartments as a time limited service during periods of documented illness.
f) Laundry
1) If requested by a resident, the SLF shall provide laundry services at least weekly at no charge to the resident.
2) The SLF shall provide for the appropriate handling, cleaning, and storage of routine personal laundry, laundry soiled with body secretions and all other laundry. This includes all detergent and fabric softeners required to perform normal routine laundry service at no cost to the resident.
3) The SLF shall provide on-site laundry equipment for resident use in accordance with Section 146.210.
4) Laundry service does not include dry cleaning services.
g) Housekeeping
1) The SLF shall provide for general housekeeping services at least weekly (house cleaning, bed making, changing of linens, dusting and vacuuming).
2) The SLF shall take into account individual habits and lifestyle preferences when providing all housekeeping services in residential apartments.
3) The SLF shall maintain all public areas in a clean and orderly condition.
4) The SLF shall maintain all common bathing rooms in a clean and orderly condition.
h) Maintenance
1) The SLF shall maintain all residential apartments in good repair.
2) The SLF shall keep the building and grounds clean and free of hazards, with all systems maintained in good working order.
i) Social and Recreational Programming
1) The SLF shall facilitate the involvement of individual and community volunteer activities with and for residents.
2) The SLF shall provide programs at least twice weekly, which include on-site programs as well as off-site trips, allowing for social and recreational programs for the residents. Transportation shall be provided or arranged at no cost to the resident by the SLF for scheduled activities off-site.
3) The SLF shall provide access to opportunities for scheduled and unscheduled individual and group socialization within the SLF and in the larger community.
4) The SLF shall make available to each resident information about community resources and make community integration part of the SLF's recreational, socialization and vocational activities.
j) Ancillary Services
1) The SLF shall provide or arrange transportation, at no charge to the residents, for scheduled shopping, community and social activities. The community outings shall reflect the interests, choices and needs of the residents and be scheduled on a regular basis and be reflected in the residents' calendar.
2) The SLF shall assist a resident in obtaining needed and preferred services offered outside the SLF at his or her request. Upon request by a resident, the SLF shall assist in making medical appointments and arranging for transportation to and from the source of medical treatment (payment for medical transportation shall be made in accordance with 89 Ill. Adm. Code 140.490 through 140.492).
3) The SLF shall provide shopping assistance when a resident is temporarily unable to shop.
k) 24 Hour Response/Security Staff
1) The SLF shall have response/security staff awake and available on the premises 24 hours a day to respond to scheduled or unpredictable needs and emergency calls from residents. Staff shall possess certification in emergency resuscitation. The SLF shall provide no fewer than one staff person for facilities with one to 75 residents, a second staff person for facilities with 76 to l50 residents, and a third staff person for facilities with 151 or more residents. In determining the number of staff, the SLF shall consider the number of floors in the building, and the medical needs of the residents. At least one certified nursing assistant shall be on-site 24 hours a day to respond to resident needs.
2) The SLF shall provide security 24 hours a day, including lockable entrances (accessibility controlled by SLF staff for security purposes during overnight hours) and on-site personnel. All residents shall have 24 hour access.
3) Rehabilitated nursing facilities shall have separate staff on-site in the SLF.
l) Health Promotion and Exercise Programming
1) The SLF shall offer and encourage the use of health promotion and exercise programs for its residents.
2) The SLF shall develop programs to be held not less frequently than three times per week geared toward promoting better health and fitness of the residents. These programs are in addition to the social and recreational programming described in this Section.
m) Emergency Call System
1) The SLF shall ensure that at least two electronic devices are available in each apartment to enable the resident to secure help in an emergency. At least one device shall be located in each bathroom. The requirement for additional devices shall be met with a device located in each bedroom or through a portable emergency home response system.
2) The SLF shall have electronic devices available in each common area, each public restroom, each common bathing room and each resident laundry room to enable residents to secure help in an emergency.
3) The emergency call system shall be capable of direct and immediate notification to staff or shall be manned by personnel 24 hours a day for transmission to available staff for assistance.
n) Daily Check
The SLF shall implement a system to check on the welfare of each resident daily.
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.235 Staffing
a) The SLP setting shall have a manager or a qualified designee present at the SLP during normal business hours plus whenever necessary to ensure attention to the management and administration of the resident contracts. Staff shall have access to the manager or the manager's designee at all times. The manager shall designate a qualified individual capable of acting in an emergency during his or her absence from the SLP setting.
b) The manager shall have at least five years' experience in providing health care services to adults with physical disabilities or the elderly population either in an assisted living program, inpatient hospital, long term care setting, adult day care or in a Department approved health related field. The manager shall also have at least two years of management experience.
c) The SLP setting shall have licensed and certified staff sufficient in number to meet the needs of the population being served.
d) Licensed nurses or certified nursing assistants on duty in the SLP setting shall not be utilized in an adjoining or other part of the building not certified in the SLP setting. This includes, but is not limited to, a nursing facility, assisted living facility, and independent living facility.
e) Staff Training. All staff training materials shall be available for review by the Department. If required by the Department, the SLP setting shall make changes in the training materials.
1) The SLP setting shall provide staff and subcontractors who provide direct care with:
A) training that takes place no later than 30 days after beginning employment and semi-annual training in areas related to their employment;
B) training that covers resident rights; infection control; crisis intervention; prevention and notification of abuse, neglect and financial exploitation; behavioral intervention; tuberculosis identification, prevention, control and reporting; encouraging independence; potential resident inquiry and admission application policy; and non-discrimination policy (these subjects shall be trained as part of staff orientation and at least annually thereafter);
C) documented training performed by qualified individuals in their area or areas of responsibility;
D) training geared toward the manner in which services are to be performed;
E) training that includes techniques for working with persons with physical disabilities and the elderly populations; and
F) in the case of an SLP setting serving persons with physical disabilities, disability specific sensitivity training conducted by an outside entity familiar with working with persons with disabilities. The training shall occur for all staff initially prior to certification, at staff orientation for new staff, and at least annually thereafter.
2) In the case of subcontractors, training by the SLP provider is not required if the SLP provider can document that similar training is being provided through the subcontractor's employer.
f) The SLP provider shall employ certified nursing assistants (CNAs) as follows:
1) Qualifications
Must be 18 years of age or older and have successfully completed no later than 120 days after employment a nursing assistant training course or a Department of Public Health approved equivalent training and competency evaluation.
2) Names of CNAs shall be checked against the Illinois Department of Public Health's Health Care Worker Registry prior to employment.
3) Job responsibilities shall include, but not be limited to:
A) Follow and help carry out a resident's written service plan;
B) Provide personal care services for residents, including but not limited to bathing, eating, dressing, personal hygiene, grooming, toileting, ambulation and assistance with transfer;
C) Observe the resident's functioning, maintain written records of the observations and report any changes to the licensed nurse; and
D) Attend initial training, in-service training sessions and staff conferences.
g) The SLP provider shall employ or contract with a dietitian. The dietitian shall comply with the following:
1) The dietitian shall be licensed under the Dietician Nutritionist Practice Act [225 ILCS 30].
2) Job responsibilities shall include, but not be limited to, consultation and training in all food service procedures such as menu planning and review, food preparation, food storage, food service, safety, sanitation and management of therapeutic diets.
3) The dietician shall come on-site at least twice per quarter for a period of not less than a cumulative total of eight hours.
h) The SLP provider shall employ a minimum of one cook who shall have at least one year of experience in commercial food preparation.
i) Twenty-four hour response staff shall be at least 18 years of age and possess at least a high school diploma or a GED. Response staff shall be certified in emergency resuscitation. The staff shall respond to scheduled or unpredictable needs and emergency calls from residents.
j) Nurses on staff, or subcontracted, shall be licensed by the State of Illinois and shall be responsible for nursing services set forth in Section 146.230.
k) The SLP provider shall designate a trained staff person to be responsible for planning and directing social and recreational activities. This person shall be at least 18 years of age and possess at least a high school diploma or a GED.
l) The SLP provider shall ensure that all employees who have or may have contact with residents or have access to the living quarters or the financial, medical or personal records of residents undergo a criminal history background check that conforms to the Health Care Worker Background Check Act [225 ILCS 46]. No SLP provider shall knowingly hire, employ or retain any individual in a position, with duties involving contact with residents, access to resident living quarters or access to the financial, medical or personal records of residents, who has been convicted of committing or attempting to commit one or more of the offenses defined under the Health Care Worker Background Check Act unless that individual has obtained a waiver issued by the Department of Public Health. An SLP provider may conditionally employ an applicant for up to three months pending the results of the criminal history record check.
m) Each employee and volunteer shall have a tuberculin skin test in accordance with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).
(Source: Amended at 44 Ill. Reg. 2331, effective January 15, 2020)
Section 146.240 Resident Contract
a) The SLF shall have a signed contract with each resident, which specifies the terms of his or her agreement.
b) The resident contract shall include, but not be limited to, the following:
1) Information regarding SLF services the resident will receive that are covered under the Medical Assistance Program;
2) Arrangements for payment;
3) A grievance procedure that meets the requirements of Section 146.260;
4) The SLF's agreement to comply with applicable federal, State and local laws and regulations;
5) The conditions under which the resident contract may be terminated by either party;
6) Rules for conduct and behavior of the staff, management and the resident;
7) A list of the resident rights as stated in Section 146.250;
8) The SLF's policy regarding temporary absences from the facility, including absences due to a resident's admission to a nursing facility;
9) The SLF's policy regarding Supplemental Nutritional Assistance Program benefits being turned over by the resident to the SLF; and
10) The SLF's requirement, if any, for security deposits charged by the SLF. When applicable, the contract shall state that all deposits will be maintained in an interest-bearing account separate from the SLF's operating accounts or the funds of any person other than another resident. The SLF shall, within 30 days after the end of each 12 month rental period, pay the resident any interest, by cash or credit applied to rent due, except when the resident is in default under the terms of the lease. If required, the SLF shall follow the provisions of the Security Deposit Return Act [765 ILCS 710] regarding the return of the security deposit when a resident vacates the premises.
c) The resident contract may include the agreement of the SLF to provide, for a fee, additional services such as barber or beauty services, sundries for personal consumption and other amenities.
d) The resident contract shall be for a term not to exceed one year and may be renewable upon the agreement of both parties.
e) The resident contract shall allow arrangements where two individuals wish to share an apartment even if one of the two individuals is not eligible for SLF services. The individuals may be related or unrelated. In the event of one resident's death or discharge, the resident contract shall include provisions that offer the remaining resident who is not receiving SLF services the option to be released from the contract immediately, if desired by the resident, or to remain in the SLF until the expiration of the resident contract as long as he or she remains in compliance with the terms of the resident contract.
f) The SLF shall ensure that all SLF materials, including the resident contract, shall be in a language appropriate to the resident population as required in Section 146.215(m).
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.245 Assessment and Service Plan and Quarterly Evaluation
a) Interview: The SLP provider shall conduct a standardized interview geared toward the resident's service needs at or before the time of occupancy but not before the DON, or successor tool, and other required PAS assessments are completed and determinations provided to the SLP provider.
b) Initial Assessment: The SLP provider shall complete an initial assessment and service plan within 24 hours after admission that identifies needs and potential immediate problems. Each assessment shall be completed by, or co-signed by, a licensed practical nurse or a registered professional nurse.
c) Comprehensive Resident Assessment: The SLP provider shall complete a Comprehensive Resident Assessment Instrument (RAI) within 14 days after admission, annually and upon a significant change in the resident's mental or physical status. Each RAI shall be completed by, or co-signed by, a registered professional nurse.
d) Service Plan: Within seven days after completion of the RAI, a written service plan shall be developed by, or co-signed by, a registered professional nurse, with input from the resident and his or her designated representative. This includes coordination and inclusion of services being delivered to a resident by an outside entity. The service plan shall include a description of expected outcomes, approaches, frequency and duration of services provided and whether the services will be provided by licensed or unlicensed staff. The service plan must be individualized to address the health and behavior needs of each resident. The service plan shall document any services recommended by the SLP provider that are refused by the resident. The service plan shall be reviewed and updated in conjunction with the quarterly evaluation or as dictated by changes in resident needs or preferences.
e) Quarterly Evaluation: A quarterly evaluation of the health and behavior status of each resident using a Department designated form shall be completed by, or co-signed by, a registered professional nurse.
f) Service Plan for Identified Sex Offenders: Within seven days after completion of the RAI, a written service plan shall be developed by, or co-signed by, a registered professional nurse that addresses the following:
1) the amount of supervision required by the individual to ensure the safety of all residents, staff and visitors; and
2) determination of approaches developed in the service plan are appropriate and effective in dealing with any behaviors specific to the identified offender.
g) Progress Notes: Progress notes shall be completed at least monthly to document decline or improvement in resident status. A progress note does not have to be completed if there is no change in resident status. Any SLP staff may write progress notes.
h) The SLP manager or licensed nursing staff shall alert the resident, his or her physician and his or her designated representative when a change in a resident's mental or physical status is observed by staff. Except in life-threatening situations, the reporting shall be within 24 hours after the observation. Serious or life-threatening situations should be reported to the physician and the resident's designated representative immediately. The SLP staff shall be responsible for reporting only those changes that should be apparent to observers familiar with the conditions of older persons or persons with disabilities.
(Source: Amended at 44 Ill. Reg. 2331, effective January 15, 2020)
Section 146.250 Resident Rights
a) Residents shall be afforded all rights guaranteed under the Constitutions of the United States and the State of Illinois, federal, State and local statutes and the Department's administrative rules.
b) Residents shall be informed of all rights in conjunction with any contracted housing and services.
c) Department posters with the phone number of the Department's Complaint Hotline shall be posted on each floor of the SLF in a location accessible to all residents. Department brochures providing resident rights and phone number to the Complaint Hotline shall be made available to all residents and their families or designated representatives.
d) Long Term Care Ombudsman Program posters provided by the ombudsman shall be posted on each floor of the SLF in a location accessible to all residents.
e) Each resident shall have the right to:
1) Be free from mental, emotional, social, and physical abuse and neglect and exploitation;
2) All housing and services for which he or she has contracted and paid;
3) Have his or her records kept confidential and released only with his or her consent or in accordance with applicable law;
4) Have access to his or her records with 48 hours notice (excluding weekends and holidays);
5) Have his or her privacy respected;
6) Refuse to receive or participate in any service or activity once the potential consequences of refusal have been explained to the resident and the resident's designated representative, if requested by the resident. Refusal shall be documented in the service plan and reviewed no less than quarterly;
7) Arrange and receive non-Medicaid covered services not available from the contracted SLF service provider at the resident's expense so long as the resident does not violate conditions specified in the resident contract;
8) Remain in the SLF, forgoing recommended or needed services from the SLF or available from others. A resident electing to remain without recommended or needed services shall acknowledge that the decision was made against the advice of the SLF, family or health care professional and shall indemnify the SLF from any liability resulting from adverse outcomes specifically associated with the decision to forgo recommended service. The SLF shall retain the right to advise a resident that the right to remain in place is restricted, as explicitly stated in the resident contract. Such indemnity agreements shall be specific to the assumed risk negotiated and do not waive general obligations of providers;
9) Be free of physical restraints;
10) Control his or her time, space, and lifestyle to the extent the health, safety and well-being of others are not disturbed;
11) Consume alcohol and use tobacco in accordance with SLF policy specified in the resident contract and any applicable statutes;
12) Have visitors of his or her choice to the extent the health, safety and well-being of others are not disturbed and the provisions of the resident contracts are upheld;
13) Have roommates only by resident choice;
14) Be treated at all times with courtesy, respect and full recognition of personal dignity and individuality;
15) Make and act upon decisions (except those decisions delegated to a legal guardian) so long as the health, safety and well-being of others are not endangered by his or her actions;
16) Participate in the development, implementation and review of his or her service plans;
17) Maintain personal possessions to the extent they do not pose a danger to the health, safety and well-being of the resident and others;
18) Store and prepare food in his or her apartment to the extent the health, safety and well-being of the resident and others is not endangered and provisions of the resident contract are not violated;
19) Designate or accept a representative to act on his or her behalf;
20) Not be required to purchase additional services that are not part of the resident contract;
21) Not be charged for additional services unless prior written notice is given to the resident of the amount of the charge; and
22) Be free to file grievances pursuant to Section 146.260 and be free from retaliation from the SLF.
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.255 Discharge
a) If a resident does not meet the terms for occupancy as stated in the resident contract, the SLF shall not commence involuntary discharge until the SLF has discussed the reasons for involuntary discharge with the resident and his or her designated representative. Documentation of the discussion shall be placed in the resident's record.
b) The SLF shall provide a resident with a 30-day written notice of proposed involuntary discharge unless such a delay might jeopardize the health, safety, and well-being of the resident or others. A copy of the notice required by this subsection (b) shall be placed in the resident's record and a copy shall be transmitted to the resident and the resident's designated representative. The notice shall be on a form prescribed by the Department and shall contain all of the following:
1) The stated reason for the proposed discharge;
2) The effective date of the proposed discharge;
3) A statement in not less than 14-point type that reads: "You have a right to appeal the SLF's decision to discharge you. You may file a request for a hearing with the Department within ten days after receiving this notice. If you request a hearing, you will not be discharged during that time unless you are unsafe to yourself or others and the SLF has given you a notice for an emergency discharge. If the SLF has not given you a notice for an emergency discharge, and if the decision following the hearing is not in your favor, you will not be discharged prior to the tenth day after receipt of the Department's hearing decision unless you are unsafe to yourself or others. If the SLF provided you with a notice of emergency discharge, and the decision following the hearing is in your favor, you will be entitled to readmission to the SLF upon the first available apartment. A form to appeal the SLF's decision and to request a hearing is attached. If you have any questions, call the Department at the telephone number listed below.";
4) A hearing request form, together with a postage paid, preaddressed envelope to the Department; and
5) The name, address, and telephone number of the person charged with the responsibility of supervising the discharge.
c) The SLF shall prepare plans to ensure safe and orderly involuntary discharge and protect resident health, safety, welfare and rights.
d) A resident may be involuntarily discharged only if one or more of the following occurs:
1) He or she poses an immediate threat to self or others.
2) He or she needs mental health services to prevent harm to self or others.
3) He or she has breached the conditions of the resident contract.
4) The SLF has had its certification terminated, suspended, not renewed, or has voluntarily surrendered its certification.
5) The SLF cannot meet the resident's needs with available support services.
6) The resident has received proper notice of failure to pay from the SLF. The resident shall have the right to make full payment up to the date that the discharge is to be made and then shall have the right to remain in the SLF. This subsection (d)(6) does not apply to Medicaid-eligible residents when the failure to pay relates to the Medicaid payment.
7) The resident exceeds the SLF's policy for what constitutes a temporary absence from the SLF. A temporary absence shall not be considered a basis for an involuntary discharge of a Medicaid-eligible resident until the Department has stopped payment pursuant to Section 146.225(f).
e) The 30-day notice required under subsection (b) of this Section shall not apply in either of the following instances; however, a notice and right to appeal information must still be provided when an immediate discharge is required:
1) When an emergency discharge is mandated by the resident's health care or mental health needs as documented in the resident record. The SLF may consult with the attending physician for additional support on the emergency discharge.
2) When the discharge is mandated to ensure the physical safety of the resident and other residents as documented in the resident record.
f) If the resident submits a request for hearing under subsection (b) of this Section, the involuntary discharge shall be stayed pending a hearing or appeal of the decision, unless the discharge is a result of a condition allowing a discharge in less than 30 days as described under subsections (e)(1) and (2) of this Section.
g) In determining whether an involuntary discharge is justified, the burden of proof in the hearing rests with the entity requesting the discharge.
h) If the Department determines that an involuntary discharge is justified under subsection (d) of this Section, the resident shall not be required to leave the SLF before the tenth day after receipt of the Department's hearing decision unless a condition which would have allowed discharge as described under subsections (e)(1) and (2) of this Section develops in the interim.
i) The SLF shall offer relocation assistance to residents involuntarily discharged under this Section, including information on available alternative placements. A resident or his or her designated representative shall be involved in planning the discharge and shall choose among the available alternative placements. Where an emergency makes prior resident involvement impossible, the SLF may arrange for a temporary placement until a final placement can be arranged. The SLF may offer assistance in relocating from a temporary to a final placement.
j) When a resident discharges on a voluntary basis, he or she shall provide the SLF with 30 days written notice of intent to discharge, except where a delay would jeopardize the health, safety, and well-being of the resident or others.
k) The Department may discharge any resident from an SLF when any of the following conditions exist:
1) The Department has terminated or suspended the SLF certification.
2) The SLF is closing or surrendering its certification and arrangement for relocation of the resident has not been made at least 30 days prior to closure or surrender.
3) The Department determines that an emergency exists which requires immediate discharge of the resident.
l) In cases of discharge under subsection (d) or (k) of this Section, the resident is no longer bound by the resident contract.
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.260 Grievance Procedure
a) An SLF shall establish a grievance procedure for reviewing grievances registered by, or on behalf of, residents. Each resident shall be informed that a grievance procedure exists.
b) Records shall be maintained and made available to the Department on all written grievances and the SLF's response to and disposition of each grievance.
(Source: Amended at 29 Ill. Reg. 4360, effective March 7, 2005)
Section 146.265 Records and Reporting Requirements
a) An SLP provider shall develop and maintain confidential written records regarding each resident, which shall include, but are not limited to:
1) The Comprehensive Resident Assessment;
2) The resident contract;
3) The service plan;
4) The quarterly evaluation;
5) Progress notes that shall be used to document decline or improvement in resident status;
6) The resident satisfaction survey;
7) Written documentation of the inquiry to the sex offender databases, including the result of the inquiry; and
8) Documentation of a tuberculosis test administered in accordance with Section 146.220(d).
b) An SLP provider shall develop and maintain confidential written personnel records that shall include, but are not limited to:
1) Job description;
2) Educational preparation and work experience;
3) Current licensure or certification, if applicable;
4) Documentation that employee has received personnel policies and procedures;
5) Documentation of on-going staff training;
6) Documentation of a tuberculosis test administered in accordance with Section 146.235(m); and
7) Results from the health care worker background check conducted in accordance with Section 146.235(l).
c) An SLP provider shall develop and maintain confidential written records regarding each potential resident, which shall include, but are not limited to:
1) Results of the Determination of Need assessment as indicated on the Interagency Certification of Screening (HFS 2536), Screening Verification Form (HFS 3864), or successor form;
2) OBRA-1 Initial Screen;
3) Standardized interview;
4) Specialized mental health evaluation, if indicated;
5) Application for admission to the SLP setting;
6) Documentation that supports the SLP provider's ability to meet the resident's needs.
d) Medication Error Report: The SLP provider shall record, and retain in a facility record, all medication errors identified and reported by staff. Errors shall be recorded on a Department designated form. Any medication error resulting in a hospitalization shall be reported to the resident's physician and to the Department within 24 hours after discovery.
e) Incident Report: Pursuant to Sections 146.295 and 146.305, the SLP shall notify the Department of suspected abuse, neglect or financial exploitation that results in contact with local law enforcement.
f) The SLP provider shall generate and submit to the Department the following reports in a format and medium designated by the Department and with the frequencies as specified:
1) Resident Identification Report, which shall be due monthly. The report shall be in two parts, one for Medicaid-eligible residents and one for private pay residents. Each part shall contain an alphabetical list of residents residing in the SLP setting, including their names, case identification and recipient numbers for Medicaid-eligible residents or Department designated identifying numbers for private pay residents, dates of admission and dates of discharge.
2) Cost Reports, which shall be submitted at any time upon request by the Department or when a significant change occurs in the SLP provider's financial status/solvency, and annually not later than 90 days after the end of the SLP provider's fiscal year. One extension up to 30 days shall be granted for circumstances that will not allow a cost report to be properly completed before the due date of the report. The written extension must be submitted to the Department's Bureau of Long Term Care prior to the original due date. Each enrolled SLP providershall file an annual report with the Department in accordance with the following requirements:
A) All schedules contained in the cost report must be completed with the exception of those schedules specified in the cost report instructions as optional.
B) The cost report is not complete until all required schedules are filed and all inquiries to the provider are satisfactorily resolved.
C) If the cost report is prepared by other than the SLP setting's manager or officer, the certification must be signed by the preparer as well as the officer or manager. The preparer's declaration is based upon all information of which the preparer has any knowledge.
D) All financial data contained in the cost report must be accounted for on the accrual basis of accounting.
E) Copies of all independent audits and reviews performed on the SLP setting by certified public accounting firms shall be provided to the Department with the cost report.
3) Cost Report for Change of Ownership. The new owner or lessee must file a cost report nine months after acquisition (covering the first six months of operation). A change of ownership is dated from the closing of the sale or from the date of the oldest lease agreement between the present incumbents of a lease. The facility must also file a cost report within 90 days after the close of its first complete fiscal year. A change of corporate stock ownership does not constitute a change of ownership.
4) Cost Report for New Facility. A full cost report must be filed within nine months after opening the facility (covering at least the first six months of operation). The facility must also file a cost report within 90 days after the close of its first complete fiscal year.
g) No funds shall be expended by the Department for the maintenance of any resident in an SLP setting that has failed to file an annual cost report.
h) The SLP provider shall retain all records in accordance with provisions of 89 Ill. Adm. Code 140.28. The SLP provider shall provide the Department or its designee with access to financial and other records that pertain to covered services. The SLP provider shall keep fiscal records in accordance with acceptable accounting procedures.
(Source: Amended at 44 Ill. Reg. 2331, effective January 15, 2020)
Section 146.270 Quality Assurance Plan
Each SLF shall be responsible for establishing an effective, internal quality assurance plan that encompasses oversight and monitoring, peer review, utilization review, resident satisfaction and ongoing quality improvement and implementation of any corrective action plans that address improved quality services. The quality assurance plan shall include:
a) Documentation of results of, and SLF responses to, the annual resident satisfaction survey that shall include, but not be limited to, whether the:
1) Residents have the opportunity to provide input into development and implementation of existing SLF policies and procedures;
2) Existing SLF policies and procedures are clear to residents;
3) Residents have access to existing SLF policies and procedures;
4) Residents have a degree of control over personal lifestyle preferences;
5) Residents have access to common areas;
6) Residents are satisfied with surroundings as "home-like"; and
7) Residents have the opportunity to exercise personal lifestyle preferences and direct services according to personal preferences (for example, meal choices and refusal of services).
b) Evaluation of care and services pursuant to accepted standards and practices and the service needs of the resident population.
c) Tracking of improvements based on care outcomes such as changes in activities of daily living, resident response to services and other indicators of service quality listed in subsection (d) of this Section.
d) A system of indicators of service quality that measure:
1) Quality of services provided;
2) Resident rating of the services, including food service;
3) Cleanliness and furnishings of the common area;
4) Service availability;
5) Adequacy of service provision and coordination;
6) Provision of safe environment, including emergency contingency plans that are in accordance with Section 146.295;
7) Socialization activities; and
8) Resident autonomy, which includes, but is not limited to:
A) Protection of resident rights;
B) Provision of appropriate oversight for vulnerable residents; and
C) Resident exercise of personal autonomy and choice.
e) Procedures for preventing, detecting and reporting resident neglect and abuse.
f) Objectives for improving service quality, including the service quality indicators and measures to determine when objectives have been met.
g) Ongoing quality improvements resulting from the quality review data.
h) A committee formed to organize and proceed with the required reviews for both the health care professionals and social service providers of the SLF staff or to serve in a contractual relationship with the SLF. Committee duties shall include:
1) A regular schedule for review, and
2) A system to evaluate the process and methods by which care is given by specific providers in accordance with the service plan developed by the SLF licensed nursing staff and approved by the resident.
i) The Department shall review the SLF's plan initially and annually thereafter.
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.275 Monitoring
a) Monitoring and oversight of the SLF shall be conducted by the Department or its designee.
b) Designated Department staff shall coordinate the program, provide technical assistance and monitor compliance no less often than annually.
c) The Department shall investigate all complaints within seven days after receipt from a resident, a resident's designated representative or others expressing concern related to the health and safety of the residents. The Department may conduct a full certification review or make referrals to other appropriate entities for additional action if the results of a complaint investigation indicate the need to do so.
d) An SLF shall not restrict or hamper access by Department designated staff to the building, residents or designated records required to conduct routine or periodic reviews or investigations. A resident may limit access to his or her private dwelling space to Department designated staff, except for reviews regarding suspected violations or situations that may pose a threat to the resident's or others' health, safety or well-being. A resident may also elect to limit access to himself or herself and his or her records, except as required as a condition of payment for housing and services by a third party.
(Source: Amended at 29 Ill. Reg. 4360, effective March 7, 2005)
Section 146.280 Non-Compliance Action
a) The Department may terminate or suspend or not renew a provider agreement subject to the provisions of 89 Ill. Adm. Code 140.16.
b) In the event that the SLF is found to be out of compliance with certification requirements during any on-site review or investigation conducted by the Department, the following procedures shall be used based on whether the non-compliance is determined to result in immediate jeopardy or non-immediate jeopardy.
c) Non-Compliance Involving Immediate Jeopardy
1) In the event that it is determined that the findings of non-compliance result in immediate jeopardy that poses a current risk to the health and safety of the residents, Department staff shall notify the SLF of the non-compliance and Department staff may stay on-site until the area or areas of non-compliance have been abated.
2) For non-compliance involving immediate jeopardy where health and safety of residents is not currently at risk, the Department shall provide a written notice to the SLF within five working days after the conclusion of the on-site review.
3) The SLF shall have five calendar days from receipt of the written notice to refute the findings or submit a plan of correction.
4) If no refutation is submitted, the SLF shall have ten calendar days from receipt of the written notice to correct the non-compliance issue or issues. No extension of the ten day period shall be granted.
5) If a refutation is submitted, the ten day correction period is stayed until a Department decision is made.
6) Department staff shall conduct a follow-up review within ten working days after the conclusion of the ten day correction period to verify compliance. If the follow-up review continues to show the potential for immediate jeopardy, the Department shall take action to suspend or terminate the SLF's provider agreement.
d) Non-Compliance Not Involving Immediate Jeopardy
1) The Department shall provide a written notice to the SLF within ten working days after the conclusion of the on-site review.
2) The SLF shall have 14 calendar days from receipt of the written notice to refute the findings or submit a plan of correction.
3) If no refutation is submitted, the SLF shall have 30 calendar days from receipt of the written notice to correct the non-compliance issue or issues.
4) If a refutation is submitted, the 30 day correction period is stayed until a Department decision is made.
5) The SLF shall provide a written notice to the Department, within 30 days after the date of the Departmental notice of non-compliance, notifying the Department that the non-compliance issue or issues are corrected or requesting an extension of the 30-day period to a specific date, along with any explanation or documentation necessary to justify the extension.
6) The Department shall provide a written decision to the SLF within ten working days after receipt of the request to extend the 30-day correction period.
7) If the first 30 day follow-up review continues to show non-compliance, the facility may be granted a second 30-day period to correct the non-compliance issues.
8) Department staff shall conduct a follow-up review within ten working days after the conclusion of the 30- and/or 60-day correction period to verify compliance.
9) If subsequent reviews continue to show non-compliance with previously cited issues, the Department shall take action to apply one or more of the following sanctions, at the Department's sole discretion, depending on the severity of the non-compliance. Continued non-compliance may result in the Department issuing additional sanctions:
A) placing a hold on payment for new admissions;
B) withholding Medicaid payments;
C) directing in-service training;
D) directing a plan of correction.
10) The SLF shall have 30 days from the date of the letter from the Department imposing sanctions to correct the findings of non-compliance. If a follow-up review finds that the SLF remains out of compliance, additional sanctions may be issued. The SLF shall have 30 days to correct the findings of non-compliance after the imposition of each sanction.
11) If the SLF wishes to refute the Department's findings of non-compliance after sanctions have been imposed, written comments with any supporting documentation shall be sent to the Department within 30 days after the date of the letter sent from the Department imposing sanctions. If the SLF believes it has corrected the issues of non-compliance, it may request an on-site review. If the review indicates the findings have been corrected, the sanction or sanctions will be rescinded.
12) If subsequent follow-up reviews continue to show non-compliance, the Department may take action to suspend or terminate the SLF's provider agreement.
e) Suspension or Termination of Provider Agreement
1) In the event the Department does not impose a sanction to withhold Medicaid payments pursuant to subsection (d)(6) of this Section, the Department will continue to make payments during the pendency of the administrative proceedings for suspension or termination of the provider agreement set forth in 89 Ill. Adm. Code 104.208 until a final administrative decision terminating or suspending the provider agreement is issued. If a final administrative decision terminating or suspending the provider agreement is issued, payments for services rendered will cease as of the date the decision is issued, and shall recommence only when the SLF is recertified as being in compliance with program requirements.
2) In the event the Department does not initially impose a hold on private pay and Medicaid admissions pursuant to subsection (d)(6)(A) of this Section, the SLF shall not admit any new private pay or Medicaid residents during the pendency of any administrative proceedings for suspension or termination of the provider agreement set forth in 89 Ill. Adm. Code 104.208. If a final administrative decision terminating or suspending the provider agreement is issued, new admissions may recommence only when the SLF is recertified as being in compliance with program requirements.
3) Upon termination of the SLF provider agreement, Department payments will continue for no more than 30 days after the date of termination to ensure a smooth transition of residents to other settings.
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.285 Voluntary Surrender of Certification
An SLF shall inform the Department in writing if it intends to voluntarily surrender its certification from the Medicaid program. The notification shall be received by the Department at least 90 days prior to the date of surrender. The Department will make SLF payments only through the day prior to the effective date of voluntary surrender. Notice by the SLF shall be given to residents pursuant to Section 146.255.
(Source: Added at 22 Ill. Reg. 4430, effective February 27, 1998)
Section 146.290 Geographic Groups
These geographic groups define boundaries, according to counties, that are used in rate setting for supportive living facilities.
a) Chicago – Cook (including the city of Chicago), DuPage, Kane, Lake and McHenry.
b) South Suburb – Grundy, Kankakee, Kendall and Will.
c) South – Alexander, Clay, Crawford, Edwards, Effingham, Fayette, Franklin, Gallatin, Hamilton, Hardin, Jackson, Jasper, Jefferson, Johnson, Lawrence, Marion, Massac, Perry, Pope, Pulaski, Randolph, Richland, Saline, Union, Wabash, Washington, Wayne, White and Williamson.
d) St. Louis – Bond, Clinton, Madison, Monroe and St. Clair.
e) Central – Bureau, Champaign, Clark, Coles, Cumberland, DeWitt, Douglas, Edgar, Ford, Fulton, Henderson, Iroquois, Knox, LaSalle, Livingston, Macon, Marshall, McDonough, McLean, Moultrie, Peoria, Piatt, Putnam, Shelby, Stark, Tazewell, Vermilion, Warren and Woodford.
f) West Central – Adams, Brown, Calhoun, Cass, Christian, Greene, Hancock, Jersey, Logan, Macoupin, Mason, Menard, Montgomery, Morgan, Pike, Sangamon, Schuyler and Scott.
g) Northwest – Boone, Carroll, DeKalb, Henry, Jo Daviess, Lee, Mercer, Ogle, Rock Island, Stephenson, Whiteside and Winnebago.
(Source: Amended at 24 Ill. Reg. 8353, effective June 1, 2000)
Section 146.295 Emergency Contingency Plan
For the purpose of this Section, "emergency" means an event, as a result of a mechanical failure or natural force such as water, wind, fire or loss of electrical power, that poses a threat to the safety and welfare of residents, personnel, and others present in the SLF.
a) Each SLF shall have a written plan, which shall be part of the SLF's Quality Assurance Plan, for protection of all persons in the event of mechanical failure or natural force emergency, for keeping persons in place, for evacuating persons to areas of refuge, and for evacuating persons from the building when necessary. The plan shall:
1) address the physical and cognitive needs of residents and include special staff response, including the procedures needed to ensure the safety of any resident. The plan shall be amended or revised whenever any resident with unusual needs is admitted;
2) provide for the temporary relocation of residents for any emergency requiring relocation;
3) provide for the movement of residents to safe locations within the SLF in the event of a tornado warning or severe thunder storm warning issued by the National Weather Service;
4) provide for the health, safety, welfare and comfort of all residents when the heat index/apparent temperature, as established by the National Oceanic and Atmospheric Administration, inside the residents' living, dining, activities, or sleeping areas of the SLF exceeds a heat index/apparent temperature of 80ºF, or falls below 55ºF, for 12 hours or more;
5) address power outages, including how residents call for help, how resident safety is monitored, and how food spoilage is checked while power is out;
6) include contingencies in the event of flooding, if located in a flood plain; and
7) be reviewed by local emergency response entities, such as fire department, ambulance and EMT services. The emergency response entities shall direct recommendations to the SLF concerning the SLF's plan and any issues that could be life threatening, and the SLFs shall make changes to the plan, as appropriate.
b) All personnel employed on the premises shall be instructed in the emergency contingency plan and the use of fire extinguishers.
c) A diagram of emergency evacuation routes shall be posted in at least all corridors and common areas and all personnel employed on the premises shall be aware of the route.
d) There shall be a means of notification to the SLF when the National Weather Service issues a tornado warning covering the area in which the SLF is located. The notification mechanism must be other than commercial radio or television. Notification measures include being within range of local tornado warning sirens, an operable National Oceanic and Atmospheric Administration weather radio in the SLF, or arrangements with local public safety agencies (police, fire, ESDA) to be notified if a warning is issued.
e) Each resident shall be oriented to the emergency plans within ten days after the resident's admission. Orientation shall include assisting residents in identifying and using emergency exits. Documentation of the orientation shall be signed and dated by the resident or the resident's representative.
f) The SLF shall conduct at least two drills per year. At least one drill shall cover evacuation during a fire and the other shall cover evacuation during a tornado.
g) The SLF shall evaluate the effectiveness of emergency plans, procedures and training.
h) Drills shall include residents, SLF personnel, and other persons in the SLF.
r) Drills shall include making a general announcement throughout the SLF that a drill is being conducted or sounding an emergency alarm. Drills may be announced in advance to residents.
j) Drills shall involve the actual evacuation of residents to an assembly point as specified in the emergency plan and shall provide residents with experience using various means of escape.
k) A written evaluation of each drill shall be submitted to the SLF manager and the Quality Assurance Committee and shall be maintained for one year from the date of the drill. The evaluation shall include the date and time of the drill, names of employees participating in the drill, and identification of any residents who received assistance for evacuation.
l) Upon the occurrence of an emergency resulting from a mechanical failure or natural force requiring hospital service, police, fire department or coroner, the SLF manager or designee must provide a preliminary report to the Department by fax within 24 hours after the occurrence. This includes, but is not limited to, loss of electrical power in excess of an hour, physical injury suffered by residents during a mechanical failure or force of nature, evacuation of residents for any reason, and fire alarm activation that results in an on-site response by the local fire department. It does not include fire department response that is the result of resident cooking mishaps that only cause minimal smoke limited to a resident's apartment or false alarm as determined by the local fire department. This preliminary report shall include, at a minimum:
1) name and location of the SLF;
2) type of emergency;
3) number of injuries or deaths to residents;
4) names of residents involved in the emergency;
5) number of units not usable due to the occurrence;
6) estimate of the extent of damages to the SLF;
7) type of assistance needed, if any;
8) location of displaced residents, if any; and
9) other State or local agencies notified about the problem.
m) The SLF manager or designee shall submit a final report to the Department that includes how the emergency was handled, final outcome, who was involved, and what steps are being taken to prevent the situation in the future.
(Source: Amended at 33 Ill. Reg. 11803, effective August 1, 2009)
a) The Department may grant a waiver from specified provisions of this Subpart B if the applicant or SLF can demonstrate that an alternative is available to ensure the residents' health, safety and welfare.
b) An applicant or SLF shall submit a written request for a waiver that includes:
1) The applicant's or SLF's name and address;
2) The specific Section of this Part for which the applicant or SLF is requesting a waiver;
3) The reason or reasons why an applicant or SLF is not able to comply with the requirements;
4) An alternative, if applicable, that ensures that the health, safety and welfare of residents are protected; and
5) The duration of the waiver.
c) The Department shall evaluate a request for a waiver as follows:
1) Review the written request;
2) Verify the submitted documentation;
3) If the requested waiver involves a physical plant requirement, inspect the SLF; and
4) If applicable, discuss the waiver with the SLF's owner, manager or manager's designee, residents or representatives, or any individual the Department determines is necessary to evaluate the request.
d) The Department shall provide a written notice of approval or denial to the applicant or SLF within 90 days after receipt of the request for a waiver.
e) The Department shall withdraw an approved waiver if:
1) An SLF does not comply with the conditions of the waiver as approved by the Department;
2) The Department determines that the health, safety or welfare of residents is not protected by the waiver;
3) The condition of the physical plant has deteriorated or its use substantially changed so that the basis upon which the waiver was issued is no longer applicable;
4) The SLF is renovated or remodeled in such a way as to permit compliance;
5) The Department determines the waiver would render the SLF noncompliant with other regulations or codes (i.e., local, State or federal requirements).
f) The Department may limit the time period that a waiver is in effect.
(Source: Added at 29 Ill. Reg. 4360, effective March 7, 2005)
Section 146.305 Reporting of Suspected Abuse, Neglect and Financial Exploitation
a) SLF staff shall make a report when there is suspected abuse, neglect or financial exploitation of the SLF resident. A person making a report in the belief that it is in the alleged victim's best interest shall be immune from criminal or civil liability or professional disciplinary action on account of making the report, notwithstanding any requirements concerning the confidentiality of information with respect to the eligible adult that might otherwise be applicable.
b) The SLF manager or employee shall contact local law enforcement authorities immediately when suspected abuse, neglect or financial exploitation involving physical injury, sexual abuse, a crime or death occurs to a resident as the result of actions by a staff member, family member, visitor, or another resident. SLFs serving persons age 22 through 59 may also contact the Department of Human Services, Office of Inspector General Hotline at 1-800-368-1463, for an investigation of allegations of abuse, neglect or financial exploitation.
c) Facility staff shall be trained at staff orientation and at least annually thereafter on the definitions of abuse, neglect and financial exploitation; on appropriate interventions; on how and to whom to report suspected abuse, neglect and financial exploitation; and emphasizing that reporting should be immediate.
d) Residents, family members and residents' designated representative shall be made aware of the SLF's policy relating to reporting of suspected abuse, neglect and financial exploitation.
e) Upon the occurrence of suspect abuse, neglect or financial exploitation that results in contact with local law enforcement, the SLF manager or designee must provide a preliminary report to the Department by fax within 24 hours after the occurrence. This includes, but is not limited to, suspected abuse of any nature, allegations of theft, elopement of residents or missing residents, and any crime that occurs on facility property. This preliminary report shall include, at a minimum:
1) name and location of the SLF;
2) description of situation, including what is alleged, what steps have been taken to immediately protect the residents involved, and any injury;
3) number and names of residents involved; and
4) other State or local agencies notified about the abuse, neglect or financial exploitation.
f) The SLF manager or designee shall submit a final report to the Department that includes how the investigation was handled, final outcome, who was involved, and what steps are being taken to prevent the situation in the future.
g) The SLF manager or designee shall be responsible for notifying the appropriate law enforcement or regulatory agency if reports of abuse, neglect or financial exploitation by a certified or licensed staff person are substantiated.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.310 Facility Management of Resident Funds
a) The SLF may manage a resident's personal funds only upon written authorization from, in order of priority, the resident, the resident's guardian, the resident's representative, or the resident's immediate family member. The authorization shall be attested to by a witness who has no pecuniary interest in the facility or its operations and who is not connected in any way to facility personnel or the manager. If the SLF manages residents' personal funds, it shall:
1) Deposit funds in excess of $50 in an interest bearing account;
2) Establish a separate, written record of each resident's account;
3) Provide a written record of the account at least quarterly to each resident or authorized representative included in the account;
4) Retain all records of managed funds for three years for residents currently residing in the facility and for residents who have died or been discharged from the facility;
5) Report changes in circumstances to the Department of Human Services (DHS) local office;
6) Notify the DHS local office of any lump sum payment received;
7) Keep resident funds in an account or accounts that are separate from any facility operating funds or the funds of any person other than another resident. The facility shall establish and maintain a system that assures a full, complete and separate accounting of each resident's account balance. For resident funds that are commingled with the funds of other residents, all interest earned on the residents' funds shall be prorated and properly credited to each resident's account balance. The system shall contain documents identifying all transactions made by the facility on behalf of the resident. All deposits and withdrawals are to be shown by date and amount, and identifiable receipts for all purchases must be retained; and
8) Notify each Medicaid-eligible resident when the amount in the resident's account reaches $200 less than the asset limit for one person or a couple.
b) SLFs that choose to manage resident funds shall purchase a surety bond to assure the security of all personal funds of residents deposited with the facility. The purpose of the surety bond is to guarantee that the facility compensates residents for any loss of funds that the facility holds, safeguards, manages and accounts for. Any resident funds that are entrusted to the facility for the resident must be covered by the surety bond, including refundable deposit fees.
c) SLFs that choose not to manage resident fund accounts, but arrange for a resident's monthly income to be direct-deposited into a facility account or name themselves as representative payee, shall deposit those funds into an account that is separate from any facility operating funds or the funds of any person other than another resident.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
SUBPART C: STATE HEMOPHILIA PROGRAM
Section 146.400 Definitions
"Available Family Income" means the lesser of:
Base income minus the sum of:
$5,500 and
$3,500 times the number of persons in the family, or
One-half of base income
"Base Income" means the income reported for State income tax purposes of all members of the family.
"Core Team" means a team that includes a board certified hematologist as a Hemophilia Service Director, a full-time board certified pediatric hematologist and/or board certified pediatrician (at a Treatment Center that serves children), a nurse coordinator, and a social worker.
"Extended Team" means a team of medical and support staff available as appropriate, and includes the following: patient's primary physician, physical therapist/physiatrist, orthopedist, infectious disease specialist, hepatologist, psychologist/psychiatrist, dentist/dental hygienist/oral surgeon, genetic counselor, nutritionist, gynecologist/obstetrician, pharmacist, education/vocation counselor and financial counselor.
"Department" means the Illinois Department of Public Aid.
"Eligible Hemophilia Services" means blood transfusions, blood derivatives, out-patient services, physicians' charges, medical supplies and appliances used in the treatment of persons eligible for the State Hemophilia Program.
"Hemophilia" means a bleeding tendency resulting from a genetically determined deficiency in the blood.
"Hemophilia Treatment Center" means a facility that has met the requirements set forth in Section 146.420 and has been designated as a Hemophilia Treatment Center by the Department.
"Patient" means a person meeting the eligibility requirements for the State Hemophilia Program as defined in Section 146.410.
"Patient Participation Fee" means the amount of expenses for eligible hemophilia services that the patient or, in the case of a minor, the patient's parent or guardian will be responsible for on an annual basis.
(Source: Added at 29 Ill. Reg. 6967, effective May 1, 2005)
Section 146.410 Patient Eligibility
a) An eligible person shall:
1) Be a resident of the State of Illinois; and
2) Not be otherwise eligible for comprehensive benefits under the Public Aid Code [305 ILCS 5] or the Children's Health Insurance Program Act [215 ILCS 106]; and
3) Submit an application form accompanied by a copy of the most recent State Income Tax Return (IL 1040) for the person or, in the case of a minor, for the person's parents or guardian; and
4) Submit the Illinois Hemophilia Program Medical Form signed by the medical director of an approved Hemophilia Treatment Center to document the person has a diagnosis of hemophilia.
b) On an annual basis, the patient shall:
1) Receive a complete comprehensive care evaluation in a Hemophilia Treatment Center, unless otherwise recommended by the center's director.
2) Submit an application form accompanied by a copy of the most recent State Income Tax Return (IL 1040) for the patient or, in the case of a minor, for the patient's parents or guardian.
3) Meet the requirements of the Patient Protection and Affordable Care Act (ACA) (26 USC 5000A) by obtaining and providing proof of health coverage. Payment of a tax penalty for not obtaining insurance does not meet the requirement.
c) Patient Participation Fee
1) The Patient Participation Fee will be determined annually and is equal to 20 percent of the patient's available family income.
2) In cases where the family has more than one patient participating in the State Hemophilia Program, the Patient Participation Fee will be applied to the family as a unit.
3) The patient or, in the case of a minor, the patient's parent or guardian will be notified in writing of the Patient Participation Fee.
d) Hardship Cases
1) A hardship case refers to a patient who has been determined by the Department to owe a Patient Participation Fee and the patient or, in the case of a minor, the patient's parent or guardian believes the charge will cause financial hardship.
A) The patient or, in the case of a minor, the patient's parent or guardian may request a redetermination of the Patient Participation Fee. The request shall include the following information:
i) Reduction in family income since the previous year;
ii) Accrued medical bills for the entire family;
iii) Other illness in the family;
iv) Increased childcare costs;
v) Extraordinary expenses incurred during the previous year;
vi) Casualty losses experienced during the previous year; and
vii) Resources to which the family has access for medical care, vocational assistance and other supportive services.
B) The patient or, in the case of a minor, the patient's parent or guardian may also submit a written narrative explaining any additional factors supporting the request for a reduction in the Patient Participation Fee.
2) The Department shall review and evaluate each hardship request. Criteria used in the review shall include the number and severity of demands being made on the family's financial resources, the availability of assistance from other sources and the potential stress placed on the family if the Patient Participation Fee is not reduced.
3) The Department will respond in writing with its determination regarding the hardship request. The Department will take one of the following actions:
A) Make no changes in the Patient Participation Fee originally assigned to the patient;
B) Reduce the amount of the Patient Participation Fee; or
C) Remove the Patient Participation Fee.
(Source: Amended at 38 Ill. Reg. 13255, effective June 11, 2014)
Section 146.420 Hemophilia Treatment Centers
Each Hemophilia Treatment Center must annually, in a format specified by the Department, attest that the services provided by the center include all of the following:
a) Twenty-four hour attendance by a physician.
b) A Core Team.
c) An Extended Team readily available and accessible for evaluations or referrals.
d) Pediatric hematology services.
e) Dental program.
f) Protocols for the management of complications of inherited bleeding disorders.
g) Comprehensive psychosocial services and counseling.
h) Genetic counseling and testing.
i) Access to laboratory services.
j) A comprehensive home infusion therapy program that provides instruction, ongoing education, monitoring and supervision by medical professionals experienced in the management of hemophilia.
k) Twenty-four hour emergency services with written treatment protocols and a hematologist on-call.
m) Twenty-four hour availability of, or accessibility to, all products for treating hemophilia and related bleeding disorders as recommended by the National Hemophilia Foundation Medical and Scientific Advisory Committee.
n) Active collaboration with local, State and national hemophilia organizations to provide outreach and education.
o) Established linkages with private, public and voluntary service organizations and health care providers to assure a full-range of services to meet clinical and psychosocial needs of the patient and the patient's family.
(Source: Added at 29 Ill. Reg. 6967, effective May 1, 2005)
Section 146.430 Comprehensive Care Evaluation
a) Each Hemophilia Treatment Center shall provide comprehensive care evaluations to patients. The components of the evaluation, specified in subsection (b) of this Section, need not all be performed at the same time or place.
b) A comprehensive care evaluation shall include:
1) Examination by a hematologist;
2) Examination by a physical therapist and/or orthopedic surgeon;
3) Dental examination;
4) Psychosocial assessment by a qualified medical social worker or other qualified person;
5) Appropriate radiographs as deemed necessary and ordered by the center director, the radiologist or orthopedist; and
6) Laboratory studies including inhibitor screen test, liver function tests, hepatitis B antigen and antibody tests, urinalysis and blood count.
c) A summary of the findings of the comprehensive care evaluation and recommendations shall be provided to the patient's primary care physician by the Hemophilia Treatment Center.
d) A review and summary of the findings signed by the center director shall be presented to the patient at the conclusion of the examination.
e) A written statement by the center director indicating that the comprehensive care evaluation has been performed shall be sent to the State Hemophilia Program each year.
(Source: Added at 29 Ill. Reg. 6967, effective May 1, 2005)
Section 146.440 Home Transfusion Arrangements
a) The State Hemophilia Program shall assist patients for whom the Hemophilia Treatment Center hematologists request assistance in securing and funding home transfusion materials, including the necessary anti-hemophilia factors in coordination with their insurance coverage. The obligation for training and supervision of patients shall remain with the center directors.
b) The Hemophilia Treatment Center hematologists shall provide to the selected manufacturer's representative or other recognized provider a prescription for the required amount, type, and assay of the specific factor.
(Source: Amended at 38 Ill. Reg. 13255, effective June 11, 2014)
Section 146.450 Obligations of the Department
a) The Department shall reimburse enrolled providers for eligible hemophilia services for patients in the State Hemophilia Program.
b) The Department's reimbursement shall be adjusted to reflect the Patient's Participation Fee, as applicable, and any amount that is eligible for payment or reimbursement by any hospital or medical insurance program, by any other government medical or financial assistance program, or by any charitable assistance program. (See 410 ILCS 420/1(7).)
(Source: Added at 29 Ill. Reg. 6967, effective May 1, 2005)
SUBPART D: CHILDREN'S COMMUNITY-BASED HEALTH CARE CENTERS
Section 146.500 General Description
The Alternative Health Care Delivery Act [210 ILCS 3/35] establishes an alternative health care delivery model, the Children's Community-Based Health Care Center. This Subpart sets forth the conditions that a Children's Community-Based Health Care Center must meet in order to participate in the Medical Assistance Program and outlines the services provided by a Children's Community-Based Health Care Center for which the Department will provide reimbursement.
(Source: Added at 29 Ill. Reg. 14987, effective September 30, 2005)
Section 146.510 Definitions
For purposes of this Subpart, the following terms shall be defined as follows:
"Children's Community-Based Health Care Center" means an entity defined as a Children's Community-Based Health Care Center under Section 35 of the Alternative Health Care Delivery Act [210 ILCS 3/35]. The term "Children's Community-Based Health Care Center" does not include:
Any institution, place, building or agency required to be licensed pursuant to the Hospital Licensing Act [210 ILCS 85];
Any person or institution required to be licensed pursuant to the Nursing Home Care Act [210 ILCS 45].
"Children's Community-Based Health Care Center Services" means services as referenced in Section 146.540 that are provided by a Children's Community-Based Health Care Center that is licensed by the Department of Public Health.
"Department" means the Illinois Department of Public Aid.
(Source: Added at 29 Ill. Reg. 14987, effective September 30, 2005)
Section 146.520 Participation Requirements
To participate in the Medical Assistance Program, a Children's Community-Based Health Care Center must, in addition to any other Department requirements, be:
a) licensed by the Illinois Department of Public Health pursuant to 77 Ill. Adm. Code 260; and
b) enrolled for participation in the Medical Assistance Program in accordance with 89 Ill. Adm. Code 140.11.
(Source: Added at 29 Ill. Reg. 14987, effective September 30, 2005)
Section 146.530 Records and Data Reporting Requirements
a) In addition to any other Department record requirements, including those specified in 89 Ill. Adm. Code 140.28, a Children's Community-Based Health Care Center must maintain complete, comprehensive and accurate medical records to ensure adequate patient care that includes, but is not limited to, the following:
1) Patient identification;
2) Significant medical history;
3) Any known allergies and abnormal drug reactions;
4) Documentation of properly executed informed patient consent;
5) Medications and treatments ordered and administered; and
6) Clinical and nursing notes.
b) Children's Community-Based Health Care Center records must contain the dates of service and the recorded dates of any medical practitioner seeing the patient at the time in the center.
c) Medical records for Medicaid patients must be made available to the Department or its designated representative in the performance of any review by the Department.
d) The Children's Community-Based Health Care Center agrees to furnish to the Department, if requested, information necessary to establish payment rates in the form and manner that the Department requires.
e) Services may be subject to on-site review by the Department.
(Source: Added at 29 Ill. Reg. 14987, effective September 30, 2005)
Section 146.540 Covered Children's Community-Based Health Care Center Services
a) The Department will reimburse a Children's Community-Based Health Care Center for services in accordance with Section 146.550 for individuals eligible under Section 146.560 for the following services:
1) nursing care up to the authorized in-home nursing hours approved by the Department for a period of one to 14 days; and
2) nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting and reuniting families for a maximum of up to 120 days.
b) In addition to those services listed in subsection (a), the Department will reimburse a Children's Community-Based Health Care Center for respite care, up to the authorized hours approved by the Department, provided to children eligible under the Illinois Home and Community-Based Services Waiver for Medically Fragile, Technology Dependent Children in accordance with 89 Ill. Adm. Code 120.530.
(Source: Amended at 45 Ill. Reg. 10015, effective July 26, 2021)
Section 146.550 Reimbursement for Services
a) Effective for dates of service on and after July 1, 2014, services provided under Section 146.540(a)(1) shall be reimbursed in accordance with 89 Ill. Adm. Code 140.474(c).
b) Services provided under Section 146.540(a)(2) shall be reimbursed on a per diem basis at the lower of the Children's Community-Based Health Care Center's usual and customary charge to the public or at the Department's statutory rate of $950. Payments at this rate are exempt from the 2.7% rate reduction required under Section 5-5e of the Public Aid Code.
c) Services provided under Section 146.540(b)(1) shall be reimbursed in accordance with 89 Ill. Adm. Code 140.474(c).
d) Effective for dates of service on or after July 1, 2012, reimbursement rates paid under this Section shall be reduced by 2.7% from the rates in effect on June 30, 2012.
(Source: Amended at 45 Ill. Reg. 10015, effective July 26, 2021)
Section 146.560 Individuals Eligible for Services Provided in a Children's Community-Based Health Care Center
The Department shall pay for services provided by a Children's Community-Based Health Care Center under this Subpart D to children eligible under the Medical Assistance Program or the Illinois Home and Community-Based Services Waiver for Medically Fragile, Technology Dependent Children who are 20 years of age and younger and who have been determined by the Department to have a medical need for in-home nursing care pursuant to 89 Ill. Adm. Code 120.530.
(Source: Added at 29 Ill. Reg. 14987, effective September 30, 2005)
Section 146.570 Prior and Post Approval of Services
Prior and post approval by the Department, or its designee, is required for services described in Section 146.540. Prior and post approval for services provided by Children's Community-Based Health Care Centers shall be determined according to the requirements at 89 Ill. Adm. Code 140.40 through 140.43.
(Source: Added at 29 Ill. Reg. 14987, effective September 30, 2005)
SUBPART E: SUPPORTIVE LIVING PROGRAM (SLP) SETTINGS WITH DEMENTIA CARE UNITS
Section 146.600 General Description
a) The Department will implement a pilot program to test the viability of a dementia care unit in SLFs. The pilot shall not exceed three years from the time the first facility is ready to operate a dementia care unit. Up to five SLFs may be admitted to the pilot in the first 12 months of the three-year period. Applicants for the pilot shall demonstrate experience with serving persons with a diagnosis of Alzheimer's disease or related dementia.
b) Unless otherwise indicated in this Subpart, the dementia care unit shall meet all requirements found in Subpart B of this Part.
c) SLFs with dementia care units shall promote independence, dignity, respect and well-being in the most cost effective manner for residents age 65 years and over who have a diagnosis of Alzheimer's disease or related dementia and meet the requirements described in Section 146.630.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.610 Structural Requirements
a) General Requirements
1) Each dementia care unit shall consist of no more than 20 apartments within each dementia care unit located within an existing SLF, attached to an existing SLF or in a free-standing SLF dementia care unit.
2) Apartments designated for a dementia care unit shall not be located above the second story and shall be contiguous.
3) Each dementia care unit shall have alarmed doors with delays requiring a resident to hold the push bar for several seconds before opening. This applies to all doors exiting the dementia care unit.
b) Resident Apartments
1) Each resident apartment shall have a sink, microwave and refrigerator with a separate freezer compartment.
2) The use and availability of a sink, microwave and refrigerator in a resident apartment shall be determined based upon individual resident assessment.
c) Dining Areas
1) The dementia care unit shall have a dining area separate from the dining area of the general population of the SLF. This provision does not apply to a free-standing SLF dementia care unit.
2) The dementia care unit shall have a refrigerator for snacks and ice.
d) Common Areas
1) The dementia care unit shall have at least one common area for every ten residents to provide residents with space for socialization. The dining room may be used as one of the common areas.
2) Access to private or public outdoor recreation areas shall be available to residents of the dementia care unit. Outdoor recreation areas shall be secure.
3) Common areas shall be available that are separate from those used by the general SLF population.
e) Laundry Rooms
Residents in the dementia care unit shall have the use of the SLF resident laundry room with facility staff oversight.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.620 Participation Requirements
If applicable, the reservation of 25 percent of apartments for Medicaid-eligible residents referenced in Section 146.215(d) shall be calculated separately from the general SLF population.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.630 Resident Participation Requirements
a) Residents in the dementia care unit shall have a diagnosis of Alzheimer's disease or related form of dementia that has been confirmed by a physician. A record of the diagnosis shall be kept in the resident's record.
b) Identified sex offenders shall not be admitted to the dementia care unit.
c) A roommate, such as a spouse, sibling, parent, other relative or significant other without dementia, may be admitted to a double occupancy apartment in the dementia care unit as long as the roommate meets the resident participation requirements found in Section 146.220.
d) The SLF shall not receive the dementia unit rate for Medicaid-eligible roommates without dementia.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.640 Services
a) Medication Administration and Oversight
1) Residents of the dementia care unit shall not be allowed to self-administer medications.
2) At a minimum, SLF medication management services shall include set up, verbal reminders, and documentation by CNA or licensed nurse, as applicable, that medication was taken or refused.
3) All medication administration shall be delivered by a licensed nurse.
b) Social and Recreational Programming
1) Activities shall be suitable for residents with dementia, and may be shared with residents in the general SLF as appropriate.
2) Activities for residents of the dementia care unit shall be carried out no less than three times a day.
3) Activities shall include group socialization with the SLF and in the larger community.
c) Daily Checks
The SLF shall implement a system to check on the welfare of each dementia care unit resident no less than three times a day, at least once per shift.
d) Delivery of Mail
The SLF may develop its own policy for mail delivery by having SLF staff deliver mail to the dementia care unit or arranging for a specific time for residents to pick up their mail with staff supervision.
e) Smoking
Residents of the dementia care unit who smoke shall be supervised when smoking in accordance with SLF policy.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.650 Reimbursement for Medicaid Residents
The Department shall establish its portion of the reimbursement for Medicaid residents residing in the dementia care unit by calculating 72 percent of the weighted average (weighted by Medicaid patient days), for the geographic group in which the Supportive Living Program (SLP) is located (see Section 146.290), paid for Medicaid-eligible nursing facility residents residing in Department of Public Health certified Alzheimer's special care units pursuant to 77 Ill. Adm. Code 300.163.
a) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, and subject to federal CMS approval, as of July 1, 2014, rates for the supportive living programs with residents residing in a dementia care unit shall no longer be 72 percent of the weighted average nursing facility rates for the geographic group rate, based upon the nursing facility geographic group in which it is located.
b) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, and subject to federal CMS approval, for dates of service on or after July 1, 2014, rates effective June 30, 2014 shall be increased 8.85 percent.
c) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, and subject to federal CMS approval of the imposition of the assessment in 89 Ill. Adm. Code 140.86, for dates of service on or after July 1, 2014, rates effective July 1, 2014 shall be increased an additional 9.09 percent.
(Source: Amended at 38 Ill. Reg. 23768, effective December 2, 2014)
Section 146.660 Staffing
a) The SLF manager shall be responsible for the entire facility, including the dementia care unit. However, this does not preclude the SLF from hiring a separate manager or director to oversee the dementia care unit.
b) The SLF shall have no less than one licensed nurse available at all times on-site or on-call to meet medication administration needs of the resident in the dementia care unit. The licensed nurse may share duties in the general SLF.
c) The SLF shall have no less than one certified nursing assistant (CNA) for every ten residents on all shifts. Roommates without dementia shall not be used when determining the 1:10 staff to resident ratio. CNAs on duty in the dementia care units shall be awake at all times. The CNA cannot work in the general SLF during the same shift.
d) The SLF dementia care unit may share activity, dietary, housekeeping and maintenance staff with the general SLF population.
e) All staff who work on the unit (e.g., nurses, CNAs, housekeepers, activities staff) shall have four hours of training specific to working with persons with Alzheimer's disease or related dementia within seven days after working on the unit. The training shall include, but not be limited to, the following:
1) Information about the causes, nature, progression and management of Alzheimer's disease and other dementia;
2) Techniques for successful communication;
3) Handling behavior;
4) Planning activities;
5) Techniques for creating an environment that minimizes behavior;
6) Identifying and minimizing safety risks;
7) Delivering personal care; and
8) How to partner with families and the community.
f) All staff as indicated in subsection (e) of this Section shall annually complete at least 12 hours of in-service training regarding Alzheimer's disease and other related dementia. Training topics may include the following:
1) Assessing resident capabilities and developing and implementing service plans;
2) Promoting resident dignity, independence, individuality, privacy and choice;
3) Planning and facilitating activities appropriate for the dementia patient;
4) Communicating with families and other persons interested in the resident;
5) Resident rights and principles of self-determination;
6) Care of elderly persons with physical, cognitive, behavioral and social disabilities;
7) Medical and social needs of the resident;
8) Pharmacological and non-pharmacological interventions for persons with dementia; and
9) Local community sources.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.670 Assessment and Service Plan and Quarterly Evaluation
a) Residents who move from the general population of the SLF to the dementia care unit shall be reassessed prior to the move. This includes a new Comprehensive Resident Assessment and Service Plan. This provision does not apply to a free-standing SLF dementia care unit.
b) In addition to the Comprehensive Resident Assessment, a more in-depth mental and cognitive assessment, the Saint Louis University Mental Status (SLUMS) or the Montreal Cognitive Assessment (MOCA), shall be required. During the term of the pilot, the Department has the sole discretion to require a different or additional in-depth assessment as determined by the Department's evaluation during the pilot.
c) A Department-designated quarterly assessment specifically designed for use in the dementia care unit shall be used.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.680 Monitoring
Designated Department staff shall monitor compliance for certification of the dementia care unit no less than biannually.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.690 Reporting Requirements
a) Costs for the dementia care unit shall be included in the cost report required under Section 146.265(c)(4); however, for purposes of this pilot, the SLF with a dementia care unit shall also submit a separate cost report reflecting only the costs associated with the dementia care unit.
b) Residents of the dementia care unit shall be identified separately when submitting the Resident Identification Report required in Section 146.265.
c) The Department reserves the right to request periodic reporting to assist with evaluation of the pilot.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Section 146.700 Resident Rights
a) Department posters with the phone number of the Department's Complaint Hotline shall be posted on the dementia care unit in a location accessible to all residents. Department brochures providing resident rights and the phone number to the Complaint Hotline shall be made available to all residents and their families or designated representatives.
b) Long Term Care Ombudsman Program posters provided by the ombudsman shall be posted on the dementia care unit in a location accessible to all residents.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
Source 146.710 Discharge
No resident shall remain in the dementia care unit if he or she is a danger to self or others and the SLF is unable to eliminate the danger through the use of treatment modalities or interventions.
(Source: Added at 33 Ill. Reg. 11803, effective August 1, 2009)
SUBPART F: BIRTH CENTERS
Section 146.800 General Description
This Part sets forth the conditions that a birth center must meet in order to participate in medical programs administered by the Department. For the purposes of this Part, "birth center" means an alternative healthcare delivery model that is exclusively dedicated to serving the childbirth-related needs of women and their newborns and has no more than 10 beds. A birth center is a designated site in which births are planned to occur following a normal, uncomplicated, and low-risk pregnancy that is away from the mother's usual place of residence.
(Source: Added at 37 Ill. Reg. 17624, effective October 28, 2013; expedited correction at 38 Ill. Reg. 4518, effective October 28, 2013)
Section 146.810 Participation Requirements
Effective May 1, 2013, to participate in medical programs administered by the Department, a birth center must:
a) Meet all requirements for licensure established by the Illinois Department of Public Health at 77 Ill. Adm. Code 265.1250.
b) Meet all requirements for enrollment and participation in medical programs administered by the Department as defined in Subpart B of 89 Ill. Adm. Code 140.
(Source: Added at 37 Ill. Reg. 17624, effective October 28, 2013; expedited correction at 38 Ill. Reg. 4518, effective October 28, 2013)
Section 146.820 Record Requirements
In addition to Department record requirements in 89 Ill. Adm. Code 140, a birth center must maintain complete, comprehensive and accurate clinical records to ensure adequate patient care. These records include, but may not be limited to, the record requirements identified in the Illinois Department of Public Health's administrative rules at 77 Ill. Adm. Code 265.2200. The Department shall describe, by notice to providers, any other records that are to be maintained.
(Source: Added at 37 Ill. Reg. 17624, effective October 28, 2013; expedited correction at 38 Ill. Reg. 4518, effective October 28, 2013)
Section 146.830 Covered Birth Center Services
a) The Department shall pay a birth center for the provision of essential delivery services, not otherwise excluded or limited, that are provided by a birth center in compliance with birth center licensure standards (see 77 Ill. Adm. Code 265).
b) The Department shall pay a birth center for observation services, the need for which must be documented in the medical record. The practitioner's orders must support the need for observation services and the corresponding nurses' notes must document that skilled observation services were furnished.
c) The Department shall pay a transfer fee to a birth center when a birth center transfers a woman to a hospital due to complications arising prior to the delivery.
(Source: Added at 37 Ill. Reg. 17624, effective October 28, 2013; expedited correction at 38 Ill. Reg. 4518, effective October 28, 2013)
Section 146.840 Reimbursement of Birth Center Services
a) Facility services provided by a birth center located in Cook County will be reimbursed at the lower of billed charges or 75 percent of the average facility payment rate made to a hospital located in Cook County for an uncomplicated vaginal birth.
b) Facility services provided by a birth center located outside of Cook County will be reimbursed at the lower of billed charges or 75 percent of the statewide average facility payment rate made to a hospital located outside of Cook County for an uncomplicated vaginal birth.
c) Observation services will be reimbursed at the lower of billed charges or at 75 percent of the rate established by the Department for the number of hours of observation billed pursuant to 89 Ill. Adm. Code 148.140(b)(1)(D) as reflected at http://www2.illinois.gov/hfs/PublicInvolvement/hospitalratereform/Pages/
Rules.aspx through dates of service on June 30, 2014. Effective for dates of service on or after July 1, 2014, observation services will be reimbursed at the lower of billed charges or $53.56 for 1 hour or more.
d) Transfer fees for a birth center located in Cook County will be reimbursed at the lower of billed charges or 15 percent of the average facility payment rate made to a hospital located in Cook County for an uncomplicated vaginal birth.
e) Transfer fees for a birth center located outside of Cook County will be reimbursed at the lower of billed charges or 15 percent of the statewide average facility payment rate made to a hospital located outside of Cook County for an uncomplicated vaginal birth.
(Source: Amended at 38 Ill. Reg. 15152, effective July 2, 2014)
SUBPART G: SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES
Section 146.900 General Provisions
a) The Specialized Mental Health Rehabilitation Act of 2013 [210 ILCS 49] provides for licensure of long-term care facilities that are federally designated as institutions for mental disease on the effective date of the Act and specialize in providing services to individuals with serious mental illness. On and after July 22, 2013, these facilities shall be governed by the Act and this Part instead of the Nursing Home Care Act.
b) All consent decrees that applied to facilities federally designated as institutions for mental disease prior to the enactment of the Specialized Mental Health Rehabilitation Act shall continue to apply to facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013.
(Source: Added at 38 Ill. Reg. 23768, effective December 2, 2014)
Section 146.910 Reimbursement
a) Facilities licensed under Specialized Mental Health Rehabilitation Act of 2013 shall be reimbursed at:
1) The rate in effect on June 30, 2014, less $7.07 for each facility previously licensed under the Nursing Home Care Act on June 30, 2013;
2) The rate in effect on June 30, 2013 for each facility licensed under the Specialized Mental Health Rehabilitation Act on June 30, 2013;
3) Effective for services provided on or after July 1, 2017, the rate in effect on June 30, 2017 increased by 2.8%;
4) Effective for services provided on or after July 1, 2018, the rate in effect on June 30, 2018 increased by 4%; or,
5) Effective for services provided on or after July 1, 2022, the rate in effect on June 30, 2022, increased by 5%.
6) Effective for services provided on or after October 1, 2022, providers outside of the Chicago metro area will have their rates increased to reflect the Chicago area regional wage factor.
b) Any adjustment in the support component or the capital component for facilities licensed by the Department of Public Health under the Nursing Home Care Act shall apply equally to facilities licensed by the Department of Public Health under the Specialized Mental Health Rehabilitation Act of 2013.
c) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153, facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall receive a payment in the amount of $29.43 per licensed bed, per day, for the period beginning June 1, 2014 and ending June 30, 2014.
d) Facilities licensed or provisionally licensed under the Specialized Mental Health Rehabilitation Act of 2013 on or before June 1, 2018 will be reimbursed for therapeutic visits that have been indicated by an interdisciplinary team as therapeutically beneficial at the following:
1) Effective for dates of service June 4, 2018 through July 26, 2018, therapeutic visits are reimbursed at a rate of 75% of the facility's rate as of June 4, 2018.
2) Effective for dates of service on or after July 27, 2018 through June 30, 2020, therapeutic visits are reimbursed at a rate of 75% of the facility's rate as of July 27, 2018.
3) Effective for dates of service on or after July 1, 2020, therapeutic visits are reimbursed at a rate of 75% of the facility's current rate.
4) Facilities may not be reimbursed for more than 10 consecutive days of therapeutic visits and no more than 20 days of therapeutic visits per State fiscal year.
e) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153 and in addition to the rate for recovery and rehabilitation, facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall receive an additional payment in the amount, as follows:
1) Effective for dates of service on or after July 1, 2019, a payment of no less than $10 per day, per single room occupancy rate.
2) Effective for dates of service on or after July 1, 2022, an additional payment of no less than $5 per day, per single room occupancy will be added to the existing $10 additional per day, per single room occupancy rate for a total of at least $15 per day, per single room occupancy.
3) Effective for dates of service on or after July 1, 2022, an additional rate for dual-occupancy rooms will be no less than $10 per day, per Medicaid-occupied bed, in each dual-occupancy room. Under this subsection (e)(3), "dual-occupancy room" means a room that contains 2 licensed beds. [210 ILCS 49/5-107]
4) The add-on amounts under subsections (e)(1), (e)(2), and (e)(3) will not be applied to leave of absence days.
5) Effective for dates of service on or after November 1, 2022, a $32 add-on to the facility rate for providers who:
A) Prior to November 1, 2022, had at least half of their facility rooms with 3 or more licensed beds; and
B) After November 1, 2022, reduced the number of licensed beds in all rooms to 2 licensed beds or fewer.
(Source: Amended at 48 Ill. Reg. 895, effective December 27, 2023)
SUBPART H: MEDICALLY COMPLEX FOR THE DEVELOPMENTALLY DISABLED FACILITIES
Section 146.1000 Applicability of This Part
a) These rules and regulations replace and supersede rules and regulations related to the reimbursement of medically complex for the developmentally disabled (MC/DD) facilities, adopted by the Illinois Department of Human Services at 89 Ill. Adm. Code 144, except that any proceeding arising from any occurrence happening prior to the applicable provision of these rules and regulations shall be governed by the above described rules.
b) This subpart addresses exceptional care requirements and reimbursement rates for MC/DD facilities. The previous requirements for exceptional care rates for these facilities at Section 153.126(i) are moved to this Subpart in accordance with Public Act 100-0646. Rates for these facilities contain three parts: active treatment costs as defined in this Subpart, capital cost (Section 140.563), and support costs (Section 140.561). These rate components are subject to the provisions of Section 153.100(a). However, if facility residents qualify for an exceptional care rate as defined in this Subpart, the exceptional care rate will be paid to the facility in lieu of the other rate components. Any rate adjustments for MC/DD facilities will continue to be listed at 89 Ill. Adm. Code 153.125.
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1001 MC/DD Service Criteria
Need for MC/DD Services
a) The need for MC/DD services shall be established through a comprehensive assessment (see 89 Ill. Adm. Code 140.642), the Level II assessment, that demonstrates that the individual has a condition requiring skilled level nursing care, needs active treatment and has either:
1) an intellectual disability; or
2) a related condition that meets all of the following conditions:
A) It is attributed to cerebral palsy, epilepsy, autism, or any other condition, other than mental illness or infirmities of aging, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of intellectually disabled persons, and requires treatment or services similar to those required for these persons;
B) It is manifested before the person reaches age 22;
C) It is likely to continue indefinitely; and
D) It results in substantial functional limitations in three or more of the following areas of major life activity: self care, understanding and use of language, learning, mobility, self direction, and capacity for independent living.
b) Active treatment is defined by federal regulations at 42 CFR 483.440(a) as a program of specialized and generic training, treatment, health services and related services, that is directed toward the acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible and the prevention or deceleration of regression or loss of current optimal functional status. Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.
c) No applicant for MC/DD services meeting the above criteria shall be found to be inappropriate for such services due to a need for the treatment of a severe or profound sensory disabling condition, motor deficit, or intellectual disability; nor shall such an applicant be denied MC/DD services due to age, medical needs, or maladaptive behavior, except as otherwise described in this Section.
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1005 Determination of Program (Active Treatment) Costs
a) The Department reimburses residential facilities for program costs associated with the delivery of active treatment to individuals with developmental disabilities, according to information obtained during each facility's most recent Inspection of Care (IOC) Review. Facilities affected by this Subpart are those certified as Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) and licensed as long term care facilities for residents with complex or extensive medical needs (hereinafter referred to as MC/DD).
b) IOC Review assessments of 100% of the Medicaid residents are conducted in these facilities by the Department of Public Health every 12 months. These will be conducted in accordance with federal regulations at 42 CFR 456, Subpart I. Program rate determination is based upon IOC Review criteria and Specialized Care needs as described in Sections 146.1020 and 146.1025 in conjunction with the reimbursement methodology found at Section 146.1035.
c) Reimbursable services under this Section do not include services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous active treatment program.
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1010 Inspection of Care and Rate Setting Appeal Process
a) Inspection of Care Appeal Process
1) Resident Assessment – A facility may request an appeal of the resident assessment conducted by the Inspection of Care (IOC) team. Examples of conditions which may be appealed include level of functioning (IQ, results of functional assessments and existence of related conditions), medical add-ons, behavioral add-ons, major life area limitations, special transportation needs, special care nursing and information on the developmental training agency attended. Differences between the facility and the IOC team regarding the conditions of the residents will be addressed using a three-step approach:
A) exit conference discussion between the facility and the IOC team;
B) informal review involving the Department of Public Health (DPH) regional supervisor and/or central office staff upon request by the facility; and
C) formal review to be heard by the Department of Healthcare and Family Services, Bureau of Long Term Care (BLTC) management.
2) Incomplete Assessments – In order for an assessment to be appealable, the assessment must be completed prior to the exit conference to be included in the IOC.
b) Examples of Appealable Situations
1) If the facility believes the surveyor has misinterpreted the regulations, or the facility disagrees with the surveyor's recommendations pertinent to the resident's condition (examples are included in subsection (a)(1)), the facility may request an appeal.
2) If the facility believes that all assessment data pertinent to the individual's status/condition have not been reviewed, the facility may bring that data to the attention of the surveyor through the appeal process. Such information must have been part of the resident's record at the time of the assessment to be considered.
3) The facility has been surveyed because of a 25 percent Medicaid eligible population change, a State Developmental Center admission or because it is a new facility, and there is disagreement with the findings.
c) Process and Time Frames
1) Exit Conference – At the exit conference, the facility may state the service needs that it disputes. The facility is responsible for providing supporting data to the IOC team at the exit conference. When the differences are not reconciled through discussion, the facility may request an appeal. The facility shall submit the written appeal request stating the service needs in dispute. The appeal request and the supporting documentation provided by the facility shall be submitted to the IOC regional supervisor (with a copy of the appeal request to DPH's Division of Long Term Care (DLTC) Field Operations) within 14 calendar days after the IOC exit date.
2) Informal Review – Within 30 calendar days after receipt of the IOC appeal request and supporting documentation, the IOC regional supervisor, the DPH central office staff, or both will review the documentation and either uphold or overturn the surveyor's findings and shall provide written notification of the decision to the facility.
3) Formal Review – The facility may request a formal review of the informal review decision. Within ten calendar days after receipt of the decision from the regional supervisor, the facility shall submit a written request for a formal review to the Department of Healthcare and Family Services, Bureau of Long Term Care with a copy to the DLTC Field Operations within DPH.
A) The formal review shall be conducted not more than 30 days after the facility's request for such a review. Not fewer than 14 days prior to the scheduled review date, the Department of Healthcare and Family Services, Bureau of Long Term Care will notify the facility in writing of the review date, with necessary instructions for the facility to request rescheduling if the date is not feasible for the facility.
B) The Department of Healthcare and Family Services, Bureau of Long Term Care will preside over the formal review. During the review, DPH representatives shall present the basis for the decision reached at the informal level of the review. The facility shall present its documentation and BLTC shall apply policy as it relates to the findings under dispute. BLTC shall send to the facility a written decision rendered as a result of the formal review within ten calendar days after the conclusion of the formal review with a copy to DPH. The decision of BLTC is final.
4) Continuation of an appeal is contingent upon following the steps and timeframes established in this Section.
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1015 Exceptional Care Needs of Clients with Developmental Disabilities
a) Exceptional Care Program
1) The Department of Healthcare and Family Services (Department) will make exceptional care payments to Medically Complex for the Developmentally Disabled Facilities (MC/DD) which meet licensure and certification requirements as may be prescribed by the Department of Public Health (DPH) (see the Department of Public Health's rules at 77 Ill. Adm. Code 390). A participating facility must maintain its licensure and certification and be in compliance with the applicable conditions of participation and licensing and certification standards to be eligible for exceptional care reimbursement. If DPH notifies the facility, in writing, of a need for a plan of correction for non-compliance with one or more conditions of participation, or that an imposed plan of correction for a Type A or B licensure finding is required, or if DPH notifies the facility because it has been declared an "immediate and serious threat" to the welfare of any residents, that facility will not be allowed to receive exceptional care reimbursement for any additional individuals from the date of DPH's written notification until the date DPH officially determines any and all of the conditions leading to the notification have been satisfactorily resolved. No payment for exceptional care shall be made retroactively for any residents admitted to the facility while the facility was in violation of DPH's rules at 77 Ill. Adm. Code 390. Exceptional care payment for such individuals shall commence when all such violations have been corrected, if such individuals are approved for exceptional care.
2) Exceptional medical care is defined as the level of care with extraordinary costs related to services which may include nurse, ancillary specialist services, and medical equipment and/or supplies that have been determined to be a medical necessity.
b) Exceptional Care Requirements. The Department will reimburse for exceptional care services only if the MC/DD provider agrees to the following conditions:
1) The provider must maintain separate records regarding costs related to the care of the exceptional care residents.
2) The provider must meet all conditions of participation in accordance with 42 CFR 483, Subpart I, Conditions of Participation for Intermediate Care Facilities for Individuals with Intellectual Disabilities. If the provider is not in compliance with a condition of participation and such noncompliance is under appeal, the Department will delay action on the provider's application to participate in the exceptional care program pending the official determination by DPH that any and all of the conditions leading to the noncompliance notification have been satisfactorily resolved.
3) The provider must demonstrate the capacity and capability to provide exceptional care as documented by DPH and Department records, including, but not limited to, being free of Type A violations and conditional license brought upon by violations relating to health care services. If the Type A violation or conditional license is under appeal, the Department will delay action on the provider's application to participate in the exceptional care program pending the satisfactory outcome of the action of DPH taken in regard to the facility's non-compliance with conditions of participation or the proper implementation of a plan of correction for a licensure finding. Newly licensed facilities are not immediately eligible to participate in the exceptional care program. An assessment will be made jointly by DPH and the Department to determine if the facility demonstrates the capacity and capability to provide exceptional care prior to the facility being open for 12 months. This assessment may be done prior to a facility having been open for 12 months when 15% or more licensed beds are filled with Medicaid eligible residents to present an accurate representation of the facility's ability to care for more medically involved individuals as determined by DPH.
4) For the purposes of this Section, a newly licensed facility is one that has never been licensed before, that has reopened after having discharged all residents or that has changed the focus of its operations (e.g., from ICF/SNF to ICF/DD or MC/DD). Facilities that were already participating in the Exceptional Care Program and are sold to a new licensee are not considered newly licensed.
5) The provider must maintain and provide documentation demonstrating:
A) Adherence to staffing requirements as described in subsection (c);
B) Adherence to staff training requirements as described in subsection (d);
C) Written agreements as required in subsection (e);
D) Presence of emergency policy and procedures as described in subsection (f);
E) Medical condition of the resident; and
F) Care, treatments and services provided to the resident.
6) When residents are mechanically supported, the provider must have and maintain physical plant adaptations to accommodate the necessary equipment, including an emergency electrical backup system and a backup ventilator available. The provider shall maintain records demonstrating the facility's maintenance of emergency equipment. Staff must be familiar with the location and operation of the emergency equipment and related procedures. To assure that staff are familiar with operating the emergency equipment, facilities must provide quarterly in-service training for all staff caring for residents.
c) Exceptional Care Staffing Requirements
1) There shall be at least one registered nurse 24 hours a day, seven days per week in the facility. Based on the Department's review of the exceptional care services needs, additional registered nurse staff may be determined necessary by the Department to implement the medical care plan and meet the needs of the individual.
2) There shall be at least one registered nurse or licensed practical nurse on duty at all times and on each floor housing residents (as required by DPH in 77 Ill. Adm. Code 390.1040(b)).
3) For those facilities providing complex respiratory or ventilator services under exceptional care, there shall be a certified respiratory therapy technician or registered respiratory therapist on staff or on contract with the facility and on call 24 hours a day.
4) For those facilities providing feeding tube services under exceptional care, there shall be a consultation to a Registered Dietitian for persons receiving 51% of caloric intake via a feeding tube (Tier1).
d) Training Requirements for Facilities Providing Exceptional Care for Persons with Feeding Tubes, Tracheostomies and Ventilator-Dependent Residents
1) At least one of the full-time professional nursing staff members must have successfully completed a course in the care of ventilator-dependent individuals and the use of ventilators, conducted and documented by a certified respiratory therapy technician or registered respiratory therapist or a qualified registered nurse who has at least one year's documented experience in the care of ventilator-dependent persons within the last three years. This nursing staff member must receive annual continuing education or in-service training on the care of ventilator-dependent individuals. This requirement may be alternatively satisfied if the facility employs on staff a certified respiratory therapy technician or registered respiratory therapist. A course is defined as a scheduled, structured, learning sessions with certification of completion.
2) All staff caring for ventilator-dependent residents must have documented in-service training in ventilator care prior to providing such care. In-service training must be conducted at least annually by a certified respiratory therapy technician, a registered respiratory therapist or a qualified registered nurse who has at least one year's experience in the care of ventilator-dependent persons. In-service training documentation shall include name and qualifications of the in-service director, duration of presentation, content of presentation and signature and position description of all participants. The training must include care and communication with ventilator patient, proper oral care and infection control techniques including handwashing and the proper care and cleaning of equipment.
3) All staff caring for persons with tracheostomies must have documented in-service training in tracheostomy care, other related medically complex procedures and infection control/universal precautions, prior to providing such care. In-service training documentation shall include the name and qualifications of the in-service director, duration of presentation, content of presentation and signature and position description of all participants. The in-services should address all extraordinary situations and/or aspects of care.
4) All staff caring for persons with feeding tube must have documented in-service training in care of feeding tube at least annually that includes, but is not limited to: fluid administration, medication administration, flushes, ostomy site care, infection control, and implementation of a nutrition care plan by a Registered Dietitian. In-service training documentation shall include the name and qualifications of the in-service director, duration of presentation, content of presentation and signatures and position description of all participants.
e) Exceptional Care Agreement Requirements. The provider must have a valid written agreement with:
1) A medical equipment and supply provider which must include a service contract for ventilator equipment when accepting ventilator-dependent residents. Supplies include oxygen, oxygen concentrator, tracheostomy supplies and any other items needed for the services to be delivered; and
2) A certified respiratory therapy technician or registered respiratory therapist (unless a respiratory therapist is on staff within the facility) when accepting ventilator-dependent residents or residents requiring respiratory therapy services.
f) Exceptional Care Emergency Policy and Procedures Requirements. The provider must have specific written policies and procedures addressing emergency care for residents requiring exceptional care.
g) Accessibility to Records. The provider must make accessible to the Department and DPH all facility, resident and other records necessary to determine the appropriateness of exceptional care services.
h) Provider Approval and Voluntary Termination Process
1) A provider should notify the Department, in writing, of its interest in participating in the Exceptional Care Program.
2) The Department shall conduct a review of the facility to assure that the facility meets all the exceptional care requirements contained in this Section.
3) The Department shall notify the provider in writing of its approval for exceptional care services.
4) Providers desiring to discontinue provision of exceptional care shall notify the Department, in writing, at least 60 days prior to the date of termination. Payment for exceptional care residents already residing in facilities which notify the Department that they wish to discontinue providing exceptional care services will be reduced to the facility's standard Medicaid per diem rate at the time exceptional care services are discontinued. The Department will review each approved exceptional care resident to determine whether the resident may remain in the facility. For the duration of the time that exceptional care residents remain in the facility, the provider must continue to meet the needs of the individual. Should a transfer to another facility be necessary, the provider must contact the responsible case coordinating agency which will assist in locating another provider.
5) It is the responsibility of a MC/DD provider to effect appropriate discharge planning for exceptional care residents when terminating services for exceptional care.
i) Exceptional Care Rate Methodology
1) Effective for dates of service on or after April 1, 2019, the conditions and services used for the purposes of this Section have the same meanings as ascribed to those conditions and services under the Federal Resident Assessment Instrument (RAI) and specified in the most recent Federal manual.
2) Effective for dates of service on or after April 1, 2019, for purposes of this Section, a person is considered complex or with extensive medical needs for exceptional care if the person is receiving one of the following medical services:
A) Tier 1 is for residents who are receiving at least 51% of their caloric intake via a feeding tube.
B) Tier 2 is for residents who are receiving daily tracheostomy care without a ventilator.
C) Tier 3 is for residents who are receiving daily tracheostomy care and ventilator care at least 16 hours per day.
3) Effective for dates of service on or after April 1, 2019, medically complex for the developmentally disabled facilities must be reimbursed an exceptional care per diem rate, instead of the base rate, for services to residents with complex or extensive medical needs.
A) Exceptional care per diem rates must be paid for the conditions or services specified under subsection (i)(2) at the following per diem rates: Tier 1 $326, Tier 2 $546, and Tier 3 $735.
B) Effective for dates of services on or after August 1, 2019, the exceptional care per diem rate in effect on July 30, 2019 shall be increased by 3.5%.
4) Payments are subject to an adjustment if the medical documentation required in (j)(3) does not support the tier of services billed. The reimbursement rate will be adjusted to the appropriate tier for services that are documented pursuant to subsection (j). If exceptional care services cannot be documented, the facility shall receive their base per diem rate.
j) Monitoring
1) The Department shall conduct reviews to determine facility compliance as defined in this Section and to determine the accuracy of resident information and services provided as related to the specific reimbursement areas. Such reviews may, at the discretion of the Department, be conducted as a desk review or onsite in the facility.
2) The facility shall provide the Department staff with access to residents, professional and non-licensed direct care staff, facility assessors, and clinical records, as well as other documentation regarding the residents' care needs and treatments.
3) Documentation requirements
A) Supportive documentation in the clinical record shall be dated during the specified timeframe and their authors identified by signature or initials. At a minimum, the signature shall include the first initial, last name, and title or credentials. Any time a facility chooses to use initials in any part of the record for authentication of an entry, there shall also be corresponding full identification of the initials on the same form or signature legend.
B) Documentation in the clinical record shall consistently support service and care delivery and reflect the care related to the symptom or problem.
C) Documentation shall support the following services or care was provided during the timeframe identified.
i) The presence of a feeding tube and the proportion of calories received through the tube feeding.
ii) The presence of a tracheostomy and the tracheostomy care provided.
iii) The use of a ventilator. Documentation shall support the device was an electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the person who is or who may become (such as during weaning attempts) unable to support his or her own respiration. The resident shall require at least 16 hours a day of ventilator support. If on a ventilator less than 16 hours a day, the facility must have physician orders that clearly define the weaning process and daily documentation of active weaning. Active weaning is defined as the act or process of gradually removing residents with reversible forms of respiratory failure who are receiving mechanical ventilation from that support. This may be done by alternating full ventilator support with increasing longer periods of unassisted breathing or by alternating ventilator settings. The documentation must support the weaning process is done as ordered and must clearly document the resident's response to the weaning process on a daily basis. This does not include ventilators used as Bi-level Positive Airway Pressure (BiPAP) or Continuous Positive Airway Pressure (CPAP) devices. devices or ventilators that is used only as a substitute for BiPAP or CPAP.
iv) Resident's assessments shall include: vitals, oxygen saturation, breath sounds and weaning potential. In addition, the assessment shall address vent settings, such as respiratory rate, fraction of inspired oxygen, tidal volume and peak inspiratory pressure.
4) All documentation that is to be considered for validation must be provided to the team prior to exit. All RAI Manual requirements and requirements identified in this subsection (i) shall be presented to validate the identified area.
k) Appeals
1) Appeals must be submitted in writing to the Department no later than 30 days after the date of the Department's notice to the facility of the rate calculation resulting from the on-site review. The revised rate shall be processed into the payment system 30 days after the date of the Department's notice in order to allow time for submission of appeals.
2) The appeal shall contain clear and relevant supportive documentation. The facility must succinctly address the area being appealed. Additional documentation not presented to the Department's review team during the review, or at the time of exit, will not be considered in the appeal process.
3) The Department will rule on all appeals within 120 days after the date of appeal, except in rare instances where the Department may require additional information from the facility. In this case, the response period may be extended.
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1020 Specialized Care – Behavior Development Programs
a) Adaptive behaviors are actions and responses which are productive and appropriate. Maladaptive behaviors are actions and responses which are nonproductive or inappropriate. Although maladaptive behaviors are generally described as nonproductive and inappropriate, in some cases, an individual's inappropriate behavior may be productive, given the social or environmental context of a particular activity. Behavior development refers to both the reduction in maladaptive behaviors and the increase in adaptive behaviors. A behavior program instituted because of maladaptive behaviors must also include the development of adaptive behaviors. Additional reimbursement is paid for an individual who needs and receives specialized care for a behavioral disability (Section 146.1035(c)(1)), when the individual's behavior development program meets the criteria in subsection (b)(1).
b) Behavior Development Program Levels
1) Behavior development programs under Specialized Care are related to maladaptive behaviors which occur with high frequency, great severity, or both high frequency and great severity. A behavior development program, including the use of psychotropics, which is developed for Specialized Care, must meet all federal and State requirements including, but not limited to: development by the Interdisciplinary Team (IDT), review and approval by a Behavior Management Committee (or Human Rights Committee) as required by 42 CFR 483.440(f)(3) (1993), and approval by the individual or guardian, if the individual is not capable of providing informed consent. The behavior development program developed by the IDT must demonstrate the need for a use of a more intensive staffing pattern (direct care staff) than that pattern which is reimbursed for under Section 146.1035(a)(1). Additional staff time provided under Specialized Care is a response to a necessary increase in staff intensity identified in the behavior development plan when other attempted interventions have failed, such as environmental changes or changes in the pattern of activities throughout the day. Specialized Care is not provided based solely on the frequency or severity of the individual's maladaptive behavior.
2) Behavior development program services under Specialized Care do not preclude the individual's participation in regular training services, activities and therapies as part of a comprehensive active treatment program.
3) The IDT provides highly specific guidelines for the individual's behavior development program relative to treatment methodology, services needed, and staff needed to deliver interventions.
A) Level I – Behavior development program services are delivered by staff specifically trained in the delivery of the prescribed interventions. Behaviors occur with high frequency but moderate severity, i.e., verbal abuse one or more times per 4 hours which is hostile in tone or content including threats or screaming, or pica occurring once per 4 hours in volumes small enough to be non-life threatening. Examples of staffing pattern changes: The staffing pattern for persons with mild intellectual disability increases from the regular pattern of 1:6.8 to 1:4.8, and for persons with severe-profound intellectual disability from 1:4.8 to 1:3.7.
B) Level II – Behavior development programs are delivered by staff trained in the delivery of each individual's intervention plan. Individuals receive personalized intervention, such as individual counseling or some one-to-one intervention. Behaviors occur with high frequency, and are aggressive or destructive, such as purposeful attacks of others resulting in minimal injuries one or more times per day. Examples of staffing pattern changes: The staffing pattern for persons with mild intellectual disability increases from the regular pattern of 1:6.8 to 1:3.7, and for persons with severe-profound intellectual disability from 1:4.8 to 1:3.
C) Level III – Behavior development programs are delivered by staff who are specifically trained to deliver the interventions. Generally, staff may be assigned to accompany the individual throughout the shift. One-to-one intervention is common. Behaviors occur with very high frequency, such as hyperactivity one or more times per minute, or occur with high frequency and are aggressive, assaultive or destructive, such as pica (daily consumption of life threatening materials), or daily physical assault resulting in injuries requiring medical attention. Examples of staffing pattern changes: The staffing pattern for persons with mild intellectual disability increases from the regular pattern of 1:6.8 to 1:2.5, and for persons with severe-profound intellectual disability from 1:4.8 to 1:2.
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1025 Specialized Care – Health and Sensory Disabilities
These specialized services refer to three categories (Levels) of care which some individuals must receive, fully or in part, in order to attain physical health and development. The delivery of specialized care in accordance with an individual's needs, as determined by the IDT's assessment, enables the individual to participate in the individual program plan (IPP) and be supported toward greater independence. Additional reimbursement is paid for an individual who needs and receives services for health and sensory disabilities (Section 146.1035(c)(2)), when those services meet the criteria under subsections (b), (c) or (d).
a) Definitions
1) Ambulatory – The individual is capable of walking without assistance or the aid of adaptive equipment or devices.
2) Mobile nonambulatory – The individual is capable of locomotion with mobility assistance such as adaptive equipment or devices.
3) Nonmobile – The individual is not capable of locomotion even with mobility assistance.
b) Specialized Care, Level I. The individual is ambulatory, mobile nonambulatory, or has the potential to become mobile nonambulatory, and requires services to compensate for a sensory disability (auditory or visual), or services enabling the individual to be mobile, or limited services to meet medical needs.
1) Sensory Disabilities
A) Visual Disabilities. The individual requires and receives specialized services due to a visual disability as defined in Section 146.1035(c)(2)(B)(i). Aids and appliances for individuals having such disabilities are limited to the following items with which facility staff can assist the individual:
i) Cane or dog used in mobility training or a sighted guide; and
ii) Visual aids.
B) Auditory Disabilities. The individual requires and receives specialized care due to an auditory disability as defined in Section 146.1035(c)(2)(B)(ii). Aids and appliances for individuals having such disabilities are limited to the following items with which facility staff can assist the individual:
i) Aided augmentative communication system. Aided modes of communication may include the use of an eye gaze communication board, or an electronic communication device that has speech output or a print tape;
ii) Assistive listening device (hearing aid); and
iii) A hearing dog.
AGENCY NOTE: An individual's treatment might need to include being desensitized to tolerate the use of a hearing aid or assistive listening device to prevent the device from being rejected or destroyed.
2) Physical Disabilities. The individual requires and receives specialized care and training related to a physical disability which prevents or limits mobility. The individual becomes mobile when employing certain adaptive equipment. Aids, appliances and other adaptive equipment which promote mobility for individuals with physical disabilities are limited to the following devices which individuals can be taught to apply, or can be applied with assistance from facility staff:
A) Arm brace;
B) Back brace, body jacket;
C) Leg brace;
D) Prosthesis;
E) Splints;
F) Adaptive wheelchair; and
G) Walker.
AGENCY NOTE: A physical disability is defined as a physical impairment which results in a functional disability, such as spasticity, poor muscle tone, paralysis, and absence of limbs. Eligibility under Physical Disabilities requires that the individual needs training in the use of a device or devices in order to achieve some level of independent mobility. An individual who is already independent in mobility and requires adaptive equipment does not qualify. This includes some individuals who are in training programs for deficits in gross or fine motor functioning, and some individuals who are not in such training programs.
c) Specialized Care, Level II. The individual is nonmobile, or mobile nonambulatory, requires mobility assistance, and requires services to meet high personal care needs. The individual may also have significant daily medical needs, and may have dual sensory disabilities (visual and auditory).
1) High Personal Care/Mobility Need (nonmobile). The individual requires and receives partial or total assistance in bathing, clothing, grooming and hygiene, eating and toileting/continence. The individual requires and receives mobility assistance, due to a functional deficit (as determined by physical or psychological causes), to transfer from a bed to an alternative positioning device. The individual also requires and receives assistance with movement/mobility around the facility. The individual may require position changes at two hour intervals, or as specified in the individual program plan, or range of motion twice a day or as specified in the individual program plan.
2) Medical Need
A) The individual requires and receives insulin injections daily or more frequently for the management of diabetes which is not stabilized. Daily monitoring by licensed personnel is required to assess the individual's status, side effects, laboratory work, and to report to the physician as necessary. The requirement for monitoring pertains also to insulin which is administered on a sliding scale basis. This monitoring results in adjustments in dosage or type of insulin, as indicated by the individual's status.
B) The individual needs and receives ostomy care for a jejunostomy, an ileostomy, or a colostomy.
3) Dual Sensory Disabilities. The individual requires and receives services as required, due to both an auditory disability and a visual disability.
d) Specialized Care, Level III. The individual is typically nonmobile or mobile nonambulatory, but may be ambulatory, and requires services to meet high medical needs. High medical needs means one or more of the following:
1) The individual requires and receives intermittent catheterization more than twice a day.
A) Daily recording of intake and output is required.
B) Infection control measures must be carried out as indicated in the facility's catheterization protocol.
2) The individual requires and receives respiratory care which includes: tracheostomy care, positive pressure breathing treatments, aerosol therapy, postural drainage with percussion, vibration or suctioning.
A) The respiratory status of the individual receiving respiratory care must be frequently assessed as required by the IPP.
B) Infection control measures must be carried out as indicated in the facility's respiratory procedure protocol.
3) The individual requires and receives feeding via a nasogastric or gastrostomy tube, or, the individual has poor sucking or swallowing reflexes and requires and receives prolonged oral feeding of two or more hours daily.
4) The individual requires and receives wound care, having been admitted to the facility with a stage III or IV decubitus ulcer, or has deep wounds, infected wounds, extensive burns or extensive lesions requiring treatment in the form of medications, dressings, whirlpool, ultraviolet light or irrigations.
A) Decubitus ulcer management includes turning, positioning, nutritional support, range of motion exercises, supportive devices and infection control.
B) The facility protocol for decubitus ulcer prevention must be adhered to.
5) The individual requires and receives intensive physical habilitation due to a functional deficit (as determined by physical or psychological causes).
A) Intensive physical habilitation occurs throughout the individual's working hours to promote skill acquisition.
B) The individual requires and receives intensive contracture prevention via "hands on" assistance.
C) When staff is meeting functional and service needs of an individual, that time should be used for priority objective/goal attainment. For example, when the individual has been repositioned, staff stimulation should occur, or the individual is ambulated with assistance to the bathroom or the dining room rather than taken in a wheelchair.
AGENCY NOTE: Range of motion to all extremities as indicated in the IPP should be incorporated into the individual's daily routine/programs (dressing, bathing, feeding, etc.).
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1030 Functional Needs
Functional needs are the basic needs of all persons. All functional needs of each individual residing in an MC/DD must be addressed. The individual's IPP must provide a current assessment of his/her developmental level in each area of functional need. On the basis of the assessment outcome, the IDT determines if each area of an individual's functional needs can be addressed independently by the person, or is to be addressed as a service need or through a training program. The IPP specifies the individual's level of dependence/independence, types of assistance needed, and developmental skill interventions (programs) designed to increase functional independence. The IPP shall address skill maintenance if the individual demonstrates any skill regression or loss of functional status. The individual's preferences shall also be acknowledged (i.e., tub or shower bathing). Additional reimbursement is paid for an individual who needs and receives partial or total assistance in meeting functional needs (Section 146.1035(c)(2)). This reimbursement is provided only when an individual meets the criteria for mobility assistance or high personal care under Specialized Care-Health and Sensory Disabilities (Section 146.1025(b) and (c)). The functional needs of all individuals are:
a) Bathing. Bathing means bathing all, or some part of the body, including the hair, whether the bath occurs in a tub, shower, or bed;
b) Clothing. Clothing means total dressing and undressing, including stockings or socks and shoes;
c) Eating. Eating means to consume or assimilate food or nutriments to fulfill nutritional needs. Eating includes both oral and tube feedings;
d) Grooming/Personal Hygiene. Grooming/personal hygiene means bodily maintenance including combing hair, cleaning and clipping nails, shaving if applicable, tooth brushing and oral hygiene including denture care, daily deodorant use, hygiene associated with menstruation, makeup application when desirable and appropriate, daily hands and face washing;
e) Toileting/Continence. Toileting means the appropriate use of a toilet, including related undressing/dressing activities, and necessary follow-up hygiene;
f) Mobility. Mobility means the power of locomotion and includes transfers/movements which are accomplished by independent ambulation and via the employment of assistive devices such as walkers, wheelchairs, braces, and prostheses; and
g) Psychosocial Mental Status. Psychosocial mental status means the achievement of a sense of well-being and emotional balance in one's relationship with self, other persons, and one's daily environment.
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.1035 Reimbursement for Program (Active Treatment) Costs in Residential Facilities for Clients with Developmental Disabilities
Residential facilities, including distinct parts of facilities, for clients with developmental disabilities (ICF/DD certification with licensure for MC/DD license), excluding State-operated facilities for individuals with developmental disabilities, will be reimbursed for an active treatment program for each client. Facility program reimbursement levels will be derived by the Department from the following four determinants which in combination will result in a total facility program per diem amount. These four determinants will be determined according to information provided in the most recent Inspection of Care (IOC) conducted by Department of Public Health survey staff. This IOC information must be validated by the survey staff prior to utilization for payment purposes. The new reimbursement level will be effective on the first day of the quarter following a facility's IOC. Where dollar, wage, or salary amounts are used, these shall be inflated to the fiscal year for which reimbursement will be made. The Department reimburses for program costs based on geographic area (see the Department's rule at 89 Ill. Adm. Code 140.Table B) in which the facility is based.
a) Minimum Staffing
1) Direct Services – Facilities must be in compliance with the Health Care Financing Administration's (HCFA) (42 CFR 483.430 (1996)) minimum average daily staffing standards relative to client population according to each individual's overall level of functioning:
|
Overall Level of Functioning |
FTE* Staff: Client Ratio |
|
Mild |
1:5 |
|
Moderate |
1:2.5 |
|
Severe or Profound |
1:2 |
*FTE = Full Time Equivalent
A) Determination of levels of functioning of clients with intellectual disability and related conditions, in accordance with the definition of the American Association on Intellectual and Developmental Disabilities (Intellectual disability is a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills. This disability originates before the age of 18), will include both:
i) an assessment of intellectual functioning as measured by a standardized, full scale, individual intelligence test such as the Stanford Binet and WAIS-R. Such an assessment must be administered by a psychologist who is registered in Illinois under the Clinical Psychologist Licensing Act (Illinois Department of Professional Regulation); and
ii) an assessment of adaptive behaviors using a nationally standardized, Department approved assessment instrument, such as the Scales of Independent Behavior (SIB) or the Inventory For Client and Agency Planning (ICAP). Such an assessment instrument will be utilized by at least one Qualified Intellectual Disabilities Professional (QIDP) to evaluate each client's functional skills and adaptive behaviors.
B) The final determination of each client's overall level of functioning employs both the assessment of intellectual functioning and the assessment of adaptive behaviors, and will be made according to the criteria set forth in Section 146.Table A and Section 146.Table B.
C) The amount for Direct Services for these staffing ratios shall be obtained by: determining the number of clients within each overall level of functioning; dividing each number by the client component of the staff: client ratio; summing these quotients; multiplying the sum by the aide hourly wage factor, and then by 2080 (52 weeks times 40 hours per week), to obtain a total annual Direct Service cost; and dividing this total by 365 days and then by the number of clients to obtain the amount for Direct Services per client per day. For example, if a facility serves 40 clients in the mild level of functioning, 30 clients in the moderate level of functioning, and 30 clients in the severe/profound level of functioning, the number of FTE Direct Services staff will be (40 divided by 5) + (30 divided by 2.5) + (30 divided by 2) = 35. If the aide hourly wage is $5.00, the total annual cost will be 35 x $5 x 2080 = $364,000. The amount for FTE Direct Services per client per day will then be $364,000 divided by 365 divided by 100 = $9.97.
2) Licensed Nurses – Facilities must be in compliance with HCFA (42 CFR 483.460 (1996)) and Illinois Department of Public Health (IDPH) (77 Ill. Adm. Code 350.1230) staffing standards relative to facility type.
A) An MC/DD licensed for a population of 90 or fewer clients, none of whom require services under Levels II and III of Specialized Care-Health and Sensory Disabilities (Section 146.1025(c) and (d)), will be reimbursed for a minimum of 4.8 FTE nurses. A facility with only such a population which has a licensed capacity greater than 90 clients will be reimbursed for additional FTE nurses according to the following Table:
|
Licensed Capacity, Client Type |
FTE Nurse:Client Ratio |
|
|
Greater than 90 clients with no Specialized Care – Health and Sensory Disabilities needs under Level II and III |
1:18.7 |
B) An MC/DD licensed for a population of 30 or fewer clients, all of whom require services under Levels II or III of Specialized Care – Health and Sensory Disabilities will be reimbursed for a minimum of 4.8 FTE nurses. A facility with only such a population which has a licensed capacity greater than 30 clients will be reimbursed for additional FTE nurses according to the following Table:
|
Licensed Capacity, Client Type |
FTE Nurse:Client Ratio |
|
|
Greater than 30 clients requiring Specialized Care – Health and Sensory Disabilities under Levels II and III |
1:6.25 |
AGENCY NOTE: The Omnibus Reconciliation Act of 1987 (P.L. 100-203) requirements prohibit the admission of individuals with a primary diagnosis of intellectual disability into non-ICF/DD facilities. Therefore, MC/DD facilities which meet ICF/DD certification requirements must be certified ICF/DD in order to comply with federal law when admitting individuals with intellectual disabilities. Facilities which undergo certification conversion to ICF/DD will retain State licensure for skilled care (MC/DD).
C) An MC/DD which has a licensed capacity of 30 clients or more, some of whom require services under Levels II or III of Specialized Care – Health and Sensory Disabilities, and some of whom do not require such services, will be reimbursed for a minimum of 4.8 FTE nurses for non Specialized Care individuals plus additional FTE nurses, up to a maximum of a 1:6.25 ratio, according to the following Table:
|
Client Type |
FTE Nurse:Client Ratio |
|
|
Client requiring Specialized Care – Health and Sensory Disabilities under Levels II and/or III |
1:6.25 |
For example, for a facility with a licensed capacity of 42 clients, 15 of whom require services under Levels II and/or III, and 27 of whom do not require such services, the number of FTE nurses will be (15 divided by 6.25 = 2.40) + (27 divided by 18.75 = 1.44, however, reimbursement will be calculated at the minimum of 4.8) = 7.2. Utilizing the maximum client ratio allowed, the facility will be reimbursed for 6.72 FTE nurses (42 divided by 6.25 = 6.72).
D) The licensed nurse component is computed similarly to the method in subsection (a)(1)(C). To determine the amount for Licensed Nurses, the number of FTE nurses required for each facility type and/or for clients receiving services under Specialized Care – Health and Sensory Disabilities, Levels II and/or III, shall be obtained according to subsections (a)(2)(A), (B) and (C). This number is multiplied by the hourly nurse wage factor and then by 2080 (52 weeks x 40 hours). The product is divided by 365 and then by the number of clients.
3) The total reimbursement amount for Minimum Staffing is the sum of the amount for Direct Staff plus the amount for Licensed Nurses.
b) Active Treatment
1) Qualified Intellectual Disabilities Professional (QIDP) – a person who has at least one year of experience working directly with persons with intellectual disabilities or other developmental disabilities, and is one of the following:
A) A doctor of medicine or osteopathy;
B) A registered nurse;
C) An individual who holds:
i) at least a bachelor's degree in one of the following professional categories: "Occupational Therapy, Physical Therapy, or Psychology";
ii) at least a master's degree in one of the following categories: Social Worker; Recreation Specialist; Registered Dietitian; or Human Services (including, but not limited to: Sociology, Special Education, Rehabilitation Counseling, and Psychology). 42 CFR 483.430.
D) The amount for QIDPs assumes that a full-time QIDP is required for every 15 clients. The number of QIDPs shall be obtained by dividing the number of clients in the facility by 15. The obtained number of QIDPs is multiplied by the hourly wage factor and then by 2080. The product is divided by 365 and then by the number of clients to arrive at an amount per client per day.
2) Interdisciplinary Team (IDT)
A) The amount for services rendered by the IDT assumes that each client requires one day of IDT services per year. This amount is computed to be $1.82 per client per day.
B) Interdisciplinary Team – A team which represents the professions, disciplines, or service areas that are relevant to identifying the client's needs and designing programs that meet the client's needs. Appropriate facility staff must participate in interdisciplinary team meetings. Participation by other agencies serving the client is required. Participation by the client, his or her parent (if the client is a minor), or the client's legal guardian is required unless the participation is unobtainable or inappropriate. (42 CFR 483.440)
3) Additional Direct Service Staff (ADSS)
A) The amount for ADSS assumes an FTE staff:client ratio of 1:7.5. The total number of clients is divided by 7.5 and a per diem amount is obtained according to the method described in subsection (a)(1)(B).
B) Additional Direct Services Staff – Staff which is in addition to HCFA's minimum average daily staffing standards (subsection (a)(1)), and for which the Department will provide reimbursement to ensure the delivery of active treatment. Examples of ADSS include, but are not limited to, staff who provide activity services, dietetic aides, and music therapists.
4) The total reimbursement amount for Active Treatment is the sum of the amounts for QIDP, IDT and ADSS.
c) Specialized Care. An additional amount shall be paid for clients meeting the requirements for services under Specialized Care. Detailed descriptions of services under Specialized Care are found in Section 146.1020 Specialized Care – Behavior Development Programs, and Section 146.1025, Specialized Care – Health and Sensory Disabilities. The service level for each client meeting the criteria of more than one level under Specialized Care shall be determined according to the individual's disability or functional deficit which represents the most intense need for services under Specialized Care, and results in the greatest reimbursement.
1) Specialized Care – Behavior Development Programs. Behavior development programs are related to maladaptive behaviors which occur with high frequency or great severity, and are instituted for the reduction of maladaptive behaviors and/or the increase of adaptive behaviors. The behavior development program shall demonstrate the need for and use of a more intensive staffing pattern (direct care staff) than the regular pattern which is reimbursed for under subsection (a)(1). The service Level for a client who meets the requirements for services under Specialized Care - Behavior Development Programs will be identified and validated during the most recent IOC.
A) Level I – .5 hours FTE Direct Service per day. More intense program services are provided for behaviors which occur with high frequency but moderate severity, such as verbal abuse one or more times per four hours which is hostile in tone and content.
B) Level II – 1.0 hours FTE Direct Service per day. More intense program services are provided for behaviors which occur with high frequency and are aggressive or destructive, such as purposeful attacks of others which may result in minimal injuries, one or more times per day.
C) Level III – 2.0 hours FTE Direct Service per day. More intense program services are provided for behaviors which occur with very high frequency such as hyperactivity one or more times per minute, or occur with high frequency and are seriously aggressive, assaultive or destructive and which may result in serious injury.
2) Specialized Care – Health and Sensory Disabilities. Specialized services for health and sensory disabilities refer to care which some clients must receive in order to attain physical health and development.
A) Definitions
i) Ambulatory – The client is capable of walking without assistance or the aid of adaptive equipment or devices.
ii) Mobile Nonambulatory – The client is capable of locomotion with mobility assistance such as adaptive equipment or devices.
iii) Nonmobile – The client is not capable of locomotion even with mobility assistance.
B) Level I – .5 hours FTE Direct Service per day. The client is ambulatory, mobile nonambulatory, or has the potential to become mobile nonambulatory, and requires services to compensate for a sensory deficit (auditory or visual), or services enabling him or her to be mobile (physical disabilities).
i) Sensory deficits – visual. The client's vision is 20/200 or less in the better eye with the greatest possible correction.
ii) Sensory deficits – auditory. The client has a hearing impairment of at least 55 decibels in the better ear, unaided.
iii) Physical disabilities means physical impairments which result in functional deficits requiring the client to receive training in the use of a device or devices, to achieve some level of independent mobility.
C) Level II – 1.0 hours FTE Direct Service per day. The client is nonmobile or mobile nonambulatory, requires mobility assistance, and requires services to meet high personal care needs. The client may also have significant daily medical needs and/or dual sensory deficits (visual and auditory).
i) Mobility assistance means assistance in transferring from a bed to an alternative position device, and assistance with movement/mobility around the facility.
ii) High personal care means one or more of the following: assistance with bathing, clothing, grooming and hygiene, eating and continence; position changes at two hour intervals, or as specified in the individual program plan; range of motion twice a day, or as specified in the individual program plan.
iii) Daily medical need means daily insulin injections, drug (insulin) monitoring, or ostomy care for a jejunostomy, ileostomy or colostomy.
iv) Dual sensory deficits means both an auditory disability and a visual disability.
AGENCY NOTE: A client who meets the criteria for Level II services is eligible for the FTE nurse:client ratio according to subsections (a)(2)(B) and (C).
D) Level III – 2.0 hours FTE Direct Service per day. The client is typically nonmobile or mobile nonambulatory, but may be ambulatory, and requires services to meet high medical needs. High medical needs mean one or more of the following:
i) daily intermittent catheterization;
ii) care for wounds including stage III and IV decubitus ulcers, deep wounds, infected wounds, extensive burns, or extensive lesions requiring treatment in the form of medications, dressings, whirlpool, ultraviolet light and/or irrigations;
iii) respiratory care including tracheotomy care, positive pressure breathing treatments, aerosol therapy, postural drainage and percussion, vibration and/or suctioning;
iv) feeding via nasogastric tube, or prolonged oral feeding; and
v) intensive physical habilitation due to a functional deficit as determined by physical or psychological causes.
AGENCY NOTE: A client who meets the criteria for Level III services is eligible for the FTE nurse:client ratio according to subsections (a)(2)(B) and (C).
3) The total reimbursement amount for Specialized Care shall be the sum of the amounts determined under subsections (c)(1) and (2), pro-rated over the number of eligible clients identified in the most recent facility reimbursement survey. For example, if the hourly wage is $5.00, assume a facility with ten residents, two of whom meet the criteria for Specialized Care – Health and Sensory Disabilities Level II, subsection (c)(2)(C), with no daily medical needs or sensory deficits, and eight of whom do not meet Specialized Care criteria. The facility will receive an amount of $.81 per client per day (two hours x 1.14 (FTE adjustment factor) divided by eight hours/day = .285 staff; then .285 x (2080 hours/year divided by 365 days/year); then divide by ten clients and multiply by $5.00 to obtain $0.81).
d) Related Costs
1) An amount per client per day will be paid for other program costs, including program – related supplies, consultants and other items necessary for the delivery of active treatment to clients in accordance with their individual program plans.
2) The amount will be determined as follows. Add the amounts determined for subsections (a), (b) and (c), but excluding the amount for the IDT (subsection (b)(2)), and then multiply this sum by the factor determined by the Department for the facility's geographic area (see 89 Ill. Adm. Code 140.Table B). The product plus the amount for the IDT (subsection (b)(2)), is then multiplied by a constant for the facility type, as follows:
|
Facility Type |
Constant |
|
|
MC/DD |
|
.15 |
3) An MC/DD with some clients requiring services under Levels II and/or III of Specialized Care – Health and Sensory Disabilities, and some clients not requiring such services will have the total related cost calculated according to the weighted sum of the number of clients requiring Levels II and/or III multiplied by .15, plus the number of clients not requiring such services multiplied by .10. For example, for a facility with a licensed capacity of 90 clients, 30 of whom require services under Levels II and/or III, and 60 of whom do not require such services, the total related cost will be calculated according to subsection (d)(2) for both groups of clients. (That is, subsections (a), (b) and (c) are summed, excluding the amount for the IDT, for clients requiring Levels II and/or III and for clients not requiring Levels II and/or III. Each sum is multiplied by the factor determined by the Department for the facility's geographic area, and the products are added to the amount for the IDT.) Each outcome is multiplied by the appropriate constant (the MC/DD constant of .15), and then by the number of clients in each group respectively. The two products are summed and then divided by the total number of clients.
4) An amount will also be paid for dental services which are in compliance with HCFA's regulations (42 CFR 483.460(e), (f) and (g)), for each client age 21 or more. This amount will be determined by adding the flat per diem of $.40 to the amount calculated according to subsection (d)(2). This per diem will cover the costs of prophylaxis treatment up to once every six months, and periodontal services as needed for each eligible client.
e) Total Program Per Diem – Total program per diem for each facility will be the sum of the amounts from subsections (a), (b), (c) and (d).
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.TABLE A Guidelines for Determining Levels of Functioning
|
COGNITIVE ABILITY IQ SCORE |
FUNCTIONAL ADAPTIVE BEHAVIORS |
CONDITIONS |
LEVEL OF FUNCTIONING |
|
|
|
|
|
|
|
|
I. |
Mild Moderate Severe/ |
Moderate or Severe Profound |
Behavior |
Based on Cognitive Ability with Specialized Service I, II, III, if applicable. |
|
|
|
|||
|
If a person's assessed adaptive behaviors are lower than the assessed cognitive ability because of behavior, then the overall functioning should be based upon the person's cognitive ability. |
||||
|
|
|
|
|
|
|
II. |
Mild Moderate Severe/Profound |
Moderate Severe Severe/Profound |
Epilepsy Autism Cerebral Palsy |
Based upon adaptive level. May also be eligible for specialized service. |
|
|
|
|||
|
If a person's assessed adaptive behavior is lower than the assessed cognitive ability because of a related condition (epilepsy, autism, cerebral palsy or a seizure disorder which is/are currently active and affect daily living), level of functioning should be based upon the person's adaptive functional behavior. |
||||
|
|
|
|
|
|
|
III. |
Mild Moderate Severe/Profound |
Moderate or Severe Severe or Profound |
None |
Based upon the cognitive ability. |
|
|
|
|||
|
If a person's assessed adaptive behavior is lower than the assessed cognitive ability, but not due to a related condition, then the overall level of functioning is based upon the cognitive ability. |
||||
|
|
|
|
|
|
|
IV. |
Mild Moderate Severe/Profound |
Mild Mild Moderate |
None |
Based upon adaptive functional behavior. |
|
|
|
|||
|
If a person's assessed adaptive behavior is higher than the assessed cognitive ability, then the overall level of functioning is based upon the adaptive behavior. |
||||
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)
Section 146.TABLE B Standardized Adaptive Functional Assessment
Mental Age Level Equivalents With Level of Functioning
|
Adult Mental Age Functional Age |
|
|
Mild |
8 years, 6 months to 10 years, 1 month |
|
Moderate |
6 years, 1 month to 8 years, 5 months |
|
Severe |
3 years, 9 months to 6 years, 0 months |
|
Profound |
Below 3 years, 9 months |
(Source: Added at 47 Ill. Reg. 18051, effective November 21, 2023)