AUTHORITY: Implementing Section 4.02 and authorized by Section 4.01(11) and 4.02 of the Illinois Act on the Aging [20 ILCS 105/4.02 and 4.01].
SOURCE: Emergency rules adopted at 4 Ill. Reg. 1, p. 67, effective December 20, 1979, for a maximum of 150 days; adopted at 4 Ill. Reg. 17, p. 151, effective April 25, 1980; amended at 4 Ill. Reg. 43, p. 86, effective October 15, 1980; emergency amendment at 5 Ill. Reg. 1900, effective February 18, 1981, for a maximum of 150 days; amended at 5 Ill. Reg. 12090, effective October 26, 1981; emergency amendment at 6 Ill. Reg. 8455, effective July 6, 1982, for a maximum of 150 days; amended at 6 Ill. Reg. 14953, effective December 1, 1982; amended at 7 Ill. Reg. 8697, effective July 20, 1983; codified at 8 Ill. Reg. 2633; amended at 9 Ill. Reg. 1739, effective January 29, 1985; amended at 9 Ill. Reg. 10208, effective July 1, 1985; emergency amendment at 9 Ill. Reg. 14011, effective August 29, 1985, for a maximum of 150 days; amended at 10 Ill. Reg. 5076, effective March 15, 1986; recodified at 12 Ill. Reg. 7980; amended at 13 Ill. Reg. 11193, effective July 1, 1989; emergency amendment at 13 Ill. Reg. 13638, effective August 18, 1989, for a maximum of 150 days; amended at 13 Ill. Reg. 17327, effective November 1, 1989; amended at 14 Ill. Reg. 1233, effective January 12, 1990; amended at 14 Ill. Reg. 10732, effective July 1, 1990; emergency amendment at 15 Ill. Reg. 2838, effective February 1, 1991, for a maximum of 150 days; amended at 15 Ill. Reg. 10351, effective July 1, 1991; emergency amendment at 15 Ill. Reg. 14593, effective October 1, 1991, for a maximum of 150 days; emergency amendment at 15 Ill. Reg. 17398, effective November 15, 1991, for a maximum of 150 days; emergency amendment suspended at 16 Ill. Reg. 1744; emergency amendment modified in response to a suspension by the Joint Committee on Administrative Rules and reinstated at 16 Ill. Reg. 2943; amended at 15 Ill. Reg. 18568, effective December 13, 1991; emergency amendment at 16 Ill. Reg. 2630, effective February 1, 1992, for a maximum of 150 days; emergency amendment at 16 Ill. Reg. 2901, effective February 6, 1992, to expire June 30, 1992; emergency amendment at 16 Ill. Reg. 4069, effective February 28, 1992, to expire June 30, 1992; amended at 16 Ill. Reg. 11403, effective June 30, 1992; emergency amendment at 16 Ill. Reg. 11625, effective July 1, 1992, for a maximum of 150 days; amended at 16 Ill. Reg. 11731, effective June 30, 1992; emergency rule added at 16 Ill. Reg. 12615, effective July 23, 1992, for a maximum of 150 days; modified at 16 Ill. Reg. 16680; amended at 16 Ill. Reg. 14565, effective September 8, 1992; amended at 16 Ill. Reg. 18767, effective November 27, 1992; amended at 17 Ill. Reg. 224, effective December 29, 1992; amended at 17 Ill. Reg. 6090, effective April 7, 1993; amended at 18 Ill. Reg. 609, effective February 1, 1994; emergency amendment at 18 Ill. Reg. 5348, effective March 22, 1994, for a maximum of 150 days; amended at 18 Ill. Reg. 13375, effective August 19, 1994; amended at 19 Ill. Reg. 9085, effective July 1, 1995; emergency amendment at 19 Ill. Reg. 10186, effective July 1, 1995, for a maximum of 150 days; emergency amendment at 19 Ill. Reg. 12693, effective August 25, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 16031, effective November 20, 1995; amended at 19 Ill. Reg. 16523, effective December 1, 1995; amended at 20 Ill. Reg. 1493, effective January 10, 1996; emergency amendment at 20 Ill. Reg. 5388, effective March 22, 1996, for a maximum of 150 days; amended at 20 Ill. Reg. 8995, effective July 1, 1996; amended at 20 Ill. Reg. 10597, effective August 1, 1996; amended at 21 Ill. Reg. 887, effective January 10, 1997; amended at 21 Ill. Reg. 6183, effective May 15, 1997; amended at 21 Ill. Reg. 12418, effective September 1, 1997; amended at 22 Ill. Reg. 3415, effective February 1, 1998; amended at 23 Ill. Reg. 2496, effective February 1, 1999; amended at 23 Ill. Reg. 5642, effective May 1, 1999; amended at 26 Ill. Reg. 9668, effective July 1, 2002; emergency amendment at 26 Ill. Reg. 10829, effective July 1, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 17358, effective November 25, 2002; emergency amendment at 28 Ill. Reg. 923, effective December 26, 2003, for a maximum of 150 days; amended at 28 Ill. Reg. 7611, effective May 21, 2004; emergency amendment at 30 Ill. Reg. 10117, effective June 1, 2006, for a maximum of 150 days; emergency amendment at 30 Ill. Reg. 11767, effective July 1, 2006, for a maximum of 150 days; amended at 30 Ill. Reg. 16281, effective September 29, 2006; amended at 30 Ill. Reg. 17756, effective October 26, 2006; amended at 32 Ill. Reg. 7588, effective May 5, 2008; emergency amendment at 32 Ill. Reg. 10940, effective July 1, 2008, for a maximum of 150 days; emergency expired November 27, 2008; amended at 32 Ill. Reg. 17929, effective November 10, 2008; amended at 32 Ill. Reg. 19912, effective December 12, 2008; amended at 33 Ill. Reg. 4830, effective March 23, 2009; amended at 34 Ill. Reg. 3448, effective March 8, 2010; emergency amendment at 34 Ill. Reg. 10854, effective July 15, 2010, for a maximum of 150 days; emergency expired December 11, 2010; emergency amendment at 34 Ill. Reg. 12224, effective August 4, 2010, for a maximum of 150 days; emergency expired December 31, 2010; amended at 35 Ill. Reg. 8919, effective June 2, 2011; emergency amendment at 35 Ill. Reg. 13936, effective July 28, 2011, for a maximum of 150 days; amended at 35 Ill. Reg. 20130, effective December 6, 2011; emergency amendment at 37 Ill. Reg. 11381, effective July 1, 2013, for a maximum of 150 days; emergency expired November 27, 2013; amended at 38 Ill. Reg. 5800, effective February 21, 2014; amended at 38 Ill. Reg. 14230, effective June 25, 2014; amended at 41 Ill. Reg. 15233, effective January 1, 2018; recodified at 42 Ill. Reg. 817; amended at 42 Ill. Reg. 20653, effective January 1, 2019; amended at 44 Ill. Reg. 2780, effective January 29, 2020; amended at 44 Ill. Reg. 5995, effective April 3, 2020; amended at 44 Ill. Reg. 8609, effective May 13, 2020; amended at 45 Ill. Reg. 13819, effective October 21, 2021; amended at 46 Ill. Reg. 12492, effective July 1, 2022; emergency amendment at 47 Ill. Reg. 7115, effective May 10, 2023, for a maximum of 150 days; emergency expired October 6, 2023; emergency amendment at 47 Ill. Reg. 15675, effective October 18, 2023, for a maximum of 150 days; emergency expired March 15, 2024; amended at 48 Ill. Reg. 1129, effective January 3, 2024; amended at 48 Ill. Reg. 11053, effective July 16, 2024.
SUBPART A: GENERAL PROGRAM PROVISIONS
Section 240.100 Community Care Program
The statutory authority for this rule is vested in the Illinois Act on the Aging, as amended. The costs of Community Care Program services provided to all eligible participants who are also enrolled in Medical Assistance Programs administered by the Illinois Department of Healthcare and Family Services (HFS) will be submitted for Federal Financial Participation under provisions of a waiver granted to the State of Illinois relevant to Title XIX of the Social Security Act (Section 1915) (42 USC 1396). The costs of Community Care Program services provided to all other eligible participants will be borne by appropriations set within the State's budget process.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.110 Department Prerogative
Other programs or demonstration/research projects may be funded by the Department on a pilot basis. These other programs or demonstration/research projects shall be funded for purposes of providing alternatives to nursing facility care; permitting equal access to Community Care Program services; evaluating the impact of the program on sustaining participants in the community and other funding opportunities for the Department; or for other purposes designated by the Department in the best interest of the Community Care Program and funding opportunities for the Department and other human service agencies through federal and State grant-making activity and waiver applications on behalf of the State of Illinois under Title XIX of the Social Security Act.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.120 Services Provided
a) The Community Care Program (CCP) provides necessary services designed to prevent premature and unnecessary nursing facility care of participants determined eligible to receive those services.
b) Services provided through the CCP are: in-home care, adult day service, emergency home response, automated medication dispenser, information and referral, care coordination, and services made available through special demonstration/research projects.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.130 Maintenance of Effort
Services made available through the Community Care Program shall not supplant the same type of services which are available through other funded sources but shall be utilized for purposes of complementation and coordination of all services available to eligible participants. Therefore, participants are not permitted to be enrolled in another Home and Community-Based Service (HCBS) Waiver.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.140 Program Limitations
The execution of all activities related to the Community Care Program, as specified in this Part, shall be subject to resources made available to the program through the appropriation process of the State of Illinois.
Section 240.150 Department Headquarters Location
The main address for the Department is:
Illinois Department on Aging
One Natural Resources Way, #100
Springfield IL 62702-1271
(Source: Added at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.160 Definitions
"Adequate person-centered plan of care" means a person-centered plan of care that provides the minimum services needed to protect the health, safety and welfare of a participant.
"Adjusted rate" means a rate other than the established fixed rate of reimbursement.
"Administrative costs" means those allowable costs related to the management and organizational maintenance of the provider as described in Section 240.2050.
"Adverse action" means the denial of CCP service; a reduction in dollars in the monthly cost of care according to the Participant Agreement – Person-Centered Plan of Care; a change in service type that could increase the participant's incurred monthly expense for care prior to July 1, 2010; or the termination from CCP service.
"Allegations" means unsubstantiated accusations or statements.
"Allowable costs" means those cost categories, as delineated in Section 240.2050, which will be considered in setting a fixed rate.
"Allowable maximums" means the highest authorized allocation available for services per month based upon Determination of Need assessment tool scores or the corollary scores on any successor assessment tool authorized by the Department to determine need for long term services and supports.
"AMD" means automated medication dispenser.
"Appellant" means the participant/authorized representative initiating an appeal as a result of Department or provider action or inaction.
"Assistive device" means crutches, walker, wheel chair, hearing aid, etc.
"Authorized representative" means an agent designated, verbally or in writing, by the participant to be their representative, or the participant's legal guardian. In the event that a participant is unable to physically write their signature, the CCU may sign for the participant at the participant's verbal request.
"Authorized representative of the provider" means an owner, officer, or employee of the provider who has the authority to commit the provider to a financial and/or contractual responsibility.
"Authorized provider" or "provider" means an entity who holds a valid contract with the Department to provide Community Care Program (CCP) services. CCP services are provided on a reimbursement basis for units of service delivery to specified participants.
"Available resources" means assistance provided to a participant by family/friends, church, community, etc.
"Best interest" means the determined needs of the participant population are being met.
"Burial merchandise" means gravesites, crypts, mausoleums, urns, caskets, vaults, grave markers or other repositories for the remains of deceased persons, shrouds, etc.
"Calendar year" means from January 1 through December 31.
"Capable person" means a person who is qualified to perform the functions required.
"Care Coordinator" means a trained individual who is employed to assess needs, conduct eligibility screenings, and perform care coordination services and care coordination functions under the Community Care Program.
"CCP" means Community Care Program.
"CCU" means Care Coordination Unit.
"Certified Public Accountant" or "CPA" means a person licensed or authorized to practice accounting under the Illinois Public Accounting Act [225 ILCS 450].
"Choices for Care" means a CCP program under which CCUs conduct prescreening or postscreening assessments to determine eligibility of participants age 60 and over for nursing facility placement, supportive living program placement, or the choice of community-based services. Screenings may be conducted in a hospital, nursing facility, supportive living program, or in the community depending on the circumstances.
"Community-based services" means services provided in an integrated setting in a participant's community.
"Comparable human service program" means a program that offers services that are similar to CCP services (e.g., home health aide, maid service).
"Compliance" means adherence to the CCP rules in this Part, to CCP policy and procedures, to the contract with the Department, and to all applicable federal, State and local laws, rules, and ordinances.
"Components" means specified parts of the service as defined in the applicable Section.
"Confused and disoriented" means unable to clearly and accurately differentiate as to time, person and/or place.
"Continuous eligibility" means that the participant has met eligibility requirements each time a subsequent redetermination was administered.
"Cost report" means a report of all categorized allowable costs to a provider that are directly associated with services purchased by the Department for its participants in categories as defined in Section 240.2050. The provider shall use the Direct Service Worker Cost Certification and the Detailed Cost Certification forms.
"Critical event" means any actual or alleged incident or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety or well-being of a participant. There are three subcategories that will be reported to the Department:
"Critical Incidents" include anticipated death, unanticipated death, hospitalization, medication error, serious injury, missing person, emergency department visit, property damage, nursing facility placement, fall (with injury), fall (without injury), special circumstance, criminal activity, and law enforcement interaction;
"Service Improvement Program Complaints" or "SIPs" is a complaint based reporting process with the purpose of identifying and resolving problematic issues related to the provision of home and community based services (HCBS); and
"Request for Change of Status" occurs anytime the condition of a CCP participant changes or there is a change in circumstances that affect the ability of the family and/or caregiver to safely provide support and assistance.
"Department" means the Illinois Department on Aging.
"Director" means the Director of the Illinois Department on Aging.
"Discontinuance" means the cessation of CCP services provided to a participant for non-payment of incurred expense for care prior to July 1, 2010.
"Documentation" means tangible documents or supporting references or records used to record participant contact, determine eligibility or substantiate adherence to rules.
"Documenting" means making written and/or electronic entries on the Case Record Recording Sheet regarding contact with a participant; and/or the viewing or receiving of a document to be placed in participant /worker files to substantiate adherence to rules.
"DON" means the Determination of Need, which is a component of the comprehensive assessment tool, or any successor assessment tool authorized by the Department, used to determine CCP eligibility under this Part.
"EHRS" means emergency home response service.
"Emergency" means a sudden unexpected occurrence demanding immediate action (e.g., participant illness, illness/death of a member of the participant's family).
"Errands" means performance of services outside the home such as essential shopping, picking up medications, and essential business needs as indicated in the person-centered plan of care.
"Escort" means accompanying those participants who are dependent on personal physical assistance to enable them to reach and use community resources in order to ensure their access to local services and to allow them to maintain independent living as required by the person-centered plan of care.
"Essential" means basic, indispensable or necessary.
"Extraordinary care" means care provided by a legally responsible individual that exceeds what would ordinarily be provided to a person of the same age without a disability or chronic condition, and is necessary to assure the health and welfare of the participant and avoid institutionalization, as documented by the Care Coordination Unit; in instances when the CCU documents there are no other qualified homecare aides available to provide the services required under the participant's person-centered plan of care; or in instances when the CCU documents the legally responsible individual has a unique ability to meet the needs of the participant, and services provided by the legally responsible individual are in the best interest of the participant.
"Face-to-face" means direct communication while physically in the presence of another person or persons.
"Face-to-face review" means an informal review (see Section 240.425) conducted in the appeal process by the Department in the home of an appellant with the participant (and appellant, if appellant is other than the participant) present.
"FUTA" means the Federal Unemployment Tax Act (26 U.S.C. 3301 through 3311).
"Fiscally sound agency" means a CCU or provider that has on file at the Department documentation that supports that the CCU or provider has adequate financial resources to perform the terms of the contract (e.g., a line of credit from a financial institution).
"Fraudulent information" means purposely erroneous or untruthful information.
"Geographic area" means a physical area (e.g., county) of the State within which a contractor is authorized to provide services to Community Care Program participants.
"Good standing" means a provider or CCU who is currently in compliance or within the permitted time frame allotted to come into compliance with the Department's administrative rules and contract.
"Home maintenance and repairs" means those non-routine tasks, excluding any work requiring a ladder or requiring specialized skills on the part of the worker, necessary to maintain a safe and healthful environment for the participant as required by the person-centered plan of care (e.g., defrosting the refrigerator; cleaning the oven; dusting walls and woodwork; cleaning closets, cupboards and insides of windows; changing filters on and cleaning humidifiers; replacing light bulbs; clearing hazards from outside steps and sidewalks if transportation and/or escort is required by the person-centered plan of care).
"Imminent" means likely to occur (e.g., injury or nursing facility care).
"Incurred monthly expense" means the participant's share of the cost of care for CCP services provided during a previous monthly period prior to July 1, 2010.
"Informal review" means the act of determining the facts relating to an appeal in an informal manner by the Department.
"In-home services" means services provided in the participant's residence with the participant present or on behalf of the participant (e.g., homecare aide).
"Legal guardian" means a person appointed by a court of competent jurisdiction to exercise certain powers on behalf of another adult. (See 405 ILCS 80/2-3).
"Legally Responsible Individual" or "LRI" means any individual who has a legal duty to provide care for a participant and includes the participant's spouse, power of attorney (medical, legal, or financial), or representational payee who is hired by a CCP in-home service provider to deliver extraordinary care to a CCP participant. An LRI is not an alternative provider as described in 240.270 or a legal guardian.
"Licensed Practical Nurse" or "LPN" means a person who is licensed as a practical nurse under the Nurse Practice Act and practices practical nursing as defined in this Act. [225 ILCS 65/50-10]
"Mandated time period" means the time frame required by pertinent rule.
"Memorandum of Understanding" or "MOU" means a written document, executed by the participant/authorized representative, CCU representative and provider representative in which all parties agree to cooperate and in which activities are specified that must be fulfilled by each party.
"Observing participant's functioning" means watching for any change in the participant's needs that could indicate that a redetermination of eligibility and/or a revision in the CCP Participant Agreement – Person-Centered Plan of Care is necessary (e.g., participant is experiencing increasing difficulty in walking; participant is becoming increasingly confused and disoriented; participant's family member is no longer available to prepare meals for the participant).
"Occupancy costs" means the costs of depreciation, amortization of leasehold improvements, rent, property taxes, interest and other related costs.
"On-Notice" means the Department sanction imposed on a provider or CCU requiring that provider or CCU to bring specified services or requirements into compliance.
"Parent organization" means an entity to which the contractual party is a subsidiary.
"Participant" means a person who made a request for services, receives services, or is appealing benefits decisions under the Community Care Program.
"Person-centered planning" means that service planning for participants in the Persons who are Elderly Waiver shall be developed through a person-centered planning process that addresses health and long-term services and supports (paid and unpaid) needs in a manner that reflects participant personal preferences, choices and goals. The person-centered planning process is directed by the participant and may include an authorized representative that the participant has freely chosen to contribute to the process. The planning process, and the resulting person-centered plan of care, will assist the participant in achieving personally defined outcomes in the most integrated community setting, including the assurance of their health, safety and welfare.
"Physician" means a person licensed under the Medical Practice Act to practice medicine in all of its branches or a chiropractic physician. [225 ILCS 60/2]
"Planning and Service Area" or "PSA" means a designated geographic area as defined in 20 ILCS 105/3.08.
"Post-screening" means screening performed after a participant has entered a nursing facility due to an emergency situation or oversight without prescreening.
"Potentially" means having the capability of occurring, but not yet in existence (e.g., deterioration in the participant's condition).
"Program support costs" means those allowable costs not included as direct service or administrative costs.
"Provider certification" means a provider has completed the certification process outlined in Section 240.1505 and has a valid contract with the Department.
"Provider Agreement" means a purchase of service agreement between the Department and an agency providing CCP services.
"Reasonable" means using and showing reason or sound judgement, sensible, not excessive.
"Reasonable and diligent effort" means perseverance on the part of the participant to dispose of an asset (e.g., as evidenced by copies of the advertisement for the sale of the asset).
"Registered Nurse", "RN" or "Registered Professional Nurse" means a person who is licensed as a professional nurse under the Nurse Practice
Act and practice nursing as defined in this Act. [225 ILCS 65/50-10]
"Reinstatement" means the resumption of services, within an established time frame, at the same level provided prior to a suspension/discontinuance of the services.
"Related parties" means any other entities having a legal or contractual relationship with the contractual party.
"Request for Proposal" or "RFP" means a form of invitation to bid that the Department uses to obtain care coordination services and demonstration/research projects under the CCP. The RFP explains the purpose of the invitation to bid, outlines the scope of the work and solicits proposals from provider agencies for the funding of services undertaken by the Department.
"Risk mitigation" means the process in which events or experiences that place the health, welfare and safety of program participants in jeopardy are evaluated in terms of nature, frequency and circumstance with the intent of providing services and supports aimed at reducing risk and the likelihood of its reoccurrence.
"Rotation plan" means a Department approved plan for the equitable distribution of participants to providers (used only if participant does not indicate a choice of providers).
"Routine procedures" means procedures performed in a hospital that result in no perceptible change in the participant's physical/mental health needs (e.g., tests, blood work-ups, x-rays, dialysis).
"Service area" means any area in which a provider has been granted a contract to provide CCP services.
"Special diet" means a dietary restriction based upon the health and safety needs of the participant and prescribed by a physician (e.g., sodium free, fat, protein, diabetic, etc.); whereas a modified diet relates to a diet containing easy to chew foods. A modified diet may be part of a specialized diet.
"State fiscal year" means from July 1 through June 30.
"Supportive Living Program" or "SLP" means the program that provides an affordable assisted living model offering limited personal and health services integrated within apartment-style housing. The SLP operates under the authority of a 1915(c) HCBS Waiver. The SLP serves persons who would otherwise need nursing facility (NF) care, but whose individual needs can be met by the SLP. HFS is the operating agency for the SLP Waiver.
"Suspension" means the temporary cessation of the provision of Community Care Program services to a participant.
"Suspension of referrals" means closed intake of new participants to a specific provider.
"Termination" means the permanent cessation of Community Care Program services and eligibility of services.
"Threat" means the existence of circumstances that indicate the intent of an individual or group to destroy the property of or to injure or punish another individual or group, or the display of a weapon at an adult day services center or home.
"Too highly impaired participant" means a participant who needs 24 hour a day care, for whom CCP cannot develop a person-centered plan of care to protect his/her physical, mental and environmental needs and who does not have sufficient outside support from family, friends, church et. al., to provide for those needs (as determined by Part B – Unmet Need for Care – of the Community Care Program – Determination of Need). (Refer to Section 240.715.)
"Unallowable costs" means those costs, as described in Section 240.2030, that will not be considered in determining the fixed rate or in meeting the required minimum direct service expenditure.
"Unit of service" means a measured length of service, such as an hour, a day, a visit, a one-way trip, or some other measurable service component that will enable the Department to determine the amount of service provided individually or in aggregate to or on behalf of a participant.
"Work days" means Monday through Friday at a minimum, excluding provider designated holidays.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.170 Variance
The Director may grant variances from this Part in individual cases when they find that:
a) The provision from which the variance is granted is not statutorily mandated;
b) No party will be injured by the granting of the variance; and
c) The provision from which the variance is granted would, in the particular case, be unreasonable or unnecessarily burdensome.
(Source: Added at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART B: SERVICE DEFINITIONS
Section 240.210 In-home Service
In-home service is defined as general non-medical support by supervised homecare aides who have received specialized training in the provision of in-home services. The purpose of providing in-home service is to maintain, strengthen and safeguard the functioning of participants in their own homes in accordance with the authorized person-centered plan of care.
a) Specific service components of in-home service shall include the following:
1) Teaching/performing of meal planning and preparation; light housekeeping tasks (e.g., making and changing beds, dusting, washing dishes, vacuuming, cleaning floors, keeping the kitchen and bathroom clean and laundering the participant's linens and clothing); shopping skills/tasks; and home maintenance and repairs.
2) Performing/assisting with essential shopping/errands may include handling the participant's money (proper accounting to the participant of money handled and provision of receipts are required). These tasks shall be:
A) performed as specifically required by the person-centered plan of care; and
B) monitored by the homecare supervisor.
3) Assisting with self-administered medication, which shall be limited to:
A) reminding the participant to take his/her medications;
B) reading instructions for utilization;
C) uncapping medication containers; and
D) providing the proper liquid and utensil with which to take medications.
4) Assisting with following a written special diet plan and reinforcement of diet maintenance (can only be provided under the direction of a physician as required by the person-centered plan of care).
5) Observing participant's functioning and condition and reporting to the supervisor, as outlined by the person-centered plan of care.
6) Performing/assisting with personal care tasks that are not medical in nature, such as the examples set forth at 77 Ill. Adm. Code 245.40(c) (e.g., shaving, hair shampooing, drying and combing, bathing and sponge bath, shower bath or tub bath, toileting, dressing, nail care, respiratory services, brushing and cleaning teeth or dentures and preparation of appropriate supplies, positioning/transferring participant, and assisting participant with exercise/range of motion), as defined by the person-centered plan of care.
7) Escort/transportation to medical facilities, or for essential errands/shopping, or for essential participant business with or on behalf of the participant, as defined by the person-centered plan of care. This escort/transportation service may be provided directly by the homecare aide, directly by the provider, by the provider through contract, or by public transportation.
8) Identifying and reporting critical events, including critical incidents, service improvement program complaints, and requests for change of status in the Department's automated reporting system. Completing initial critical event reports will occur within seven days after the date the event occurred or was identified to have occurred. Assisting CCUs in their efforts to safeguard participant health, safety and welfare by demonstrating a willingness to collaborate, discuss and resolve issues that likely place a participant at increased risk for experiencing future critical events. Supporting CCU risk mitigation efforts by demonstrating a willingness to communicate about necessary adjustments to a participant's care plan in response to a critical event.
b) Unit of Service
1) One unit of in-home service is one hour of direct service provided to the participant in the participant's home, while providing transportation/escort, or while running errands and/or shopping on behalf of the participant.
2) Refer to Section 240.1930 for further information regarding reimbursement.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.230 Adult Day Service (ADS)
Adult day service is the direct care and supervision of adults aged 60 and over in a community-based setting for the purpose of providing personal attention and promoting social, physical and emotional well-being in a structured setting. These services shall be provided pursuant to an ADS Addendum to the participant's person-centered plan of care.
a) Required Service Components
1) Assessment of the participant's strengths and needs and development of an individual written person-centered plan of care for each participant that establishes specific participant goals for all service components to be provided or arranged for by the service provider.
A) The individual ADS Addendum will be developed by the adult day service team consisting of participant/authorized representative, Program Coordinator/Director and Program Nurse, and may include other staff at the option of the program Coordinator/Director.
B) The participant, caregiver and other service providers will have the opportunity to contribute to the development, implementation and evaluation of the individualized ADS Addendum.
C) The individualized ADS Addendum is to be established not later than the fourth week of service.
D) The individualized ADS Addendum shall address the needs identified by the CCU, as described in the comprehensive assessment.
E) The individualized ADS Addendum to the person-centered plan of care shall address the need identified by the service provider's staff and participant/authorized representative/caregiver during the individualized ADS Addendum process.
F) Reassessing the participant's needs and reevaluating the appropriateness of the individualized person-centered plan of care shall be done as needed, but at least annually.
2) A balance of purposeful activities to meet the participant's interrelated needs and interests (social, intellectual, cultural, economic, emotional, physical and spiritual) designed to improve or maintain the optimal functioning of the participant.
A) Activity programming shall take into consideration participant differences in age, health status, sensory deficits, lifestyle, ethnicity, religious affiliation, values, experiences, needs, interests and abilities by providing for a variety of types and levels of involvement.
B) Time for rest and relaxation shall be provided as needed or prescribed.
C) Activity opportunities shall be available whenever the service provider's facility is in operation and participants are in attendance.
D) A monthly calendar of activities shall be prepared and posted in a visible place.
E) Opportunities to participate in other activities outside of the ADS shall be provided. The setting will be integrated in, and support access to, the greater community.
3) Assistance with or supervision of activities of daily living (e.g., walking, eating, toileting and personal care), as needed.
4) Provision of health-related services appropriate to the participant's needs as identified in the provider's assessment and/or physician's orders, including health monitoring, nursing intervention on a moderate or intermittent basis for medical conditions and functional limitations, medication monitoring, medication administration or supervision of self-administration, and coordination of health services.
5) Provision of a daily meal that meets the Dietary Guidelines for Americans, 2020-2025, 9th edition, published by the Secretary of Health and Human Services and the Secretary of Agriculture; and that provides each participant a minimum of 33.5% of the Dietary Reference Intakes (DRI) as established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences. Supplementary nutritious snacks shall also be provided. Special diets shall be provided as directed by the participant's physician.
6) Agency provision or arrangement for transportation, with at least one vehicle physically accessible, to enable participants to receive adult day service at the adult day service provider's site and participate in sponsored outings.
7) Provision of emergency care as appropriate in accordance with established adult day service provider policies and Section 240.1510.
8) Identifying and reporting critical events including critical incidents, service improvement program complaints, and requests for change of status in the Department's automated reporting system. Completing initial critical event reports will occur within seven days after the date the event occurred or was identified to have occurred. Assisting CCUs in their efforts to safeguard participant health, safety and welfare by demonstrating a willingness to collaborate, discuss and resolve issues that likely place a participant at increased risk for experiencing future critical events. Supporting CCU risk mitigation efforts by demonstrating a willingness to communicate about necessary adjustments to a participant's person-centered plan of care or ADS Addendum in response to a critical event.
b) Ancillary Service Components
1) Ancillary services, including physical, occupational, speech and creative arts therapies may be provided by site staff or through contractual arrangements when needed by participants. If provided, ancillary services shall be within the framework of the individualized person-centered plan of care and ADS Addendum and shall be in accordance with professional practice standards and applicable State and federal regulations.
2) Skilled nursing services, including, but not limited to, catheter installation, irrigations and care, dressings, enemas, oxygen therapy, suction/posturing, ostomy care and restorative nursing such as bladder retraining. (All these procedures/interventions require physician orders and shall be administered by a Registered Nurse or a Licensed Practical Nurse, in accordance with the Illinois Nurse Practice Act [225 ILCS 65].)
3) Shopping assistance.
4) Escort to medical and social services.
5) Reimbursement for costs of ancillary services is not included in the unit rate paid by the Department and will not be paid by the Department.
c) Unit of Service
1) One unit of ADS is defined as one direct participant contact hour (excluding transportation time) provided to a participant. A direct participant contact hour is defined as 60 consecutive minutes of active programming, i.e., providing one or a combination of the service components listed in subsections (a)(2) through (7).
2) One unit of documented ADS transportation, provided by the ADS provider, is defined as a one-way trip per participant to or from the adult day service provider's site and the participant's home. No more than two units of transportation shall be provided per participant in a 24-hour period, and shall not include trips to a physician, shopping, or other miscellaneous trips.
3) Refer to Section 240.1950 for further information regarding reimbursement.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.235 Emergency Home Response Service
a) Service Definition
Emergency home response service (EHRS) is defined as a 24-hour emergency communication link to respond to emergent participant needs. EHRS is provided by a two-way voice communication system which may consist of a base unit that can be activated using landline, cellular, and/or internet-based access and a water-resistant activation device worn by the participant that will automatically link the participant to a professionally staffed support center. When the system is engaged by a participant, the support center shall assess the situation and direct an appropriate response. EHRS equipment shall include a variety of remote or specialty activation devices from which the participant can choose in accordance with their specific need as outlined in their authorized person-centered plan of care.
b) A EHRS provider shall provide the participant with a base unit, when it is required for the equipment to function, and an activation device with all connectors, parts and equipment necessary for installation.
c) A participant may choose an activation device capable of sensing at least a 36-inch drop when the participant has fallen and automatically alerting the support center for assistance.
d) A participant may choose to switch from the standard activation device to a mobile device that is not connected to a landline and that is capable of providing the support center with the participant's latest location using GPS. The device must allow for two-way interactive communication and include an optional all-in-one device. The device must have at least a five-day battery life, depending on usage, and be compatible with a fall detection device if the participant so chooses.
e) The activation device shall be adaptive for participants with functional limitations (visual, audio, physical, etc.). These devices shall be provided at no extra cost to the participant.
f) A participant shall inform their EHRS provider if they are away from home for longer than 30 consecutive calendar days. A participant who resides outside of the State for more than 60 calendar days may lose eligibility to received EHRS services and may have their services terminated.
g) An EHRS provider shall:
1) deliver and install the EHRS equipment to the participant within 15 calendar days after the date of referral. This service shall not be subcontracted and shall be completed by trained employees who must have identification that they work for the EHRS provider;
2) train the participant and their designated emergency contacts on the proper use of the equipment at the time of installation and provide easy to use written instructions on how to use the equipment. Instructions must be provided in a language or format easiest for the participant to use;
3) assist the participant in selecting and designating up to three local emergency contacts, which must be updated by the EHRS provider at least every six months. Each contact shall receive both verbal and written instructions from the provider;
4) obtain participant's/authorized representative's signature to document that the EHRS equipment was delivered and installed and that instructions and demonstration were given and understood. A copy of this receipt must be sent to the CCU;
5) have a support center to provide live monitoring on a continuous basis, direct an appropriate response whenever the EHRS system is activated, and provide necessary technical support for fault conditions, including a language line that provides interpreter service for languages most commonly spoken by older adults in the state and communication facilitated by a teletypewriter (TTY) communication device for the deaf, as appropriate;
6) have a back-up support center that provides all components specified in subsection (e)(5) and operates on a separate power grid;
7) maintain adequate local staffing levels of qualified personnel to service necessary administrative activities, installation, in-home training, signal monitoring, technical support and repair requests in a timely manner. A provider agency must have a training program for personnel and be able to demonstrate staff qualifications;
8) in the event of a malfunction, repair or replace the base unit or activation device within 24 hours after receiving the malfunction report;
9) alert the participant when electric power to the base unit has been interrupted (e.g., unplugged) and the unit is operating on a standby power source;
10) notify the CCU within one business day after activation of the base unit and work with the appropriate care coordination supervisor to resolve service complaints from the participant or emergency responder;
11) notify the CCU immediately if EHRS services cannot be initiated or must be terminated; and
12) maintain records in accordance with Section 240.1542 relating to participant referral and service statistics, including equipment delivery; device activation; participant and responder training; signal monitoring and test transmission activity; equipment malfunction, repair and replacement; power interruption alerts; and notification of the CCUs, plus billing and payment information, and personnel matters.
h) Units of Service
1) One unit of installation service is the one-time fee to the EHRS provider for the activity associated with the installation of the base unit in the participant's home.
2) One unit of monthly service is the fixed unit rate of reimbursement, per month, for the EHRS provider activity associated with providing EHRS to each participant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.237 Automated Medication Dispenser Service
a) Service Description
1) AMD service is defined as a portable, mechanical system for individual use that can be programmed to dispense or alert the participant to take non-liquid oral medications through auditory, visual or voice reminders; to provide notification of a missed medication dose; and to provide 24-hour technical assistance for the AMD service in the participant's residence. The service may include medication specific directions or reminders to take other types of medications such as liquid medications or injections based on individual need. The AMD unit is connected to a Department approved support center through a telephone line or wireless/cellular connection in the participant's residence.
2) The purpose of the service is to provide eligible participants with medication reminders to foster timely and safe administration of a medication schedule, thereby promoting independence and safety of all participants in their own residence, as well as reducing the need for nursing home care.
3) The authorization to receive this service is determined by the care coordinator through a screening process set forth in Section 240.741, which requires the participant/authorized representative to designate an assisting party to manage the AMD unit and medications.
4) The Department does not perform medication management, oversight or handling of the participant's medications.
5) Provision of this service is contingent upon it continuing to be an approved service under the HCBS Waiver for Persons Who are Elderly.
b) Specific components of AMD service must include, at a minimum, the following:
1) an AMD unit installed in the participant's residence with all connectors, parts and equipment necessary for installation, and adaptations for operation by individuals who have functional, hearing or visual impairments, or who exhibit language barriers.
2) delivery of the AMD unit to the participant and installation of the unit within 48 hours after the referral when the participant is at imminent risk of institutionalization and within 15 calendar days from the date of the referral in all other instances.
A) This timeline can be extended if requested by the participant/authorized representative/assisting party.
B) This service shall not be subcontracted and shall be provided by trained employees who will identify themselves by picture identification that can be verified by the participant/authorized representative/assisting party.
C) Delivery and installation of the AMD unit may include coordination of EHRS for a participant.
D) Provider shall make every effort to schedule and conduct the installation when the participant, authorized representative (if applicable), and assisting party are present. Documentation of such efforts shall be provided to the Department upon request.
3) training for the participant/authorized representative and assisting party on the proper use of the AMD system at the time of installation and subsequently when needed. The training will include:
A) demonstration of the use, including any adaptations for operation, general care, and maintenance of the unit/equipment;
B) explanation of the AMD provider's services and notification processes;
C) instruction on any testing or monitoring used to assure the proper functioning of the AMD unit/equipment, including how to report any malfunctions; and
D) providing the participant/authorized representative/assisting party with easy to understand written instructions in the use, general care and maintenance of the AMD unit/equipment. These instructions will be available in options such as non-English languages, large print, Braille, and audible recordings to meet the participant's needs.
4) ensuring the participant/authorized representative reviews their assisting party designation at least every six months. Any changes in this designation must be sent to the CCU within five calendar days after the date of execution of the assisting party change. If there is a change in designation, the AMD provider must complete new training as required under subsection (b)(3) within seven calendar days after the date of execution of the assisting party change.
5) both:
A) obtaining the signature of the participant/authorized representative to verify that:
i) the AMD unit/equipment was delivered and installed; and
ii) instructions and demonstration were given and understood by the participant/authorized representative; and.
B) providing to the CCU and the participant/authorized representative a copy of the verification, to be kept on file at the CCU.
6) maintaining adequate local staffing levels of qualified personnel to conduct and provide necessary administrative activities, installation, in-home training, unit/equipment monitoring, technical support, AMD unit programming, and repair requests in a timely manner. An AMD provider must have a written training program for personnel and be able to demonstrate that its staff members are qualified and have passed background checks.
7) repairing or replacing the AMD unit/equipment within 24 hours after receiving a malfunction report. This timeline will be extended if requested by the participant/authorized representative/assisting party.
8) alerts to the participant/authorized representative and assisting party when electric power to the AMD unit has been interrupted (e.g., unplugged) and the unit is operating on a standby power source.
9) notification to the CCU within one calendar day after installation of the AMD unit and working with the appropriate care coordinator to resolve service complaints from the participant/authorized representative/assisting party.
10) notification to the CCU within two calendar days if the AMD service cannot be initiated or must be terminated.
11) maintaining records in accordance with Section 240.1544 relating to participant referral and service statistics, including unit/equipment delivery; unit installation and programming; participant/authorized representative and assisting party training; missed medication notifications and dispositions; other AMD unit/equipment monitoring and test transmission activity; unit/equipment malfunction, repair and replacement; power interruption alerts; notifications to the CCUs; billing and payment information; and personnel qualifications, training and background checks.
12) making available participant reports on missed medication doses, power and battery status, and other reporting features on an ongoing basis to the participant/authorized representative, assisting party and care coordinators via a privacy-protected and secure website or other modality.
13) providing access to individual and aggregate reports and AMD system performance measures on an ongoing basis to authorized persons through a privacy-protected and secure website or other modality.
14) providing ad hoc reports to the Department upon request.
c) Units of Service
1) One unit of installation service is the one-time fee to the AMD provider for the activity associated with the installation of the AMD unit/equipment in the participant's residence and training of the participant/authorized representative and assisting party.
2) One unit of monthly service is the fixed unit rate of reimbursement, per month, for the provider agency activity associated with providing the AMD service to each participant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.240 Information and Referral
Information and Referral service is defined as assistance to participants to enable them to gain access to appropriate services and to receive services.
a) Service components of information and referral include:
1) A brief assessment of the participant's needs to facilitate appropriate referral to and follow-up with community resources;
2) Assisting participants in applying for benefits provided by federal, state and local agencies;
3) Follow-up to ensure that participant was linked to community-based services and supports;
4) Information and referral may also encompass program-related public information efforts.
b) Unit of Service
One unit of Information and Referral service is one incoming telephone call received by the professional information and referral staff.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.250 Demonstration/Research Projects
a) Demonstration/research projects are defined as services designated to test or demonstrate, as specified in Section 240.110, effective service delivery to participants 60 years of age and older to prevent/reduce the incidence of premature or inappropriate nursing facility care. These projects are study programs testing the feasibility of new types of services, service delivery methods or service components which, as a result of the demonstration/research, will be considered for incorporation in the CCP.
b) Unit of Service
A unit of service for a demonstration/research project shall be as stated in each contract/grant executed.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.260 Care Coordination Service
Care coordination service is defined as the provision of a comprehensive needs assessment and service coordination by CCUs to assist an older person to gain access to and receive needed services. The participant/authorized representative is provided the opportunity to lead the person-centered planning process.
a) Service Components
Specific components of care coordination service include the following:
1) Review of all inquiries to determine if a request for CCP services is desired, and maintenance of a referral request log.
2) Distribution and assistance with completion of CCP applications for charitable, private, and public benefits provided by federal, State and local agencies, including assistance with the initial application and redetermination for Medicaid benefits.
3) Performance of determinations/redeterminations of eligibility, including a comprehensive needs assessment, the development of a person-centered plan of care and authorization/referral of CCP services.
4) Completion of a minimum of one face-to-face contact with the participant in between initial assessment and annual reassessment. The face-to-face visit is to occur between four and eight months after the last determination or redetermination of eligibility.
5) Reporting of critical events includes critical incidents, service improvement program complaints, and requests for change of status in the Department's automated reporting system. Completing initial critical event reports will occur within seven days after the date the event occurred or was identified to have occurred. All critical event reports will be closed to reflect mandatory follow-up with CCP participants within 60 days after the date the event occurred or was identified to have occurred. Critical event report closure will occur through completion of the 60-day review summary housed in the Department's automated reporting system.
6) Availability to receive inquiries and requests for services and supports, by telephone or in person, and respond to those inquiries and requests.
7) Choices for Care prescreenings and postscreenings (see Section 240.1010).
8) Department of Healthcare and Family Services (HFS) Level I Screen.
9) Provide referrals to other needed services.
10) Implementation of services and participant transfers.
11) Authorization of all actions related to the disposition of CCP services as required by this Part.
b) Comprehensive Assessments
1) A comprehensive assessment is required when a participant needs services to remain living independently in the community or is at imminent risk of nursing facility placement.
2) A comprehensive assessment is not warranted when a participant only requires a referral to services (e.g., providing contact information for a vendor).
3) Conditions triggering a comprehensive assessment may include, but are not limited to:
A) multiple or complex health problems which are often chronic in nature, and may affect the ability of the participant to live independently, such as musculoskeletal disorders, strokes, heart disorders, or mental health issues (e.g., Alzheimer's disease, major depression, or organic brain syndrome);
B) lack of sufficient formal or informal supports; or
C) sudden and permanent loss of a primary caregiver.
4) The Care Coordinator will appropriately complete the comprehensive assessment tool authorized by the Department, or any successor assessment tool, used to determine need for community-based or long-term services and supports, that is relevant to the participant in a manner consistent with the responsibilities set forth under Section 240.1420.
c) Goals of Care
1) Each participant/authorized representative is provided the opportunity to lead the person-centered planning process where possible. The participant's authorized representative should have a participatory role, as needed and defined by the participant, unless State law confers decision-making authority to the legal representative.
2) If a participant's Goals of Care cannot be developed to create an adequate person-centered plan of care, the Care Coordinator is required to discuss the risks associated with the preferences and selections made regarding one or more specific goals by the participant/authorized representative and suggest any alternative options and/or referrals that might be available to mitigate risk.
3) Each participant will be advised by the Care Coordinator of their right to accept or refuse some or all offered services developed in participants' Goals of Care.
d) Reassessments
1) A reassessment will be conducted face-to-face on at least an annual basis to determine if the participant remains eligible for the program or if changes in the participant's services under the person-centered plan of care are needed and/or the Goals of Care need to be revised.
2) A reassessment will also be conducted when requested by a participant/authorized representative or when a participant may have experienced a change in their needs.
3) The participant/authorized representative develops their own revised Goals of Care with input from the Care Coordinator consistent with the responsibilities set forth in Section 240.1420.
e) Unit of Service
Several different types of assessments constitute a care coordination unit of service for which reimbursement is made.
1) Completion of one initial eligibility determination for CCP services constitutes one unit.
2) Completion of one required continuous eligibility redetermination of CCP eligibility constitutes one unit. A redetermination shall be completed at least annually.
3) Completion of either one face-to-face prescreening or postscreen of a participant constitutes one unit.
4) Completion of one HFS Interagency Certification of Screening Results form constitutes one unit.
5) Availability to receive participant inquiries and requests, by telephone or in person, and to respond to those inquiries and requests for each active participant per month constitutes one unit.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.270 Alternative Provider
a) An alternative provider is defined as an individual selected by the participant, assisted by the CCU and authorized by the Department to provide CCP services to a participant only if the following criteria are met:
1) a contractual provider has failed to provide the services as required by the person-centered plan of care; and
2) there is no contractual provider available to provide the services as required by the person-centered plan of care.
b) The alternative provider must meet all the requirements for employment and be hired by the contractual provider.
c) The contractual provider is required to supervise the alternative provider. The service components and hours of service to be provided, as required by the person-centered plan of care, shall conform to the service components as defined in Section 240.210.
d) An alternative provider shall be authorized by the Department prior to provision of services to the participant.
e) Unit of Service
One unit of alternative in-home service is one hour of direct service provided to the participant while in the participant's home, while providing transportation/escort to the participant to medical facilities, or while performing essential errands/shopping or conducting essential participant business with or on behalf of the participant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.280 Individual Provider (Repealed)
(Source: Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART C: RIGHTS AND RESPONSIBILITIES
Section 240.300 Participant Rights and Responsibilities
The Department will administer CCP to assure certain rights to participants in accordance with the Home Care Participant Bill of Rights (see 20 ILCS 2405/17.1 and 320 ILCS 42/40) and the Medicaid Recipient Bill of Rights (see 305 ILCS 5/11-28). In addition, the Department will assure that participants receive an explanation of their rights and responsibilities. A copy of the rights and responsibilities shall be provided in written format to all participants during the initial visit for determination of eligibility and upon request by the participant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.310 Right to Request Services
Any participant desiring to request CCP services shall have the right to request those services and to receive a written decision relative to that request.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.320 Nondiscrimination
a) No eligible participant with a disability or protected person under other federal and State civil rights laws who requests/receives services may be discriminated against under CCP.
b) A participant/authorized representative may file a discrimination complaint with a provider, a CCU, the Department, or other federal or State agency with jurisdiction over civil rights laws (see 4 Ill. Adm. Code 1725).
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.330 Freedom of Choice
a) A participant has the right to request and, if eligible, to receive available CCP services. A participant may choose at any time not to receive services for which eligibility has been determined.
b) A participant/authorized representative shall be informed of, and have the right to choose from, choices regarding available services, supports and providers in the participant's CCU service area:
1) at the time of initial determination of eligibility or subsequent redetermination of the participant;
2) at the time of determination of presumptive eligibility for interim services;
3) at any time the participant/authorized representative requests a change of providers; or
4) at the time of a Department-initiated total or partial caseload transfer.
c) The person-centered planning process includes a method for the participant/authorized representative to request updates to the person-centered plan of care.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.340 Confidentiality/Safeguarding of Case Information
a) For protection purposes, any information about a participant's case is confidential and may be used only for purposes directly related to the administration of the CCP. Information that is considered to be included in the administration of the program is as follows:
1) Establishing a participant's initial/continuing eligibility, preventing duplicate coverage under another Home and Community-Based Service (HCBS) Waiver, and providing assistance in transitioning to other programs in appropriate instances.
2) Establishing the extent of a participant's: assets and income; determination of need under CCP; person-centered plan of care; case notes and other benefits. This includes recovery of payments and investigating allegations of fraud or other abuse of publicly funded benefits. This information may be shared in a secure manner by and among the Department and the Social Security Administration, the Department of Employment Security, HFS, the Department of Human Services, the Department of Revenue, the Secretary of State, the U.S. Department of Veterans Affairs, and any other governmental entity only to the extent that there is no conflict with any federal or State law or regulation.
3) Finding and linking needed services and resources available to an eligible participant, including information about new laws or changes in public benefit programs.
4) Assuring the health, safety, and welfare of the participant, submission of required critical events reports, reporting alleged or suspected abuse, neglect, financial exploitation, or self-neglect, assisting with investigations conducted under the Adult Protective Services Program, and making referrals to the State/Regional Long Term Care Ombudsman Programs.
5) Collecting data for the Department's demonstration/research projects.
6) Compliance with legal proceedings in response to valid court or administrative agency orders.
7) Directing and planning programming to transform long-term services and supports in Illinois and to maximize Federal Financial Participation in State expenditures under Medical Assistance Programs.
b) Use of information for commercial, personal, political or other purposes not specified in this Section is specifically prohibited. Information about a participant's case under the CCP is exempt from disclosure under the Freedom of Information Act [5 ILCS 140].
c) The Department, CCUs and vendors shall inform all agencies and governmental departments to whom information is furnished that this material is confidential and must be so considered by the agency or governmental department.
d) Any information received from other agencies or persons, which includes the express statement that the information is not to be released to the participant/authorized representative or to any other person or agency under any circumstances, is prohibited from release as case information. Requests for this information shall be referred to the originator of the restricted information.
e) If any information about a participant or document contained in the participant's case file is to be used for any purpose other than the administration of CCP, the CCU shall obtain a Release of Information form signed by the participant /authorized representative. The Release of Information form shall be placed in the participant's case record.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.350 Participant/Authorized Representative Cooperation
Participants/authorized representatives shall cooperate with the representatives of the Department/CCUs/providers in determinations of eligibility, redeterminations, other necessary or required face-to-face visits, or provision of CCP services.
a) The actions specified below shall be considered non-cooperative and may result in a MOU as set forth in Section 240.930 or termination from CCP services:
1) Repeated absences that disrupt the provision of in-home services or ADS services without advising the provider. Such absences shall result in a reassessment before pursuing a MOU;
2) Refusing to allow the provider to enter the home to provide services;
3) Interfering with any provision of the services specified in the person-centered plan of care;
4) Residing outside the State for longer than 60 days while receiving EHRS services without an exemption from the CCU; or
5) Purposefully damaging or losing AMD equipment or EHRS base unit or activation devices without a law enforcement report of theft or intentional damage.
b) The provider must document each time the participant engages in any of the non-cooperative actions listed in subsection (a). If the action is due to an emergency, then it will not be considered non-cooperative.
c) The provider shall verbally notify the CCU on the same day, if possible, but no later than the next work day, that the participant was non-cooperative. Within two working days after the verbal notification, the provider shall submit to the CCU a written report including, at a minimum, the names of the participant and the worker, the dates a brief description of the incident.
d) The actions specified in this subsection (d) shall also be considered non-cooperation and shall be cause for denial of a request for services or termination of service, as appropriate.
1) Refusal to sign an MOU;
2) Failure to adhere to the terms of an MOU;
3) Refusal to provide the necessary documentation needed to determine initial and continuing eligibility for CCP services; or
4) Refusal to provide a mailing address and/or an email address, including sufficient information to enable the Department/CCU/provider to locate the participant/authorized representative (i.e., the name, address and telephone number of a contact through whom the participant may be located; it may be necessary to provide directions to the participant's home).
e) Each action specified in subsection (d) shall be documented by the provider and the documentation submitted to the CCU within two work days. The written report must include the names of the participant and/or the worker, the dates the action occurred, and a brief description of the action.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.355 Violence By Participants/Authorized Representatives
a) A participant, authorized representative, or any family member shall not threaten or act abusively against any representative of the Department, CCU, or CCP provider who is present in the participant's home, or against any person at an ADS site. Such actions include physical, verbal or sexual threats or actions, including display of a gun, knife or other weapon, by a participant, authorized representative, or by any family member, friend or acquaintance of the participant /authorized representative who is present. The participant/authorized representative shall be responsible for any animal present in the home of the participant and shall prevent the animal from physically harming a representative of the Department/CCU/provider.
1) If the threat or abuse takes place in a participant's home, the party who has been threatened or abused shall leave the premises immediately and verbally advise the CCU on the same day, if possible, but not later than the next work day.
2) If the threat or abuse takes place in an ADS site, the family/authorized representative shall be advised immediately and the CCU shall verbally be advised on the same day, if possible, but not later than the next work day.
3) The provider shall submit to the CCU a written report including, at a minimum, the name of the participant and the in-home worker/ADS site worker, and the date and details of the threat or abuse, within two work days after the date that the threat or abuse occurred.
4) Upon receipt of verbal notification of threat or abuse, the CCU shall, on the same day, if possible, but not later than the next work day:
A) suspend a participant's services in the participant's home and/or at an ADS site pending the issuance of a MOU, and
B) suspend a participant's determination of eligibility process pending the issuance of a MOU.
5) The CCU must inform the participant/authorized representative of the suspension within one calendar day of the suspension. The date of suspension shall be the date that the participant/authorized representative is notified.
6) The CCU shall have five calendar days from the date of suspension to execute a MOU with the participant.
b) If any representative of the Department, CCU, or CCP provider suffers physical injury inflicted by a participant/authorized representative, or by a family member, friend or acquaintance of the participant/authorized representative, either in the participant's home or while the participant is attending an ADS site, the following actions shall be taken:
1) If the infliction of physical injury takes place in the participant's home, the injured party shall leave the premises immediately and verbally advise the CCU on the same day, if possible, but not later than the next work day.
2) If the infliction of physical injury takes place in an ADS site, the family/authorized representative shall be advised immediately, and the participant shall be removed immediately. The CCU shall verbally be advised on the same day, if possible, but not later than the next work day.
3) The provider shall submit to the CCU a written report including, at a minimum, the names of the participant and the worker/ADS site worker, and the date and details of the infliction of physical injury, within two work days after the date that the physical injury was inflicted.
4) Upon receipt of verbal notification of physical injury, the CCU shall, on the same day, if possible, but not later than the next work day:
A) institute immediate denial of a request for services or termination of services. The effective date of denial or termination shall be the date that the infliction of physical injury occurred;
B) verbally notify the participant/authorized representative of the denial or termination. Written notification shall be mailed or emailed to the provider within five calendar days after the date of the verbal notification; and
C) verbally notify the Department of the denial or termination followed by a written report within five calendar days after the date of the verbal notification.
(Source: Added at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.360 Reporting Changes
It shall be the responsibility of the participant/authorized representative to report changes in circumstances (including household composition, change of address, change in level of services needed, and enrollment status in the Medical Assistance Program) that might affect eligibility for CCP within 30 calendar days after the effective date of the change. Benefit changes at the federal level that affect a group of participants (such as increases in Social Security payment, etc.) need not be reported by the participant/authorized representative.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.370 Voluntary Repayment
Any participant who is receiving or has received services through CCP may voluntarily repay to the State of Illinois any amount up to the total cost expended by the State in providing Community Care services to the participant.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART D: APPEALS
Section 240.400 Appeals and Fair Hearings
a) Any participant who requests or receives CCP services has the right to appeal a decision, action, or failure to take action of the Department, a CCU or a provider. If the decision, action or inaction is based on automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation, that adversely affect some or all participants, the appeal will be automatically denied, and the participant will not be afforded a hearing.
b) The participant/authorized representative shall be informed in writing by the CCU of their right to appeal at the initial home visit, at the time the action is taken and upon request.
c) A participant/authorized representative may file an appeal with the Department by completing and submitting a Notice of Appeal form, which may be obtained by calling the Senior HelpLine at 1-800-252-8966. If the Department is advised of a participant's/authorized representative's intent to appeal either by letter or by telephone, the Department shall, within two business days after being so advised, send to the appellant a Notice of Appeal form.
d) The written Notice of Appeal to Department on Aging shall include the following:
1) the name, address and telephone number of the participant filing the appeal, or on whose behalf the appeal is filed; and
2) the name, address and telephone number of the authorized representative, if any, filing the appeal on behalf of the participant;
3) the specific action being appealed, including the date of notice advising the participant/authorized representative of the action appealed and the effective date of that action; and
4) the name of the CCU, as indicated on the notice of the action being appealed.
e) CCUs are to provide a copy of any notice of adverse action to any participant's authorized representative, if the participant has earned ten points on the Mini-Mental State Examination (MMSE). A single notice to a residence will suffice if the authorized representative is a family member living with the appellant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.405 Representation
The appellant may represent him/herself and/or may authorize legal counsel, a relative, a friend or other spokesperson to represent him/her.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.410 When the Appeal May Be Filed
a) The request for an appeal must be on a Notice of Appeal form and must be filed within 60 calendar days after the date the notice of the action being appealed was sent to the participant.
b) If a Notice of Appeal form is filed after the 60 calendar day time period, the appeal will be automatically denied.
c) The 60 calendar day time limitation does not apply when a CCU or the Department fails to send the required written notification of the action taken that is being appealed.
d) CCP services shall be continued at the level in effect prior to the notice of adverse action until the final decision in the appeal is reached, except for instances involving automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation. In addition, if the Department determines that the health, safety or welfare of the provider/direct service worker will be jeopardized if service is continued (see Section 240.355), the participant's right to continued service may be denied until the appeal decision is reached.
e) Services shall not be continued during the appeal process for a participant receiving interim services. Those participants receiving interim services have not received full eligibility for the CCP and are only presumed eligible until a full determination of eligibility has been completed.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.415 What May be Appealed
The following actions of CCUs, providers or the Department may be appealed:
a) A decision to deny, reduce, terminate, or in any way change CCP services or how those services are provided. If the decision to reduce, terminate or in any way change CCP services is based on automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation, which adversely affects some or all participants, the appeal will be automatically denied, and the participant affected will not be afforded a hearing.
b) A decision to deny a request for redetermination.
c) Failure to make a decision or take appropriate action on any reasonable request made by a participant within 15 calendar days after the date of the request.
d) A decision to place a participant on a MOU.
e) A decision to renew a MOU.
f) The outcome of the determination of the eligibility for nursing facility level of care or the supportive living program setting.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.420 Consolidation of Appeals
The Department may consolidate a number of participant appeals for the purpose of conducting a single group informal review and subsequent hearing if it determined that all of the appeals involve the same complaint, and the only issue in question is one of State or federal law or policy. Consideration shall be given to the geographic proximity and the physical condition of the appellants. Each appellant has the option of withdrawing from the group and presenting their appeal individually.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.425 Informal Review
a) The Department will review each Notice of Appeal form and make a recommendation to the Director.
b) The Department may contact the appellant/authorized representative to discuss the appeal request and/or request additional information.
c) The recommendation will be submitted to the Director within 60 calendar days after the receipt of the Notice of Appeal form or receipt of the additional information, whichever is later.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.430 Informal Review Findings
a) Based on the recommendation, the Director will:
1) Dismiss the appeal based on any of the factors listed in Section 240.436, after which the appellant/authorized representative may request reconsideration within 15 days after receipt of the Director's decision consistent with Section 240.436;
2) Uphold the appeal and the appeal file shall be closed;
3) Modify the original action and the appellant/authorized representative may request a hearing within 15 calendar days after receipt of the Director's decision; or
4) Deny the appeal, which will then be automatically referred to the Department of Healthcare and Family Services' Fair Hearings Section.
b) The Director's decision shall be in writing and sent by mail or email (if consented to) to the appellant/authorized representative.
c) If a hearing is withdrawn within 15 days after receiving notice of the Director’s decision, the Director's decision is a final administrative decision. The Department will make any planned change in services, which had been delayed pending the outcome of the appeal, immediately and will notify all parties to the appeal in writing.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.435 Withdrawing an Appeal
The appellant/authorized representative may withdraw an informal review request or an appeal at any time prior to or during the appeal process. The withdrawal must be submitted in writing and upon receipt, the Department will close the file.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.436 Dismissing an Appeal
a) The Department may dismiss an appeal at any time during the appeal process for any of the following reasons:
1) Appellant's death;
2) Appellant never received a notice of adverse action from the Department;
3) Appellant is not a CCP participant;
4) Appellant moves out of State;
5) Appellant's appeal is upheld by the Department;
6) The Department does not have jurisdiction;
7) Appeal is not related to any CCP services; and/or
8) Appeal is filed by an unauthorized representative.
b) The Department shall advise the appellant/authorized representative that the appeal is dismissed by mail or email (if consented to) and shall include the reason why the appeal was dismissed and the right to request reconsideration.
c) If the appellant/authorized representative does not agree with the reason for dismissal, the appellant/authorized representative may request reconsideration of the dismissal. The request must be in writing and submitted within ten calendar days after receipt of the dismissal. The request should include any documentation that disproves the Department's finding.
d) The Department shall review the request for reconsideration and determine if the appeal should be reinstated. Department may reinstate the appeal and continue the appeal process.
e) The Department shall furnish copies of the dismissal to all interested parties to the appeal.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.440 Exchanging Records and Pre-hearing Conferences
The Department and the appellant/ authorized representative will provide copies of relevant documents, a list of potential witness, and a summary of potential testimony to be used at the hearing, to the other party. The Hearing Officer may schedule one or more pre-hearing conferences.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.445 Hearing Officer
All hearings will be conducted by an impartial Hearing Officer authorized by the Director to conduct the hearing.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.450 The Hearing
The hearing will be conducted in accordance with Article 10 of the Illinois Administrative Procedure Act [5 ILCS 100/10] unless otherwise specified in this Part.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.451 Conduct of Hearing
The hearing may be conducted in person or with some or all parties, including the Hearing Officer, present at different locations connected with each other by telephone, videoconference, or other electronic means. The proceedings will be recorded.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.455 Continuance of the Hearing (Repealed)
(Source: Repealed at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.460 Continuance or Postponement of the Hearing
a) The appellant/authorized representative or the Department Representative may request a continuance or postponement, which shall be in writing to the Hearing Officer before the scheduled hearing date. A verbal request may be made when the hearing is convened.
b) The Hearing Officer may continue or postpone the hearing to another date.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.465 Dismissal Due to Non-Appearance
a) The failure to appear by the appellant/authorized representative to proceed with the hearing is considered a non-appearance. The appeal is considered abandoned and shall be dismissed.
b) Dismissal of an appeal is a final administrative decision. The Department will make any planned change in services, which had been delayed pending the outcome of the appeal, immediately upon receipt of written notification from the Hearing Officer and will notify all parties to the appeal in writing.
c) The Department will send a written notice to the appellant/authorized representative and all parties to the appeal advising that the appeal has been dismissed for non-appearance.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.470 Rescheduling the Appeal Hearing
a) Within ten calendar days after the date of the dismissal notice, the appellant/authorized representative may submit a written request to reschedule the appeal hearing. The written request to reschedule the appeal hearing must be sent to the Hearing Officer as shown on the dismissal notice issued by the Hearing Officer. The dismissal will be vacated if good cause can be shown for the non-appearance that led to the dismissal. Good cause is defined as:
1) Death in the family;
2) Personal injury or illness that reasonably prohibits the appellant from attending the hearing; or
3) Sudden and unexpected emergencies.
b) If the appeal hearing is rescheduled, a Hearing Officer will send a letter rescheduling the hearing to the appellant/authorized representative with copies to all parties to the appeal. The Department shall restore any benefits due the participant that were terminated or reduced as a result of the dismissal, shall send a letter so advising to the appellant/authorized representative, and shall send copies of the letter to all parties to the appeal.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.475 Recommendations of Hearing Officer
The Hearing Officer shall certify the entire record of the hearing to the Director and shall recommend a decision on each issue in the hearing. The Hearing Officer shall not render a final decision relevant to any issue in the hearing.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.480 The Appeal Decision
a) The decision resulting from the appeal shall be made in writing no later than 90 calendar days after the Hearing Officer's recommendation. The appellant/authorized representative and all other parties to the appeal shall be notified by sending to them a copy of the decision by mail or email. The decision shall be made by applying Department rules to the particular case situation. Appeals shall be considered on a case-by-case basis.
b) The Director shall issue the final administrative decision and it shall either:
1) accept or modify the Hearing Officer's recommendation; or;
2) reject the Hearing Officer's recommendation.
c) The decision shall instruct the provider/CCU/Department to take corrective action as appropriate.
d) The decision resulting from the appeal and the recorded transcript shall become a part of the record of the appeal.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.485 Reviewing the Official Report of the Hearing
At any time within 5 years after the date of the release of the Department's final administrative decision, upon written request to the Office of General Counsel, the appellant/authorized representative may review the official report of the hearing.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART E: REQUEST FOR SERVICES
Section 240.510 Participant Agreement for Community Care Program
If an individual is determined eligible for CCP, he/she or an authorized representative shall sign a written Participant Agreement and Consent Form to request services.
a) Any participant requesting CCP services orally or in writing, shall be contacted by the CCU within five calendar days after the date of the inquiry/request.
b) The signed Participant Agreement and Consent Form will accompany an appropriately completed person-centered comprehensive assessment.
c) The participant/authorized representative shall be informed in writing of eligibility requirements to receive services under CCP and of the participant's right to appeal under this Part.
d) When a participant has a legally appointed guardian, the guardian shall sign the Participant Agreement and Consent Form – Person-Centered Plan of Care. A legally appointed guardian may serve as the "guardian of the person" and/or "guardian of the estate". One legally appointed guardian may serve as guardian of the person while a second legally appointed guardian may serve as guardian of the estate. If two different persons are appointed guardian for an individual, one of the person and one of the estate, the guardian of the person determines which one is to sign the Participant Agreement and Consent Form.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.520 Who May Make Application (Repealed)
(Source: Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.530 Date of Application (Repealed)
(Source: Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.540 Participant Agreement and Consent Form
A participant must be notified on the Participant Agreement and Consent Form that:
a) A decision regarding eligibility for CCP services must be made within 30 calendar days after the submission of the Participant Agreement and Consent Form;
b) The participant must be notified by the CCU in writing of the decision within 15 calendar days after decision;
c) Services must be provided within 15 calendar days after the notice is sent to the participant; and
d) Any delays attributable to the participant will extend the required time frame.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.550 Person-Centered Planning Process
A person-centered plan of care will be developed in collaboration with the participant who is eligible for services using a person-centered planning process with the CCU.
a) The person-centered planning process will ensure:
1) the opportunity for the participant/authorized representative to lead and direct the planning process, whenever possible, and to select other persons to participate in decision-making;
2) the scheduling of timely meetings that occur at times and locations convenient to the participant/authorized representative, preferably in the participant's place of residence to assess the participant's environment to ensure the development of a person-centered plan of care that considers the participant's safety;
3) the provision of necessary information and support to enable the participant/authorized representative to make informed choices and decisions;
4) the inclusion of strategies for solving disagreements within the planning process, including clear guidelines for conflicts of interest on the part of all who participate in decision-making;
5) the protection of the rights of the participant/authorized representative to choose available services, supports and providers/vendors; and
6) the sharing of contact information for the CCU/Care Coordinator so the participant/authorized representative can request a redetermination of eligibility, additional or new services, or other updates and changes to the person-centered plan of care.
b) The CCU will provide all information and support in a culturally-sensitive manner to ensure that the participant/authorized representative is able to make informed choices and decisions, including appropriate available options for limited English-proficient persons and/or those with a disability.
c) The CCU will provide a copy of the final person-centered plan of care and any subsequent revisions to the participant/authorized representative and any other person identified as being responsible for monitoring or implementing the plan, including the providers/vendors.
d) The CCU will monitor the participant to prevent unnecessary or inappropriate care.
e) Review of the Person-Centered Plan of Care
1) The CCU will review and revise a person-centered plan of care:
A) at least every 12 months following an assessment/reassessment of functional needs;
B) when a participant's personal circumstances or functional needs change significantly; and
C) at the request of a participant/authorized representative.
2) The CCU will document its periodic review of the participant and any information that is collected under the measures being used to evaluate the effectiveness of the services and supports based on the described needs and related conditions of the participant.
3) Revisions will be supported by a specific assessed functional need of the participant and a written justification included in the revised person-centered plan of care, indicating that the use of the previously identified adherence interventions and risk strategies were unsuccessful before changing services, supports and/or providers/vendors. Changes will be scaled as appropriate first using the least intrusive options.
4) The CCU shall document that positive interventions and supports were used prior to any modification and that less intrusive methods were tried but were unsuccessful.
(Source: Added at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART F: ELIGIBILITY FOR COMMUNITY CARE PROGRAM SERVICES
Section 240.600 Eligibility Requirements
For purposes of being determined eligible to receive Community Care Program services, requirements of eligibility specified in Sections 240.710 through 240.875 must be satisfied.
(Source: Amended at 13 Ill. Reg. 11193, effective July 1, 1989)
Section 240.610 Establishing Initial Eligibility
a) Once a participant/authorized representative has contacted the CCU, establishing initial eligibility is the joint responsibility of the participant/authorized representative and the CCU.
b) It is the responsibility of the participant/authorized representative to provide the factual information necessary to establish eligibility. Should the participant/authorized representative be unable to do so, CCU staff, with the consent of the participant/authorized representative, shall assist in obtaining this information.
c) If the participant/authorized representative refuses to give consent, and information needed for eligibility determination is, therefore, unavailable, the request for services shall be denied.
d) If a home visit, as required by Section 240.620, is made at the address provided by the participant/authorized representative and the participant cannot be located, the request for services shall be denied.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.620 Home Visit
a) Determinations and redeterminations of need for CCP services shall be administered during a visit to the home of the participant, except when conducted in the prescreening process or when a CCP participant has been hospitalized or placed in any type of institution and will be discharged to the community in less than 60 calendar days.
b) A home visit shall be conducted, and a redetermination of need administered in the participant's home, within 15 calendar days after a participant's discharge from a hospital or other institution.
c) A home visit shall not be required in the conduct of determinations or redeterminations of need following hospitalization for routine procedures, as defined in Section 240.160.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.630 Determination of Eligibility
a) A determination of eligibility is an examination of each participant's circumstances to determine the functional need for receipt of CCP, nursing facility, or supported living program provider services. This determination shall consist of analyzing, evaluating and documenting, when necessary, current, full and complete information obtained from the face-to-face comprehensive assessment of the participant in their place of residence.
b) The assessment shall include the comprehensive assessment tool and all required CCP forms authorized by the Department, or any successor assessment tool and forms used to determine the need for long-term services and supports.
c) A participant's request/services may be denied or terminated when eligibility criteria are not met, as required by Sections 240.710 through 240.875.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.640 Eligibility Decision
A decision regarding the participant's initial eligibility or ineligibility to receive CCP services shall be made within 30 calendar days after the date of receipt by the Department or its CCU of a completed referral form for CCP services, unless delayed by the participant/authorized representative. (See Section 240.660.)
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.650 Continuous Eligibility
Eligibility shall be continuous throughout the participant's participation in CCP. Continuous eligibility is validated through the redetermination process specified in Section 240.655, except for instances involving an automatic, non-discretionary change in eligibility, rates or benefits by federal or State statute or regulation. A redetermination of eligibility shall be conducted at least once annually or as requested, and as required by Section 240.655.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.655 Redeterminations Process
Redetermination of CCP shall be conducted by the CCU at least annually; whenever requested by the participant/authorized representative; or whenever the participant may have experienced a change in their needs that indicates the need for a redetermination to assure continued eligibility (see Section 240.630).
a) A decision on the redetermination shall be made within 30 calendar days after the date the redetermination process begins, except as extended by the Department.
b) Redeterminations conducted at the request of the participant/authorized representative or whenever the participant may have experienced a change in needs shall be accomplished and a decision rendered within 30 calendar days after the date of the request for redetermination, except as extended by the Department.
c) The 30 calendar day time limit for completion of a redetermination of a participant's eligibility shall be extended by any delay caused by the participant/authorized representative.
1) Participant delay is defined as the number of calendar days a redetermination of eligibility is delayed because of the participant's/authorized representative's failure to provide documentation supporting their eligibility or otherwise cooperate as set out in Section 240.350.
2) In the event that a participant's eligibility cannot be determined due to the participant's/authorized representative's failure to provide documentation within 30 calendar days after the date it is verbally requested by the CCU, the CCU shall extend the time limit for an additional 60 calendar days, after which services shall be terminated if documentation is not provided.
d) The participant shall maintain eligibility and services shall continue to be provided throughout the redetermination process unless the participant/authorized representative delays the process beyond the additional 60 calendar days specified in subsection (c)(2).
e) Written notification to the participant/authorized representative shall be made as required by Section 240.945.
f) Any change in services shall be initiated within 15 calendar days after the date the written notice is mailed or emailed to the participant/authorized representative, as required by Section 240.945.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.660 Extension of Time Limit
The 30 calendar day time limit for completion of a determination of a participant's eligibility may be extended by any delay caused by the participant.
a) Participant delay is defined as the number of calendar days a determination of eligibility is delayed because of the participant's/authorized representative's failure to provide documentation supporting their eligibility.
b) In the event that a participant's eligibility cannot be determined due to the participant's/authorized representative's failure to provide documentation within 90 calendar days after the date of receipt of the completed referral form, the request for services shall be denied.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART G: NON-FINANCIAL REQUIREMENTS
Section 240.710 Age
To be eligible to receive CCP services, a participant shall be at least 60 years of age. A participant's/authorized representative's statement regarding age shall be accepted unless the information is contradictory, not specific, or otherwise questionable. In these cases, the participant/authorized representative is responsible for providing documentation of age to supplement the statement.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.715 Determination of Need
a) To be eligible to receive CCP services, a participant shall exhibit a need for nursing facility, supportive living program, or home and community-based services. The Determination of Need assessment tool or any successor assessment tool authorized by the Department specifies the factors that together, determine the participant's need for long term care or home and community-based services.
b) The need for long term care is based upon the determined need for a continuum of in-home and community-based services to prevent inappropriate or premature placement in a nursing facility.
c) The extent and degree of a participant's need for long term care shall be determined on the basis of impaired cognitive and functional status as well as the available physical/environmental supports provided to the participant by family, friends or others in the community.
d) The Determination of Need assessment tool consists of two parts:
1) The Mini-Mental State Examination (Folstein, Folstein and McHugh, 1975, no later editions or amendments included) measures cognitive functioning of the participant.
A) The participant who receives a score of 21 or higher shall be considered cognitively intact and zero points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool.
B) The participant who receives a score of 20 or less or who has been diagnosed by a physician or psychiatrist as having dementia, Alzheimer's disease, or organic brain syndrome shall be considered cognitively impaired and ten points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool.
C) Ten additional points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool for the participant who meets the following three criteria:
i) Participant has been adjudicated disabled or incompetent by a Probate Court judge or judge assigned to render a decision on such matters in a court of competent jurisdiction;
ii) a physician or psychiatrist licensed by the State of Illinois has certified that, in their professional judgement, the participant suffers from Alzheimer's disease, organic brain syndrome, or dementia; and
iii) a physician or psychiatrist licensed by the State of Illinois has certified that, in their professional judgement, the participant requires 24-hour home and community-based services to remain in the home.
2) The Determination of Need assessment tool measures the participant's ability to perform the following activities of daily living (ADLs) and instrumental activities of daily living (IADLs):
A) Activities of Daily Living
i) Eating
ii) Bathing
iii) Grooming
iv) Dressing
v) Transferring
vi) Incontinence
B) Instrumental Activities of Daily Living
i) Preparing meals
ii) Being alone
iii) Telephoning
iv) Managing money
v) Routine health
vi) Special health
vii) Outside home
viii) Laundry
ix) Housework
e) The Determination of Need assessment scale includes the six ADLs and nine IADLs identified. Each function is scored in two parts: Part A – Level of Impairment, and Part B – Unmet Need for Care.
1) Part A − Level of Impairment, of the Determination of Need assessment tool measures the ability of the participant to perform each ADL and IADL function. A scoring range of zero through three indicates the degree of impairment of the participant in the performance of ADLs and IADLs.
A) A score of zero for any function indicates that the participant performs or can perform all essential components of the activity, with or without an existing assistive device, such that:
i) no significant impairment of function remains;
ii) activity is not required by the participant (routine health and special health only);
iii) the participant may benefit from but does not require supervision or physical assistance.
B) A score of one for any function indicates that the participant performs or can perform most essential components of the activity, with or without an existing assistive device, but some impairment of function remains such that the participant requires some supervision or physical assistance to accomplish some or all components of the activity. This includes the participant who:
i) experiences minor, intermittent fatigue in performing the activity;
ii) takes longer time to accomplish than an unimpaired person requires; or
iii) must perform the activity more frequently than an unimpaired person.
C) A score of two for any function indicates that the participant cannot perform most of the essential components of the activity, even with an existing assistive device, and requires a great deal of assistance or supervision to accomplish the activity. This includes the participant who:
i) experiences frequent fatigue in performing the activity;
ii) takes an excessive amount of time to perform the activity; or
iii) must perform the activity much more frequently than an unimpaired person.
D) A score of three for any function indicates that the participant cannot perform the activity and requires someone to perform the task, although the participant may be able to assist in small ways, or requires constant supervision.
2) Part B, Unmet Need for Care, of the Determination of Need assessment tool measures the need of the participant for assistance/performance/supervision for each ADL and IADL function that is not being met by non-CCP resources in the community (e.g., family, friends, local services).
A) A score of zero for any function indicates that there is no impairment, or that the participant's need for assistance is met to the extent that the participant is at no risk to health or safety if additional assistance is not acquired, or that additional assistance will not benefit the participant, or that the participant's needs are being met by non-CCP resources and, therefore, the participant has no need for assistance.
B) A score of one for any function indicates that the participant's need for assistance is met most of the time, but the participant's health and safety are at minimal risk if additional assistance is not acquired.
C) A score of two for any function indicates that the participant's need for assistance is not met most of the time, and the participant's health and safety are at moderate risk if additional assistance is not acquired.
D) A score of three for any function indicates that the participant's need for assistance is rarely, or never, met and the participant's health and safety are at severe risk, which would require acute medical intervention, if additional assistance is not acquired.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.727 Minimum Score Requirements
Participants determined eligible to receive CCP services shall have their need for nursing facility care or home and community-based services established by receipt of a minimum score of 29 points on the DON, 15 of which must be scored on Total Impairment, which includes Part A and the MMSE (see Section 240.715).
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.728 Maximum Payment Levels for Person-Centered Plans of Care Including In-home Service
Maximum monthly service dollars are calculated according to the participant's total DON score and approved person-centered plan of care for in-home service or other combination of options, excluding ADS. These maximum monthly service dollars will be adjusted by the Department to be consistent with any future unit rate adjustments for CCP providers in accordance with the methodology outlined in Section 240.1910 and will be posted and updated on the Department's website.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.729 Maximum Payment Levels for Person-Centered Plans of Care Including Adult Day Service
Maximum monthly service dollars are calculated according to the participant's total DON score and approved person-centered plan of care for ADS or other combination of options including ADS. These maximum monthly service dollars will be adjusted by the Department to be consistent with any future unit rate adjustments for CCP providers in accordance with the methodology outlined in Section 240.1910 and will be posted and updated on the Department's website.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.730 Person-Centered Plan of Care
a) A person-centered plan of care will be developed using the person-centered planning process in accordance with Section 240.550.
b) The person-centered plan of care, and any subsequent revisions, shall be written in plain language and shall reflect the participant's goals, preferences and desired outcomes, indicating services and supports important to the participant, based upon the functional needs identified by the comprehensive assessment, including:
1) a description of the conditions that directly correspond to the assessed functional needs, including:
A) the strengths and preferences of the individual, and resources available to that individual;
B) the clinical and support needs as identified through a comprehensive assessment of functional needs;
C) paid and unpaid services and supports that will assist the participant to achieve identified goals, and natural supports and vendors available to meet those needs;
D) risk factors and measures in place to minimize harm, including possible interventions that may be used if aid is necessary for adherence to program requirements, and the customized strategies and back-up plans to minimize any risk factors for the individual;
E) identification of the Care Coordinator and other individuals/vendors responsible for monitoring the person-centered plan of care;
F) any measures that will be used to support how to evaluate the effectiveness of the services and supports; and
G) the time limits for periodic reviews to determine if services and supports are still appropriate, need to be modified, or can be terminated.
2) a summary of the alternatives and settings considered by the participant/authorized representative and their final selections of services, supports and providers/vendors as reinforcement that the right of freedom of choice may be exercised.
A) The CCU will list all providers or programs in the service area and document the available options discussed with the participant/authorized representative.
B) The CCU will also afford the participant/authorized representative an opportunity to visit all of the adult day facilities in their service area before finalizing any selections.
3) an acknowledgement of informed consent by the participant/authorized representative.
c) Services are to be offered to each participant who meets the minimum required scores on the DON; who meets all other eligibility requirements; for whom an adequate person-centered plan of care has been developed; and whose service costs are within the allowable maximums. Care coordinators and participants/authorized representatives shall develop the person-centered plan of care in the best interest of the participant/authorized representatives, based on services selected by the participants/authorized representatives from among those available in the community. Maximum monthly service dollars are only available to fund services provided through the CCP.
d) If a person-centered plan of care cannot be developed that adequately meets the participant's needs within the allowable maximums for cost of service, CCP services shall be denied or services terminated, as appropriate to the case.
e) Each participant/authorized representative must be advised by the CCU of their right to refuse the offered services, to choose to enter a long-term care facility or to choose neither.
f) The allowable monthly cost for services provided to an eligible participant and paid for through the CCP cannot exceed the maximum monthly cost as determined by the score attained on the CCP DON that is determined by the CCU based on current, full and complete information on the specific needs of the participant. A person-centered plan of care shall be based upon the number of days in a month.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.735 Supplemental Information
The CCP determination of eligibility shall be supplemented by any collateral casework information (e.g., medical statement from attending Physician, Nurse Practitioner, Registered Nurse or Christian Science Practitioner, and documentation of family support) deemed necessary by the Department. Supplemental casework information will be included in the case notes.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.740 Assessment of Need
a) The CCP comprehensive assessment tool and determination of need for CCP services shall be administered by CCU care coordinators or Department personnel who are technically competent persons certified by the Department to conduct the comprehensive assessment and determinations of need.
b) The certification shall result from the successful completion of training, which includes, but is not limited to, the following topics.
1) financial eligibility determination (see Sections 240.800 through 240.875);
2) administration of the DON (see Section 240.715);
3) person-centered plan of care development and implementation;
4) performance of Choices for Care screenings (see Section 240.1010); and
5) form utilization and flow.
c) Scoring of the CCP DON shall be accomplished without regard to the capability of CCP providers to totally meet the determined needs of the participant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.741 Prerequisites for Automated Medication Dispenser Service
a) Authorization for the AMD service is determined based on a participant's need for the service, including the participant's medication, medical, cognitive and physical needs that indicate the potential to benefit from the AMD service.
b) To be authorized for the service, the participant must:
1) meet all of the following criteria:
A) eligibility for CCP services;
B) take one or more medications that necessitate the medications be taken at a set schedule to avoid complications;
C) have the potential to benefit from the service, understand the need to take medications, respond to alerts to take medication and is physically able to take medication independently from the AMD unit;
D) designate an assisting party to assist with the AMD unit and medications; and
E) commit to using the AMD unit appropriately; and
2) exhibit at least one of the following issues or diagnoses:
A) a history of non-adherence to treatment, medication or therapy regimens;
B) resides alone or lacks assistance from others to assist with regular medication administration;
C) impaired motor function that causes difficulty in handling medication receptacles and small pills;
D) attempts at using less costly alternatives (e.g., pill reminders, medication organizers with alarms and telephone reminders/prompts) have failed;
E) recent transition from a more restrictive care setting, such as a hospital or nursing facility;
F) has a diagnosis of cognitive impairment;
G) has a diagnosis of diabetes;
H) has a diagnosis of congestive heart failure;
I) has a diagnosis of hypertension;
J) has a diagnosis of depression/mental illness; or
K) has a diagnosis of cancer.
c) Other criteria may be developed by the Department to assist in determining what is the most appropriate AMD system to meet the participant's needs.
d) The participant/authorized representative and/or the assisting party shall complete documentation acknowledging that the AMD was installed. Whenever possible, the assisting party should be present during the AMD installation.
e) The assisting party must complete documentation requested by the Department agreeing that they will be responsible for:
1) administration and oversight of the participant's medications;
2) manually filling or arranging for another person, who could be the participant, to fill the AMD unit in accordance with prescribing instructions;
3) working with the AMD provider to program the dispenser for the initial medication schedule and subsequent changes;
4) using best efforts to ensure no illegal substances are placed in the AMD unit;
5) serving as a point of contact for the AMD provider and taking reasonable and necessary actions based on any notifications of missed medication doses and other system issues;
6) receiving and understanding the instructions and demonstration given by the AMD provider for the AMD equipment;
7) understanding how to access reports about the unit and medication regimen and contacting the AMD provider when medication schedules are changed; and
8) providing reasonable advance notice to the AMD provider, CCU, and participant/authorized representative if unable to continue acting as the assisting party.
f) A participant/authorized representative will be responsible for damages to or loss of the AMD equipment unless a law enforcement report of theft has been filed.
1) The provider will document the damages/loss of equipment.
2) One documented occurrence of damages/loss of equipment may be cause for a MOU or termination, in accordance with the Participant Agreement and Section 240.350.
g) Whenever an assisting party can no longer meet the obligations set out in subsection (e), it is the responsibility of the participant/authorized representative to identify a new assisting party and cooperate with arrangements for that individual to be trained by the AMD provider. Notification of the change shall be communicated to the AMD provider and the CCU before the change is made.
h) An assisting party cannot be an individual or entity providing other services under CCP, such as an in-home service provider.
i) Failure to have a current assisting party designation may result in the participant's termination from the AMD service.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.750 Citizenship
To be eligible for CCP, a participant must be either a U.S. citizen or a noncitizen within the specific categories and subject to the restrictions set forth at 89 Ill. Adm. Code 120.310.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.755 Residence
a) To be eligible for CCP, a participant must be a resident of the State of Illinois as defined in Section 2-10 of the Public Aid Code [305 ILCS 5].
b) Only those persons who are legally admitted to the U.S. can be found to be residents of the State of Illinois. The residency of a participant is based on one of the following factors:
1) A participant whose residence is located in Illinois, but whose U.S. Post Office address indicates a state other than Illinois (i.e., a participant residing near the State line), is a resident of Illinois;
2) An individual currently living in Illinois and receiving a State Supplementary Payment (as defined in 42 CFR 435.4), Mandatory State Supplement or Optional State Supplement from a different state, is not a resident of Illinois for purposes of CCP eligibility;
3) A participant who is incapable of stating their intent to remain in Illinois is a resident of Illinois if they currently lives in Illinois.
c) The Department cannot deny eligibility to a participant who, although currently residing in Illinois, has not lived in this State for a specific period of time. An Illinois resident who is temporarily absent from the State retains Illinois residency if the individual intends to return to Illinois when the reason for the absence is accomplished. If an individual remains outside of Illinois for a continuous period of more than 12 months, they will provide evidence (e.g., a copy of their most recent State Income Tax return) documenting that the absence was not due to an intent to change their residency.
d) The Department cannot deny eligibility to a participant who is temporarily absent from Illinois and plans to return when the purpose of his/her absence has been completed unless the absence will exceed 60 calendar days or unless the other state has determined that the participant is a resident of that state.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.760 Social Security Number
a) To be eligible for CCP, each participant must furnish a Social Security Number (SSN). If more than one SSN has been used by a participant, then all SSNs are to be furnished.
b) If any CCP participant does not have an SSN, the Department or CCU shall assist them in making the application.
c) CCP services will not be denied, delayed or discontinued pending the issuance or validation of an SSN if the participant has applied for the SSN.
d) Participants who refuse to furnish an SSN, and/or apply for an SSN when requested, are ineligible for CCP.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART H: FINANCIAL REQUIREMENTS
Section 240.800 Financial Factors
a) All CCP participants/authorized representatives are required to provide information, relative to the value and types of assets owned, requested to determine eligibility for services under CCP based on enrollment in a medical assistance program administered by HFS.
b) All participants/authorized representatives are required to provide information, relative to the amount and source of all income, requested to determine eligibility for services under CCP based on enrollment in a medical assistance program administered by HFS.
c) To determine whether a participant is presumptively eligible for enrollment to receive interim services under Sections 240.865 and 240.1020, CCUs will determine assets and income in accordance with the requirements set forth by HFS at 89 Ill. Adm. Code 120 (Medical Assistance Programs).
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.810 Assets
a) To be eligible to receive CCP services, a participant shall not own interest in non-exempt assets having a combined value in excess of $17,500, if:
1) unmarried; or
2) married and:
A) spouse is receiving CCP services;
B) spouse is in a nursing facility;
C) spouse does not reside on a permanent basis with, and does not receive support from or give support to, the participant;
D) spouse is abandoned; or
E) spouse is potentially abusing the participant.
EXCEPTION: A participant, who is married and the spouse does not receive CCP services, shall not own interest in non-exempt assets having a total value in excess of the asset disregard amount allowed by HFS for Medicaid in a pre-paid burial plan or life insurance policy + burial merchandise. Non-exempt assets having value over the asset disregard amount up to the amount allowed by the Community Spouse Asset Allowance, as adopted by HFS at 89 Ill. Adm. Code 120.379(d), must be transferred to or for the sole benefit of the community spouse. If the couple owns assets that exceed the asset disregard and prevention of spousal impoverishment amounts allowed by statute, the excess (up to the amount of non-exempt assets allowed after transfer, and/or up to the amount of countable monthly income allowed after diversion) shall be designated as a spend down, to be spent before Medicaid enrollment is established.
b) The value of non-exempt assets shall be considered in determining eligibility for CCP.
c) All assets not specifically exempt are non-exempt.
d) When a participant's non-exempt assets are greater than the allowable disregard as specified in subsection (a), consideration of non-liquid assets may be deferred as follows:
1) real property may be deferred from consideration for six months;
2) the participant shall sign an agreement to dispose of the real property in excess of the allowable disregard within six months after the date of the agreement; and
3) the six-month period for disposition may be extended an additional six months if the participant fails to dispose of the asset (through no fault of their own) despite reasonable and diligent effort.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.815 Exempt Assets
a) Exempt Assets
1) Homestead property.
2) Clothing and personal effects.
3) Household furnishings.
4) Business or farming equipment used for the production of income.
5) Motor vehicles except those primarily used for recreational purposes.
6) Group life insurance held as a condition of employment or provided by employer.
7) The principal of a trust fund only when the instrument establishing the trust specifically states the principal cannot be impaired.
8) One of the following:
A) a prepaid burial plan with a total value of up to the amounts specified in 89 Ill. Adm. Code 120.381(c) and (d) if burial merchandise is not specified. If burial merchandise is specified in the burial plan, that merchandise shall be exempt. Any excess of the allowed amounts in value for burial services shall be considered non-exempt; or
B) life insurance policy with a total face or cash value of the amount specified in 89 Ill. Adm. Code 120.381(a)(5) or less. When both cash and face value exceed this amount, apply the excess cash value over this amount toward the non-exempt assets.
C) Burial spaces intended for use of the participant and grave markers shall be exempt (see 89 Ill. Adm. Code 120.381(b)).
9) The value of the allotment under the Supplemental Nutrition Assistance Program (SNAP) Act of 2008 (7 USC 2017(b)).
10) The value of the U.S. Department of Agriculture donated foods (surplus commodities).
11) The value of supplemental food assistance received under the Child Nutrition Act of 1966 as amended (42 USC 1780(b)) and the special food service program for children under the National School Lunch Act, as amended (42 USC 1760).
12) Assets protected by purchase of a certified long-term care insurance policy that meets State standards [320 ILCS 35/25(a)(1) through (5)].
b) In addition to the exempt assets listed in subsection (a), the following assets are exempt. These assets remain exempt only so long as they can be identified by a separate account.
1) Any benefits received under Title III, Part C, Nutrition Program for the Elderly, of the Older Americans Act of 1965, as amended (42 USC 3030(e) and (f)).
2) Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 USC 4636).
3) Any funds distributed per capita to or held in trust for members of any Indian tribe under P.L. 92-254, P.L. 93-134 or P.L. 97-458 (25 USC 1407).
4) Tax-exempt portions of payments made pursuant to the Alaska Native Claims Settlement Act (43 USC 1626).
5) Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into prior to January 1, 1975, under Section 23 of the U.S. Housing Act of 1937, as amended (42 USC 1437 (f)).
6) Effective October 17, 1975, receipts distributed to certain Indian tribal members for marginal land held by the United States government.
7) Payments to volunteers under the 1973 Domestic Volunteer Service Act (42 USC 5044, Section 4951). These include:
A) Vista Volunteers;
B) Volunteers serving as senior health aides, senior companions, foster grandparents, or persons serving in the National Senior Volunteer Corps (NSVC).
8) Any grant or loan to any undergraduate student for educational purposes made or insured under any program administered by the Secretary of Education.
9) Supplemental Security Income (SSI) lump sum payments.
10) Income received under Section 4(c) of the Senior Citizens and Persons with Disabilities Property Tax Relief Act [320 ILCS 25]. This includes both the benefits commonly known as the "circuit breaker" and the "additional grants".
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.820 Asset Transfers
a) The following transactions are considered transfers of assets:
1) when a participant buys, sells or gives away real or personal property; or
2) if the participant changes the way real or personal property is held.
b) Transfers of assets that are exempt at the time of transfer do not affect eligibility.
c) Transfers of non-exempt assets completed within 60 months before the date of request for CCP services shall be considered in determining eligibility. If a fair market value was not received, the value of the transferred asset shall be considered toward non-exempt assets and any excess amount shall be considered available to meet service costs unless it is proven that the participant did not transfer the property to qualify for or increase the need for CCP.
1) If real property was transferred, fair market value is to be determined by use of statements from reputable realtors or other community members recognized as knowledgeable of property value (e.g., bankers, tax assessors, auctioneers).
2) If personal property was transferred, fair market value is to be determined by use of a statement from an institution having knowledge of the property at the time of the transfer, or from an individual who has specific knowledge of the transfer and/or the value of the asset at the time of the transfer.
3) Factors to be considered when determining whether a transfer of property was made to qualify for or increase the need for CCP include but are not limited to:
A) the participant's physical and mental condition at the time of transfer;
B) the participant's financial situation at the time of transfer;
C) the participant's need for services at the time of transfer;
D) changes in the participant's living arrangements at the time of transfer; and
E) how soon after the transfer the participant applied for services.
d) If after consideration of these factors the participant is ineligible, the period of ineligibility begins at the date of request for services for participants and the date of termination for participants. The period of ineligibility lasts from the initial date for as long as the asset would meet the cost of CCP services if it were available to the participant, but in no case shall it last longer than 60 months after the date of transfer.
e) A participant determined ineligible under subsection (d) may become eligible if the following occurs:
1) the property is reconveyed to the participant; or
2) an adequate consideration is paid to the participant.
f) It shall be the responsibility of a participant to report all property transfers to the CCU within five days after the date of the transaction.
g) If an unreported transfer of property was made by a participant within 60 months prior to the date of request for services or was made after the submission of the request for services but before CCP services were authorized, and services to which the participant was not entitled were received as a result of the failure to report the transfer, services shall be terminated.
h) Involuntary transfers do not affect eligibility.
i) When the property transfer was made to obtain support or care, and the terms of the agreement are being met, only those needs not included in the agreement may be met through CCP.
j) Transfers because of separation, divorce or other settlement shall not affect eligibility if:
1) they are court ordered; or
2) if there is no court order and the participant and their spouse divide the property in half.
k) Transfers from an individual bank account to a joint bank account do not affect eligibility if the participant retains access to the money and the money continues to be used for the participant's needs.
l) Income tax refunds are available assets. If the refund is based on a joint income tax return, one-half of the refund is to be considered as belonging to the participant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.825 Income
a) Documentation of all currently available income that is not specified as exempt shall be provided during the participant's determination/redetermination of eligibility for CCP.
b) In accordance with provisions of 89 Ill. Adm. Code 120.379, a participant whose spouse (i.e., community spouse) is not receiving CCP services may divert income to their spouse so that the spouse may have exempt income up to the amount exempted by HFS (see 89 Ill. Adm. Code 120.379(e)) for a community spouse.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.830 Unearned Income Exemptions
Unearned income is all income other than that received in the form of salary or wages for services performed as an employee or profits from self-employment.
a) The following unearned income shall be exempt from consideration in determining eligibility:
1) Any allotment under SNAP (7 U.S.C. 2017(b));
2) The value of the U.S. Department of Agriculture donated foods (surplus commodities);
3) Any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.C. 4636);
4) Any per capita judgment funds paid under Public Law 92-254 to members of the Blackfeet Tribe of the Blackfeet Indian Reservation, Montana and Gros Ventre Tribe of the Fort Belknap Reservation, Montana (25 U.S.C. 1264);
5) Any benefits received under Title III, Nutrition Program for the elderly, of the Older Americans Act of 1965, as amended (42 U.S.C. 3030(e));
6) Any compensation provided to individual volunteers under the Retired Senior Volunteer Program (42 U.S.C. 5001) and the Foster Grandparent Program (42 U.S.C. 5011) and Older Americans Community Service Programs (42 U.S.C. 3056) established under Title II of the Domestic Volunteer Service Act, as amended (42 U.S.C. 5001 through 5023);
7) Income in an amount not greater than the current amount allowed received by a beneficiary of life insurance which is expended on the funeral and burial of the insured;
8) Income received under Section 4(c) of the Senior Citizens and Persons with Disabilities Property Tax Relief Act. This includes both the benefits commonly known as the "circuit breaker" and "additional grants";
9) Payments to volunteers under the 1973 Domestic Volunteer Service Act (48 U.S.C. 5044(q)). These include:
A) Vista Volunteers;
B) volunteers serving as senior health aides, senior companions, or foster grandparents;
C) persons serving in the Service Corps of Retired Executives (SCORE) or the Active Corps of Executives (ACE);
10) Social Security death benefits expended on a funeral/burial;
11) The value of home produce that is used for personal consumption;
12) The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, (42 U.S.C. 1780(b)) and the special food service program for children under the National School Lunch Act, as amended (42 U.S.C. 1760);
13) Any payments distributed per capita or held in trust for members of any Indian tribe under Public Law 92-254, 93-134 or 94-450 (25 U.S.C. 1407);
14) Tax exempt portions of payments made pursuant to the Alaska Native Claims Settlement Act (43 U.S.C. 1626);
15) Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into prior to January 1, 1975 under Section 23 of the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437(f));
16) That portion of an educational benefit that is actually used for items such as tuition, books, fees, equipment or transportation, necessary for school attendance:
A) Veterans Educational Assistance –
Income from educational benefits paid to a veteran or to a dependent of a veteran shall be exempt only to the extent that it is applied toward educational expenses;
B) Social Security Administration (SSA) Benefits –
Income received as a SSA benefit paid to or for an individual and conditioned upon the individual's regular attendance in a school, college or university, or a course of vocational or technical learning, shall be exempt to the extent that it is applied toward educational expenses;
C) Loan and Grants –
Income from educational loans and grants obtained and used under conditions that prevent their use for current living costs shall be exempt;
17) Income from educational loans and grants made or insured under any program administered by the Secretary of Education is totally exempt whether the grant is paid directly to the schools or to the student. These loans and grants include the National Direct Student Loans, Basic Educational Opportunity Grants, Supplementary Educational Opportunity Grant, Work Study Grant, and the Guaranteed Loan Program;
18) The following incentive allowances:
A) National Training Services Grant –
Incentive payments which the Department of Rehabilitation Services authorizes to be paid for a maximum of two years to disabled persons receiving categorical public assistance and enrolled in the National Training Service Project;
B) Jobs Training Partnership Act (JTPA) –
Needs based payments (e.g., transportation); case assistance (e.g., uniforms and lunches); compensations in lieu of wages; and allowances received under JTPA are exempt.
b) Unearned Income In-Kind
1) Unearned income in-kind is payment made by a person other than a member of a participant's family on behalf of or in the name of a member of the participant's family (e.g., payment of CCP incurred expense for care, medical bills, etc.).
2) Unearned income in-kind shall be exempt.
3) When the participant's family shares a dwelling unit with another family or individuals, the exchange of cash for purposes of satisfying payment of shelter related obligations shall not constitute an income in-kind payment and shall not be considered available to the person who receives and disburses the shelter-related payment.
c) Earmarked Income
1) Earmarked income is income restricted for the use of a specified participant by court order or by legal stipulation of a contributor.
2) Earmarked income shall be considered as income of the specified participant only.
d) Lump Sum Payments
1) Lump sum payments shall be considered available for the eligibility period in which it is received and are not exempt.
2) Supplemental Security Income (SSI) lump sum payments are exempt income. SSI lump sum payments that are kept separately and are not combined with other monies remain exempt.
e) Protected Income
SSI is protected income and not considered available to be applied toward the incurred expense for CCP services of anyone other than the SSI recipient.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.835 Earned Income
Earned income is remuneration acquired through the receipt of salaries or wages for services performed as an employee or profits from an activity in which the participant is self-employed. Income received as payment for jury duty or serving as an election judge is considered earned income. This includes any payments for mileage, meals, etc.
a) Exempt Earned Income
The first $20.00 of gross monthly earned income plus one-half of the next $60.00 shall be exempt. Additionally, the following recognized expenses of employment shall be exempt:
1) Withholding taxes (federal and state)
2) Social Security tax
3) Transportation costs. If the participant's own car is the means of transportation, the mileage reimbursement rate paid by the State of Illinois per mile shall be allowed as transportation expense.
4) Lunch supplementation
A) If carried from home, 15 cents per working day to a maximum of $3.00 per month.
B) If purchased at work, 45 cents per working day to a maximum of $9.00 per month.
5) Special tools and uniforms required by employment
6) The following expenses ONLY if mandatory as a condition of employment:
A) Union dues
B) Group life insurance premiums
C) Group health insurance premiums
D) Retirement plan withholding
b) Earned Income from Work/Study/Training Programs
1) Income from the Job Training Partnership Act (JTPA) shall be considered earned income.
2) Income from college work-study is considered exempt income.
c) Earned Income from Self-Employment
1) Income realized from self-employment shall be considered earned income.
2) Accurate and complete records shall be kept on all monies received and spent through self-employment. If the participant fails or refuses to maintain complete (i.e., adequate to complete federal income tax return) business records, the participant shall be ineligible.
3) Business expenses shall be documented. The participant shall have full responsibility for proof of any business expense. No deduction shall be allowed for depreciation/obsolescence/similar losses (e.g., theft, breakage) in the operation of the business.
4) Gross income from the business shall be turned back into the business only to replace stock actually sold.
5) The net income shall be the gross remaining after the replacement of stock and business expenses and the appropriate employment expenses, as specified in subsection (a), have been deducted. The earned income exemption, if applicable, shall be computed on the net income.
d) Income from Rental Property
1) Income a participant receives from rental property he/she owns shall be considered earned income if the participant is actively engaged in the management of the property. The activity is to be determined by the participant's declaration or by viewing a management agreement.
2) When determining net income, the reasonable and necessary rental expenses the participant incurs in the production of income may be deducted from the gross income. Reasonable and necessary rental expenses include repairs, taxes, insurance, mortgage payments and utilities if the landlord pays them.
3) If a participant is responsible for cleaning a room and providing clean linens, the income he/she receives shall be considered earned income from a roomer rather than earned income from rental property.
4) After deduction of rental expenses (which determines net rental income), the appropriate earned income exemption/employment expenses, as specified in subsection (a), shall be deducted from net rental income to determine net income.
5) The appropriate earned income exemption shall be deducted from gross rental income (after deducting expenses) to determine net income.
e) Earned Income In-Kind
1) Earned income in-kind is remuneration received in a form other than cash for services performed. That remuneration shall include, but is not limited to: housing, food (except meals provided while working), satisfaction of a debt, or a service provided by the employer for the employee.
2) Earned income in-kind shall be exempt.
f) Income from Earned Income Credit
Earned Income Credit payments received as a part of an income tax refund are considered earned income when received as:
1) an advance payment; or
2) part or all of an income tax refund.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.840 Potential Retirement, Disability and Other Benefits
a) Participants are required to apply for all financial benefits for which they may qualify and to avail themselves of those benefits at the earliest possible date.
b) The CCU is responsible for making participant referrals to the appropriate agency or resources when it appears that financial benefits may be available.
c) Potential benefits may include, but are not limited to the following:
1) Social Security Benefits
2) Railroad Retirement Benefits
3) Veterans' Benefits
4) Servicemen's Dependents Allowances
5) Unemployment Compensation Benefits, Supplementary Unemployment Assistance
6) Worker's Compensation Benefits
7) Black Lung Disease Benefits
8) Benefits from private industry, professional groups, labor unions and other organizations.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.845 Family
For purposes of this Subpart, family means the participant, their spouse or partner in a civil union if residing in the same household, and any persons declared by the participant and spouse or civil union partner, if applicable, as dependents for federal income tax purposes. Any income received by any family member shall be considered family income.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.850 Monthly Average Income
Income to be received on a monthly basis during the twelve month period is to be added to the total amount of income received during the previous twelve months from irregular (other than monthly) sources: e.g., farm, interest and/or dividend income. The total amount of income thus determined is to be divided by twelve to arrive at the monthly average.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.855 Applicant/Client Expense for Care (Repealed)
(Source: Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.860 Change in Income
It is the responsibility of a participant/authorized representative to inform the CCU/Department of any change in the participant's income. Change in income shall be reported at the time of determination or redetermination of eligibility or within 30 calendar days after the date of the change, whichever is sooner. The participant/authorized representative shall provide written documentation when available. (See Section 240.360.) Failure to notify the CCU/Department of a change in income may result in reimbursement to the Department or termination.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.865 Application For Medical Assistance (Medicaid)
Participants/authorized representatives will be required to apply for and, if financially eligible, enroll in medical assistance under Article V of the Illinois Public Aid Code as a condition of eligibility for (CCP).
a) The Care Coordinator shall, when needed:
1) provide the participant/authorized representative with a copy of the mail-in medical assistance application and/or the web portal address for the online application, as appropriate;
2) assist the participant/authorized representative with completing the application; and
3) submit the application at the web portal address or to the participant's local Department of Human Services (DHS) office.
b) Completing an application for medical assistance includes, but is not limited to, obtaining, completing and submitting a medical assistance application, together with any required supporting documentation.
c) Services shall be provided to participants by the Department during the period in which a medical assistance application is pending.
d) Although participants/authorized representatives must agree to apply for and, if financially eligible, enroll in medical assistance, participants are not required to meet the eligibility criteria for medical assistance under Article V of the Illinois Public Aid Code to receive services under CCP.
(Source: Amended at 48 Ill. Reg. 1129, effective January 3, 2024)
Section 240.870 Determination of Applicant/Client Monthly Expense for Care (Repealed)
(Source: Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.875 Participant Responsibility
If a participant desires services in addition to those authorized by CCP, the participant shall be responsible for full payment for those additional services.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART I: DISPOSITION OF DETERMINATION
Section 240.905 Prohibition of Institutionalized Individuals From Receiving Community Care Program Services
a) CCP services shall not be provided to:
1) any participant who is eligible for those services while an in-patient of any institution that is subject to licensure as required by the Nursing Home Care Act [210 ILCS 45].
2) any individual residing in a public institution (see 42 CFR 435.1009).
3) any individual confined or detained in any local or State penal or correctional institution or by a federal law enforcement agency.
b) A resident of a private institution who has a contract with the institution providing total needs throughout life is ineligible for this program, as no needs remain to be met.
c) A resident of a private institution (other than those who have purchased life care contracts) is ineligible for this program when he/she has purchased care and maintenance to provide for all their needs in the institution and the amount paid has not been wholly consumed for care.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.910 Written Notification
Each participant requesting CCP services shall receive written notification of eligibility or ineligibility to receive CCP services.
a) Written notification shall be sent to the participant/authorized representative within 15 calendar days after the date of the completed determination of eligibility.
b) If the participant has not received a homecare aide within 15 days of the Notice of Eligibility, the participant/authorized representative may find their own homecare aide in accordance with Section 240.270. The Notice of Eligibility must contain a statement informing the participant/authorized representative of this right.
c) If it is necessary for the participant/authorized representative to hire their own homecare aide due to the failure of the authorized provider to provide CCP services within 15 calendar days, the temporary services and payment for those services shall terminate immediately upon initiation of service provided by a CCP approved provider. (See Section 240.1580(c).)
d) If a participant is determined ineligible and request for CCP services is denied, the written notification shall be sent to the participant/authorized representative by mail, email, or given to the participant/authorized representative personally, in which case the participant/authorized representative shall provide a signed and dated receipt for the notice. The notice shall clearly state the reason for the denial and shall advise the participant/authorized representative of their right to appeal the decision.
e) The date of the written notice of eligibility or ineligibility shall be the same date as the date of mailing or emailing. The provider shall be notified on the same date as the participant.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.915 Service Provision
If a participant is determined eligible for CCP, services shall be provided in accordance with the person-centered plan of care within 15 calendar days after the date of the notification of eligibility unless delayed by the participant/authorized representative.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.920 Reasons for Denial
Denial of CCP eligibility shall be based upon one or more of the reasons identified in this Section:
a) Participant is less than 60 years of age at the time of the determination of eligibility.
b) Participant is not in need of CCP services: scored less than 29 total points/less than 15 points on Part A, Level of Impairment, of the DON.
c) Participant/legal guardian/authorized representative refuses to sign the Participant Agreement – Person-Centered Plan of Care.
d) Participant/authorized representative does not agree with the person-centered plan of care/hours of service and an agreement could not be reached during the person-centered planning process.
e) Participant is deceased.
f) Participant has been institutionalized or is not otherwise available for services for more than 60 calendar days after the date of referral.
g) Participant/authorized representative voluntarily withdraws a request.
h) Participant cannot be located to determine eligibility for or to provide CCP services.
i) Participant/authorized representative has not provided reasonable documentation supporting eligibility as required by the Department or its CCU within 90 calendar days after the date of receipt of referral.
j) Participant/authorized representative has not cooperated with the Department/CCU/provider.
k) Participant does not meet citizenship requirements.
l) Participant does not meet residency requirements.
m) The CCU determines that an adequate person-centered plan of care cannot be developed that adequately meets the participant's determined needs under Section 240.715.
n) The total value of participant's non-exempt assets is in excess of $17,500.
o) Eligibility could not be established for a participant who was receiving interim services based upon presumptive eligibility.
p) Participant/authorized representative provided fraudulent information.
q) A participant whose request for CCP services was previously denied or whose services were terminated for non-cooperation as set forth in Section 240.350 or 240.255 shall be denied services upon a subsequent request for services, unless the situation or condition that led to MOU has been permanently resolved. In this instance, a CCU must conduct a reassessment of the participant's circumstances to determine whether the situation or condition that led to an MOU has been permanently resolved.
r) Participant/authorized representative refuses to sign the Participant Agreement and Consent Form.
s) Participant/authorized representative has transferred non-exempt assets or failed to report a transfer within the past 60 months for the purpose of obtaining CCP services.
t) Participant/authorized representative has not reported or refused to provide documentation of changes in circumstances that have occurred prior to eligibility determination.
u) Participant/authorized representative refuses to apply for and, if eligible, enroll in medical assistance under Article V of the Illinois Public Aid Code.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.925 Frequency of Redeterminations (Renumbered)
(Source: Section 240.925 renumbered to Section 240.655 at 13 Ill. Reg. 11193, effective July 1, 1989)
Section 240.930 Memorandum of Understanding
a) A provider may request a MOU from the CCU when a participant has not cooperated with the provider in the provision of services as set forth in Section 240.350.
b) When determining if a MOU is appropriate, the provider and CCU must consider whether the participant's behavior is due to a diminished mental capacity or mental illness and the participant's ability to comply with the terms of the MOU. Prior to the issue of a MOU, the CCU must document efforts to resolve the conflict in coordination with the participant and the provider.
c) Upon receipt of the provider’s verbal request for a MOU, the CCU shall immediately, but not later than the next work day, begin the process of preparing the MOU.
d) A MOU must include a detailed account of the actions or behaviors that resulted in the need for a MOU and outline the corrective steps that the participant needs to take to address the actions or behaviors.
e) The CCU must provide the participant with a copy of the MOU in their primary language.
f) A copy of the executed MOU must be provided to the participant/authorized representative by mail or email, if consented to. A copy shall be placed in the participant's file.
g) The CCU must complete an annual review of each MOU it has issued. The CCU must determine if the participant has successfully complied with the terms of the MOU and if the MOU should be terminated. The CCU must send the participant a letter detailing its decision to terminate or renew the MOU. The decision to renew a MOU may be appealed by the participant/authorized representative.
h) A MOU does not automatically transfer when a participant transfers to a new provider or CCU. The CCU must review the participant's case file and determine if a MOU is still necessary. If the CCU determines that a MOU is necessary, a new agreement must be executed.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.935 Discontinuance of Services to Clients (Repealed)
(Source: Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.940 Penalty Payments (Repealed)
(Source: Repealed at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.945 Notification of a Change in Service
a) Any participant whose CCP services are being changed in the following manner shall be advised of the change by written notice: change of service type; reduced amount of service; increased amount of services; or termination.
1) The written notice shall be sent to a participant/authorized representative by mail, email (if consented to), or given personally.
2) The notice shall clearly state the reason for the action being taken.
3) The participant/authorized representative shall be notified of the action being taken no later than 15 calendar days after the date of assessment or redetermination and the action shall be effective no sooner than 15 calendar days after the date of the notice if the action is adverse to the participant. This time frame does not apply to termination as a result of the non-cooperative act specified in Section 240.355.
4) In instances involving an automatic, non-discretionary change in eligibility, rates or benefits required by federal or State statute or regulation, the participant/authorized representative will be notified of the action being taken at least 15 calendar days prior to the implementation by the CCU of the change affecting the participant. The action will be effective no sooner than 15 calendar days after the date of notice if the action is adverse to the participant.
5) In the event of a death, the termination shall be effective the date of the participant's death. The form shall be dated and mailed/hand-delivered upon the Department or the CCU being informed of the death.
b) CCP services may be changed, reduced or terminated at the request of the participant/authorized representative and do not require the 15-calendar day notice period under the following circumstances:
1) the participant/authorized representative provides the CCU with a signed statement that the change, reduction or termination is at their request;
2) the CCU, participant/authorized representative and provider mutually agree to the initiation of the change, reduction or termination on the agreed upon date (which may be less than the required 15 calendar days after the date of the notice to the participant/authorized representative);
3) a written notice is provided to the participant/authorized representative prior to the initiation of the change or reduction. The notice shall indicate the agreed upon effective date; and
4) the CCU has documented all of the requirements of this subsection (b) and placed the participant's statement in the case record.
c) When an assessment or reassessment for services requires an increase, or no change in service, the participant/authorized representative and the provider shall be notified in writing. The notice shall be mailed or emailed within 15 calendar days after the date of the assessment or reassessment.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.950 Reasons for Termination
a) A participant shall be terminated from CCP for one or more of the reasons identified in this Section:
1) participant is deceased;
2) participant has been institutionalized or is otherwise not available for services for more than 60 calendar days;
3) participant's condition has improved and there is no longer a need for CCP services as measured by the CCP DON to determine need for long-term services and supports;
4) participant cannot be located;
5) participant/authorized representative has requested termination of services;
6) participant/authorized representative refuses transfer to a different provider/CCU and the current provider/CCU cannot provide services needed by the participant;
7) participant/authorized representative has failed to cooperate with the Department/CCU/provider as required and as specified in Section 240.350;
8) participant no longer meets citizenship requirements;
9) participant no longer meets residency requirements;
10) the CCU determines that an adequate person-centered plan of care cannot be developed that meets the participant's determined needs under Section 240.715.
11) the total value of a participant's non-exempt assets has increased and exceeds $17,500;
12) participant/authorized representative failed to report the transfer of non-exempt assets within the past 60 months for the purpose of obtaining CCP services;
13) participant/authorized representative has failed to report or refused to provide documentation of changes in circumstances, as required by Section 240.360;
14) participant/authorized representative refuses to sign a Participant Agreement – Person-centered Plan of Care;
15) participant refuses to sign the Participant Agreement and Consent Form in accordance with Section 240.330;
16) participant/authorized representative refuses to apply for and, if eligible, enroll in medical assistance under Article V of the Public Aid Code, as required by Section 240.865;
17) participant/authorized representative threatened violence or committed actual violence against a Department representative/CCU/provider as specified in Section 240.355; or
18) participant has been convicted of fraud or an OIG investigation has determined that fraud has occurred.
b) A participant cannot be terminated for attempting to exercise or exercising their right to appeal an action by the CCU or provider.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.955 Reasons for Reduction or Change
Reasons for reduction in level or amount of services provided to a participant or change in type of services or any other change in service shall be based on current determination of eligibility.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART J: SPECIAL SERVICES
Section 240.1010 Choices for Care Pre and Post Screening and Informed Choice
a) Choices for Care prescreening is the determination of the need for institutional long term care services and/or other long term services and supported programs that require an institutional level of care, including the supportive living program settings. All participants age 60 and over, regardless of the payment source, must be determined eligible prior to placement in a nursing facility (licensed under the Nursing Home Care Act; certified to participate in the Medicare program under Title XVIII of the Social Security Act (42 U.S.C. 301 et seq.), or certified to participate in the Medicaid program under Title XIX of the Social Security Act; placement in a supportive living program (Medicaid waiver)); or to determine if the participant/authorized representative chooses community-based services and supports.
b) Except as indicated in subsections (j) and (l), any participant seeking admission to a nursing facility or supportive living program must be screened to determine their level of care need for nursing facility or supportive living program services pursuant to this Section.
c) Prescreening includes the completion of the level of care to determine eligibility for institutional level of care or supported living program setting placement. In addition, the participant will receive copies of brochures related to the following subject matters:
1) Privacy Practices; and
2) Adult Protective Services brochure.
d) In compliance with federal Preadmission Screening and Resident Review (PASRR) requirements, when CCUs completing the HFS Level I Screen for individuals residing in the community to determine if there is a suspicion of and a reasonable basis to suspect mental illness and/or developmental disability, the CCU shall make the appropriate referral to the state designed entity within one day to determine if an HFS Level II Screen is required. If it is determined that no further screening is required, the CCU shall complete the required forms. If further screening is required by the state designated entity, that entity shall complete the required forms.
e) The hospital shall notify the CCU at least 24 hours prior to discharge.
f) CCUs will have the capacity to complete face-to-face prescreenings seven days per week, at a minimum of seven hours per day.
g) Responsibility for prescreenings shall be vested in the CCUs. The CCU is responsible for ensuring that copies of the HFS Interagency Certification of Screening Results form and the HFS Level I Screen shall be submitted to the state designated entity within the required timeframe.
h) The participant who is prescreened shall:
1) be afforded informed choice including an explanation of all support options, including nursing facility, supportive living program setting, home and community-based services; and
2) be advised of their right to refuse nursing facility, supportive living program setting, home and community-based, or all services.
i) Postscreening shall occur if a participant is admitted to a nursing facility or supportive living program setting without benefit of prescreening.
1) Postscreening may occur for any of the following reasons:
A) after nursing facility or supportive living program setting placement in an emergency situation when there is a pre-existing condition of need for a caregiver and the caregiver is no longer able to provide care. The CCU shall conduct prescreening within two calendar days after the date of the request for postscreening;
B) for nursing facility or supportive living program admissions from a hospital emergency department or outpatient services; or
C) for nursing facility or supportive living program setting admissions for participants coming from out-of-state.
2) The CCU shall conduct a postscreening within two calendar days after the date of the request for postscreening.
j) Nursing facility prescreening does not apply to the following:
1) Transfers from one nursing facility to another.
2) Admissions to a continuing care retirement community with which the participant has a life care contract.
3) Participants who are receiving or will be receiving hospice services.
4) Returns to a nursing facility from a hospital.
5) Admissions to a nursing facility from the community for respite care for a period of no more than 15 calendar days.
6) Admissions to sheltered care facilities.
7) Participants who resided in a nursing facility on June 30, 1996.
8) Participants who resided in a nursing facility for a period of at least 60 calendar days who are returning to a nursing facility after an absence of not more than 60 calendar days.
k) A prescreening or postscreening for supportive living program setting admissions is not required for:
1) Hospice services;
2) Caregiver respite services;
3) Transfers from nursing facilities licensed under the Nursing Home Care Act and certified to participate in the Medicaid program or another supportive living program setting without a break in service. It is the admitting supportive living program setting's responsibility to ensure that a screening document is received from the transferring nursing facility or supportive living program setting; or
4) Residents who were admitted to a supportive living program setting from a hospital to which they were transferred for the purpose of receiving care.
l) Any participant who has been admitted to a nursing facility that operates under the Hospital Licensing Act [210 ILCS 85], or provider licensed under Section 35 of the Alternative Health Care Delivery Act [210 ILCS 3/35], whose actual length of stay in the facility exceeds 21 calendar days, shall be screened to determine the participant's need for continued services.
m) Nursing facility conversion screening is the assessment of the appropriateness of in-home and community-based care for nursing facility residents age 60 and over who have applied for and been found eligible for Medicaid assistance.
1) Conversion screens shall be initiated by a referral from HFS.
2) Conversion screens shall be accomplished in accordance with Deinstitutionalization (see Section 240.1960(g)). A Deinstitutionalization assessment will be conducted within 60 days after the date of admittance to the nursing facility if the participant chooses to have follow-up by the CCU.
3) Conversion screens shall include the option of CCP transitional services for those participants who are appropriate for in-home and community-based services.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1020 Interim Services
Interim services are CCP services provided to participants age 60 and over on an interim basis, dependent upon the participant's presumptive eligibility and following prescreening of the participant.
a) Presumptive eligibility shall be based upon the following criteria:
1) A referral has been received from a participant age 60 or over, or from the participant's authorized representative, following prescreening.
2) Notification has been received by the CCU from a hospital or from a participant/authorized representative or agency in the community that the participant is at imminent risk of nursing facility placement within three calendar days.
3) The DON to determine need for long-term services and supports has been administered.
4) The participant/authorized representative has provided declared information on all other CCP eligibility requirements.
5) The participant/authorized representative has signed a Participant Agreement and Consent Form.
6) After presumptive eligibility has been determined, the CCU shall notify the provider within the next business day and services will start within two business days.
b) When presumptive eligibility has been determined and interim services are approved in accordance with the person-centered plan of care, services shall be initiated by the provider to the participant within two work days after the date of notification to the provider of the participant's presumptive eligibility.
c) A comprehensive assessment shall be administered in the residence of the participant by the CCU.
1) When the assessment is not conducted in the community, the CCU will make the follow-up home visit within 15 calendar days after the date of the participant's discharge.
2) When the assessment is conducted in the community, the CCU will make the follow-up home visit within 30 calendar days after the date of the interim assessment.
3) The formal determination of eligibility for CCP services shall be completed within 90 calendar days after the date of receipt of the referral.
d) Interim services may continue up to a maximum of 90 calendar days after the date of referral, pending finalization of the formal determination of eligibility by the CCU. Services shall be denied at any time during the 90 calendar day interim service period:
1) if evidence of ineligibility, based upon any eligibility requirement, is determined;
2) if the participant/authorized representative fails to cooperate in the determination of eligibility process;
3) as specified in Section 240.660, in the event that a participant's eligibility cannot be determined due to the participant's/authorized representative's failure to provide accurate and verifiable documentation regarding eligibility within 90 calendar days after the date of receipt of the referral; or
4) if a person-centered plan of care cannot be developed that adequately meets the participant's determined needs (see Section 240.920(n)).
e) Notification of eligibility or ineligibility shall be provided in writing. If eligibility is denied, provision of interim services shall cease on the date of receipt by the provider of the Participant Agreement – Person-Centered Plan of Care.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1040 Intense Service Provision
Several CCP workers' services (not to exceed four) may be utilized, on a one-time basis only, to clean a new participant's home, thereby making it possible to maintain the health and safety of the participant. However, the total monthly service costs may not exceed the maximum monthly cost allowable as indicated on the participant agreement.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1050 Temporary Service Increase
A participant who is currently receiving services under CCP may request a temporary service increase when they is at imminent risk of nursing facility care or has been hospitalized for not more than 60 calendar days.
a) The CCU will conduct the DON to determine need for long-term services and supports within two calendar days after notification.
b) The CCU will assist the participant/authorized representative with the completion of the Participant Agreement and Consent Form. The CCU shall verbally authorize a temporary increase in services if the need is indicated by the determination. The CCU shall notify the provider by telephone to reinstate services, giving the date of discharge and the temporary increase.
c) Notification shall be given to the participant/authorized representative and the provider immediately following completion of the required forms. The notification shall be confirmed in writing. Both the verbal and written notification shall indicate the increase and the temporary nature of the increase.
d) The CCU shall make a home visit to the participant for the purpose of redetermination of need to determine if the temporary increase should be continued or reduced. (See Section 240.620(c).)
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART K: TRANSFERS
Section 240.1110 Participant Transfer Request − Provider to Provider − No Change in Service
a) The Department, a CCU or a participant/authorized representative may request a transfer for provision of CCP services from one provider to another provider, within the same service area, and without any change in service needs. The transfer request may be initiated by verbally advising the CCU of the desired change in provider. The CCU shall verbally advise the participant of the provider choices available. The CCU shall complete a new Participant Agreement and Consent Form – Person-Centered Plan of Care, including choice of vendor based upon that verbal advice from the participant/authorized representative as to their selection.
b) Reasons for the CCU to authorize a provider to provider transfer with no change in services provided may include:
1) the needs of a participant are not being met by the current provider; or
2) the participant has exercised their right of freedom of choice and requested transfer.
c) Within five work days after the date of receipt of a verbal request to effect a transfer, the CCU shall forward a new Participant Agreement and Consent Form and new CCP Participant Agreement to the participant/authorized representative for signature.
d) Within 30 calendar days after the date of receipt of the signed Participant Agreement and Consent Form:
1) the CCU shall:
A) complete a person-centered plan of care establishing the effective date of transfer; and
B) forward:
i) the person-centered plan of care to the participant/authorized representative;
ii) a copy of the Participant Agreement − Person-Centered Plan of Care to the receiving provider on the same day the Participant Agreement − Person-Centered Plan of Care is sent to the participant; and
iii) a copy of the Participant Agreement − Person-Centered Plan of Care to transferring provider.
2) upon receipt of the provider's signature on the Participant Agreement – Plan of Care, the CCU shall place a copy of the executed Participant Agreement – Plan of Care in the CCU's participant file and a copy shall be forwarded to the participant/authorized representative.
e) The effective date of the transfer shall be within 15 calendar days after the date of the Participant Agreement − Person-Centered Plan of Care and service shall be initiated by the receiving provider without service interruption.
f) If a delay in any of the time frames established in this Section is caused by the documented action or inaction of the participant/authorized representative, time frames shall be extended by the number of calendar days of the delay.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1120 Participant Transfer Request – Provider to Provider – With Change in Service
a) A request for transfer of a CCP participant from one provider to another provider within the same service area that requires a change in the services provided shall be completed by the CCU following a redetermination of need. The request may be initiated by the Department, CCU, the vendor, or the participant/authorized representative verbally or in writing to the CCU. The CCU shall complete the redetermination of need, including obtaining a completed and signed Participant Agreement and Consent Form – Person-Centered Plan of Care from the participant/authorized representative, within 30 calendar days after the date of the request unless delayed by the participant/authorized representative.
b) Reasons for a provider to provider transfer with a required change in service may include:
1) a change in the participant's condition; and
2) the provider's inability to meet the service needs of the participant, as required by the person-centered plan of care.
c) The CCU shall:
1) no later than 15 calendar days after the date of redetermination, complete in accordance with Section 240.945 and forward:
A) the Participant Agreement − Person-Centered Plan of Care to the participant/authorized representative;
B) a copy of the Participant Agreement − Person-Centered Plan of Care, the CCP Participant Agreement to the receiving provider on the same day the Participant Agreement − Person-Centered Plan of Care is sent to the participant/authorized representative;
C) a copy of the Participant Agreement − Person-Centered Plan of Care to the transferring provider.
2) Upon receipt of the provider's signature on the Participant Agreement – Person-centered Plan of Care, a copy of the executed Participant Agreement – Person-centered Plan of Care shall be placed in CCU's participant file and a copy shall be forwarded to the participant/authorized representative.
d) The effective date of transfer shall be no later than 15 calendar days after the date of the Participant Agreement − Person-Centered Plan of Care and service shall be initiated by the receiving provider without service interruption.
e) If any delay in any of the time frames established in this Section is caused by the documented action or inaction of the participant/authorized representative, time frames shall be extended by the number of calendar days of delay.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1130 Participant Transfers – Care Coordination Unit to Care Coordination Unit
a) A CCP participant may transfer from one CCU service area to another CCU service area with continuous eligibility pending a redetermination of eligibility by the receiving CCU. The transfer may be requested by the Department, a CCU, or the participant/authorized representative verbally or in writing.
b) A reason for transfer from CCU to CCU shall be a geographic change in the participant's residence.
c) The effective date of transfer shall be within 15 calendar days after the date of the Participant Agreement − Person-Centered Plan of Care and services shall be initiated by the receiving provider without service interruption.
d) To implement the transfer, the transferring CCU, within five work days after the date of a request or notice of need to transfer, or five work days prior to the effective date of transfer, whichever provides the most notification to the receiving CCU, shall:
1) notify the receiving CCU of the impending transfer and the desired date of transfer;
2) forward to the receiving CCU the original case record of the transferring participant; and
3) forward the Participant Agreement − Person-Centered Plan of Care to the participant/authorized representative and a copy to the transferring provider.
e) The receiving CCU shall:
1) Upon receipt of the participant's case record, advise the participant/authorized representative as to the providers in the CCU's area that are authorized, and appropriate, to provide the participant's service needs in accordance with the participant's person-centered plan of care. The participant shall advise the CCU as to their selection and the CCU shall complete a new Participant Agreement and Consent Form − Person-Centered Plan of Care.
2) Forward to the participant/authorized representative a new completed Participant Agreement and Consent Form – Person-Centered Plan of Care for signature.
3) Upon receipt of the signed Participant Agreement and Consent Form – Person-Centered Plan of Care, establishing the effective date of the transfer.
4) Forward:
A) the Participant Agreement − Person-Centered Plan of Care to the participant/authorized representative;
B) a copy of the Participant Agreement − Person-Centered Plan of Care and the old Participant Agreement – Person-Centered Plan of Care and a copy of the applicable pages of the comprehensive assessment to the receiving provider on the same day the Participant Agreement − Person-Centered Plan of Care is sent to the participant/authorized representative.
5) Upon receipt of the provider's signature on the new Participant Agreement – Person-Centered Plan of Care, a copy of the executed Participant Agreement – Person-Centered Plan of Care is to be placed in CCU's participant file and a copy shall be forwarded to the participant/authorized representative.
f) If any delay in any of the time frames established by this Section is caused by the documented action or inaction of the participant/authorized representative, time frames shall be extended by the number of days of delay.
g) The receiving CCU shall perform an initial determination of eligibility of the participant and develop a new person-centered plan of care within 30 calendar days after the date of receipt of the case record.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1140 Transfers of Pending Requests for Services
If a transfers of pending requests for services occur, the purpose of those transfers shall be to assure that the participants maintain their status and to assure that appropriate action will be completed as specified in Section 240.610.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.1150 Interagency Transfers
Participants from the DHS-Division of Rehabilitation Services (DHS-DORS) may transfer to the Department on Aging if in accordance with the interagency agreement executed between both Departments and if the participant meets eligibility requirements established by the Department on Aging for CCP.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.1160 Temporary Transfers – Care Coordination Unit to Care Coordination Unit
a) A CCP participant/authorized representative may request a transfer from the participant's CCU service area to another CCU service area for a temporary period of time, not to exceed 31 calendar days, when the participant is temporarily residing with a relative, or other responsible individual, but intends to return to the participant's permanent residence. When the temporary transfer exceeds 31 calendar days, the transfer is considered to be permanent (see Section 240.1130).
b) The managing CCU shall retain primary responsibility for the participant and maintenance of the participant's original records.
c) To implement the temporary transfer, the managing CCU, within five work days after the date of request or notice of need to transfer, shall:
1) notify the temporary CCU of the impending transfer, the participant's name, temporary address and telephone number, the anticipated length of stay and the type and amount of CCP service to be provided, and whether the participant has an authorized representative;
2) obtain from the temporary CCU, and provide to the participant/authorized representative, a list of authorized and appropriate providers in the temporary CCU's service area;
3) complete a Participant Agreement and Consent Form and obtain signatures from the participant/authorized representative;
4) complete a new Participant Agreement – Person-Centered Plan of Care, obtain signatures and forward copies as appropriate;
5) provide the temporary CCU with a copy of the Case Documentation for Determination of Need;
6) prepare and forward a Participant Agreement − Person-centered Plan of Care;
7) authorize the temporary provider to receive payment for CCP services provided, beginning on the effective service date;
8) provide the temporary provider with information required for billing for CCP services provided to the participant.
d) The temporary provider shall advise the temporary CCU of any needed adjustments in the participant's person-centered plan of care.
e) The temporary CCU shall:
1) if advised by the temporary provider, make a home visit to the participant and identify possible needed changes;
2) advise the managing CCU and the temporary provider of any changes needed in the participant's person-centered plan of care;
3) monitor the provision of services to the participant;
4) advise the managing CCU of the date of the participant's expected return to a permanent residence.
f) The participant/authorized representative shall advise the temporary CCU of the date of the participant's expected return to their permanent residence no later than five work days prior to the date of the participant's return.
g) Upon the participant's return to their permanent residence, the managing CCU shall:
1) terminate the authorization of the temporary provider to receive payment for CCP services provided to the participant;
2) reinstate authorization for the permanent provider to receive payment for CCP services provided to the participant;
3) notify the permanent provider of the reinstatement and the first day that services shall be provided to the participant by the permanent vendor;
4) prepare and forward a Participant Agreement − Person-Centered Plan of Care.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1170 Caseload Transfer – Provider to Provider
a) A caseload transfer shall occur when the serving provider's contract for provision of CCP services has been terminated by either party to the contract.
b) The Department shall notify the appropriate CCU of the impending transfer and the effective termination date, and forward a copy of each notification to the respective transferring and receiving providers.
c) The participant/authorized representative shall complete the Participant Agreement and Consent Form and forward it to the CCU by the date specified in the Department notice (no later than 15 calendar days after the date of mailing by the Department).
d) Within five work days after the date specified by the Department in subsection (c), the CCU shall identify the receiving provider for each participant in the caseload, using the completed Participant Agreement and Consent Form or the approved rotation plan, if a Participant Agreement and Consent Form has not been received.
e) Upon adequate notification by the Department of the provider's intent to terminate its contract, the CCU shall:
1) advise the receiving provider verbally of the impending transfer of the participants and the date that service must be initiated for each participant to prevent interruption of service;
2) send written notification to the participants/authorized representatives giving the date of initiation of service by the receiving provider; and
3) send a new Participant Agreement – Person-Centered Plan of Care and applicable pages of the comprehensive assessment for each transferring participant to the appropriate receiving provider.
f) The time frame specified in subsection (e) does not apply when an emergency procurement action is required due to contract termination and to prevent interruption of participant services.
g) The participant's/authorized representative's signature shall be obtained on the new Participant Agreement – Person-Centered Plan of Care and copies distributed as appropriate.
h) The transfer of a caseload must be completed no later than the effective termination date of the contract.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1180 Caseload Transfer – Care Coordination Unit to Care Coordination Unit
a) A caseload transfer shall occur when the authorized CCU's contract for provision of CCP care coordination services has been terminated by either party to the contract.
b) The transferring CCU shall:
1) transfer each participant's original case record file to the receiving CCU no later than the termination date of transferring CCU's contract;
2) the transferring CCU shall retain all records relating to requests for payment and receipt thereof and any documents peculiar to that agency.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART L: ADMINISTRATIVE SERVICE CONTRACT
Section 240.1210 Administrative Service Contract
The Department shall designate, through purchase of service contracts, individuals/agencies to carry out administrative duties in support of the Community Care Program. Specific responsibilities are delineated in the Administrative Service Contract.
(Source: Amended at 13 Ill. Reg. 11193, effective July 1, 1989)
SUBPART M: CARE COORDINATION UNITS AND PROVIDERS
Section 240.1310 Standard Contractual Requirements for Care Coordination Units and Providers
a) The contract shall be an agreement between the Department and the CCU or provider agency as evidence of the terms and conditions of the contract. The terms and conditions shall, at a minimum, include the following:
1) the contractual agreement between the Department and the CCU/provider may be terminated without cause by either party upon 60 calendar days written notice;
2) the contractual agreement between the Department and the CCU/provider may be amended, with the mutual consent of both parties, at any time during the term of the contract; and
3) all program and financial records, reports, and related information and documentation, including participant files, that are generated as a result of the agreement shall be considered the property of the Department.
b) Upon written notification from the Department of a change in the fixed unit rates of reimbursement, the CCU/provider may exercise its 60 calendar day termination rights if the CCU/provider no longer wishes to provide service at the newly established fixed unit rates of reimbursement.
c) CCUs and providers shall have sufficient personnel to ensure service to all CCP participants.
d) At the time of application for award of contracts, CCUs and providers shall submit documentation specified by the Department to confirm the legal structure under which they are doing business.
e) CCUs and providers may be units of State government, units of local government, for-profit or not-for-profit corporations, limited liability companies, sole proprietorships, partnerships or individuals.
1) An agency of State government must submit a letter from the Director or head of the agency citing the statutory authority for the agency to enter into a contract to provide the proposed CCP service.
2) A unit of local government must submit a copy of the resolution or ordinance duly passed by the governing body of the unit of government authorizing the execution of the contract. The resolution or ordinance shall designate the individual authorized to execute the agreement in behalf of that unit of government.
3) A partnership, individual or sole proprietorship must submit copies of "Certificate of Ownership of Business" issued by the County Clerks for the counties in which the applicant agency is proposing to provide service.
4) A corporation or limited liability company must submit a "Certificate of Good Standing" from the Office of the Illinois Secretary of State certifying that the corporation has complied with the requirement to file an annual report and has paid required franchise taxes.
5) A not-for-profit corporation shall submit:
A) a "Certificate of Good Standing" from the Office of the Illinois Secretary of State certifying that the corporation has complied with the requirement to file an annual report; and
B) a current letter from the Office of the Illinois Attorney General certifying that the corporation is in full compliance with or is exempt from the charitable trust laws of the State of Illinois. Thereafter, a non-exempt provider shall provide a letter, certified by the provider's Board of Directors, to the Department upon request, stating that the provider remains in compliance or is exempt.
6) A nongovernmental agency shall certify that:
A) CCU/provider or any of its officers, agents or employees have not been convicted of bribery or attempting to bribe an officer or employee of the State of Illinois nor made an admission of guilt of such conduct which is a matter of record; and
B) CCU/provider is not in arrears or not in default to the State of Illinois upon any debt or contract, and that it is not in default as to the surety, or otherwise, upon any obligation to the State of Illinois, and that it has not failed to perform faithfully any previous contract with the State of Illinois.
f) CCUs and providers shall certify that their respective agency acknowledges and complies with the Illinois Human Rights Act [755 ILCS 5]; the Equal Employment Opportunity Act of 1974, as amended (Title VII of the U.S. Civil Rights Act of 1964, as amended (42 U.S.C. 2000e et seq.)); the Civil Rights Act of 1964, as amended (42 U.S.C. 2000d et seq.); section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 790 et seq.); and the Immigration Reform and Control Act of 1986 (8 U.S.C. 1101 et seq.).
g) CCUs and providers shall certify to the Department that their respective agencies are fiscally sound, as defined in Section 240.160, or demonstrate the ability to obtain financial resources as required during the performance of their contract.
h) Assignment by a CCU or provider of a contract awarded between the CCU or provider and the Department to any other organizations or entities shall result in the immediate termination of the CCU or provider contractual agreement.
i) Failure by CCUs or providers to seek and obtain written Department approval prior to entering into subcontracts with other entities for the provision of CCPCCP services shall result in the immediate termination of the CCU or provider contractual agreement.
j) The Department shall be immediately notified in the event of a merger/consolidation/sale of assets of a CCU or provider by the CCU or provider and provided with copies of all relevant supporting documents.
1) Following review of the merger/consolidation/sale of assets documents by General Counsel, the Department will determine whether the merger/consolidation/sale of assets has resulted in an assignment of the contract (see subsection (h)).
2) If the merger/consolidation/sale of assets has not resulted in an assignment, the Department retains the right to terminate the contract if performance of the contract by the new corporate structure is not in the best interests of the CCP, such as a merger or consolidation with an entity that has been subject to previous contract action by the Department or some other state or federal agency.
3) Failure to notify the Department shall result in termination of the CCU or provider contract.
k) The CCU/provider must notify the Department and receive approval before initiating any pilot program involving participants. Failure to receive approval may result in contract action.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1320 Provider or Care Coordination Unit Fraud/Illegal or Criminal Acts
a) Reporting of Illegal Acts
1) Any entity involved in the administration of the CCP or in the provision of CCP services, upon receipt of any report of or evidence of an improper or unlawful act having been committed by their employees, for the purpose of illegally obtaining money or extorting payment for care, goods, services or supplies, shall immediately:
A) inform the appropriate law enforcement authorities; and
B) report to the Department, including any documentation which may have been obtained, regarding any alleged theft or missing items having value over $50.00 or such unlawful activities which result in a police report.
2) Failure of a CCU or provider to make a report to the appropriate law enforcement authorities and to the Department shall result in contract action as delineated in Section 240.1665.
b) Department staff, designated by the Director, shall make an immediate investigation of the alleged improper or unlawful acts. When the result of the Department's investigations produces evidence that indicates CCU/provider improprieties or unlawful activities, the Department shall make an immediate report to the appropriate law enforcement authorities.
c) Any entity or individual provider involved in the administration/provision of CCP services shall not bill the Department for more services than were provided to or on behalf of CCP participants.
1) Anyone in receipt of information that the Department has been improperly billed for services shall report the incident to the Department and provide the Department with any report/documentation that may have been obtained.
2) Department staff, designated by the Director, shall complete an immediate review of the report.
3) If the Department determines that the allegations in the report are factual, based upon the above cited-review, the Department will advise the CCU or provider in writing regarding what action shall be taken (e.g., no action, if in the best interests of the participant; suspension; termination).
d) Any entity or individual involved in the provision of CCP services shall cooperate with and provide assistance to the Department/law enforcement authorities in any investigation of any alleged illegal or criminal act.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1399 Termination of a Provider or Care Coordination Unit (CCU)
In the event conditions warrant termination of an Agreement or a Contract, termination shall be in accord with provisions in the Agreement or Contract.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART N: CARE COORDINATION UNITS
Section 240.1400 Community Care Program Care Coordination
a) A designated CCU, as outlined in 89 Ill. Adm. Code 220.600 through 220.675, shall be contracted with as a CCU by the Department for a specific geographic area by executing a contract for the provision of CCP care coordination services.
b) All providers of CCP care coordination services shall meet all standards promulgated by the Department relating to the services provided, upon completion of the procurement. All Department funded CCUs must adhere to the equal opportunity requirements of the Illinois Department of Human Rights and the contract executed between the CCU and the Department.
c) Care coordination services shall be purchased only from providers determined capable and competent by the Department to provide those services, once a procurement has occurred.
d) CCU contracts with the Department to provide CCP care coordination services shall not be assigned.
e) CCUs shall not subcontract for the direct provision of CCP care coordination services unless prior written approval has been obtained from the Department.
f) A CCP provider may not serve as a CCU in the same contract service area except temporarily to provide for the orderly transition of duties while the Department seeks a replacement CCU or the Department seeks a replacement provider, as indicated in the particular case. In no instance shall that arrangement exist for longer than a three month period.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1410 Care Coordination Unit Administrative Minimum Standards
a) A CCU must meet the Standard Contractual Requirements of Section 240.1310.
b) A CCU shall be open for business at least seven hours each weekday (Monday through Friday) and shall have and utilize an alternative method approved by the Department, and on file at the CCU, for receiving requests from participants on any weekdays (excluding holidays) when the CCU is not open for business.
c) All program records, reports, and related information and documentation, including participant files, that are generated in support of the contract between the CCU and the Department shall be considered the property of the Department.
1) The CCU shall submit, upon demand, or otherwise make available at the option of the Department, all such records, information and documentation to the Department/Department authorized designee.
2) All the records, information and documentation shall be maintained by the CCU in accordance with provisions of 89 Ill. Adm. Code 220.100.
3) All records, case notes or other information maintained on persons served under the contract shall be confidential and shall be protected by the CCU from unauthorized disclosure as required by 89 Ill. Adm. Code 220.100 and Section 240.340 of this Part.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1420 Care Coordination Unit Responsibilities
CCUs, in the performance of their CCP contract, shall have the following responsibilities for purposes of care coordination:
a) Intake to address public inquiries regarding services and supports and making preliminary decisions regarding need for a home visit for a comprehensive assessment.
b) Determine functional and financial eligibility for services, including:
1) scheduling a face-to-face meeting between a certified Care Coordinator and a participant/authorized representative;
2) utilizing the comprehensive assessment tool, or any successor assessment tool used to determine need for long-term services and supports authorized by the Department, including all addenda, to assess the participant's functional needs, cognitive, psychological, and social well-being, including but not limited to participant demographics, physical health history and assessment, behavioral health, medications, nutritional screening, caregiver, transportation, environment, financial, legal status, and person-centered goals of care, as well as other factors contributing to quality of life and the ability to live independently in the community;
3) reporting alleged or suspected abuse, neglect, financial exploitation, or self-neglect; assisting with investigations conducted under the Adult Protective Services Program; and making referrals to the State/Regional Long Term Care Ombudsman Programs.
4) identifying existing informal and formal support systems and the need for further evaluation by other disciplines, and/or services that would assist the participant in maintaining independent living and coordinating available resources to assist the participant/authorized representative to gain access to and receive needed services and supports, whether paid or unpaid, that will assist the participant to achieve identified goals, including distributing and assisting with completion of applications and forms required to access services identified in the goals of care; and
5) maintaining relationships with DHS, HFS, managed care entities, physicians, hospital discharge personnel, and providers for the purpose of receiving input that may be beneficial to the CCU in exercising these responsibilities.
c) Full responsibility for the performance of CCP determinations/redeterminations of eligibility, including residents of nursing homes seeking to return to the community, and development of a Participant Agreement – Person-Centered Plan of Care for each CCP client. (The Participant Agreement – Person-Centered Plan of Care can be revised only by the CCU.) CCUs should maintain liaison with DHS, HFS, physicians, hospital discharge personnel, and providers for the purpose of receiving input that may be beneficial to the CCU in exercising these responsibilities.
d) Develop a Participant Agreement − Person-Centered Plan of Care for each participant receiving CCP services based on person-centered planning and freedom of choice in the selection of services, supports and providers.
e) Monitor the person-centered plan of care, including the Goals of Care, to ensure that services/resources are being provided.
f) Implement transfer of a participant as required by Sections 240.1110 through 1180.
g) Send deliver a person-centered plan of care to the participant/authorized representative. Also send/hand-deliver to providers on same day the CCU sends the form to the participant/authorized representative, the following:
1) the applicable sections of the comprehensive assessment tool; and
2) copy of the Participant Agreement − Person-Centered Plan of Care.
h) During the face-to-face/in-person visit and, upon subsequent request, advise participants/authorized representatives of all rights and responsibilities under the CCP and furnish each participant/authorized representative with a copy of those rights and responsibilities, including a copy of "Things You Need to Know" brochures and Home Care Participant Bill of Rights brochures. Also provide a copy of the Request for Appeal form as promulgated by the Department and rendering assistance in filing the Request for Appeal form as requested or needed.
i) Arrange for the implementation of CCP services by CCP providers in accordance with the person-centered – plan of care, and develop memoranda of understanding when needed to maintain service.
j) Submit to HFS all requested records for issues under the Medical Assistance Program, and any other information or records for HFS to discharge its responsibilities as the Single State Agency under Title XIX of the Social Security Act.
k) Send notification to the participant/authorized representative if a participant is determined ineligible for CCP services and providing linkage to other indicated services (e.g., Older Americans Act (42 U.S.C. 3001 et seq.) services).
l) Inform and assist the participant in the exercise of his/her rights to obtain an alternative provider as specified in Section 240.270 if provision of CCP service is delayed beyond the required time frame.
m) Maintain a record of all participants receiving services under the CCP being served within the CCU's jurisdiction.
n) Address any request by participant/authorized representative/provider relating to CCP services and respond verbally/in writing within 15 calendar days after the date of request and so document in the participant's file.
o) Document in the participant's file all contact, verbal or written, with or on behalf of participants/authorized representatives.
p) Monitor for critical event notifications coming from Adult Protective Services, Emergency Home Response, In-Home and Adult Day Service providers. CCUs will respond to all critical event notifications by providing mandatory follow-up with CCP participants who have experienced a critical event. All critical event reports will be closed to reflect mandatory follow-up with CCP participants within 60 days after the date the event occurred or was identified to have occurred. CCUs will close critical event reports through completion of the 60-day review summary housed in the Department's automated reporting system.
q) Complete and submit CCP assessment billing data to the Department; review and correct rejects; and provide assistance to providers with billing errors.
r) Provide, in a timely manner, copies of all participant documents requested by the Department for participant appeals or other Departmental matters.
s) Attend hearings on appeals affecting participants under the CCU's jurisdiction and testify as requested. The CCU shall make available the appellant's case records at the hearing.
t) Complete Choices for Care pre and post screening requirement within the required time frames and provide informed choice to participate in accordance with Section 240.1010.
u) Comply with deinstitutionalization requirement as outlined in Section 240.1010.
v) Provide the Department with an annual financial audit report completed in accordance with Generally Accepted Audit Standards and Audit Guidelines issued by the Department.
1) The financial audit report shall be filed within six months after the close of the CCU's business fiscal year. The annual financial audit report must include, at a minimum, an income and expense statement and a balance sheet with the auditor's opinion and findings.
2) The annual financial audit report shall be filed with the Department at its main office in Springfield.
w) Maintain all records and documentation as specified in this Part and applicable procedures.
x) Respond to correspondence as required in performing all specified responsibilities.
y) Obtain any necessary consent and cooperation for release of information when required to document case record material and to take subsequent indicated action.
z) Develop and maintain resource listings for the geographic area served by the CCU, which will be shared with the Department upon request, to ensure that choices are presented to participants/authorized representatives in an objective manner that also allows for a rotation system for referrals to providers when the participant/authorized representative elects not to make a choice.
aa) Perform other activities as required by State or federal or local rules, regulations and ordinances as they relate to the CCP.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1430 Care Coordinator Staff Positions, Qualifications and Responsibilities
a) A CCU shall have specified staff to carry out the following functions:
1) care coordination; and
2) supervision of care coordinators.
b) Care coordination supervisor qualifications shall be as specified in 89 Ill. Adm. Code 220.605(a)(2).
c) Care coordination qualifications shall be as specified in 89 Ill. Adm. Code 220.605(b)(2).
d) Care coordinator activities and responsibilities shall, at a minimum, include:
1) administration of the DON;
2) development of a Participant Agreement – Person-Centered Plan of Care;
3) performance and/or approval of Choices for Care screening;
4) performance of HFS Level I Screen;
5) authorization of CCP services; and
6) attendance at appeal hearings.
e) Required activities that may be performed by a care coordinator or other CCU staff include:
1) screening of inquiries;
2) arranging for service implementation in accordance with each specific Participant Agreement – Person-Centered Plan of Care;
3) completing required billing activities with the Department;
4) reviewing and correcting required billing activities with the Department;
5) assisting providers with Vendor Request for Payment (VRFP) rejects;
6) timely provision of documents requested by the Department for participant appeals or other Departmental matters;
7) implementing case transfers; and
8) assisting with completion and submission of participant Medicaid applications.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1440 Training Requirements For Care Coordination Supervisors and Case Coordinators
CCUs in the performance of their CCP contracts, shall adhere to the following training requirements.
a) Care Coordinator (CC) Certification and Recertification
1) Prior to performing CCP eligibility determinations and developing person centered plans of care, each care coordinator and each supervisor acting as a care coordinator shall successfully complete Department sponsored training on the CCP training comprehensive assessment tool, care planning, dementia training, and Choices for Care screening.
2) Successful completion of this training shall be established by certification.
3) Recertification of CCP training must be completed within the 18 months anniversary of each previous certification.
b) In-Services Training Requirements
1) Annually, each care coordinator supervisor and care coordinator shall compete 20 hours of documented in-service training on aging related subjects. 2 of those hours shall be dementia training which shall include subjects related to Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior.
2) For partial years of employment, training shall be prorated to equal 1.5 hours for each full month of employment. Documented participation in in-house staff training and/or local, State, regional or national conferences on aging related subjects will qualify as in-service training on an hour-for-hour basis. Recertification hours will not qualify for successful completion of this training. Completion of this training shall be established by certification.
c) All CCU employees not in receipt of Department training certificates must complete two hours of dementia training within 30 days of their employment and every calendar year thereafter. This training must include the following subjects: Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART O: PROVIDERS
Section 240.1505 Administrative Requirements for Certification
a) In order to qualify for certification as a provider of CCP services, a provider agency must, to the satisfaction of the Department, meet the following administrative requirements:
1) Serve an entire CCP geographic area.
A) Other than in Cook County, the geographic area will be the county.
B) In Cook County outside the City of Chicago, the geographic area will be the township.
C) Within the City of Chicago, the geographic area will be the following subareas, defined by Zip Code:
i) 60626, 60640, 60645, 60659, 60660
ii) 60625, 60630, 60631, 60646, 60656
iii) 60634, 60639, 60641
iv) 60613, 60614, 60618, 60647, 60657
v) 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60610, 60611, 60622, 60642, 60654, 60661
vi) 60615, 60616, 60637, 60649, 60653
vii) 60609, 60623, 60629, 60632, 60638
viii) 60619
ix) 60620, 60621, 60636, 60643, 60652, 60655
x) 60608, 60612, 60624, 60644, 60651.
xi) 60628
xii) 60617, 60633, 60827.
2) The Department reserves the right to adjust this geographic area requirement to assure that:
A) no geographic area remains unserved.
B) the following entities are not excluded from participation as service providers in the CCP:
i) entities serving limited- or non-English-speaking participants;
ii) providers that are, or are controlled by, a unit of local government and cannot operate outside the jurisdiction of that local government; and
iii) regional benevolent, charitable, social or religious organizations that have as their charter providing services to a specific population or geographic area smaller than a county, township or CCP subarea.
C) transportation to/from adult day service facilities can be completed in a reasonable period of time.
3) Submit a request for certification providing the information described in this Section and Sections 240.1600 and 240.1605, in the form and manner prescribed by the Department, including all required supporting compliance material or other information documenting its administrative and operational ability, and institute all necessary action based on the outcome of the Department's review.
4) Document the legal structure under which it is organized to do business as set forth in Section 240.1607(h).
5) Provide a list of the directors, officers or owners, as applicable to the legal structure of the provider agency.
6) Verify experience in providing service comparable to the CCP, as defined in Sections 240.210, 240.230, 240.235 and 240.237, for which certification is requested, and that is consistent with the requirements set forth in this Part.
A) Required Experience
i) For prospective emergency home response service provider agencies: A minimum of five years experience in business operations providing emergency home response service.
ii) For prospective adult day service provider agencies: A minimum of two years experience providing direct social services programming.
iii) For prospective in-home service providers: A minimum of three years experience in business operations providing in-home service, one of which must be in Illinois.
iv) For prospective AMD service provider agencies: a minimum of five years experience in business operation providing AMD services.
B) At the Department’s discretion, the Department may:
i) issue provisional certification to provider agencies, including, but not limited to, those that have not previously been certified or are not in operation at the time the application is made. The provisional certification shall not exceed two years and the Department will conduct additional oversight during the provisional period to protect participant health, safety and welfare. A provider with a provisional certification cannot expand until they have received their first successful review.
ii) adjust the experience requirement (e.g., substituting management team experience for agency experience). The Department will continue to assure that any adjustment of the experience requirement will occur only when the health, safety and welfare of CCP participants and the quality of services provided will not be adversely affected. The Department will not consider any substituted experience that has been used to support another application.
7) Disclosure of information regarding past business practices of the provider agency and its affiliates, including the managers, directors or owners, relevant to the service applied for, involving, but not limited to, the following circumstances:
A) denial, suspension, revocation or termination for cause of a license or Provider Agreement, or any other enforcement action, such as civil court or criminal action;
B) termination of a Provider Agreement or surrender of a license before expiration or allowing a contract or a license to expire in lieu of enforcement action;
C) any federal or state Medicaid or Medicare sanctions or penalties relating to the operation of the agency, including, but not limited to, Medicaid abuse or fraud;
D) any federal or state civil or criminal felony convictions;
E) operation of an agency that has been decertified in any state under Medicare or Medicaid; or
F) citations for participant abuse, neglect, injury, financial exploitation or inadequate care in any state.
8) Document its written policies and procedures in compliance with the applicable administrative standards imposed on provider agencies under the CCP, as set forth in Section 240.1510.
9) Document its ability to comply with all applicable responsibilities imposed on provider agencies under the CCP, as set forth in Section 240.1520, including proof of required insurance coverages.
10) Submit audited financial reports from the last complete business fiscal year, unless the provider agency is a newly established business entity.
A) Newly established for profit business entities, regardless of relationship to any other provider agency, shall:
i) submit proof that employee tax accounts are reestablished with the State of Illinois and the U.S. Treasury; and
ii) submit either:
• a bank approved business plan with approved financial backing; or
• if financial resources are from individuals, the most recent two years of tax returns, and if applicable any bank approved individual financial backing for use in the business.
B) Newly established not-for-profit business entities, regardless of relationship to any other provider agency, shall submit:
i) Bank approved business plan with approved financial backing or a signed financial statement illustrating restricted and nonrestricted funding; and
ii) Proof that employee tax accounts are established with the State of Illinois and the U.S. Treasury.
11) Submit proof that it is fiscally sound, as that term is defined in Section 240.160, by verifying assets (e.g., audited financial statements with accompanying notes, bank statements, investment statements, or letters of credit from financial institutions) sufficient to cover 90 days of operating expenses for the service line applied for (i.e., specifically ADS, In-Home Services, EHRS or AMD), as defined by the agency business plan. No more than 30 of the 90 days should be based on a line of credit.
12) Provide assurance that its business operations comply with the service, staffing and training requirements imposed on provider agencies under this Part.
13) Provide a minimum of five references from such entities as persons who have been served by the provider, nonprofit or business organizations or governmental bodies that have observed the operations and/or services of the provider, employees of the provider, an Area Agency on Aging, etc., attesting to the provider agency's qualifications relevant to providing CCP services. The references shall be from independent and diverse group of knowledgeable entities. The Department will not accept reference letters from entities or persons who are affiliated with the applicant and/or entities who have common control/owners with the applicant.
14) Comply with all applicable federal, State and local laws, regulations, rules, service standards and policies or procedures pertaining to the provider agency in its business operations and to the services provided under the CCP.
b) If a provider agency is not able or is unwilling to meet the administrative requirements in subsection (a), the Department shall deny its request for certification.
c) The Department reserves the right to accept documentation of Illinois Department of Public Health (DPH) home service licensure for applicable administrative requirements. (See 77 Ill. Adm. Code 245.Subpart B.)
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1510 Provider Administrative Minimum Standards
The provider shall establish and comply with written policies and procedures. Provider policies shall include the following:
a) Confidentiality of participant records is maintained as required by Section 240.340, including:
1) Ensure access to participant records is limited to specific areas within the office and only available to personnel with need for the information.
2) Establish and maintain current and archived files in a secure and confidential manner.
b) The type and amount of service is provided in accordance with the Participant Agreement – Person-centered Plan of Care as developed and authorized by the CCU in collaboration with the participant/authorized representative.
c) Money handling activities related to necessary shopping/errand activities, including receipt procedures, are monitored.
d) Staff development plans that show each job category and include a job description and a wage range plus personnel policies that include benefits, promotion and evaluation criteria so:
1) Each employee is provided a written job description that applies to his/her job category.
2) A copy of current written personnel policies for the specific job category is available to all employees.
3) Each employee is informed of the wage range for the specific job category at the time of employment and upon any subsequent revisions.
4) Employee benefits and grievance procedures are clearly stated in writing and comply with both State and federal regulations.
5) Personnel records are maintained for each employee and include at least the following:
A) employee application;
B) annual face-to-face performance evaluation;
C) documentation of participation in pre-service, in-service and other pertinent training (orientation in agency policies) in accordance with Department training required by Sections 240.1535 and 240.1555;
D) documentation of supervisory visits, quarterly conferences and evaluations;
E) documentation to support qualifications;
F) documentation of vehicle insurance for those employees who provide participant transportation in their own vehicles;
G) documentation that the websites for the federal Department of Health and Human Services (HHS) and HFS, Office of Inspector General, were checked for excluded providers; and
H) documentation of a criminal background check and waiver, if applicable, as required by the Illinois Healthcare Worker Background Check Act [225 ILCS 46] and an online check of the Adult Protective Services Registry, as required by the Adult Protective Services Act [320 ILCS 20/7.5(c)].
e) All Department required documentation to support units of service requested for reimbursement shall be retained in paper or electronic format for a minimum of six years after the ending year for its creation date or the ending year when it was last in effect, whichever is later.
f) Ongoing quality improvement, reviewed at least annually, through:
1) staff and community agency surveys;
2) program and service reviews; and
3) implementation of changes:
A) based upon program and service review findings and submission of documentation of those changes to the Department, in accordance with Department policy; and
B) to comply with Medicaid waiver quality assurance regulations.
g) U.S. Department of Labor, Occupational Safety and Health Administration (OSHA) Regulation (29 CFR 1910.1030) (2008).
h) National Labor Relations Act (29 U.S.C. 151-169) and any applicable collective bargaining agreements.
i) U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services (8 U.S.C. 1324(a) et seq.).
j) Drug Free Workplace Act [30 ILCS 580].
k) Patient Self-Determination Act (42 U.S.C. 1396(a) et seq.).
l) Health Care Surrogate Act [755 ILCS 40].
m) Control of the spread of infectious diseases and compliance with universal precautions.
n) Assure nondiscrimination in accordance with Section 240.320 and the Department's civil rights program.
o) Develop, maintain and protect administrative and participant records, including observance of confidentiality in the maintenance and transmission of records, as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. 1320d et seq.).
p) Receive and resolve complaints as required by Section 240.1650.
q) Develop an all hazards disaster operations plan to respond to emergency situations, including, but not limited to, medical emergencies, home or site-related emergencies, emergencies related to the participant, weather-related emergencies, and vehicle/transportation emergencies.
r) Adequate supervision of all persons, both staff and volunteers, having direct service contact, as required by Section 240.1535 or 240.1555, respectively.
s) Mandated reporting of all conditions or circumstances that place the participant, or the participant's household, in imminent danger (e.g., situations of abuse or neglect), as required by 89 Ill. Adm. Code 270.
t) Prohibiting the use of seclusion and/or restraint against a participant, unless supported by documentation in the person-centered plan of care and the employees have received training on restraint and seclusion practices.
u) Participate in all Department-mandated training for staff and volunteers, including, but not limited to:
1) Training on universal precautions as required by OSHA (29 CFR 1910.1030) (2008);
2) Training on emergency procedures; and
3) Training for abuse, neglect, exploitation and incident reporting required by the Adult Protective Services Act [320 ILCS 20].
v) Develop and adhere to marketing standards for services that:
1) require all persons involved with marketing and sales efforts to refrain from incomplete service comparisons or otherwise misleading representations (twisting) and high pressure sales tactics (playing on explicit or implicit fear and threats);
2) ensure the confidentiality and security of sensitive personal identification, financial and health information of current and prospective program participants that is obtained during discussions;
3) prohibit unsolicited telephone calls (cold-calling) and door-to-door solicitations; sales activities, as opposed to educational or informational activities, at community meetings, educational events and health care facilities; and cross-selling of non-CCP-related services to current and prospective participants in the program;
4) prohibit the use of independent agents for marketing of CCP-related services to participants; and
5) limit the value of any incentives and promotional products offered to current and prospective participants in the program.
w) Documentation that employees having direct contact with participants are annually educated about: the significant risks (including death) frail older adults face when exposed to the influenza virus; the steps homecare aides can take to minimize the risks of exposure, including immunizations; and the locations of resources within the provider's service area where immunizations are available, highlighting those that offer the vaccination for free or nominal costs. The provider shall maintain records of employees with direct participant contact who have received influenza vaccine by January 31 of each calendar year.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1520 Provider Responsibilities
a) CCP services shall be purchased only from providers certified by the Department to provide those services.
b) Providers shall carry occurrence based general liability insurance in the single limit minimum amount of $1,000,000 per occurrence, $3,000,000 in the aggregate.
c) Providers shall also carry the following insurance coverages:
1) worker's compensation for direct service staff;
2) volunteer protection equivalent to employees' coverage, including coverage for volunteer drivers/escorts, if applicable; and
3) motor vehicle liability, uninsured motorist and medical payments, if agency staff transport participants in agency vehicles, or proof of minimum motor vehicle liability, uninsured motorist and medical payments, if agency staff transport participants in the staffs' own vehicles.
d) The policies or current letters documenting all provider agency insurance coverage and policies or current letters documenting staff coverage specified in subsection (b) or (c) shall be available to the Department upon request.
e) All providers of CCP services must comply with all applicable local, State and federal statutes, rules and regulations.
f) A provider shall provide services to all CCP participants referred by the CCU, with the following exceptions:
1) The person-centered plan of care is determined to be inappropriate in the professional judgement of the provider.
A) The provider shall immediately notify the CCU of the provider's assessment and evaluation of the situation.
B) The provider and the CCU shall work together to determine if a person-centered plan of care that adequately meets the participant's needs can be developed.
C) In the event the provider and the CCU cannot reach an agreement, the Department shall be contacted and shall determine the final resolution.
2) The provider is unable to accept all CCP referrals.
A) The provider shall request a cap on the number of participants to be served (service cap), in writing, to the Department.
B) The Department will not approve a service cap for a provider that is the only provider of in-home service in the service area or when it is not in the best interest of the program.
C) Upon approval of the request, the provider assumes responsibility for managing intake to maintain the cap.
g) Any temporary change or deviation from the person-centered plan of care must be documented by the provider in the participant's file. A provider shall not deviate from the participant's person-centered plan of care without receipt of verbal (followed up, within two working days, with written instruction to be placed in the participant's file) or written instruction from the Department or the CCU, except in cases of emergency, refusal of service or failure of a participant to be home to receive service.
h) It shall be the responsibility of the provider to advise the CCU of any change in the participant's physical/mental/environmental needs that the provider, through the direct service worker/supervisor, has observed, when the change would affect the participant's eligibility or service level or would necessitate a change in the person-centered plan of care.
i) All providers shall reply to requests by a participant, by telephone or in writing, within 15 calendar days after the date of the request. The request and the response shall be documented in the participant's file.
j) Providers shall electronically submit a Vendor Request for Payment (VRFP) that shall be received by the Department no later than the 15th day of the month following the month in which services were provided.
1) The VRFP shall state the number of units of service provided to each identified participant during the service month.
2) Providers shall be reimbursed by the Department for the entire rate for each unit of service. Providers shall bill the Department for service rendered to participants in increments of quarter units.
k) Providers shall provide the Department with an annual audit report to be completed by an independent licensed Certified Public Accountant (CPA) and in accordance with 74 Ill. Adm. Code 420.Subpart D. The audit report shall be filed at the main office of the Department, within six months after the date of the close of the provider's business fiscal year.
l) Providers must accept all correspondence from the Department. Failure to do so may lead to contract action.
m) Records
1) Providers must maintain records for administration, audit, budgeting, evaluation, operation and planning efforts by the Department in offering CCP services, including:
A) records of all CCP referrals to the provider, including the disposition of each referral;
B) records for participants, which shall include, but are not limited to, applicable forms as required by the Department;
C) administrative records, including:
i) data used by the Department to provide information to the public;
ii) service utilization;
iii) complaint resolution; and
iv) billing and payment information, plus the underlying documentation to support the units of service submitted to the Department for reimbursement.
2) These records shall be available at all times to the Department, HFS, HHS, and/or any designees, and shall be maintained for at least six years after the termination date of the Provider Agreement. Any records being maintained under this subsection (m) by a provider who ceases to provide the agreed services shall be transmitted in accordance with Subpart K.
n) Providers must notify the Department within seven days after any change in agency information (e.g., acquisition, assignment, consolidation, merger, sale of assets or stock, transfer, etc.) or contact information (e.g., address, telephone, fax, email address, contact person, authorized representative, etc.).
1) Providers must notify the Department at least 30 days in advance of any relocation of their administrative office.
2) Providers must submit documentation of changes in provider name, corporate structure and/or Federal Employer Identification Number to the Office of General Counsel. This documentation shall be reviewed to determine if an assignment of the Provider Agreement has occurred (see Section 240.1607(k)).
o) Providers must conduct a criminal background check, as required by the Illinois Healthcare Worker Background Check Act; an online check of the Adult Protective Services Registry, as required by the Adult Protective Services Act [320 ILCS 20/7.5(c)]; and a check of the HHS exclusion database and the HFS Office of Inspector General database on all agency staff and all regularly scheduled volunteers having access to financial information or one-on-one contact with CCP participants.
1) Provider agencies shall comply with the requirements of the Health Care Worker Background Check Act and the Adult Protective Services Act.
2) Staff refusing to submit to a background check shall not have contact with CCP participants in any capacity.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1525 Standard Requirements for In-home Service Providers
a) In-home service providers shall maintain a physical facility in each Planning and Service Area (PSA) in which service is provided or have a facility in a neighboring PSA of sufficient capacity to serve all contiguous areas. The facility must be located in a properly zoned location for a business, cannot be operated from a private residence, and must have all of the following:
1) a designated locked storage space for participant records;
2) accessibility of records for all participants served in the PSA when required by Department review staff or designees;
3) a primary business telephone listed under the name of the business locally that allows for reliable, dependable and accessible communication;
4) internet, facsimile and email access; and
5) sufficient office space, office equipment and office support to fulfill the requirements of the Provider Agreement.
b) The in-home service provider shall include, as part of the annual audit report required by the Department, an independent CPA's opinion concerning the provider's compliance with the financial reporting requirements outlined in Section 240.2020. The CPA's opinion may be limited to assurances that:
1) the provider prepared the cost report by using acceptable accounting methods to allocate cost; and
2) the cost reports are supported by provider accounting records.
c) Management staff of the in-home service provider shall be required to complete in-home service management training provided by the Department or its designee.
1) Training shall be completed by the provider prior to the award of a CCP in-home service Provider Agreement.
2) At a minimum, the individual responsible for administration of the CCP in-home service program shall complete this training.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.1530 General In-home Service Staffing Requirements
a) Each in-home service provider shall have specified staff adequate in number to comply with Section 240.1520(f) to carry out the following functions:
1) A designated individual who has responsibility for administration of the CCP in-home service program.
2) Qualified in-home service staff to meet the needs of all cases referred for the provision of in-home services. In determining what services are sufficient, the Department shall look to whether in-home services are adequate. Inadequate in-home services are characterized by delays or interruptions in the provision of in-home services or by failure to provide in-home services as required by the person-centered plan of care.
b) The in-home service provider shall assign responsibilities to staff, including the following:
1) Planning and administration of the in-home service program; assuring adequate staff to provide required services at all times; serving as liaison between the staff and the community; implementing policies according to regulations promulgated by the Department that govern the program; recommending policy and program changes to the Department; and recruiting, training and supervising staff.
2) Supervising of homecare aides shall be accomplished by qualified staff who have responsibility to ensure that the aides are scheduled and that assignments are kept.
c) Each in-home service provider shall ensure that supervisors maintain a maximum 15-minute response time when homecare aides they supervise are serving in a participant's home and request information, assistance or direction as it relates to the participant's status, health or welfare. A supervisor must be available to respond to a homecare aide by available technology, such as by the participant's phone, or the aide's/provider's electronic equipment, email, cell phone, 24/7 live answering system, two-way radio, or any other similar or suitable technology, according to the provider's written procedures.
d) In-home service providers shall not subcontract for management, supervisory or in-home staff.
e) In-home service providers shall make one hour service segments available when needed to meet participant needs.
f) Electronic Visit Verification
1) The Department requires in-home service providers to maintain electronic visit verification (EVV), based on global positioning systems or other cost-effective technology, for monitoring and verifying the work schedules of, and the work performed by, all homecare aides.
2) EVV systems must meet the requirements set forth in Section 240.1531.
g) In-home service providers shall make evening and weekend service available to CCP participants as required by the person-centered plan of care.
1) Evening service shall be available until at least 8 p.m. Monday through Friday.
2) Weekend service shall be available from at least 8 a.m. until 8 p.m. on Saturday and Sunday.
3) Provider offices are not required to be open for business during evening and weekend hours; however, a supervisor must be on-call and available whenever service is being provided.
h) In-home service providers shall provide escort/transportation when required by the person-centered plan of care.
i) In-home service providers may hire relatives and legal guardians of a participants, legally responsible individuals,, or homecare aides who are recommended by a participant, once they have met all applicable CCP requirements and any other agency employment requirements. A relative, legal guardian, legally responsible individual, or homecare aide who is recommended by the participants shall not be required to care for other participants served by the in-home service provider.
j) In-home service providers shall report and regularly update, as required by law, any registry of individuals certified as homecare aides (e.g., the DPH Health Care Worker Registry).
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1531 Electronic Visit Verification (EVV) Requirements for In-home Service Providers
a) EVV is based on global positioning systems or other cost-effective technology and secure applications for monitoring work schedules of homecare aides supplied by and paid for by the in-home service provider agency, including:
1) cellular phone or other mobile devices with activated global positioning systems;
2) Telephony/Integrated Voice Recognition (IVR); or
3) an alternative auditable technology when a phone is not available in the participant's home, such as, but not limited to, a fixed visit verification device installed in the participant's home.
b) An EVV system must meet the following minimum standards:
1) Functional Capacity
A) Verification of Hours Worked
i) The system must maintain accurate time reporting and allow for review/approval of time by the participant or participant designee, including participants with visual and physical disabilities.
ii) The system must allow the participant or designee to manually or electronically verify that services were delivered and that time reporting is accurate.
B) Multiple Input Options
i) The system must include electronic verification options, including a cellular phone or other mobile devices with activated global positioning systems, telephony/IVR, or an alternative auditable technology, when a phone is not available in the participant's home, such as, but not limited to, a fixed visit verification system installed in the participant's home for authentication purposes.
ii) The electronic verification options must include the ability to create and manage related work schedule timesheets and participant service calendars, as authorized in the participant's person-centered plan of care.
C) Flexibility
i) The system must support the addition of services, participants, and homecare aides, as needed.
ii) The system must accommodate multiple participants and/or service provider agencies.
iii) The system must accommodate multiple work shifts (e.g., more than one participant and/or homecare aide in the same home or at the same phone number; participants and homecare aides who live at the same address; multiple work shifts per day per participant/homecare aide combination; homecare aides who work for multiple participants; and participants who have multiple homecare aides).
D) Capacity
i) The system must record new EVV data.
ii) The system must retain all EVV data for up to six years from the last date of service.
iii) The system must retrieve archived data in a timely manner.
E) Tracking
i) The system must document and track unedited sign-in and sign-out times of all homecare aide visits.
ii) The system should allow for multiple sign in/out activities per day to accommodate time tracking for breaks in service, meals, and other service provider agency reporting requirements.
F) Recording Increments: The system must record homecare aide visits in quarter-hour increments and bill to the nearest quarter-hour, consistent with the federal Fair Labor Standards Act (29 USC 201) and related regulations (29 CFR 785.48(b)).
G) Identification (ID) Capture: The system must electronically capture all relevant service visit data, including:
i) participant ID;
ii) service provider agency ID;
iii) homecare aide ID;
iv) date and time that service delivery begins and ends;
v) location of the service; and
vi) CCU and Care Coordinator ID.
H) Access: The system must be accessible for input and/or service approval 24-hours per day, 7 days per week for participants and homecare aides with hearing, physical or visual impairments.
I) Alerts: The system must notify supervisory staff at the service provider agency of any untimely and missed shifts or deviation in schedules.
2) Billing Integration and Data Sharing
A) Real-Time Data
i) The system must enable service provider agencies to obtain real-time data to arrange regular scheduled visits.
ii) The system must enable service provider agencies to respond in a timely manner to missed visits to ensure reliability in the delivery of care.
iii) The system must enable the use of the recorded EVV data for billing, verification, automated billing, and improved administrative efficiencies.
B) Secured Transaction Data
i) The system must enable service provider agencies to upload transactions data to the Department in a secured manner that would facilitate, at a minimum, daily billing data.
ii) The system must enable service provider agencies to securely handle internal billing and/or payroll functions pursuant to the recorded EVV data.
C) Modifications and Adjustments
i) The system must track and report modifications after the direct care staff input their time.
ii) The system must record justification of manual time reporting adjustments or exceptions.
D) Reports and Queries
The system must create user-friendly reports and data files that enable the service provider agency and Department staff to run data queries and facilitate management reports.
3) Data Storage and Security
A) Confidentiality
The system must be compliant with electronic data interchange standards for electronic healthcare transactions pursuant to the Medicaid Information Technology Architecture under the Health Insurance Portability and Accountability Act to ensure security of confidential participant information and medical data.
B) Backup and Recovery
i) The system must maintain reliable backup and recovery processes in the event of a system malfunction or disaster situation.
ii) The system must provide an alternative system for timekeeping due to a service provider agency's temporary failure or inability to use the system for a start or end of the homecare aide's shift.
4) Electronic Reporting Interface
A) The system must be able to provide a secured interface to transmit the EVV visits to the Department's electronic Community Care Program Information System.
B) The interface file must include the homecare aide's Social Security Number or another unique personal identifier acceptable to the Department, visit start times and end times, and any other billing data required by the Department.
5) Disaster Recovery
A) The EVV system must maintain a Disaster Recovery Plan that complies with electronic data interchange standards for electronic healthcare transactions pursuant to the Medicaid Information Technology Architecture under the Health Insurance Portability and Accountability Act, identifying every resource that requires backup, to what extent backup is required and that conducts backup minimally on a daily basis in the event of a system failure.
B) The plan must include offsite electronic and physical storage in the United States, preferably in Illinois, and should include, at a minimum, the following:
i) recovery procedures for all events ranging from a minor malfunction to a major disaster;
ii) for offsite environments, roles and responsibilities of vendor and outsourcer staff;
iii) checkpoint/restart capabilities;
iv) retention and storage of backup files and software;
v) hardware backup for the main processor;
vi) application and operating system software libraries, including related documentation;
vii) identification of the core business processes involved in the system;
viii) documentation of contingency plans;
ix) definition of triggers for activating contingency plans; and
x) plan for replacement of hardware and software.
6) A system is subject to review and audit by the Department.
c) An in-home service provider agency must adopt internal policies and procedures regarding the EVV system.
d) An in-home service provider agency must provide training resources and technical support for their employees on the proper utilization of their EVV systems.
e) An in-home service provider agency must provide help desk or call center access for participants and homecare aides regarding the delivery of services.
f) All in-home service provider agencies are required to file certification and documentation with the Department to verify compliance and implementation of their EVV system.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1535 In-home Service Staff Positions, Qualifications, Training and Responsibilities
a) Homecare Supervisor
1) Activities of a homecare supervisor shall include:
A) documenting participant contacts and activities related to participant services in the participant's file;
B) preparing or reviewing reports and service calendars;
C) monitoring receipt procedures in the conduct of essential shopping and errands as stated in the person-centered plan of care;
D) providing input to the care coordinator on the services that are needed for each participant as a result of conferences with the homecare aide or in-home visits;
E) planning, preparing and documenting contact and quarterly conferences with each assigned homecare aide;
F) evaluating each assigned homecare aide annually;
G) coordinating the homecare aide's activities with other components of the person-centered plan of care as required;
H) making and documenting semi-annual in-home supervisory visits to a participant's home for each assigned homecare aide;
I) making home visits, as necessary, to provide hands-on training and assistance; and
J) initiating and/or participating in participant staffing discussions with the case manager, as necessary.
2) Qualifications for a homecare supervisor shall include:
A) a high school diploma or general education diploma;
B) combination of skills and experience that indicate that the participant has the ability to perform the supervisory activities; and
C) certification of completion of Department sponsored CCP training required by subsection (a)(3)(A).
3) Homecare supervisors shall meet the following training requirements:
A) Within 90 calendar days after the date of employment with the provider agency in a homecare supervisor position, each supervisor shall complete Department sponsored CCP training on policy and procedures, billings, evaluations, homecare aide and participant files;
B) Within each calendar year, each supervisor shall complete 26 hours of documented in-service training on aging related subjects, including documented participation in in-house staff training and/or local, State, regional or national conferences. Two of those hours shall be dementia training which shall include subjects related to Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior. At least 16 of the remaining hours of training shall be selected from among the following topics:
i) Promoting participant dignity, independence, self-determination, privacy, choice and rights;
ii) Person-centered care planning;
iii) Special characteristics of the elderly population; physical, emotional and developmental needs of the participant;
iv) Recognizing participant abuse, neglect, exploitation, and self-neglect; abuse and neglect prevention and reporting requirements;
v) Communication skills;
vi) Universal precautions, blood-borne pathogens and infection control;
vii) Fire and life safety, including emergency procedures to be implemented under the agency's all hazards disaster operations plan;
viii) Dealing with adverse behaviors (e.g., mental illness, depression and aggression);
ix) Family dynamics;
x) Diseases of the elderly;
xi) Body mechanics and normal range of motion, transfer techniques and positioning;
xii) Chronic illness, death and dying;
xiii) Medicaid fraud and abuse;
xiv) Appropriate and safe techniques in performing and assisting with personal care;
xv) First aid and/or cardiopulmonary resuscitation (CPR);
xvi) Understanding advance directives;
xvii) Respiratory services;
xviii) Use of seclusion and restraint.
b) Homecare Staff
1) Activities of homecare aides include the following:
A) following a participant's written person-centered plan of care;
B) carrying out duties as assigned by the supervisor;
C) observing the participant's functioning and reporting to the homecare supervisor;
D) providing necessary receipts and documentation in the conduct of essential shopping/errands;
E) maintaining records of daily activities, observations, and direct hours of service; and
F) attending pre-service training, in-service training sessions and staff conferences.
2) Qualifications of a homecare aide shall include:
A) one of the following types of education or experience:
i) a high school diploma or general education diploma;
ii) one year of employment in a comparable human service capacity, or experience in care for a dependent child or adult family member; or
iii) demonstration of continued progress towards meeting the educational requirement of a general education diploma by current registration and evidence of successful completion of course work (successful completion means achievement of a grade of "C" or higher); and
B) the training required in subsection (b)(3).
3) Homecare aides shall meet the following training requirements:
A) 24 hours of initial pre-service training, including agency orientation of not more than two hours, prior to assignment to provide services to a CCP participant without a supervisor or trainer present (not to exceed a six month period from the training to first assignment). Initial homecare aide training shall be subject to a competency evaluation conducted by the agency and include all in-home services (see Section 240.210), as well as the following additional topics:
i) The homecare aide's job responsibilities and limitations;
ii) Communication skills, including communicating with special participant populations such as the hearing impaired and participants with dementia or other special needs;
iii) Observation, reporting and documentation of participant status and of the service furnished;
iv) Performance of specific service components of in-home services authorized under Section 240.210(a), including, but not limited to, personal care tasks for participants that are not medical in nature (e.g., shaving, hair shampooing and combing, bathing and sponge bath, shower bath or tub bath, toileting, dressing, nail care, respiratory services, brushing and cleaning teeth or dentures and preparation of appropriate supplies, positioning/transferring participant, and assisting participant with exercise/range of motion);
v) Ability to assist in the use of specific adaptive equipment, if the aide will be working with participants who use the device;
vi) Basic hygiene and basic infection control practices;
vii) Maintenance of a clean, safe and healthy environment;
viii) Basic personal and environmental safety precautions;
ix) Use of seclusion and restraint;
x) Recognizing emergencies and knowledge of emergency procedures;
xi) Confidentiality of participant personal, financial and health information;
xii) Knowledge and understanding of abuse and neglect prevention and reporting requirements;
xiii) Respiratory services;
B) a new employee may be exempt from pre-service training, but not mandated dementia training, if the employee:
i) has had previous documented and supervised training within the past two years prior to this employment, equivalent to 24 hours of homecare aide pre-service training, as determined by the provider with appropriate documentation in the employee's personnel file; or
ii) has a valid RN, LPN, MD, physician assistant license or certification as a CNA and has been employed in the field within the past two years; or
iii) has been employed as a CCP homecare aide within the past year;
C) a minimum of 12 hours per calendar year of interactive, (face-to-face, audiovisual presentations, computer-based instruction, etc.) in-service training approved by the provider agency shall be mandatory for all homecare aides. Two of those hours shall be mandatory dementia training which shall include subjects related to Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior. Pre-service training shall fulfill the first three hours of in-service training required for new employees, except for homecare aides exempted under subsection (b)(3)(B). In-service training for homecare aides shall include at least 9 hours of training selected from among the following topics:
i) Promoting participant dignity, independence, self-determination, privacy, choice and rights;
ii) Special characteristics of the elderly population; physical, emotional and developmental needs of the participant;
iii) Recognizing participant abuse, neglect and/or exploitation; abuse and neglect prevention and reporting requirements;
iv) Confidentiality of participant information;
v) Communication skills;
vi) Universal precautions, blood-borne pathogens and infection control;
vii) Fire and life safety, including emergency procedures to be implemented under the agency's all hazards disaster operations plan;
viii) Dealing with adverse behaviors (e.g., mental illness, depression and aggression);
ix) Family dynamics;
x) Diseases of the elderly;
xi) Body mechanics and normal range of motion, transfer techniques and positioning;
xii) Chronic illness, death and dying;
xiii) Medicaid fraud and abuse;
xiv) Cultural diversity;
xv) Food, nutrition and meal planning and preparation, including special diets;
xvi) Maintenance of a clean, safe and healthy environment, including laundry and house cleaning skills;
xvii) Appropriate and safe techniques in performing and assisting with personal care;
xviii) Assistance with self-administered medications;
xix) Recognizing changes in bodily functions that should be reported to the supervisor;
xx) Respiratory services;
xxi) Use of seclusion and restraint;
xxii) First aid and/or CPR;
xxiii) Understanding advance directives; and
D) progress toward certification in a related field (e.g., CNA) may be used for up to three hours of in-service training per calendar year.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1541 Minimum Equipment Specifications for Emergency Home Response Service
a) All EHRS equipment must be tested, approved, and meet the requirements in the Department's EHRS equipment and service policies found at the partner portal on the Department website.
b) All home units must be capable of signaling from both the activation device remote and the base unit.
c) Activation Device Specifications
1) The activation device must be a portable and water-resistant type of wireless remote that meets the requirements in the Department's EHRS equipment and service policies.
2) The activation device must be capable of conducting automatic battery testing and transmitting the results through the base unit to the support center on a regular basis.
3) An adaptive version of the activation device must be available that can be used by hearing, mobility and visually-impaired participants.
d) Base Unit Specifications
1) The base unit must meet the Department's requirements including:
A) an easily identifiable indicator to verify whether the batteries on the activation device and base unit are charged;
B) an easily identifiable indicator that notifies the participant when the support center has received a signal;
C) a battery that automatically charges whenever the base unit is powered and that maintains a charge for at least 12 hours when the electric power to the base unit is interrupted;
D) transmission capability to signal the support center if the base unit battery fails or has a low charge, or electric power to the base unit is interrupted;
E) the ability to allow two-way communication between the participant's home and the support center. The support center must be able to control both the microphone sensitivity and speaker volume; and
F) appropriate certification by the Federal Communications Commission under 47 CFR 15 and 47 CFR 68.
2) The base unit must give both audible and visual confirmation of the signal status using digitized voice technology and lighting cues to help the participant stay calm while waiting on his or her designated emergency contact or other appropriate response to the situation directed by the support center.
3) The base unit must reattempt signaling on a regular basis until the support center confirms its receipt.
e) Support Center Specifications
1) The EHRS support center must have back-up monitoring capacity to take over all monitoring functions and handle all incoming emergency signals. It must have a back-up battery and electrical generating capacity, as well as telephone line monitoring abilities.
2) All EHRS support center and back-up center equipment, at a minimum, must:
A) monitor the EHRS system for the receipt of incoming signals from connected base units in participants' homes, including test transmissions and fault conditions, on a continuous basis;
B) have an audible and visual alarm for the notification of all signals, including test transmissions and fault conditions;
C) direct an appropriate response within one minute of the receipt of a signal as an operational average without disrupting or terminating the connection to the base unit in the participant's home, 24 hours a day, 365 days a year, including interpretation services and communication facilitated by a teletypewriter (TTY) communication device for individuals experiencing hearing loss or impairment;
D) provide technical support as required, 24 hours a day, 365 days a year;
E) identify each participant and simultaneously record all communication among the participant, support center and responder, as applicable, for all signals, including test transmissions and fault conditions;
F) display, print and archive the participant identifier, date, time, communication and response period for each incoming signal, which must be maintained for at least a three year period for quality control and liability purposes;
G) have an uninterruptible power supply back-up that will automatically take over system operation in the event electric power to the support center is interrupted, other type of malfunction occurs, or repairs are needed. The back-up power supply must be sufficient to operate the entire system for a minimum of 12 hours;
H) have separate and independent primary and back-up receivers, computer servers, databases, and other components to provide an uninterruptible monitoring system in the event of equipment malfunction;
I) perform self-diagnostic testing for malfunctions in equipment in participant homes and at the support center, and for fault conditions in the primary and back-up operating systems and power supply at the support center, that could interfere with receiving and responding to signals, such as non-operational receivers and transmitters, signals received with no communications, telephone line outages, power loss, etc.; and
J) maintain appropriate certification by the Federal Communications Commission under 47 CFR 15 and 47 CFR 68.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1542 Administrative Requirements for Emergency Home Response Service Providers
a) In order to qualify for certification, a provider agency must, to the satisfaction of the Department:
1) meet the administrative requirements under Section 240.1505;
2) meet the certification requirements under Section 240.1600 or 240.1605;
3) provide assurance that its equipment and support center are in continual compliance with the technology requirements imposed under Section 240.1541;
4) maintain adequate records for administration, audit, budgeting, evaluation, operation and planning efforts by the Department in offering EHRS as a service through the CCP, including participant records, which shall include, but are not limited to:
A) dates and times of all signaling, and the name of the emergency responder for each signaling;
B) dates and times of all equipment tests; and
C) disposition of all emergency signaling;
5) ensures equipment meets the requirements in the Department's equipment and service policies;
6) complete management training provided by the Department or its designee:
A) Training shall be completed by management staff (e.g., managers, supervisors, billing agents) of the EHRS provider prior to the award of a EHRS contract;
B) At a minimum, the individuals responsible for administration of the EHRS program at the provider agency shall complete this training;
C) The Department is authorized to charge a reasonable fee for this training to cover related administrative costs.
b) If a EHRS provider is not able to meet these administrative requirements, then the Department shall deny its request for a certification of qualifications under Section 240.1600.
c) All employees of an EHRS provider must complete two hours of dementia training within 30 days of the start their employment and every calendar year thereafter. This training must include the following subjects: Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1543 Minimum Equipment Specifications for Automated Medication Dispenser Service
a) An AMD unit/equipment must be capable of portability to be temporarily transferred to another non-institutional residence in Illinois without additional fees.
b) AMD Unit Specifications
1) The AMD unit must be a portable mechanical system configured with:
A) all the cords and interfaces needed for installation;
B) an internal battery:
i) capable of operating as a power source for a minimum of three years;
ii) that automatically charges whenever the base unit is powered; and
iii) maintains a charge for at least 12 hours when the electric power to the base unit is interrupted;
C) the ability to verify whether the batteries on the base unit are charged and when the battery charge is low;
D) components certified as appropriate by the Federal Communications Commission (FCC) under 47 CFR 15 and 68;
E) appropriate Underwriters Laboratories (UL) safety standards (UL 60950 and 60950-1) certification for battery powered technology equipment;
F) an integrated unit that connects to either a telephone line or wireless/cellular system that does not interfere with the normal use of the telephone or other devices using the telephone line, such as Emergency Home Response Service;
G) an Underwriters Laboratory (UL) approved plug as the connector to a standard residential electrical outlet for its power supply; and
H) transmission capability to signal the support center or notify the participant/authorized representative/assisting party if the base unit battery fails or has a low charge, or if electric power to the base unit is interrupted.
2) The AMD unit must have the following operating features:
A) ability to be loaded, programmed and changed to add and remove medications, including:
i) local or remote programming accessibility;
ii) medication dispensed at least four times a day; and
iii) alerting the participant at the times programmed for dispensing medication;
B) ability to be filled with medications, including:
i) holding at least seven days' supply of medications;
ii) holding multiple medications in individual compartments;
iii) access to medication for an early dose option; and
iv) locking after the medication is loaded;
C) ability to alert the participant when it is time to take medications at least every five to ten minutes for at least 60 minutes until the dose is taken or the dose is locked, including:
i) using verbal, auditory or visual prompts such as flashing lights and audible tones or verbal instructions, which may also provide messages to take medication that cannot be stored in the machine (e.g., take medications with food; time to take insulin) based on the individual's needs; and
ii) dispensing medications at the correct time of day in the correct combinations and in the correct quantities;
D) use privacy-protected and secure methods of communication with the participant/authorized representative/assisting party, including:
i) notification when battery is low or unit is jammed, or if the participant has not taken the medication within 90 minutes after the prescribed time;
ii) contact by the unit or support center to the participant/authorized representative/assisting party to assure adherence or needed intervention; and
E) ability to securely transmit information and provide data to the participant/authorized representative/responsible party, the Department or its designees.
3) The AMD unit must be capable of conducting automatic battery testing and transmitting the results through the AMD unit to the support center on an ongoing basis.
4) If an AMD unit is a Class I medical device, the AMD unit is subject to the General Controls mandated by the Federal Food and Drug Administration, including provisions that relate to adulteration (21 U.S.C. 351); misbranding (21 U.S.C. 352); device registration and listing (21 U.S.C. 360); notification, including repair, replacement, or refund (21 U.S.C. 360h); records and reports (21 U.S.C. 360i); and restricted devices (21 U.S.C. 520(e)). In addition, the manufacturer of the device must fulfill requirements under 21 CFR 820.180 (Record keeping) and 820.198 (Complaint files). If an AMD unit has enhanced features, such as remote capability, it may be classified as a Class II medical device and must then meet applicable Special Controls under the FDA.
5) The AMD unit must have adaptations for operation by participants who have functional, hearing or visual impairments, and language barriers at no extra cost to the participants.
c) Support Center Specifications
1) The AMD support center must have back-up monitoring capacity to take over all medication dispenser notification functions, monitoring and technical support functions.
2) The AMD back-up monitoring center must be at a location different from the primary center, on a different power grid system, and on a different telephone trunk line. It must have a back-up battery and electrical generating capacity, as well as telephone line and wireless/cellular system monitoring abilities. If the back-up center is in the same city as the support center, the AMD provider must provide assurances that back-up can be maintained in the event of a natural disaster.
3) All AMD support center and back-up center equipment, at a minimum, must:
A) monitor the AMD system for the receipt of incoming signals from an installed and programmed AMD unit in a participant's residence, including missed medication doses, power interruptions and outages, and test transmissions and fault conditions, on a continuous basis;
B) direct an appropriate response to the receipt of a signal immediately via texts/emails to the assisting party and other designees and call the assisting party and other designees within 90 minutes after missed medications and within eight hours after power interruptions and outages;
C) provide technical support as required, 24 hours a day, 365 days a year;
D) identify each participant and simultaneously record all communication between the participant/authorized representative/assisting party and the support center, as applicable, for all signals, including missed medication doses, test transmissions and fault conditions;
E) display, print and archive the individual identifier, date, time, communication and response for each signal, test and fault condition, which must be maintained for at least a three-year period of time for quality control and liability purposes;
F) have an uninterruptible power supply back-up that will automatically take over system operation in the event electric power to the support center is interrupted, other type of malfunction occurs, or repairs are needed. The back-up power supply must be sufficient to operate the entire system for a minimum of seven calendar days;
G) have separate and independent primary and back-up systems, computer servers, databases, and other components to provide an uninterruptible monitoring system in the event of equipment malfunction;
H) perform self-diagnostic testing for malfunctions in the unit/equipment in a participant's residence and at the support center, and for fault conditions in the primary and back-up operating systems and power supply at the support center, that could interfere with receiving and responding to signals, such as non-operational AMD units, messages sent from the AMD unit to the participant/authorized representative/assisting party or designees without confirmation of receipt, telephone line outages, power loss, etc.;
I) capability to centrally generate medication compliance data and reports as requested by the Department;
J) have quality management systems that include tracking and trending of data, response times and dispositions; and
K) maintain appropriate certification by the FCC under 47 CFR 15 and 68, if applicable.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1544 Administrative Requirements for Automated Medication Dispenser Service Providers
a) In order to qualify for certification, an Automated Medication Dispenser (AMD) provider must, to the satisfaction of the Department, meet and comply with all applicable rules, including but not limited to:
1) meet the administrative requirements and minimum administrative standards under Sections 240.1505 and 240.1510;
2) meet the applicable responsibilities imposed on provider agencies set forth in Section 240.1520;
3) meet the certification requirements under Sections 240.1600 or 240.1605;
4) provide assurance that its equipment and support center are in continual compliance with the business and technology requirements imposed on provider agencies under Section 240.1543;
5) provide assurance that its business operations comply with the service, staffing and training requirements under Section 240.237;
6) attend and complete management training provided by the Department or its designee:
A) Training shall be attended and completed by management staff (e.g., managers, supervisors, billing agents) of the AMD provider prior to the award of a CCP AMD contract from the Department;
B) At a minimum, the individual responsible for administration of the CCP AMD program at the provider agency shall attend and complete this training;
C) The Department is authorized to charge a reasonable fee for this training to cover related administrative costs;
7) accept all correspondence from the Department and maintain adequate records for administration, audit, budgeting, evaluation, operation and planning efforts by the Department in offering the AMD service through the CCP, which shall include, but are not limited to:
A) records of all referrals, including the disposition of each referral;
B) participant records, which shall include, but are not limited to:
i) applicable forms required by the Department;
ii) dates and times of all AMD notifications and communications with the participant/authorized representative/assisting party or designees;
iii) disposition of all participant/authorized representative/assisting party or designees communications;
iv) dates and times of all equipment tests and system interruptions; and
C) administrative records, including but not limited to:
i) service statistics;
ii) complaint resolution;
iii) billing and payment information plus the underlying documentation to support the units of service submitted to the Department for reimbursement; and
8) comply with all applicable federal, State and local laws, regulations, rules, service standards and policies or procedures pertaining to the AMD provider in its business operations and to the services provided under the CCP.
b) If an AMD provider is not able to meet these administrative requirements, the Department shall deny its request for a certification of qualifications under Section 240.1600.
c) All employees of an AMD provider must complete two hours of dementia training within 30 days of the start of their employment and every calendar year thereafter. This training must include the following subjects: Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1550 Standard Requirements for Adult Day Service Providers
a) An adult day service provider shall have on file and utilize written procedures to manage storage and administration of medications, including:
1) storing and locking medications;
2) labeling medications brought to the adult day service provider's site; and
3) ensuring that:
A) prescribed medication is administered by an appropriately licensed professional to those adult day service participants who are determined to be unable to self-administer medications;
B) judgment of a participant's inability to self-administer medications shall be documented by a physician's order or the CCU person-centered plan of care and/or the adult day service person-centered plan of care addendum by the program nurse;
C) administration of all medications administered by the adult day service provider staff (prescription and non-prescription) are recorded in the participant's case record; and
D) physician orders for medication are utilized and filed in the participant's case record.
b) A facility that houses an adult day service program (including satellite sites) shall meet the following criteria:
1) A location will have a home and community-based setting that allows for services to be provided in the most integrated setting appropriate for each participant without having the effect of isolating any participant from the broader community. (See 42 CFR 441.301(c)(5)(v) and 42 CFR 441.301(c)(4)(i).)
A) An integrated setting will:
i) ensure a participant's rights of privacy, dignity and respect and freedom from coercion and restraint;
ii) optimize, but not regiment, participant initiative, autonomy, and independence in making life choices, including daily activities, physical environment, and with whom to interact (See 42 CFR 441.301(c)(4)(iv)); and
iii) facilitate participant choice regarding services and supports, and who provides them.
B) A location is not presumed to be a home and community-based setting if set in a publicly or private-owned facility providing inpatient treatment; on the grounds of, or adjacent to, a public institution; or with the effect of isolating participants from the broader community of individuals not receiving Medicaid Waiver services, as determined by the federal Centers for Medicare and Medicaid Services on a case-by-case basis.
2) There shall be a minimum of 40 square feet of activity area per participant. (Multiple-use areas must be pro-rated on both time and participant basis.) The activity area in the square feet per participant requirement is exclusive of exit passages and fire escapes, administrative space, storage areas, bathrooms, kitchen used for meal preparation, space required for equipment and gymnasiums or other areas when used exclusively for active sports.
3) All adult day service providers shall comply with the applicable provisions of the following codes and standards.
A) State of Illinois Codes and Standards
|
|
Code or Standard |
Agency |
|
i) |
Ill. Plumbing Code (77 Ill. Adm. Code 890) |
Department of Public Health or its authorized local designee |
|
ii) |
Illinois Accessibility Code (71 Ill. Adm. Code 400)
Environmental Barriers Act [410 ILCS 25] |
Capital Development Board offers guidance to design professionals and building code officials regarding the interpretation and application of the Illinois Accessibility Code |
|
|
|
NOTE: It shall be incumbent upon the provider to assure that its facility meets all applicable requirements as promulgated by the Capital Development Board. (No written documentation shall be required.) |
|
iii) |
Fire Prevention and Safety (41 Ill. Adm. Code 100) |
Office of State Fire Marshal |
|
iv) |
Illinois Vehicle Code [625 ILCS 5] |
Secretary of State of Illinois |
|
v) |
Food Service Sanitation (77 Ill. Adm. Code 750) |
Department of Public Health or its authorized local designee |
B) Other Codes and References
|
|
Code or Standard |
Agency |
|
i) |
National Fire Protection Association, 1 Batterymarch Park, Quincy MA 02169-7471 (NFPA 101 Life Safety Code: Chapters 16 and 17; 2018 edition; this incorporation includes no later editions or amendments) |
National Fire Protection Association and Office of State Fire Marshal shall inspect |
|
ii) |
Americans With Disabilities Act (42 U.S.C. 12101 et seq.) |
|
C) In addition to compliance with the standards set forth in this subsection (b)(3), all applicable local and State building, fire, health and safety codes, ordinances and regulations that are enforced by city, county or other local jurisdictions in which the facility is, or will be, located must be observed and documented through required inspections by appropriate officials.
4) Each facility shall have posted an emergency plan for evacuation and shall conduct quarterly fire drills in accordance with subsection (b)(3)(B)(i). Written documentation of the dates of the quarterly fire drills must be on file at the facility. A diagram of emergency evacuation routes shall be posted, at a minimum, in all corridors and common areas. All personnel employed on the premises shall be aware of the routes.
5) Each facility shall maintain room temperatures in the facility of not less than 70 degrees Fahrenheit and not more than 85 degrees Fahrenheit by utilizing heating system/air conditioning/circulating fans.
6) Each facility shall designate a dining area (equipped with enough chairs and table space) to accommodate the daily number of participants.
7) Each facility shall have and maintain in working order during operating hours at least one bathroom facility that is physically accessible to persons with disabilities for up to 12 participants and a minimum of 2 bathroom facilities (one accessible to persons with disabilities) to serve 13 or more participants.
8) Each facility shall have locked space for storage of office equipment, chemicals/cleaning products and other hazardous supplies.
9) Hot water temperatures shall be controlled to not exceed 119 degrees, but shall not be less than 100 degrees, Fahrenheit in all locations where participants have access to dispensing hot water, including bathroom facilities through appropriate plumbing mechanisms (e.g., anti-scald devices, pumps, and/or hot water tank thermostat settings). Hot water temperatures at all locations within the ADS shall be checked weekly and a written log shall be securely kept in the main administrative office.
10) Unsupervised participants shall not be allowed in the kitchen if water temperatures are not controlled as required in subsection (b)(9). Participants should not be allowed in areas where supplies/medications are stored or where a microwave is in use unless supervised.
11) Each facility shall have at least one quiet place equipped with a reclining chair, cot or bed where a participant may rest.
12) Exit areas shall be clear of equipment and debris at all times and shall be equipped with monitoring or signaling devices to alert staff to participants leaving the facility unattended.
13) One landline telephone capable of accessing and being located by a 911 emergency response system, if available in the area, shall be immediately available within the activity area for participants. A list of emergency numbers shall be posted by the telephone.
14) Supplies and equipment for emergency first aid shall be immediately accessible to activity areas for participants.
c) An adult day service provider (including each satellite site) shall meet the following criteria relative to meals provided to participants (prepared on-site or contractual):
1) The adult day service provider shall provide to each participant one meal at mid-day that meets the Dietary Guidelines for Americans, 2015-2020, 8th edition, published by the Secretary of Health and Human Services and the Secretary of Agriculture; and provide each participant a minimum of 33½ percent of the Dietary Reference Intakes (DRI) as established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences. Supplementary nutritious snacks shall also be provided. The adult day service provider shall provide modified diets as directed by the participant's physician.
2) Adult day service providers (whether meals are prepared on-site or contractually) shall:
A) Have menus approved and so documented by the registered dietitian. Menus shall reflect portion sizes as appropriate.
B) Post menus in advance in a location visible to the participants within the adult day service facility.
C) Assure that menus are planned for a minimum of four weeks on a menu form.
D) Develop methods and follow written procedures to control portion sizes and to meet the one-third daily dietary reference intakes recommended.
E) One employee at each adult day service site, either handling/preparing or supervising the handling/preparing of foods, shall meet DPH Food Service Sanitation rules (77 Ill. Adm. Code 750).
F) Have on file and follow written procedures for receiving and storing food that must include:
i) verification of food quantities;
ii) checking and documentation of food temperatures at time of delivery and serving;
iii) equipment to be utilized;
iv) procedures to follow for foods that arrive above or below temperature, deteriorated food and food shortages.
G) Ensure that catered meals are transported in equipment that maintains temperatures of hot food at 140 degrees Fahrenheit, or above, and cold foods at 41 degrees Fahrenheit, or below. Foods shall be maintained and served at the above temperatures at the adult day service site.
H) Ensure that potentially hazardous foods (i.e., food that consists in whole or in part of milk, milk products, eggs, meat, poultry, fish, shellfish or other ingredients, including synthetic ingredients, in a form capable of supporting rapid and progressive growth of infectious or toxigenic microorganisms) intended to be served cold shall be pre-chilled and transported/maintained at a temperature of 41 degrees Fahrenheit, or below. Potentially hazardous food intended to be served hot shall be transported/maintained at a temperature of 140 degrees Fahrenheit, or above.
I) Ensure that potentially hazardous foods prepared on-site shall be prepared in accordance with required cooking temperatures as specified by 77 Ill. Adm. Code 750 and maintained until service at 140 degrees Fahrenheit, or above, for hot foods and 41 degrees Fahrenheit, or below, for cold foods.
J) If food is prepared by a caterer, the adult day service provider shall keep a copy of the current caterer's inspection certificates/letters on file to verify that the operation complies with all health, safety and sanitation regulations.
d) An adult day service provider (including each satellite site) shall comply with applicable requirements of the current Illinois Vehicle Code [625 ILCS 5] and meet the following criteria relative to transportation provided to participant's (directly or contractually):
1) Adult day service provider vehicles that transport participants shall be equipped with a working two-way communications device and written procedures to be followed in the event of an emergency.
2) An adult day service provider that uses its own vehicles to transport participants shall have on file and utilize written procedures to ensure, to the extent possible, that safe transportation is provided.
3) An adult day service provider that subcontracts with another entity to transport participants shall have on file and incorporate written procedures in the service agreement to ensure, to the extent possible, that safe transportation is provided.
e) Adult day service providers shall acquire and have on file an emergency contact and a recent photograph of each participant for emergency purposes.
f) An adult day service provider shall provide services to all participants in the CCP referred by the CCU, except:
1) participants who do not meet the adult day service provider's admission criteria; and
2) participants whose condition warrants discharge under the adult day service provider's discharge criteria.
g) It is the adult day service provider's responsibility to advise the primary caregiver, the participant's care coordinator and/or appropriate professional of any changes in the participant's health or functional ability.
h) Management staff of the adult day service provider shall be required to complete adult day service management training.
1) Training shall be completed by the provider prior to the award of a CCP adult day service contract from the Department.
2) At a minimum, the provider Program Administrator, or Program Coordinator/Director if also functioning as the Program Administrator, shall complete this training.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1555 General Adult Day Service Staffing Requirements
a) A separate and identifiable staff must be designated for sole use by the adult day service program.
b) Each adult day service provider shall have at the adult day service site adequate personnel in number and skill to comply with subsection (c) and Section 240.1520(f) and to provide for:
1) program and fiscal administration;
2) nursing and personal care services;
3) nutritional services;
4) planned therapeutic/recreational activities;
5) obtaining prompt services of emergency personnel and hospitalization, if needed;
6) immediately notifying the participant's authorized representative or family member of any illness, accident or injury to the participant;
7) provision/arrangement of transportation services to and from the adult day service site;
8) record keeping;
9) development, implementation and semi-annual review of individualized person-centered plans of care;
10) program evaluation and marketing;
11) supervision and evaluation of staff;
12) monitoring and meeting staff training needs; and
13) maintenance of a clean and safe physical environment.
c) The minimum ratio of full-time staff (qualified adult day service staff, trained volunteers or substitutes) or full-time equivalent (FTE) staff present at the adult day service site to participants, when participants are in attendance, shall be:
|
Staff |
Participants |
|
2 |
1 to 12 |
|
3 |
13 to 20 |
|
4 |
21 to 28 |
|
5 |
29 to 35 |
|
6 |
36 to 45 |
1) Add one additional staff person for each seven additional participants.
2) Fifty percent or more of a staff member's time shall be spent in on-site direct service or supervision on behalf of one or more participants in order to be considered in the ratio.
3) Staff included in the staff-participant ratio shall include only those who work on site, are actively involved with the participants, and are immediately available in the activity area, except for during client drop-off and pick-up times in normal business hours, to meet the participants' needs.
d) Each adult day direct service contact employee shall have:
1) Pre-service Training
Pre-service training totaling a minimum of 26 hours training within the first week of employment (exclusive of orientation). Two of those hours shall be mandatory dementia training which include shall include subjects related to Alzheimer's Dementia and Related Disorders; Safety risks; and Communication and behavior. A worker may be exempted from pre-service training, but not dementia training, by the provider if the worker has had previous documented training equivalent to 24 hours, with another CCP agency, or in a related field, within the past two years prior to this employment or is an active CNA or CMA or holds a valid RN or LPN license, and/or a BA, BS, BSW or higher degree. At least 18 hours of the remaining training selected from the following topics:
A) Purpose and goals of adult day service;
B) Facility, environmental and safety considerations;
C) Assistance with activities of daily living;
D) Basic principles of personal care;
E) Dealing with adverse behaviors: wandering, aggression, mental illness and depression;
F) Promoting participant dignity, independence, self-determination, privacy, choice and rights;
G) Understanding aging and functionally-impaired persons;
H) Recognizing participant abuse, neglect and/or exploitation; abuse and neglect prevention and reporting requirements;
I) Confidentiality of participant information;
J) Communication/interaction skills;
K) Universal precautions, blood-borne pathogens and infection control;
L) Fire and life safety, including emergency procedures to be implemented under the agency's all hazards disaster operations plan;
M) Family dynamics;
N) Body mechanics and normal range of motion, transfer techniques and positioning;
O) Cultural diversity;
P) Recognizing changes in bodily functions that should be reported to the supervisor;
Q) Nutrition and safe food handling;
R) CPR and first aid;
S) Participant activities;
T) Respiratory services;
U) Use of seclusion and restraint.
2) In-service Training
A minimum of 14 hours of in-service training for continuing education per year shall be mandatory for all adult day service employees. Pre-service training received under subsection (d)(1) shall fulfill the continuing education requirement for new employees for the first year. Two of those hours shall be mandatory dementia training which include shall include subjects related to Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior. At least the remaining nine hours of training selected from among the following topics:
A) Responding to emergency situations, including, but not limited to, site-related emergencies (e.g., late pick-up of participants), participant-related emergencies (e.g., participants leaving the site unattended), choking prevention and intervention techniques;
B) Appropriate and safe techniques in performing and assisting with personal care;
C) Developing and improving participant centered activities;
D) Modification of the environment to support engagement/well-being;
E) Promoting participant dignity, independence, self-determination, privacy, choice and rights;
F) Special characteristics of the elderly population; physical, emotional and developmental needs of the participant;
G) Recognizing participant abuse, neglect and/or exploitation; abuse and neglect prevention and reporting requirements;
H) Confidentiality of participant information;
I) Communication skills;
J) Universal precautions, blood-borne pathogens and infection control;
K) Fire and life safety, including emergency procedures to be implemented under the agency's all hazards disaster operations plan;
L) Dealing with adverse behaviors, e.g., mental illness, depression, aggression and wandering;
M) Family dynamics;
N) Body mechanics and normal range of motion, transfer techniques and positioning;
O) Chronic illness, death and dying;
P) Medicaid fraud and abuse;
Q) Cultural diversity;
R) Recognizing changes in bodily functions that should be reported to the supervisor;
S) CPR and first aid;
T) Understanding advance directives;
U) Nutrition and safe food handling;
V) Respiratory services;
W) Use of seclusion and restraint.
3) Progress toward certification in a related field (e.g., CNA) may be used for up to three hours of in-service training per calendar year.
4) All provider employees not in receipt of Department training certificates must complete two hours of dementia training within 30 days of the start of their employment and every calendar year thereafter. This training must include the following subjects: Alzheimer's Dementia and Related Disorders; Safety Risks; and Communication and Behavior.
e) At least two program adult day service staff shall be certified in CPR and trained in first aid, and at least one trained staff shall be on-site when participants are present.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1560 Adult Day Service Staff
a) The following staff qualifications shall be required throughout the term of the contract of all adult day service providers (with specified exceptions):
1) An Adult Day Service Program Administrator shall:
A) Meet the following qualifications:
i) have a bachelor's degree in a health or human services or related field (including social or health sciences, public administration or physical education) or be a Registered Nurse or Health Services Administrator; or
ii) demonstrate two years of progressively responsible supervisory experience in a program serving the elderly for each year of education being replaced (up to 4) in the disciplines defined in subsection (a)(1)(A)(i).
B) The responsibilities of the Administrator may be performed by the Program Coordinator/Director. If the Administrator's function is also performed by the Program Coordinator/Director, only the qualification requirements for Program Coordinator/Director apply.
2) An Adult Day Service Program Coordinator/Director shall:
A) Meet the following qualifications:
i) have a bachelor's degree in health or human services, social or health sciences, physical education, or related field;
ii) be a Registered Nurse; or
iii) demonstrate two years of progressively responsible supervisory experience in a program serving the elderly for each year of education being replaced (up to four) in the disciplines defined in subsection (a)(2)(A)(i).
B) Be on duty full time when participants are in attendance or have a qualified substitute (meets or exceeds the qualifications set out in subsection (a)(2)(A)(i) through (iii)).
3) A program nurse shall be:
A) a RN or LPN under the supervision of a RN (RN may be contractual and must meet with the LPN at least monthly to review person-centered plans of care and medication administration records, and be available to provide direction as needed);
B) on duty at least one-half of a full-time (FTE) work period each day when participants are in attendance, either as staff or on a contractual basis; and
C) full time, if also serving as the Program Administrator or Program Coordinator/Director, and shall meet the qualifications for a program nurse and fulfill responsibilities for all assigned positions.
4) A transportation Driver/Escort (provider employed or contractual) for those adult day service providers who provide the transportation service component shall:
A) meet all applicable requirements of the Illinois Vehicle Code [625 ILCS 5];
B) be certified in CPR and trained in first aid; and
C) have the appropriate driver's license or endorsements based upon the size and type of the vehicle being driven.
5) Nutrition Staff:
A) Nutrition staff (provider employed or contractual) shall include:
i) at least one staff person who meets the requirements of the Food Service Sanitation Code (77 Ill. Adm. Code 750).
ii) a Nutrition Consultant/Dietitian, either paid or in-kind, who shall be licensed by the Department of Financial and Professional Regulation with experience in an agency setting and who shall approve menus for adult day service providers to meet requirements stated in subsection (a)(5)(B).
B) The nutrition staff is responsible for providing daily meals meeting requirements specified in Section 240.230(a)(5).
b) The following optional staff, either contractual or employed by an adult day service provider, shall meet the specified qualifications:
1) A social service worker shall:
A) be under the direction of the Program Coordinator/Director;
B) possess a Bachelor's degree in Social Work or a related field and have at least one year's work experience, preferably with programs for the elderly and disabled; and
C) if the social service worker function is performed by the Program Administrator or Program Coordinator/Director, that person must be full time, and must meet the qualifications for a social worker and fulfill responsibilities for all assigned positions.
2) Program assistants shall have a high school diploma or general education diploma, or two years of prior documented experience working in programs for the elderly, or demonstrate continued progress towards meeting the educational requirement of a general education diploma by current registration and evidence of successful completion of course work.
3) A medical consultant shall be a physician with an active license.
4) A rehabilitation consultant shall be licensed, registered or certified by the Department of Financial and Professional Regulation in a discipline that relates to rehabilitation.
c) The following requirements shall apply to substitutes for staff positions and/or regularly scheduled volunteers/students/student interns utilized by an adult day service provider:
1) the adult day service provider shall have on file information documenting the same personal, health, administrative and professional qualifications for substitutes as are required of staff for whom they act as substitutes;
2) persons agreeing to be available as substitutes or for use in emergencies shall sign a written statement kept on file at the adult day service site, certifying to their availability and agreement to serve in the particular capacity. The file of each person serving in this capacity shall contain such a statement for each calendar year of availability;
3) volunteers/students/student interns shall complete an application indicating their reason for participation in the program and special skills;
4) volunteers/students/student interns may serve in any capacity for which they are qualified (refer to subsection (c)(1));
5) substitutes and volunteers/students/student interns shall be supervised by the staff person supervising the function to which the volunteer or substitute is assigned;
6) substitutes and volunteers/students/student interns who are not used to meet program requirements are exempt from pre-service and in-service training requirements.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1565 Adult Day Service Satellite Sites
a) A contracted adult day service provider shall request, in writing, authorization from the Department to develop a satellite site.
b) The provider shall submit a proposal for the satellite site and shall notify the Department when the provision of service will begin at the satellite site.
c) The Department or its designee will conduct an on-site review of the satellite site in accordance with Sections 240.1510, 240.1520, 240.1550, 240.1555 and 240.1560.
(Source: Amended at 26 Ill. Reg. 9668, effective July 1, 2002)
Section 240.1570 Service Availability Expansion
a) A CCP participant may be allowed access to CCP ADS in a service area in which the participant does not reside (outlying service area) under the following circumstances:
1) the CCU has determined the needs of the participant may best be served by a provider in an outlying service area;
2) either:
A) the geographic area in which the participant resides does not have a provider of the needed services; or
B) the participant may be provided services more conveniently/appropriately by a CCP provider in an outlying service area for the following reasons:
i) the authorized CCP providers in the participant's service area have reached the maximum capacity and have approval to not accept new participants and/or is unable to provide a service without delay and/or interruption;
ii) optional service components required by the participant are unavailable from the CCP authorized provider in the participant's service area but are available from a CCP authorized provider in another service area;
iii) transportation can be more conveniently arranged to a CCP authorized provider in another service area (adult day service only); or
iv) special needs of the participant (e.g., language-appropriate workers) can only be met by a CCP authorized provider in another service area; and
3) The CCP authorized provider in the outlying service area agrees to provide the service required without delay/interruptions to the referred participant.
b) A CCP in-home care participant may be allowed access to CCP in-home care services in a service area in which the participant does not reside (outlying service area) upon receipt of written approval to the CCU from the Department under the following circumstances:
1) The CCU has determined that the special needs of the participant (e.g., language specific workers) can only be met by a CCP authorized provider in another service area; and
2) The CCP authorized provider in the outlying area agrees to provide the service required without delays/interruptions to the referred participant; and
3) The CCP authorized providers in the participant's area of residence are unable to meet the special needs of the participant without delays/interruptions.
c) A request by a participant to receive CCP services from a provider in an outlying service area is inappropriate if the participant refuses to accept CCP services deemed appropriate by the CCU in the participant's service area. In this instance, service will be denied or terminated as appropriate.
d) If a provider's contract period is extended in writing by the Department, approval of the service availability expansion is also extended for the same effective period.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1575 Adult Day Service Site Relocation
Any CCP adult day service provider intending to relocate its primary or satellite site shall obtain written approval of the new facility from the Department.
a) For all reasons for relocation except an emergency:
1) the provider shall file a letter of intent to relocate, providing detailed information including the reason for the relocation, the proposed relocation site and assurance that requirements specified in subsections (a)(2)(A) and (a)(2)(B) are met.
2) the letter of intent to relocate shall be received by the Department at least 30 calendar days prior to the anticipated date of the proposed relocation.
A) The proposed facility shall meet all CCP standards, and federal, State and local codes, as set forth in Section 240.1550.
B) The provider shall assure the Department that service to the provider's CCP participants will be uninterrupted.
C) A request for a contract amendment may be made by the provider if the relocation affects the designated address to which the Department mails its correspondence, etc., to the provider.
3) upon receipt and approval of the letter of intent to relocate, the Department shall issue a temporary authorization to provide service in the new location.
4) final approval of the relocation shall be based upon on-site review of the facility by the Department (see Section 240.1550).
b) When any emergency requires relocation of an ADS site the provider shall immediately notify the Department.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1580 Standards for Alternative Providers
a) In the event that CCP services are not provided to an eligible participant within the time limit specified in Section 240.910, the eligible participant may arrange to receive CCP in-home services from an individual of the eligible participant's choice 15 calendar days after the date of the notice of eligibility. The CCU and Department shall approve the participant's choice of individual prior to initiation of services.
b) The contractual provider shall pay the alternative provider at its usual and customary rate of pay.
c) The contractual provider may terminate the alternative provider if the contractual provider has a person who can provide the services in accordance with the person centered plan of care.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1590 Standard Requirements for Individual Provider Services (Repealed)
(Source: Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART P: PROVIDER PROCUREMENT
Section 240.1600 Provider Agency Certification
a) All services provided to CCP participants shall be delivered in accordance with Provider Agreements entered into between certified provider agencies and the Department.
b) For purposes of administrative efficiency, the Department may initiate the provider certification process for the CCP by a specific service, on a geographic basis, or in accordance with other criteria determined by the Department.
c) Initial Certification
Any willing and qualified provider agency (see the federal Medicaid waiver, this Part and 42 CFR 431.51 (2008)) interested in the opportunity to enter into a Provider Agreement with the Department for the provision of CCP services shall comply with the following certification procedures:
1) A provider agency requesting initial certification of qualifications shall submit, in a form and manner prescribed by the Department, material documenting the ability to comply with administrative requirements, service specifications and any other administrative or operational information required by the Department for the applicable service.
A) The Department or its designee will review the material submitted and, if necessary, will request additional information. The Department or its designee will conduct on-site reviews of a prospective provider agency for in-home service and adult day service under the CCP unless a performance review of the provider agency has already been completed by the Department or its designee within the prior 12 months. The Department reserves the right to conduct on-site reviews of a prospective provider agency for emergency home response service and AMD service under the CCP. Failure of a prospective provider to respond to the Department's request for a site-visit may result in the denial of certification.
B) If additional information is requested by the Department, the provider agency has 30 calendar days after the date of request to submit this information.
C) After 60 calendar days, the provider agency's request for certification of qualifications will be closed and all information must be resubmitted to the Department if the provider agency wants to continue to request certification.
2) Provider agencies will be notified in writing of the results of the certification request. Those provider agencies determined by the Department to be qualified will be certified for a period of no more than 3 years and afforded the opportunity to execute a Provider Agreement (generally for a three-year period) for the applicable service.
d) Recertification
The Department, or its designee, shall conduct recertification of each provider agency with a valid Provider Agreement no less frequently than every three years to determine continued compliance with qualifications for the applicable service. The timing of recertification shall be based upon the timing of the initial certification (see subsection (b)) or of the most recent recertification.
1) The Department, or its designee, shall notify each provider agency, in writing, at least 30 calendar days prior to recertification to request the material required for the recertification. Any provider agency interested in renewing its Provider Agreement shall submit, in a form and manner prescribed by the Department, material documenting the continued ability to comply with the administrative requirements, service specifications, and any other administrative or operational information required by the Department for the applicable service.
2) Before recertifying a service provider, the Department will conduct a performance review under Section 240.1660.
3) Provider agencies will be notified in writing of the results of the recertification.
4) Those provider agencies determined by the Department to be qualified will be recertified for a period of no more than three years and afforded the opportunity to execute renewal of the Provider Agreement (generally for a three-year period) for the applicable service.
e) Other initial certification or recertification considerations include, but are not limited to:
1) pending or current Departmental on-notice or contract action for failure to adhere to Provider Agreement requirements, including a history of non-compliance with the Provider Agreement;
2) notification from another governmental entity of similar contract actions or non-compliance findings;
3) financial insolvency, criminal indictment or conviction, or other legal issues that, in the opinion of the Department, would make the award of a Provider Agreement contrary to the best interest of the State;
4) complaints forwarded to the Department by the Attorney General's office, the Better Business Bureau or other consumer protection organizations; or
5) the current provider agency is not in good standing with the Department.
f) The Department may require completion of additional disclosure statements and/or background inquiries if there is reason to believe offenses have occurred since completion of previous disclosures and background inquiries.
g) The Director shall represent and act for the State in all matters pertaining to the Application for Certification process and Provider Agreements awarded. The Director receives all recommendations and has the ultimate decision making authority for issuing Provider Agreements. The Director reserves the right to allow the applicant to correct inadvertent, technical errors in the application when, in the Director's opinion, the best interest of the State will be served by the correction.
h) Any provider agency denied initial certification of qualifications or recertification for the provision of CCP services shall be afforded the opportunity to submit another request to the Department after a 60-day period of time after issuance of the determination or notification of a final decision or other action on an objection filed pursuant to Section 240.1645. The provider agency may also object to the decision in a form and manner prescribed by the Department in the written notification of denial (see Section 240.1645).
i) Provider Agreements will be entered with qualified provider agencies on a schedule determined by the Department, but no more frequently than semiannually after initial certification.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1605 Emergency Certification
a) The Department shall obtain CCP services through any means of selection likely to result in provider certification and subsequent issuance of a Provider Agreement under the following circumstances:
1) service is immediately needed to prevent interruption of services to current participants;
2) service is immediately needed to protect a participant's health, safety or welfare;
3) service is of such a nature or the market place is such that only one provider is reasonably capable and willing to perform the requisite services; and/or
4) to establish new or additional services in an area in which the Department has determined an underserved population exists.
b) The Department shall assure, to the extent possible, through the certification process, that any provider selected under the emergency circumstances included in subsection (a) is qualified to provide CCP services and that the health, safety and welfare of participants are protected.
c) Certification issued under this Section is not renewable. Recertification of the provider must occur under Section 240.1600.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1607 Standard CCP Provider Agreement
a) In order to enter into a CCP Provider Agreement, a provider must first be certified by the Department under Section 240.1600 or 240.1605.
b) A Provider Agreement shall be entered into between the Department and the certified provider agency as evidence of the terms and conditions of the agreement to provide CCP services within the geographic area specified within the Provider Agreement. Except during the transition period referred to in Section 240.1600(b), Provider Agreements generally will be for a period of three years. A Provider Agreement does not guarantee that the provider will be the sole provider of CCP services within the described geographic area.
c) The terms and conditions of the Provider Agreement shall, at a minimum, include the following:
1) the Provider Agreement may be terminated without cause by either party upon 60 calendar days written notice;
2) the Provider Agreement may be amended, with the mutual consent of both parties, at any time during the term of the Agreement; and
3) all program and financial records, reports and related information and documentation, including participant files, that are generated as a result of the Provider Agreement shall be considered the property of the Department.
d) At the time of application for certification and before the Provider Agreement is entered, the provider shall submit documentation specified by the Department to confirm the legal structure under which it is doing business.
1) The Department shall be immediately notified by the provider in the event of a merger/consolidation/sale of assets of a provider and shall be given copies of all relevant supporting documents.
A) Following review of the merger/consolidation/sale of assets documents, the Department will determine whether the merger/consolidation/sale of assets has resulted in an assignment of the Provider Agreement (see subsection (k)).
B) If the merger/consolidation/sale of assets has not resulted in an assignment, the Department retains the right to terminate the Provider Agreement if performance of the Provider Agreement by the new corporate structure is not in the best interests of the CCP, such as a merger or consolidation with an entity that has been subject to previous contract action by the Department or some other state or federal agency.
2) Failure to notify the Department shall result in termination of the Provider Agreement.
e) Upon written notification from the Department of a change in the fixed unit rates of reimbursement, the provider may exercise its 60 calendar day termination rights if the provider no longer wishes to provide service at the newly established fixed unit rates of reimbursement.
f) Providers shall have sufficient personnel to ensure service to all CCP participants.
g) During the term of the Provider Agreement, the provider will maintain its adherence to the Illinois Act on the Aging, this Part and any requirements and representations made by the provider during the certification process.
h) Providers may be units of State government, units of local government, for-profit or not-for-profit corporations, limited liability companies, sole proprietorships or partnerships.
1) An agency of State government must submit a letter from the head of the agency citing the statutory authority for the agency to enter into a Provider Agreement to provide the proposed CCP service.
2) A unit of local government must submit a copy of the resolution or ordinance duly passed by the governing body of the unit of government authorizing the execution of the Provider Agreement. The resolution or ordinance shall designate the individual authorized to execute the Agreement on behalf of that unit of government.
3) A partnership or sole proprietorship must submit copies of the "Certificate of Ownership of Business" issued by the county clerks for the counties in which the provider is proposing to provide CCP service.
4) A corporation or limited liability company must submit a "Certificate of Good Standing" from the Office of the Illinois Secretary of State certifying that the corporation has complied with the requirement to file an annual report and has paid required franchise taxes.
5) A not-for-profit corporation shall submit:
A) a "Certificate of Good Standing" from the Office of the Illinois Secretary of State certifying that the corporation has complied with the requirement to file an annual report; and
B) a current letter from the Office of the Illinois Attorney General certifying that the corporation is in full compliance with or is exempt from the charitable trust laws of the State of Illinois. When renewing a Provider Agreement, a non-exempt provider shall submit to the Department, upon request, a letter certified by the provider's Board of Directors stating that the provider remains in compliance or is exempt.
6) A nongovernmental agency shall certify that it is legally qualified to contract with the State of Illinois.
i) Providers shall certify that they acknowledge and comply with the Illinois Human Rights Act [755 ILCS 5]; the Equal Employment Opportunity Act of 1974, as amended (Title VII of the U.S. Civil Rights Act of 1964, as amended (42 U.S.C. 2000e et seq.)); the Civil Rights Act of 1964, as amended (42 U.S.C. 2000d et seq.); Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 790 et seq.); and the Immigration Reform and Control Act of 1986 (8 U.S.C. 1101 et seq.).
j) Providers shall certify to the Department that they are fiscally sound, as defined in Section 240.160 and further provided in Section 240.1505(a)(10 and 11).
k) Assignment by a provider of a Provider Agreement to any other organizations or entities is not allowed. Any succeeding provider must be certified as a CCP provider under this Part and must enter into a new Provider Agreement with the Department.
l) Failure by providers to seek and obtain written Department approval prior to entering into subcontracts with other entities for the provision of CCP services shall result in the immediate termination of the Provider Agreement.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1615 Provider Initiated Service Area Modifications
a) To request approval to modify a service area, a certified provider agency must submit in writing to the Department a plan of the proposed expansion or reduction, reasons with supportive information for the modification, and the revised boundaries of the agency's original service area.
b) The Department may approve or deny requests for service area modification based upon one or more of the following reasons:
1) demonstrated ability or inability to comply with standards as illustrated by substantiated complaint history, review reports or prior contract actions;
2) evidence of ability or inability to manage and supervise services throughout the current service area;
3) continuity or disruption of participant care;
4) assurance of, or failure to assure, participant freedom of choice; or
5) action in, or failure to act in, the best interest of the participant or the CCP.
c) If the Department approves the service area modification, the Provider Agreement shall be amended to include the modified service area.
d) An agency shall provide a minimum of 60 days notice to the Department prior to the proposed effective date of a service area reduction.
e) A provider who has been granted a provisional contract is not eligible for a service area expansion.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1645 Objection to Certification Decision
a) A provider may file an objection, in limited circumstances, if a certification request is denied by the Department.
b) Examples of circumstances that do not constitute an appealable basis for objection include:
1) timing of initiation of certification process by the Department;
2) termination of eligibility by closure of the file due to a provider's failure to comply with time frames for submitting a certification request under Section 240.1600(b);
3) new supporting documentation to establish eligibility for certification or recertification as a service provider under the CCP following failure to comply with time frames for submitting material requested by the Department;
4) issues upon which the Department has already made a final administrative decision as a result of a previous objection or contract action involving the provider;
5) issues upon which an independent trier of fact has made a final determination or issued an order;
6) disputes as to service rates or the underlying methodology for calculating those rates;
7) duration of a service provider certification;
8) timing of the Provider Agreement process by the Department; or
9) other matters of general applicability that are not specifically adverse to the provider.
c) Procedures for Filing an Objection
1) An objection regarding a certification decision must be in writing and must be received at the Department's Springfield office on or before the tenth calendar day after the date of the applicant's receipt of the notice of the objectionable action. If the objection is not received before the close of business on the tenth calendar day, the objection shall be disregarded.
2) Each objection must contain a full and concise statement of the facts and circumstances of the action that is alleged to be objectionable, legally or otherwise, and a statement of the relief sought.
A) The Department may request additional details at any time.
B) Failure to supply any information requested by the Department will be cause for dismissal of the objection.
d) Upon receipt of written objection, the Department shall immediately review the certification decision in question and shall issue a written response. The certification decision shall not be considered final until any relevant objections are resolved.
e) The decision of the Director is final and shall be sent by mail or email.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1650 Classification, Identification and Receipt of Provider Service Violations
Failure to comply with the contract, proposal and Department rules shall be identified and classified by the Department.
a) In determining the classification assigned to each provider service violation, the Department shall consider the following:
1) the severity of the violation;
2) the danger posed by the violation to the health, safety or welfare of the participant, based upon degree of participant impairment and availability of support sources;
3) the provider's efforts to correct violations;
4) the volume and scope of violations.
b) There are three classifications of violations: Type I, Type II and Type III.
1) Type I provider service violations are participant-centered violations that pose an imminent risk to the health, safety or welfare of the CCP participant, and/or represent situations in which failure to correct the violation could result in the participant's potential hospitalization or nursing facility placement. Type I violations shall receive priority attention, requiring immediate (within 24 hours) correction to remove the risk environment. Permanent correction must be achieved within 30 calendar days after receiving notice of the violation.
2) Type II provider service violations are participant-centered violations that pose a potentially serious risk to the participant. These violations are to be corrected within 60 calendar days.
3) Type III provider service violations are administrative violations that pose a very low risk to the participant. The time frame for correction of Type III violations shall be 60 calendar days or as established in an approved work plan.
c) Provider service violations include, but are not limited to, violation of the following CCP rules:
1) adult day service standard requirements (Section 240.1550);
2) adult day service and in-home provider staffing requirements (Sections 240.1530 and 240.1555);
3) special services (Subpart J);
4) provider administrative minimum standards and responsibilities (Sections 240.1510, 240.1520, 240.1542, 240.1544 and 240.2020);
5) service components (Sections 240.210, 240.230, 240.235, 240.237 and 240.270);
6) adult day service and in-home provider staff qualification and responsibilities (Sections 240.1535 and 240.1560);
7) service provision requirements (Subpart B and Section 240.915);
8) emergency home response equipment (Section 240.1541);
9) AMD equipment (Section 240.1543).
d) The Department will be in receipt of reported violations through the following methods:
1) Performance reviews of contracted provider agencies (Section 240.1660);
2) Service complaints/violations that are reported directly to the Department or to the Senior HelpLine of the Department or are referred to the Senior HelpLine by the Department/CCU or service provider/other; and/or
3) Reports from Department staff.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1660 Provider Performance Reviews
a) Providers under contract to the Department must comply with federal, State and local laws, regulations, Department rules and the contract requirements. When the provider signs the contract, this signature shall be the provider's certification that all applicable laws, rules and regulations, contract requirements, and statements included in the Provider Proposal shall be complied with. The Department shall have the authority to conduct performance reviews of a contracted provider agency at any time during the course of the provider's contract period. Any findings and/or contract actions resulting from a performance review may be appealed (see Section 240.1661).
b) The Provider Performance Review consists of a sample of rules, of RFP requirements, and of cases that will be reviewed for performance.
c) If non-performance findings result from the Provider Performance Review, the provider shall receive a written report of the findings and have a specified period of time for adherence. The allowable time period shall be relevant to the classification of the violation and the applicable corrective action time frames specified in Section 240.1650.
d) If non-performance findings result from the follow-up review, the Department may impose one or more of the contract actions specified in Section 240.1665.
e) The Department may initiate the termination of the provider agreement after three consecutive performance reviews resulting in non-compliance findings as indicated on the written report.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1661 Provider and Care Coordination Unit Right to Appeal
The provider and CCU have the right to appeal any finding and/or contract action (see Section 240.1665) resulting from a performance review. When an appeal of contract action is received, the contract action shall be stayed unless there is a Type I violation (see Section 240.1650), in which case the contract action shall continue during the appeal process.
a) Upon receipt of written notification of contract actions to be taken, a provider or CCU may request an appeal in writing within 15 calendar days from the date of the notice. If the request for appeal is not filed within 15 calendar days, the appeal shall be automatically denied.
b) Appeals shall be submitted in the manner and form specified by the Department in its notice of contract action and shall be mailed or emailed to the Office of General Counsel (OGC) in Springfield.
c) The OGC, with appropriate Department staff, will conduct an informal review and make a recommendation to the Director.
d) The OGC may contact the appellant to discuss the appeal request and/or request additional information.
e) The OGC shall submit a recommendation to the Director within 60 days after receipt of the appeal or receipt of the requested information, whichever is later.
f) The Director will review the OGC recommendation within 30 days after its receipt and may accept or reject all or part of the recommendation.
1) If the Director determines that the finding and/or contract action is valid, the appeal will be denied and the finding/action shall be upheld/implemented.
2) If the Director determines that the finding and/or contract action is invalid, the appeal shall be upheld and the finding/action shall be modified or expunged, in whole or in part, with letter placed in the provider or CCU file.
g) The Director may determine that the circumstances causing the contract actions warrant a hearing that shall be conducted at a location designated by the Department. A provider or CCU may request an administrative hearing following the Director's decision after the informal review. A provider or CCU must submit its request for a hearing by close of business on the 15th calendar day after the receipt of the Director's decision. Request not timely submitted shall be denied.
h) All hearings shall be conducted by an impartial Hearing Officer authorized by the Director.
i) The Hearing Officer may schedule one or more pre-hearing conferences.
j) The Department and the appellant will provide copies of relevant documents, a list of potential witnesses, and a summary of potential testimony to be used at the hearing, to the other party. Depositions, interrogatories, other discovery mechanisms may be used upon the mutual consent of the parties. The hearing officer shall exclude immaterial, irrelevant, or unduly repetitious evidence.
k) The hearing shall be conducted in accordance with Article 10 of the Illinois Administrative Procedure Act [5 ILCS 100] unless otherwise specified in this Part. Unless otherwise provided by law, the burden of proof will be by the preponderance of the evidence and will be on the moving party or the party bringing the action.
l) The hearing may be conducted in person or with some or all parties, including the Hearing Officer, present at different locations connected with each other by telephone, videoconference, or other electronic means. The proceedings will be recorded.
m) The appellant or a Department Representative may request a continuance, which shall be in writing to the Hearing Officer before the scheduled hearing date. A verbal request may be made when the hearing is convened. The Hearing Officer may continue the hearing to another date acceptable to all parties and the Hearing Officer.
n) The appellant may withdraw the appeal at any time prior to or during the appeal process. The withdrawal must be submitted in writing and the Department will close the appeal file. If the withdrawal occurs after the appeal has been assigned to a Hearing Officer, the withdrawal must be submitted in writing to the Hearing Officer and the Department. The Hearing officer will make an oral finding on the record that the appeal has been withdrawn.
o) The failure to appear by the appellant or to proceed with the hearing is considered a non-appearance. The appeal is considered abandoned and shall be dismissed. Dismissal of an appeal is a final administrative decision.
p) Within ten calendar days after the date of the dismissal notice, the appellant may request the reinstatement of the appeal sent in writing to the Hearing Officer and Department. The appellant's request must contain facts and supporting documentation, where applicable, to support the reinstatement. The Hearing Officer may or may not reinstate the appeal.
q) The Hearing Officer shall certify the entire record of the hearing to the Director and shall recommend a decision on each issue in the hearing within 60 calendar days from the close of evidence and argument in the appeal. The Hearing Officer shall not render a final decision relevant to any issue in the hearing.
r) The Director may accept or reject all or part of the recommendations. Their decision shall be made by applying the Department's rules to the particular case situation.
s) The Director shall issue their decision in writing no later than 90 calendar days after the Hearing Officer's recommendation. The Department shall send a copy of the decision to the parties of the appeal by mail or email. The Director's decision is final.
t) At any time within five years after the date of the release of the Department's final administrative decision, upon written request to the Office of General Counsel, the appellant/authorized representative may review the official report of the hearing.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1665 Contract Actions for Failure to Comply with Community Care Program Requirements
The Department may impose one or more of the following contract actions upon any CCP provider or contracted CCU that fails to comply with Department rules or contract/Provider Agreement requirements, including any statements made on the CCU Proposal or the provider's application for certification. These actions include:
a) prohibition of specified staff from serving CCP participants (imposed when the Department finds that a worker, case manager, supervisor or other designated staff fails to comply);
b) purchase of a limited financial audit (imposed when the Department finds that a provider or CCU has failed to adhere to the fiscal requirements specified in this Part);
c) suspension of referrals for up to 90 days;
d) transfer of a portion of the participants served under the contract or Provider Agreement;
e) training of staff;
f) termination of Provider Agreement or CCU contract and transfer of all participants;
g) requiring a review by the provider or CCU of all or a specified subset of files and provider or CCU certification of corrective action;
h) requiring the provider or CCU to contract with an outside management firm to evaluate program management and to implement recommendations for improvement as provided in the evaluation and negotiated with the Department;
i) suspending all or a portion of CCP payments until the action is corrected;
j) deducting overpayments to provider or CCU from future Provider or CCU Requests for Payment or requiring the provider or CCU to reimburse the Department;
k) refusing to accept a proposal from a CCU or to enter into a Provider Agreement with the provider in one or more specified areas open for procurement; and/or
l) taking any other action the Director determines to be appropriate to the non-performance circumstances.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1666 Termination of Provider Agreement
a) If the Department terminates a provider agreement, the provider cannot reapply for certification until six months after the receipt of the termination letter or the conclusion of an appeal process, whichever is later. This prohibition on reapplying extends to the owners and/or administrators of the provider agency.
b) If the Department terminates a provider a second time, then the provider is prohibited from applying for another agreement for a year after the receipt of the termination letter or the conclusion of an appeal process, whichever is later. This prohibition on reapplying extends to the owners and/or administrators of the provider agency.
c) To reapply for certification after a termination, the provider must provide a corrective action plan that addresses each of the corrective actions listed in the termination letter and last QI review report. The plan must list concrete steps that the provider will take to ensure these issues will not continue under a new agreement.
d) The Department will deny a new application if the provider fails to provide an adequate corrective action plan.
(Source: Added at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART Q: CARE COORDINATION UNIT PROCUREMENT
Section 240.1710 Procurement Cycle for Care Coordination Services
The Department will solicit proposals as specified in 89 Ill. Adm. Code 220.610 through 220.645. When conducting the solicitation as specified in 89 Ill. Adm. Code 220.655(e), the Department shall assume all responsibilities specified for the Area Agency on Aging in 89 Ill. Adm. Code 220.610 through 220.645.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.1720 Care Coordination Unit Performance Review
a) Each CCU under contract to the Department must comply with the Request for Proposal, federal, State and local laws, regulations and Department rules, policies and procedures. When the CCU signs the contract, this signature shall be the CCU's certification that all applicable laws, rules and regulations will be complied with, as well as all statements included in the CCU Proposal except those contradicting applicable laws, rules and regulations.
b) The Department shall have the authority to conduct a review of a contracted CCU agency at any time during the course of the CCU's contract period for the purpose of protecting the health, safety and welfare of CCP participants.
c) The Department shall conduct a review in accordance with Department procedures.
d) Review Reports shall be maintained by the Department and findings shall be acted upon as specified in 89 Ill. Adm. Code 220.670 and/or 240.1665.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
SUBPART R: ADVISORY COMMITTEE
Section 240.1800 Community Care Program Advisory Committee
a) The Director shall appoint individuals to serve on the Community Care Program Advisory Committee (CCPAC) that shall advise the Department on rates of reimbursement for the CCP service delivery network and issues affecting the CCP service delivery network and recommend solution strategies. The CCPAC shall meet on a bi-monthly basis.
b) Persons appointed to the CCPAC shall be appointed based upon their experience with the CCP, geographic representation, and willingness to serve. Representatives shall serve at their own expense and must abide by all applicable ethics laws. Representatives will be appointed to represent older adults and provider, advocacy, policy research and other constituencies committed to the delivery of high quality in-home and community-based services to older adults. Representatives shall be appointed to assure representation from:
1) adult day service providers;
2) in-home service providers;
3) CCUs;
4) emergency home response providers;
5) statewide trade or labor unions that represent homecare aides and direct care staff;
6) Area Agencies on Aging;
7) adults over age 60;
8) membership organizations representing older adults; and
9) other organizational entities, providers of care, and/or individuals determined by the Director to have demonstrated interest and expertise in the fields of in-home and community-based care.
c) Nominations may be presented from any agency or State association with interest in the CCP.
d) The Director, or designee, will serve as permanent Co-chair of the CCPAC . One other Co-chair shall be nominated and approved annually by members of the CCPAC.
e) The Director will designate Department staff to provide technical assistance and staff support to the Committee. Department representation will not constitute membership on the CCPAC.
f) Terms of appointment will be for four years. Members shall continue to serve until their replacements are named.
g) The Department will fill vacancies that have a remaining term of over one year, and this replacement will occur through the annual replacement of expiring terms.
h) All papers, issues, recommendations, reports and meeting memoranda will be advisory only. The Director, or designee, will make a written response/report, as requested, regarding issues before the CCPAC.
i) The Director retains full decision making authority on the CCP regarding any recommendations presented by the CCPAC.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART S: PROVIDER RATES
Section 240.1910 Establishment of Fixed Unit Rates
Rate methodologies and rates of payment for the Persons who are Elderly Waiver program are developed by the Department with consultation, oversight, and final approval by HFS, the State Medicaid agency. During the Waiver's five-year renewal process, the federal Centers for Medicare and Medicaid Services review the State's Elderly Waiver compliance, including rate sufficiency.
a) The fixed unit rates will be reviewed annually, at a minimum, and adjustments will be made to conform to CCP's appropriation and to program service requirements and federal and State changes in statutes and rules affecting CCP.
b) In establishing fixed unit rates of reimbursement, the Department will take into consideration the following:
1) cost information provided by service providers;
2) current market conditions and trend analyses; and
3) CCP appropriation levels.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1920 Contract Specific Variations
The Department will consider reimbursing a provider at a rate other than the established fixed unit rate to compensate for contract specific variations in cost. This consideration will be made under the following circumstances:
a) Evidence suggests that a contract area currently served by a provider will become "unserved" due to inadequate reimbursement by the State to cover costs. An adjusted rate will be used only after the "emergency contracting process", as defined in Section 240.1605, has shown that no provider offered an emergency contract is willing to provide service in the contract area at the established fixed unit rate. The adjusted rate will then be determined through the competitive procurement process as defined in Section 240.1605.
b) Once a contract area has established an adjusted rate, that rate shall be effective until a new procurement process has been initiated.
c) The adjusted rate contractor must still meet the requirements for an in-home service provider as stated in Sections 240.2020 and 240.2040.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.1930 Fixed Unit Rate of Reimbursement for In-home Service
The Department will establish a fixed unit rate of reimbursement for in-home service exclusive of those services defined in Section 240.270. Current providers will be notified in writing of any change in the fixed unit rate. The fixed unit rate of reimbursement will be published on the Department's website.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1940 Fixed Unit Rates of Reimbursement for Adult Day Service and Transportation
The Department will establish fixed unit rates of reimbursement for adult day service and transportation as defined in Section 240.230. Current providers will be notified in writing of any change in the fixed unit rate. The fixed unit rates of reimbursement will be published on the Department's website.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1950 Adult Day Service Fixed Unit Reimbursement Rates
Adult day service providers shall be uniformly reimbursed for the provision of adult day service at the rates established by the Department. The reimbursable units of adult day services shall be as follows:
a) One unit of adult day service is defined in Section 240.230(c)(1) as one direct participant contact hour (excluding transportation time) provided to a participant.
b) One unit of documented adult day transportation provided by the adult day service provider is defined in Section 240.230(c)(2) as a one-way trip per participant to or from the adult day site and the client's home.
1) No more than two units of transportation shall be provided per participant in a 24 hour period.
2) A unit of transportation shall not include transportation on outings, trips to physicians, shopping or other miscellaneous trips.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1955 Fixed Unit Rates of Reimbursement for Emergency Home Response Service
EHRS providers shall be uniformly reimbursed for the provision of EHRS at fixed unit rates of reimbursement established by the Department. The reimbursable units of EHRS shall be as follows:
a) Installation and Removal
The Department shall pay a one-time installation fee at a fixed unit reimbursement rate established by the Department for the installation of the base unit in the participant's home. The Department shall not pay any fee for expenses incurred by the EHRS provider if service could not be provided due to either the participant's absence or the participant's refusal to admit the EHRS provider's employee into the home. The Department shall not pay any fee for removal of the base unit.
b) Monthly Service
The Department shall pay a monthly service fee per participant at a fixed unit reimbursement rate established by the Department for providing EHRS to participants. The Department shall not pay for the cost of maintaining telephone service for the participants or any associated charges or fees.
c) The rates will be reviewed annually, at a minimum. Adjustments may be made to conform to the appropriation, service requirements and/or changes in federal and State laws, regulations and/or rules affecting the service.
d) In establishing the rates of reimbursement, the Department will comply with federal requirements for Medicaid waivers, which are described in the State Medicaid Plan maintained by HFS and posted on the HFS website. The Department will use a Request for Information process to obtain rate information from providers and then consider whether the resulting average is supported by the appropriation level for the program in light of trend analyses on use of the service and current market conditions. The goal is to ensure adequate provider participation and participant choice. The specific amount that the service provider will be reimbursed for a unit of service is reflected in the provider contract and is listed on the Department's website.
e) Upon written notification from the Department of a change in the rates of reimbursement, an EHRS provider may exercise its 60 calendar day termination rights if the EHRS provider no longer wishes to provide services thereafter at the new rates of reimbursement.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1957 Fixed Unit Rates of Reimbursement for Automated Medication Dispenser Service
AMD service providers shall be uniformly reimbursed for the provision of AMD units at fixed unit rates of reimbursement established by the Department. The reimbursable units of AMD service shall be as follows:
a) Installation, Initial Training and Removal
The Department shall pay a one-time installation fee at a fixed unit reimbursement rate established by the Department for the installation and initial training of the participant/authorized representative/responsible party of the AMD unit in the participant's residence. The Department shall not pay any fee for expenses incurred by the AMD provider if service could not be provided due to either the participant's absence or the participant's refusal to admit the AMD provider's employee into the residence. The Department shall not pay any fee for removal of the AMD unit.
b) Monthly Service
The Department shall pay a monthly service fee per participant at a fixed unit reimbursement rate established by the Department for providing AMD service that includes maintaining administrative and technical support to program machines; providing 24 hour technical assistance and additional training; signal monitoring, troubleshooting, machine maintenance, repair and replacement; notifications to the responsible party on missed medication doses and power outage; tracking and analyzing data; and providing reports as requested by the Department. The Department will not pay for the cost of maintaining telephone service for the participant or any associated charges or fees.
c) The rates will be reviewed annually, at a minimum, and adjustments may be made to conform to the appropriation, service requirements and/or changes in federal and State laws, regulations and/or rules affecting the service.
d) In establishing the rates of reimbursement, the Department may consider any of the following factors:
1) appropriation levels;
2) cost information provided by the providers; and/or
3) current market conditions and trend analyses.
e) Upon written notification from the Department of a change in the rates of reimbursement, an AMD provider may exercise its 60 calendar day termination rights if the AMD provider no longer wishes to provide services thereafter at the new rates of reimbursement.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1960 Care Coordination Fixed Unit Reimbursement Rates
Care Coordination Units under contract with the Department shall be uniformly reimbursed for the provision of CCP care coordination services at the rates established by the Department. The reimbursable CCP care coordination service activities subsequent to a procurement as follows:
a) completion of each initial eligibility determination for CCP services;
b) completion of each redetermination of CCP eligibility not to exceed one redetermination per month per participant;
c) completion of each face-to-face screening of a participant;
d) completion of each HFS Interagency Certification of Results – Determination of Imminent Risk form, following prescreening by Choices for Care screeners;
e) completion of each HFS Level I Screen;
f) availability to receive participant inquiries and requests, by telephone or in person, and to respond to those requests and inquiries for each active participant per month;
g) completion of each Deinstitutionalization assessment;
h) completion of one face-to-face visit between initial assessment and annual reassessment that is to occur between four and eight months after the last determination or redetermination of eligibility.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.1970 Enhanced Rate for Health Insurance Costs
The Department may be appropriated funds to pay an enhanced rate under CCP to those in-home service provider agencies that offer health insurance coverage as a benefit to their direct service worker employees.
a) Definitions
For purposes of this Section:
"Direct service worker" means an employee who provides homecare aide services for an in-home service provider agency under CCP.
"Health insurance" means a Type 1 plan or a Type 2 plan.
1) Type 1 Plan
A Type 1 plan must comply with, be comparable to, or exceed required mandated benefits, coverages, and co-payment levels for individual and group insurance policies under the Illinois Insurance Code [215 ILCS 5] and 50 Ill. Adm. Code, Subchapter ww and individual and group contracts for health maintenance organizations under the Health Maintenance Organization Act [215 ILCS 125] and 50 Ill. Adm. Code 4521.
2) Type 2 Plan
A Type 2 plan is employer-paid health insurance as part of collective bargaining with unionized direct service workers through a Taft-Hartley Multi-employer Health and Welfare Plan that defines the eligibility requirements and coverage under section 302(c)(5) of the Labor Management Relations Act of 1947 (29 U.S.C. 141).
b) Initial Application
An interested in-home service provider agency must submit an initial application at least 120 days prior to the end of each State fiscal year. Applications will be accepted by the Department at its main office located in Springfield.
c) Eligibility
Eligibility requirements include:
1) Verification of a current contract as an in-home service provider agency with the Department under CCP.
2) A copy of a health insurance plan or a certificate of insurance, and the effective date of that document, to establish that:
A) the in-home service provider agency provides health insurance at its own expense to its direct service workers, which may include coverage for those employees' dependents; or
B) the in-home service provider agency will provide for health insurance as part of collective bargaining with unionized direct service workers, which may include coverage for those employees' dependents through a Taft-Hartley Multi-employer Health and Welfare Plan.
3) Specification of the total number of employees and the total number of direct service workers, together with a certification from a responsible party for the in-home service provider agency to the effect that:
A) under a Type 1 health insurance plan:
i) health insurance coverage is offered to all direct service workers who have worked at least an average of 20 hours per week for three consecutive months under the CCP; and
ii) at least 25% of the total number of direct service workers accept the offer of health insurance.
B) under a Type 2 health insurance plan:
i) health insurance coverage is offered to all of the direct service workers subject to the collective bargaining agreement who have worked at least an average of 20 hours per week for three consecutive months under the CCP; and
ii) at least 25% of the total number of direct service workers, or any higher percentage required under federal law, accept the offer of health insurance.
4) Submission of any other relevant information requested by the Department for administrative or audit purposes.
d) Impact on Financial Reporting
1) An in-home service provider agency shall not report the enhanced rate for health insurance costs paid by the Department under this Section as part of its revenue for purposes of the required financial reporting under Subpart T.
2) An in-home service provider agency shall not report health insurance for direct service workers as an incurred cost for purposes of the required financial reporting under Subpart T, except for an amount in excess of the enhanced rate paid by the Department during a reporting period.
e) Payment
1) If an in-home service provider agency is determined eligible for this enhanced rate, the Department will thereafter calculate the appropriate payment based on the number of units of in-home service accepted as billed per contract once the provider agency submits its VRFP under the CCP (see Section 240.1520) for reimbursement under this Section. Payments may be adjusted by the Department to properly account for services provided to participants. Payment is subject to the availability of appropriations during the State fiscal year.
2) An in-home service provider agency that makes a switch between a Type 1 and a Type 2 plan is not entitled to any retroactive payments for a period of time preceding the date on which benefits are actually available under the new plan.
3) No in-home service provider agency is entitled to a duplicate payment for the same period of time or for the same units of in-home service accepted as billed per contract.
4) By accepting any payment under the CCP, an in-home service provider agency agrees to repay the State of Illinois if:
A) the total revenue from the enhanced rate for health insurance costs exceeds the actual, documented expenses for its health insurance costs for the reporting period; or
B) an error in eligibility of an in-home service provider agency or the amount of revenue from the enhanced rate for health insurance or the amount of the health insurance costs is subsequently determined by an in-home service provider agency or the Department.
5) In the case of a financial or operational hardship, the Department may deduct an overpayment from future VRFPs submitted by the in-home service provider agency instead of collecting a lump-sum amount.
f) Notification
It is the responsibility of an in-home service provider agency to notify the Department within seven days after any change in its eligibility status, including, but not limited to, cancellation or termination of the health insurance plan or purchase of a new plan. An in-home service provider agency is only required to monitor participation by direct service workers in order to submit the initial application, the annual insurance review, and required financial reporting.
g) Annual Insurance Review
1) Once an in-home service provider agency is determined eligible by the Department and is paid an enhanced rate for health insurance costs, the provider agency shall thereafter substantiate its continued eligibility under subsection (c) by submitting appropriate supporting documentation at the same time as its annual financial report under Subpart T.
2) As part of the annual insurance review, an independent certified public accounting firm for the in-home service provider agency must verify the actual, documented expense for health insurance for the period listed as part of the required financial reporting under Subpart T.
3) The Department reserves the right to require an in-home service provider agency to engage an independent certified public accounting firm to verify the information and data submitted by the provider agency if the Department is in possession of evidence to suggest the information and data submitted is inaccurate, incomplete or fraudulent. This audit will be performed at the in-home service provider agency's expense.
4) The Department shall notify an in-home service provider agency in the event of a determination during the annual insurance review that:
A) the in-home service provider agency is no longer eligible for continued payment of the enhanced rate for health insurance costs;
B) the total revenue from the enhanced rate for health insurance costs exceeds the actual, documented expenses for health insurance costs for the reporting period;
C) there was an error in eligibility of an in-home service provider agency for the prior reporting period;
D) there was an error in the amount of revenue from the enhanced rate for health insurance costs; or
E) there was an error in the amount of the health insurance costs.
5) An in-home service provider agency may appeal from an adverse eligibility decision regarding continued payment of the enhanced rate for health insurance costs or a repayment decision in accordance with Section 240.1661. The Department will continue to pay the enhanced rate for health insurance costs until the appeal is resolved.
6) Supporting documentation may be subject to release under the Freedom of Information Act unless an applicable exemption for confidentiality, privacy, or other proprietary business purpose is marked on the face of any submission.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
SUBPART T: FINANCIAL REPORTING
Section 240.2020 Financial Reporting of In-home Service
a) Provider agencies will be required to submit a cost report as described in this Section (Direct Service Worker Cost Certification). The report must be based upon actual, documented expenditures.
1) The report must be submitted annually, within six months after the end of the reporting period, and may be prepared as a part of the provider's annual audit.
2) The report may be on either a calendar year basis or the provider's fiscal year (once a provider has elected to base the reports on a calendar or fiscal year, this election can be changed only upon written approval of the Department).
b) The cost report must demonstrate that the provider has expended a minimum of 77% of the total revenues due from the Department, to include the participant incurred expense that may have been applicable prior to July 1, 2010, for direct service worker costs as enumerated in Section 240.2050. For purposes of this report, the phrase "total revenues due from the Department" does not include any amount received as an enhanced rate for health insurance costs by a qualifying in-home service provider.
c) The cost report shall identify the provider's expenditures for direct service worker costs of program support costs and administrative costs as enumerated in Section 240.2050.
d) The accuracy of the report must be attested to by an authorized representative of the provider.
e) The Department reserves the right to require the provider to engage an independent certified public accounting firm to verify the information and data submitted by the provider if the Department is in possession of evidence to suggest the information and data submitted is inaccurate, incomplete or fraudulent. This audit will be performed at the provider's expense.
(Source: Amended at 48 Ill. Reg. 11053, effective July 16, 2024)
Section 240.2023 Financial Reporting of Rate-Based Wage Increases for Direct Service Workers
a) In-home service provider agencies will be required to submit a cost report to the Department to document compliance with any rate increase authorized for the purpose of increasing wages paid by a provider agency to direct service workers who provide homecare aide services under the Community Care Program.
b) The cost report must be submitted within 60 calendar days after issuance of written notification of such a rate increase by the Department.
c) The accuracy of the cost report must be attested to by an authorized representative of the in-home service provider agency.
d) The Department reserves the right to require the in-home service provider agency to engage an independent certified public accounting firm to verify the information and data submitted by the provider if the Department is in possession of evidence to suggest the information and data submitted is inaccurate, incomplete or fraudulent. This audit will be performed at the provider agency's expense.
e) The Department may take appropriate contract enforcement action in the following instances:
1) an in-home service provider agency did not submit a cost report;
2) a cost report is inaccurate, incomplete, or fraudulent; or
3) an in-home service provider agency did not increase the wages paid to its direct service workers in the amount required by a rate increase under the Community Care Program.
f) Possible contract enforcement action includes, but is not limited to, imposition of a corrective action plan, closure of intake on contracts, suspension or debarment from doing business with the Department, and termination of contracts.
g) An in-home service provider agency may appeal contract enforcement action in accordance with Section 240.1661.
(Source: Added at 32 Ill. Reg. 19912, effective December 12, 2008)
Section 240.2030 Unallowable Costs for In-home Service
Certain costs shall not be considered by the Department in establishing a fixed rate of reimbursement for in-home service:
a) expenses resulting from transactions with related parties/parent organizations that are greater than the going market cost of the transactions to the provider;
b) non-straightline depreciation;
c) bad debts;
d) special benefits to owners, including owner and key-man life insurance;
e) compensation to non-working owners and officers;
f) discounts, rebates, allowances, and charity grants offered by the agency;
g) entertainment expenses;
h) fundraising;
i) legal fees for litigation with governmental agencies;
j) awards, grants and gifts to individuals;
k) fines and penalties;
l) contingency funds;
m) losses on other grants and contracts; and
n) health coverage costs incurred for direct service workers by any qualifying provider for which an enhanced rate is paid for that purpose by the Department under Section 240.1970.
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.2040 Minimum Direct Service Worker Costs for In-home Service
a) Providers are required to expend a minimum of 77% of the total revenues due from the Department (see Section 240.2020(b)) to include the participant incurred expense that may have been applicable for direct service worker costs prior to July 1, 2010, as enumerated in Section 240.2050, during a reporting year.
1) This percentage is to be adhered to on a statewide basis.
2) The remaining 23% of the total revenues may be spent by the provider agencies, at their discretion, on administrative or program support costs, also delineated in Section 240.2050.
b) Failure of the provider to meet the requirements in subsection (a) may result in the following:
1) The provider will be required to submit and observe a Department-approved corrective action plan that shall include provider payments to current direct service workers in an amount that will, in total, bring the provider into compliance with the requirements of subsection (a).
2) Failure by the provider to submit and/or observe a corrective action plan may result in the following Department sanctions:
A) closure of intake (all or some contracts) for a period of time provided by written notice to the provider; or
B) termination (all or some contracts).
(Source: Amended at 42 Ill. Reg. 20653, effective January 1, 2019)
Section 240.2050 Cost Categories for In-home Service
Providers of in-home service for which a fixed rate is established will provide for cost reporting based on the following categories:
a) Direct service worker costs (costs paid to or on behalf of direct service workers), which may include:
1) wages, time paid on behalf of the worker (i.e., vacation, sick leave, holiday and personal leave);
2) health coverage for any provider that does not qualify for an enhanced rate under Public Act 95-713 on or after July 1, 2008, or the amount of cost incurred in excess of the enhanced rate paid to the provider during a reporting period; life insurance; and disability insurance;
3) retirement coverage;
4) FICA;
5) uniforms;
6) workers' compensation;
7) FUTA;
8) travel time and travel reimbursement;
9) unemployment insurance; and
10) other costs approved, in advance, as direct service costs by the Department.
b) Administrative Costs:
1) personnel:
A) administrator;
B) assistant administrator;
C) accountant/bookkeeper;
D) clerical;
E) other office staff;
F) other personnel expenses;
2) consultant:
A) auditors;
B) management consultants;
C) management fees from the parent organization;
D) other related consultant costs;
E) other consultant expenses;
3) non-personnel:
A) office supplies;
B) office equipment (expense or depreciation based upon company policy);
C) telephone/telegraph;
D) conferences, conventions, meeting expenses;
E) subscriptions and reference materials;
F) postage and shipping;
G) advertising;
H) outside printing and art work;
I) membership dues;
J) moving and recruiting;
K) other general operating expenses;
L) profit;
4) occupancy:
A) depreciation;
B) amortization of leasehold improvements;
C) rent;
D) property taxes;
E) interest;
F) other related occupancy costs.
c) Program support costs that include all allowable costs not specifically made a part of direct service costs or administrative costs. These may include:
1) training expenses;
2) malpractice insurance;
3) direct service worker supervisor costs.
(Source: Amended at 32 Ill. Reg. 19912, effective December 12, 2008)