Section 147.350  Reimbursement for Additional Program Costs Associated With Providing Specialized Services for Individuals with Developmental Disabilities in Nursing Facilities

a)         Nursing facilities (ICF and SNF) providing specialized services to individuals with developmental disabilities, excluding state operated facilities for the developmentally disabled, will be reimbursed for providing a specialized services program for each client with developmental disabilities as specified in 89 Ill. Adm. Code 144.50 through 144.250.

b)         Beginning February 1, 1990, facility reimbursement for providing specialized services to individuals with developmental disabilities will be made upon conclusion of resident reviews that are conducted by the state's mental health authority or their contracted agent.  Facility reimbursement for providing specialized services as a result of resident reviews concluded prior to February 1, 1990, will begin with the facility's February billing cycle.

c)         The additional reimbursement for costs associated with specialized services programs is based upon the presence of three (3) determinants.  The three determinants are:

1)         Minimum Staffing

A)        Direct Services – Facilities must be in compliance with the Health Care Financing Administration's (HCFA) (42 CFR 442.201 or 42 CFR 442.302 (1989)) and the Illinois Department of Public Health's (IDPH) (77 Ill. Adm. Code 300.1230) minimum staffing standards relative to facility type.

B)        The number of additional direct services staff necessary for delivering adequate specialized services programs for individuals with developmental disabilities is based upon a full time equivalent (FTE) staff to client ratio of 1:7.5.

2)         Qualified Mental Retardation Professional Services

A)        Each individual's specialized services program must be integrated, coordinated and monitored by a Qualified Mental Retardation Professional (QMRP).  Any facility required to provide specialized services programs to individuals with developmental disabilities must provide QMRP services. Delivery of these services is based upon a full-time equivalent ratio of one (1) QMRP to thirty (30) individuals being served.

B)        A Qualified Mental Retardation Professional (QMRP) is a person who has at least one year of experience working directly with persons with mental retardation and is one of the following:

i)          A doctor of medicine or osteopathy;

ii)         A registered nurse;

iii)        An individual who holds at least a bachelor's degree in one of the following professional categories:  Occupational Therapist; Occupational Therapy Assistant, Physical Therapist, Physical Therapy Assistant, Psychologist, Master's Degree; Social Worker; Speech-Language Pathologist or Audiologist; Recreation Specialist; Registered Dietitian; and Human Services, including but not limited to Sociology, Special Education, Rehabilitation Counseling, and Psychology (42 CFR 483.430(1989)).

3)         Assessment and Other Program Services

A)        A comprehensive functional assessment that identifies an individual's needs must be performed as needed to supplement any preliminary evaluations conducted prior to admission to a nursing facility.

B)        A Comprehensive Assessment must include:

i)          physical development and health;

ii)         dental examination that includes an assessment of oral hygiene practices;

iii)        nutritional status;

iv)        sensorimotor development/auditory functioning;

v)                  social development;

vi)               speech and language development;

vii)             adaptive behaviors or independent living skills necessary for the individual to be able to function in the community (Scales of Independent Behavior (SIB) or the Inventory for Client and Agency Planning (ICAP) are the assessment instruments that must be used for this assessment);

viii)           vocational or educational skills (if applicable);

ix)        cognitive development;

x)         medication and immunization history;

xi)        psychological evaluation (within 5 years) that includes an assessment of the individual's emotional and intellectual status;

xii)       capabilities and preferences relative to recreation/leisure activities;

xiii)      other assessments indicated by the individual's needs, such as physical and occupational therapy assessments;

xiv)      seizure disorder history (if applicable) with information regarding frequency of occurrence and classification; and

xv)       screenings (the facility performs or obtains) in the areas of nutrition, vision, auditory and speech/language.

d)         Costs associated with specialized services programs reimbursement includes other program costs, such as consultants, inservice training, and other items necessary for the delivery of specialized services to clients in accordance with their individual program plans.

e)         Total program reimbursement for the additional costs associated with the delivery of specialized services to individuals with developmental disabilities residing in nursing facilities will be ten dollars ($10) per day, per individual being served.  Facility eligibility for specialized services program reimbursement is dependent upon the facility meeting all criteria specified in Sections 147.5 through 147.205, 147.350 and 144.25 through 144.250.

(Source:  Amended at 16 Ill. Reg. 17332, effective November 6, 1992)