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)