Section 686.930  Monitoring and Liability of Provider

a)         The HSP Ashburn Unit shall monitor the case management agency to assure compliance with this Subpart by:

1)         reviewing and approving the assessment (Section 686.910(c)).  The review will be conducted pursuant to the DHS' Home Services Program (89 Ill. Adm. Code 682), the service plan, and payments for services;

2)         reviewing provisional case managers as set forth in subsection (d);

3)         reviewing, on an annual basis, a random sample 10% of the cases handled in the preceding 12 months or two cases, whichever is greater;

4)         visiting, at least annually, all contracting case management agencies.

b)         The HSP Ashburn Unit shall monitor the service plans of customers served by a case manager to ensure that:

1)         The case manager is monitoring the customer's case at least monthly by carrying out at least one face-to-face visit and two other contacts with the customer;

2)         The case manager is reassessing the service plan at least every 12 months for those cases in formal eligibility and every three months for those cases which have been presumptively determined eligible;

3)         Each of the reassessments undertaken by the case manager is complete and accurate;

4)         Any amendments to the service plan are consistent with the findings of the reassessment; and

5)         The service plan remains cost effective (i.e., the cost of the service plan is equal to or less than the long term care costs).

c)         DHS-DRS, Central Office quality assurance staff shall:

1)         monitor the quality of the reviews conducted annually;

2)         provide case reviews of selected cases Statewide; and

3)         tabulate the findings from all reviews to determine accuracy levels, Statewide need for training and individual training needs.

d)         All provisional case managers and case management supervisors will work toward meeting the case manager standards within six months after receiving the HSP Ashburn Unit's Case Management Training.  Case managers and case management supervisors with a gap in service of greater than one year must complete the certification process.  Complete case manager status will be granted when six case file reviews attain a competency score of 98-100% using the review process described in this subsection (d).

1)         The HSP Ashburn Unit will review at least six case files within six months after the date of the provisional case manager's completion of the Case Management Training for the case manager.  A combination of the following case types and amounts may be used to satisfy the requirement:

A)        six fee-for-service initial assessments;

B)        three fee-for-service initial assessments and three fee-for service reassessments; or

C)        two fee-for-service initial assessments, two fee-for-service reassessments, and four Managed Care Organization (MCO) assessments of any type.

2)         The HSP Ashburn Unit will review each case file using the HSP Ashburn Unit case file review quality assurance form.

3)         The HSP Ashburn Unit will discuss areas of deficiency with the case manager.

4)         The HSP Ashburn Unit will work with the case manager to resolve all deficiencies in the case files.

5)         The case manager will correct and complete all deficient areas prior to the next review of case files.

6)         The HSP Ashburn Unit will re-review all deficient files for compliance with case management practices.

7)         The above process will continue, within the six-month review period, until the cases reviewed for the case manager meet a 98-100% compliance score.

e)         Return to Provisional Status

1)         A case manager shall return to provisional status when any of the following events occur:

A)        A review of files, per this Section, results in a score of 89% or less; or

B)        Within the last year, the HSP Ashburn Unit has made five requests for materials that were not submitted on time or for assessments not completed timely; or

C)        Sufficient documentation is not available to demonstrate that the case manager has successfully completed case management training.

2)         Prior to the initiation of action to return a case manager to provisional status, the case management agency of the case manager will be sent a letter outlining the issues.  The case management agency will have 10 days to respond.  The case manager will return to provisional status unless the case management agency can prove the event causing the action did not occur.  Once a case manager is returned to provisional status, the case manager must complete the measures outlined in subsection (d).

f)         Liability

1)         DHS shall assume no liability for actions of the case management agency.

2)         The case management agency shall agree to hold DHS harmless against any and all liability, loss, damage, cost or expenses arising from wrongful or negligent acts of the provider.

3)         The case management agency shall certify that it has maintained and will maintain liability insurance coverage.  Upon request, the provider shall make available policies, certificates of insurance or current letters documenting all insurance coverage.

4)         The case management agency shall remain liable for the performance of any person, organization, unincorporated association or corporation with which it contracts.

(Source:  Amended at 47 Ill. Reg. 19328, effective December 13, 2023)