Section 144.1  Incorporation By Reference

 

Any rules or regulations of an agency of the United States or of a nationally recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified, and do not include any later amendments or editions.

 

Section 144.5  Determination of Program (Active Treatment) Costs

 

a)         The Department reimburses residential facilities for program costs associated with the delivery of active treatment to individuals with developmental disabilities, according to information obtained during each facility's most recent Inspection of Care (IOC) Review.  Facilities affected by this Part are those certified as Intermediate Care Facilities for the Mentally Retarded (ICF/MR) and licensed as:

 

1)         intermediate care facilities for individuals with developmental disabilities (ICF/DD) (including specialized living centers (SLC));

 

2)         long term care facilities for residents under 22 years of age (hereinafter referred to as SNF/PED); and

 

3)         intermediate care facilities for individuals with developmental disabilities of 16 beds or less (ICF/DD-16) (including small scale facilities with four or six beds).

 

b)         IOC Review assessments of 100% of the Medicaid residents are conducted in these facilities by the Department of Public Health every 12 months. These will be conducted in accordance with federal regulations at 42 CFR 456, Subpart I. Program rate determination is based upon IOC Review criteria and Specialized Care needs as described in Sections 144.125 and 144.150 in conjunction with the reimbursement methodology found at Section 144.275.

 

c)         Reimbursable services under this Section do not include services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous active treatment program.

 

(Source:  Amended at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.25  ICF/MR Service Criteria

 

a)         Need for ICF/MR Services

 

1)         The need for ICF/MR services shall be established through a comprehensive assessment (see 89 Ill. Adm. Code 140.642), the Level II assessment, that demonstrates that the individual needs active treatment and has either:

 

A)        mental retardation; or

 

B)        a related condition that meets all of the following conditions:

 

i)          It is attributed to cerebral palsy, epilepsy, autism, or any other condition, other than mental illness or infirmities of aging, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons.

 

ii)         It is manifested before the person reaches age 22.

 

iii)        It is likely to continue indefinitely.

 

iv)        It results in substantial functional limitations in three or more of the following areas of major life activity:  self care, understanding and use of language, learning, mobility, self direction, capacity for independent living.

 

2)         Active treatment is defined by federal regulations at 42 CFR 483.440(a) as a program of specialized and generic training, treatment, health services and related services, that is directed toward the acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible and the prevention or deceleration of regression or loss of current optimal functional status.  Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.

 

3)         No applicant for ICF/MR services meeting the above criteria shall be found to be inappropriate for such services due to a need for the treatment of a severe or profound sensory handicap, motor deficit, or mental retardation; nor shall such an applicant be denied ICF/MR services due to age, medical needs, or maladaptive behavior, except as otherwise described in this Section.

 

b)         Need for ICF/MR (SNF/PED License) Services

 

1)         ICF/MR (SNF/PED license) services will only be approved for individuals who are under the age of 21 at the time of admission to the facility.

 

2)         The need for such services shall be established through a comprehensive assessment, the Level II assessment, that demonstrates that the individual has a medical (physical) condition requiring skilled level nursing care; or has mental retardation or a related condition and/or a severe medical or physical disability or a combination of severe disabilities.

 

(Source:  Section repealed at 18 Ill. Reg. 16619, effective October 27, 1994; new Section adopted at 20 Ill. Reg. 9072, effective June 28, 1996)

 

Section 144.30  Developmental Disability Provider Rate Adjustments

 

a)         Adjustments in FY 18 and FY 19

Pursuant to PA 100-23 and PA 100-587, providers of services to individuals with developmental disabilities shall ensure that all wages earned by front-line direct care personnel are at least $1.25 per hour higher than those wages that existed on July 31, 2017.

 

b)         Adjustments in FY 20

Pursuant to PA 101-10, rates established for providers of services to individuals with developmental disabilities effective July 1, 2019 shall be increased 3.5 percent above rates in effect on June 30, 2019, subject to federal approval.  Providers shall determine whether to allocate the entirety or a portion of the 3.5 percent to the wages of direct care staff.

 

c)         Adjustments in FY 21

 

1)         Pursuant to Public Act 101-0636 and subject to federal approval of the increases, providers of community-based services and supports to individuals with developmental disabilities shall increase wages for non-executive staff as follows:

 

A)        Effective July 1, 2020, by $1.00 per hour, with at least eighty (80) cents per hour of those funds to be provided for a direct increase to non-executive staff wages, with priority given to direct care staff; and

 

B)        Effective January 1, 2021, by $0.50 per hour, with at least forty (40) cents per hour of those funds to be provided for a direct increase to non-executive staff wages, with priority given to direct care staff.

 

2)         Non-executive staff, for purposes of subsection (c)(1), includes but is not limited to direct care staff (direct support persons (DSPs), front-line supervisors, qualified intellectual disabilities professionals, and nurses) and non-administrative support staff working in community-based provider organizations that serve individuals with developmental disabilities.

 

d)         Adjustments in FY 22

 

1)         Pursuant to Public Act 102-0016 and subject to federal approval of the rate increases, providers of community-based services and supports to individuals with intellectual and developmental disabilities shall increase wages as follows:

 

A)        Effective January 1, 2022 or upon federal approval, whichever is later, for DSPs, by $1.50 per hour, with at least $0.75 per hour of those funds to be provided for a $0.75/hour direct increase to all DSP wages, with the remaining 50% ($0.75 per hour) to be used flexibly for wage increases for DSPs and other frontline staff not covered in subsection (d)(1)(B); and

 

B)        Effective January 1, 2022 or upon federal approval, whichever is later, for non-executive direct care staff, excluding DSPs, to the federal Department of Labor’s Bureau of Labor Statistics’ mean hourly wage based on the same or similar occupation title, as outlined in the Guidehouse Rate Study (available at https://3m4psa58y9z2vlhqru7ram5-wpengine.netdena-ssl.com/wp-content/uploads/2020/12/Final-Guidehouse-Rates-Report-12.08.2020.pdf).

 

2)         Any increases provided to DSP wages on or after July 1, 2021, that a provider has voluntarily provided or been required to provide based on local minimum wage requirements, will be included as all or part of the DSP wage increase required.

 

3)         Non-executive direct care staff, for purposes of subsection (d)(1)(B), includes but is not limited to supervisors, qualified intellectual disabilities professionals, dietitians, licensed practical nurses, registered professional nurses, and non-administrative support staff working in community-based provider organizations that serve individuals with developmental disabilities.

 

(Source:  Amended at 46 Ill. Reg. 7755, effective April 27, 2022)

 

Section 144.50  Inspection of Care and Rate Setting Appeal Process

 

a)         Inspection of Care Appeal Process

 

1)         Resident Assessment – A facility may request an appeal of the resident assessment conducted by the Inspection of Care (IOC) team.  Examples of conditions which may be appealed include level of functioning (IQ, results of functional assessments and existence of related conditions), medical add-ons, behavioral add-ons, major life area limitations, special transportation needs, special care nursing and information on the developmental training agency attended.  Differences between the facility and the IOC team regarding the conditions of the residents will be addressed using a three-step approach:

 

A)        exit conference discussion between the facility and the IOC team;

 

B)        informal review involving the Department of Public Health (DPH) regional supervisor and/or central office staff upon request by the facility; and

 

C)        formal review to be heard by the Department of Mental Health and Developmental Disabilities' (DMHDD) management.

 

2)         Incomplete Assessments – In order for an assessment to be appealable, the assessment must be completed prior to the exit conference to be included in the IOC.

 

b)         Examples of Appealable Situations

 

1)         If the facility believes the surveyor has misinterpreted the regulations, or the facility disagrees with the surveyor's recommendations pertinent to the resident's condition (examples are included in subsection (a)(1)), the facility may request an appeal.

 

2)         If the facility believes that all assessment data pertinent to the individual's status/condition have not been reviewed, the facility may bring that data to the attention of the surveyor through the appeal process.  Such information must have been part of the resident's record at the time of the assessment to be considered.

 

3)         The facility has been surveyed because of a 25 percent Medicaid eligible population change, a State Developmental Center admission or because it is a new facility, and there is disagreement with the findings.

 

c)         Process and Time Frames

 

1)         Exit Conference – At the exit conference, the facility may state the service needs that it disputes.  The facility is responsible for providing supporting data to the IOC team at the exit conference.  When the differences are not reconciled through discussion, the facility may request an appeal.  The facility shall submit the written appeal request stating the service needs in dispute.  The appeal request and the supporting documentation provided by the facility shall be submitted to the IOC regional supervisor (with a copy of the appeal request to DPH's Division of Long Term Care (DLTC) Field Operations) within 14 calendar days after the IOC exit date.

 

2)         Informal Review – Within 30 calendar days after receipt of the IOC appeal request and supporting documentation, the IOC regional supervisor and/or DPH central office staff will review the documentation and either uphold or overturn the surveyor's findings and shall provide written notification of the decision to the facility.

 

3)         Formal Review – The facility may request a formal review of the informal review decision.  Within ten calendar days after receipt of the decision from the regional supervisor, the facility shall submit a written request for a formal review to the Associate Director of the Division of Developmental Disabilities within DMHDD with a copy to the DLTC Field Operations within DPH.

 

A)        The formal review shall be conducted not more than 30 days after the facility's request for such a review.  Not fewer than 14 days prior to the scheduled review date, the Division of Developmental Disabilities will notify the facility in writing of the review date, with necessary instructions for the facility to request rescheduling if the date is not feasible for the facility.

 

B)        The Associate Director and/or his or her designee will preside over the formal review.  During the review, DPH representatives shall present the basis for the decision reached at the informal level of the review.  The facility shall present its documentation and DMHDD shall apply policy as it relates to the findings under dispute.  The Associate Director shall send to the facility a written decision rendered as a result of the formal review within ten calendar days after the hearing with a copy to DPH. The decision of the Associate Director is final.

 

4)         Continuation of an appeal is contingent upon following the steps and timeframes established in this Section.

 

d)         Use of IOC Data in Rate Calculation

            DMHDD will explain the use of IOC data in rate calculations upon written or telephone requests and/or personal visits.  DMHDD will correct any errors in processing or using this IOC data to calculate rates.  Rate methodology is promulgated by rulemaking according to the Illinois Administrative Procedure Act and is subject to review only through the formal rulemaking comment and hearing process.

 

(Source:  Section repealed at 18 Ill. Reg. 16619, effective October 27, 1994; new Section added at 20 Ill. Reg. 11326, effective August 1, 1996)

 

Section 144.75  Comprehensive Functional Assessments and Reassessments (Repealed)

 

(Source:  Repealed at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.100  Exceptional Care Needs of Clients with Developmental Disabilities

 

a)         Exceptional Care Program

 

1)         The Department of Human Services (Department) may make payments to facilities that meet licensure and certification requirements for skilled nursing facilities – under age 22 (SNF/Ped as may be prescribed by the Department of Public Health (DPH) (see the Department of Public Health's rules at 77 Ill. Adm. Code 390).  A participating facility must maintain its licensure and certification and be in compliance with the applicable conditions of participation and licensing and certification standards to be eligible for exceptional care.  If DPH notifies the facility, in writing, of a need for a plan of correction for non-compliance with one or more conditions of participation, or that an imposed plan of correction for an A or B licensure finding is required, or if DPH notifies the facility because it has been declared an "immediate and serious threat" to the welfare of any resident(s), that facility will not be allowed to receive exceptional care reimbursement for any additional individuals from the date of DPH's written notification until the date DPH officially determines any and all of the conditions leading to the notification have been satisfactorily resolved.  No payment for exceptional care shall be made retroactively for any residents admitted to the facility while the facility was in violation of DPH's rules at 77 Ill. Adm. Code 390.  Exceptional care payment for such individuals shall commence when all such violations have been corrected, if such individuals are approved for exceptional care.

 

2)         Exceptional medical care is defined as the level of care with extraordinary costs related to services which may include nurse, ancillary specialist services, and medical equipment and/or supplies that have been determined to be a medical necessity.  This may apply to Medicaid clients who currently are residing in SNF/Ped facilities, Medicaid patients who are being discharged from the hospital or other setting where Medicaid reimbursement is at a rate higher than the exceptional care rate for related services, or persons who are in need of exceptional care services and who would otherwise be in an alternative setting at a higher cost to the Department or the Department of Public Aid.  This includes but is not limited to persons with complex respiratory illness, ventilator-dependent persons or persons with high medical needs for whom the SNF/Ped provides a cost-effective living arrangement.  High medical needs is defined as licensed staffing costs 50 percent above the level III medical add-on licensed staffing reimbursement rate.

 

3)         The Department shall recommend rates to the Department of Public Aid (DPA) for DPA approval in accordance with the provisions of Section 18.2 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705/18.2] and Section 5-11 of the Illinois Public Aid Code [305 ILCS 5/5-11].  The Department will calculate the rates for exceptional care service categories by using data collected from SNF/Ped exceptional care providers.

 

b)         Exceptional Care Requirements

            The Department may reimburse for exceptional care services only if the SNF/Ped provider agrees to the following conditions:

 

1)         The provider will maintain separate records regarding costs related to the care of the exceptional care residents.

 

2)         The provider must meet all conditions of participation in accordance with 42 CFR 483, Subpart I, Conditions of Participation for Intermediate Care Facilities for the Mentally Retarded (1996).  If the provider is not in compliance with a condition of participation and such noncompliance is under appeal, The Department will delay action on the provider's application to participate in the exceptional care program pending the official determination by DPH that any and all of the conditions leading to the notification have been satisfactorily resolved.

 

3)         The provider must demonstrate the capacity and capability to provide exceptional care as documented by DPH and Department records, including, but not limited to, being free of Type A violations and/or conditional license brought upon by violations relating to health care services.  If the Type A violation and/or conditional license is under appeal, the Department will delay action on the provider's application to participate in the exceptional care program pending the satisfactory outcome of the action of DPH taken in regard to the facility's non-compliance with conditions of participation or the proper implementation of a plan of correction for a licensure finding.  Newly licensed facilities are not immediately eligible to participate in the exceptional care program.  An assessment may be made jointly by DPH and the Department to determine if the facility demonstrates the capacity and capability to provide exceptional care prior to the facility being open for 12 months.  This assessment may be done prior to a facility having been open for 12 months when 15% or more licensed beds are filled with Medicaid eligible residents to present an accurate representation of the facility's ability to care for more medically involved individuals as determined by DPH.

 

4)         For the purposes of this Section, a newly licensed facility is one that has never been licensed before, that has reopened after having discharged all residents or that has changed the focus of its operations (e.g., from ICF/SNF to ICF/MR or SNF/Ped).  Facilities that were already participating in the Exceptional Care Program and are sold to a new licensee are not considered newly licensed.

 

5)         The provider must maintain and provide documentation demonstrating:

 

A)        Adherence to staffing requirements as described in subsection (c) of this Section;

 

B)        Adherence to staff training requirements as described in subsection (d) of this Section;

 

C)        Written agreements as required in subsection (e) of this Section;

 

D)        Presence of emergency policy and procedures as described in subsection (f) of this Section;

 

E)        Medical condition of the resident; and

 

F)         Care, treatments and services provided to the resident.

 

6)         When residents are mechanically supported, the provider must have and maintain physical plant adaptations to accommodate the necessary equipment, e.g., emergency electrical backup system.  The provider shall maintain records demonstrating the facility's maintenance of emergency equipment.  Staff must be familiar with the location and operation of the emergency equipment and related procedures.  To assure that staff are familiar with operating the emergency equipment, facilities must provide quarterly in-service training for all staff caring for residents.

 

c)         Exceptional Care Staffing Requirements

 

1)         There shall be at least one registered nurse 24 hours a day seven days per week in the facility.  Based on the Department's review of the exceptional care services needs, additional registered nurse staff may be determined necessary by the Department to implement the medical care plan and meet the needs of the individual.

 

2)         There shall be at least one registered nurse or licensed practical nurse on duty at all times and on each floor housing  residents (as required by DPH in 77 Ill. Adm. Code 390.1040(b)).

 

3)         For those facilities providing complex respiratory or ventilator services under exceptional care, there shall be a certified respiratory therapy technician or registered respiratory therapist on staff or on contract with the facility.

 

d)         Training Requirements for Facilities Providing Exceptional Care for Persons with Tracheostomies and Ventilator-Dependent Residents

 

1)         At least one of the full-time professional nursing staff members must have successfully completed a course in the care of ventilator-dependent individuals and the use of ventilators, conducted and documented by a certified respiratory therapy technician or registered respiratory therapist or a qualified registered nurse who has at least one year's documented experience in the care of ventilator-dependent persons within the last three years.  This nursing staff member must receive annual continuing education/in-service training on the care of ventilator-dependent individuals.  This requirement may be alternatively satisfied if the facility employs on staff a certified respiratory therapy technician or registered respiratory therapist.

 

2)         All staff caring for ventilator-dependent residents must have documented in-service training in ventilator care prior to providing such care. In-service training must be conducted at least annually by a certified respiratory therapy technician, a registered respiratory therapist or a qualified registered nurse who has at least one year's experience in the care of ventilator-dependent persons.  In-service training documentation shall include name and qualifications of the in-service director, duration of presentation, content of presentation and signature and position description of all participants.

 

3)         All staff caring for persons with tracheostomies must have documented in-service training in tracheostomy care, other related medically complex procedures and infection control/universal precautions, prior to providing such care.  In-service training documentation shall include the name and qualifications of the inservice director, duration of presentation, content of presentation and signature and position description of all participants.  The in-services should address all extraordinary situations and/or aspects of care.

 

e)         Exceptional Care Agreement Requirements

            The provider must have a valid written agreement with:

 

1)         A medical equipment and supply provider which must include a service contract for ventilator equipment when accepting ventilator-dependent residents.  Supplies include oxygen, oxygen concentrator, tracheostomy supplies and any other items needed for the services to be delivered;

 

2)         A local emergency transportation provider;

 

3)         A hospital capable of providing the necessary care for equipment-dependent residents, when appropriate; and

 

4)         A certified respiratory therapy technician or registered respiratory therapist (unless a respiratory therapist is on staff within the facility) when accepting ventilator-dependent residents or residents requiring respiratory therapy services.

 

f)         Exceptional Care Emergency Policy and Procedures Requirements

 

            The provider must have specific written policies and procedures addressing emergency care for residents requiring exceptional care.

 

g)         Accessibility to Records

            The provider must make accessible to the Department, DPA and/or DPH all facility, resident and other records necessary to determine the appropriateness of exceptional care services.

 

h)         Provider Approval and Voluntary Termination Process

 

1)         A provider should notify the Department, in writing, of its interest in participating in the Exceptional Care Program.

 

2)         The Department shall conduct a review of the facility to assure that the facility meets all the exceptional care requirements contained in this Section.

 

3)         The Department shall notify the provider in writing of its approval for exceptional care services.

 

4)         Providers desiring to discontinue provision of exceptional care shall notify the Department, in writing, at least 60 days prior to the date of termination.  Payment for exceptional care residents already residing in facilities which notify the Department that they wish to discontinue providing exceptional care services will be reduced to the facility's standard Medicaid per diem rate at the time exceptional care services are discontinued.  The Department will review each approved exceptional care client to determine whether he or she may remain in the facility.  For the duration of the time that exceptional care clients remain in the facility, the provider must continue to meet the needs of the individual.  Should a transfer to another facility be necessary, the provider must contact the responsible case coordinating agency which will assist in locating another provider.

 

5)         It is the responsibility of a SNF/Ped provider to effect appropriate discharge planning for exceptional care residents when terminating services for exceptional care.  The Department will assist providers with any information available regarding appropriate placement settings.

 

i)          Determining Eligibility for Exceptional Care Payment

 

1)         A person currently residing in a SNF/Ped, a person being discharged from a hospital or a person who is in another setting must be approved by an authorized Department representative to be eligible for exceptional care payment.

 

2)         Eligible items which may be used in computing the cost of the person's care include nursing services costs, therapy services costs, and medical equipment and supply costs.  Computations for determining cost of care shall be based upon reasonable costs for services, medical equipment and supplies for the facility as determined by the Department.

 

3)         The provider must submit a request for exceptional care to the Department.  An authorized Department representative will conduct a medical review of the required care and related costs of equipment and supplies.  The Department will compute the exceptional care rate as the licensed staff cost in excess of the licensed staff cost of the standard rate methodology of the medical level III add-on plus a related cost factor of 15 percent for equipment and supplies.  The Department will notify the provider of the rate to be paid for the exceptional care services provided.

 

j)          Monitoring

 

1)         The Department shall provide for a program of delegated utilization review and quality assurance.

 

2)         The Department shall review exceptional care residents' utilization of services at least once every 90 days.  A review may be waived by the Department staff if one or more previous reviews show that a resident's condition has stabilized.  However, two consecutive reviews shall not be waived.  The Department exceptional care staff will maintain contact with the SNF/Ped regarding the resident's condition during the time period any review is waived.

 

3)         In the event that it is determined that the resident is no longer in need of or is no longer receiving exceptional care services, the Department shall discontinue the exceptional care payment rate for the resident and reduce the rate of payment to the provider to the facility's standard Medicaid per diem rate, effective the later of either the date of the review or the determination by the Department.  Notice of this action shall be sent to the provider within 30 days.

 

4)         Providers shall be reviewed annually to determine whether they continue to meet all the criteria to participate in the exceptional care program.  If the annual review indicates the facility does not meet the exceptional care criteria or the resident is no longer in need of or is no longer receiving exceptional care services, the Department shall terminate the agreement.  If the Department terminates the agreement, the exceptional care rate will be reduced to the facility's standard Medicaid per diem rate.  Termination of the agreement shall be effective 30 days after the date of the notice.  The Department will review each formerly approved exceptional care client to determine whether he or she may remain in the facility.  For the duration of the time that formerly approved exceptional care clients remain in the facility, the provider must meet the needs of the individual.  If a transfer to another facility is necessary, the provider must contact the responsible case coordinating agency which will assist in locating another provider.

 

(Source:  Amended at 23 Ill. Reg. 932, effective January 6, 1999)

 

Section 144.102  High Medical/High Personal Care Needs of Individuals with Developmental Disabilities

 

a)         For services provided on or after July 1, 2010, daily rates for qualifying ICFs/MR shall have their own reimbursement rates adjusted pursuant to this Section.

 

b)         Qualifying Criteria

In order to receive rate adjustments under this Section, facilities must meet the following criteria:

 

1)         Be a licensed ICF/MR, as defined in 77 Ill. Adm. Code 350, with more than 16 licensed beds and is not:

 

A)        An SNF/PED, as defined in 77 Ill. Adm. Code 390; or

 

B)        A campus facility, as defined under 89 Ill. Adm. Code 140.583.

 

2)         For the immediately preceding month, as documented in the remittance advice report, have:

 

A)        An occupancy level of at least 93 percent of licensed ICFDD bed capacity; and

 

B)        At least 93 percent of the ICFDD residents eligible for, and enrolled in, medical assistance under 89 Ill. Adm. Code 120.

 

3)         Based on the most recently conducted annual inspection of care survey, at least 50 percent of the residents of the facility must qualify as Medical Level III.

 

c)         Adjustment Methodology

The program and support components of the per diem rate for qualifying facilities shall be replaced with the adjusted program and support components, determined as follows:

 

1)         Adjustment Factor

The adjustment factor for a facility shall be the product of the difference between the Medical Level III percentage and 50 percent and:

 

A)        For facilities with a Medical Level III percentage less than 80 percent − 3.9; or

 

B)        For all other facilities – 5.0.

 

2)         Adjusted Program Component

The adjusted program component shall equal the product of the following:

 

A)        The program component of the per diem rate, as determined under Section 144.275; and

 

B)        The sum of 1.000 plus the adjustment factor for the facility, as determined in subsection (c)(1).

 

3)         Adjusted Support Component

The adjusted support component shall equal the SNF/PED ceiling for the geographic area in which the facility is located.

 

4)         Subsequent Adjustments

 

A)        Adjusted program and support components shall be redetermined when:

 

i)          Changes to the program or support rate components are required in accordance with 89 Ill. Adm. Code 153; and

 

ii)         The percentage of the residents who are classified as Medical Level III changes as a result of the facility's annual inspection of care survey.  The adjusted program component shall be recalculated and effective the first day of the month following the Medical Level III determinations.

           

B)        All high medical/high personal care rates for residents classified as Medical Level III will be reviewed and updated for changes in the facility population at least once annually upon issuance of respective facility Inspection of Care surveys.

 

(Source:  Amended at 41 Ill. Reg. 2950, effective February 24, 2017)

 

Section 144.105  Individual Program Plan (IPP) (Repealed)

 

(Source:  Repealed at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.125  Specialized Care – Behavior Development Programs

 

a)         Adaptive behaviors are actions and responses which are productive and appropriate.  Maladaptive behaviors are actions and responses which are nonproductive and/or inappropriate.  Although maladaptive behaviors are generally described as nonproductive and inappropriate, in some cases, an individual's inappropriate behavior may be productive, given the social or environmental context of a particular activity.  Behavior development refers to both the reduction in maladaptive behaviors and the increase in adaptive behaviors.  A behavior program instituted because of maladaptive behaviors must also include the development of adaptive behaviors.  Additional reimbursement is paid for an individual who needs and receives specialized care for a behavioral disability (Section 144.275(c)(1)), when the individual's behavior development program meets the criteria in subsection (b)(1) of this Section.

 

b)         Behavior Development Program Levels

 

1)         Behavior development programs under Specialized Care are related to maladapative behaviors which occur with high frequency and/or great severity.  A behavior development program, including the use of psychotropics, which is developed for Specialized Care, must meet all federal and State requirements including, but not limited to, development by the IDT, review and approval by a Behavior Management Committee (or Human Rights Committee) as required by 42 CFR 483.440(f)(3), 1993 and approval by the individual or guardian, if the individual is not capable of providing informed consent.  The behavior development program developed by the IDT must demonstrate the need for a use of a more intensive staffing pattern (direct care staff) than that pattern which is reimbursed for under Section 144.275(a)(1).  Additional staff time provided under Specialized Care is a response to a necessary increase in staff intensity identified in the behavior development plan when other attempted interventions have failed, such as environmental changes or changes in the pattern of activities throughout the day.  Specialized Care is not provided based solely on the frequency or severity of the individual's maladaptive behavior.

 

2)         Behavior development program services under Specialized Care do not preclude the individual's participation in regular training services, activities and therapies as part of a comprehensive active treatment program.

 

3)         The IDT provides highly specific guidelines for the individual's behavior development program relative to treatment methodology, services needed, and staff needed to deliver interventions.

 

A)        Level I – Behavior development program services are delivered by staff specifically trained in the delivery of the prescribed interventions. Behaviors occur with high frequency but moderate severity, i.e., verbal abuse one or more times per 4 hours which is hostile in tone or content including threats or screaming, or pica occurring once per 4 hours in volumes small enough to be non-life threatening.  Examples of staffing pattern changes:  The staffing pattern for persons with mild mental retardation increases from the regular pattern of 1:6.8 to 1:4.8, and for persons with severe-profound mental retardation from 1:4.8 to 1:3.7.

 

B)        Level II – Behavior development programs are delivered by staff trained in the delivery of each individual's intervention plan.  Individuals receive personalized intervention, such as individual counseling or some one-to-one intervention.  Behaviors occur with high frequency, and are aggressive or destructive, such as purposeful attacks of others resulting in minimal injuries one or more times per day.  Examples of staffing pattern changes:  The staffing pattern for persons with mild mental retardation increases from the regular pattern of 1:6.8 to 1:3.7, and for persons with severe-profound mental retardation from 1:4.8 to 1:3.

 

C)        Level III – Behavior development programs are delivered by staff who are specifically trained to deliver the interventions.  Generally, staff may be assigned to accompany the individual throughout the shift.  One-to-one intervention is common.  Behaviors occur with very high frequency, such as hyperactivity one or more times per minute, or occur with high frequency and are aggressive, assaultive or destructive, such as pica (daily consumption of life threatening materials), or daily physical assault resulting in injuries requiring medical attention.  Examples of staffing pattern changes:  The staffing pattern for persons with mild mental retardation increases from the regular pattern of 1:6.8 to 1:2.5, and for persons with severe-profound mental retardation from 1:4.8 to 1:2.

 

(Source:  Amended at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.150  Specialized Care  – Health and Sensory Disabilities

 

These specialized services refer to three categories (Levels) of care which some individuals must receive, fully or in part, in order to attain physical health and development.  The delivery of specialized care in accordance with an individual's need(s), as determined by the IDT's assessment, enables him/her to participate in his/her IPP and be supported toward greater independence.  Additional reimbursement is paid for an individual who needs and receives services for health and/or sensory disabilities (Section 144.275(c)(2)), when those services meet the criteria under subsections (b),(c) and/or (d) of this Section.

 

a)         Definitions

 

1)         Ambulatory – The individual is capable of walking without assistance or the aid of adaptive equipment or devices.

 

2)         Mobile nonambulatory – The individual is capable of locomotion with mobility assistance such as adaptive equipment or devices.

 

3)         Nonmobile – The individual is not capable of locomotion even with mobility assistance.

 

b)         Specialized Care, Level I

            The individual is ambulatory, mobile nonambulatory, or has the potential to become mobile nonambulatory, and requires services to compensate for a sensory deficit (auditory and/or visual), or services enabling him/her to be mobile, or limited services to meet medical needs.

 

1)         Sensory Deficits

 

A)        Visual Disabilities

            The individual requires and receives specialized services due to a visual disability as defined in Section 144.275(c)(2)(B)(i). Aids and appliances for individuals having such disabilities are limited to the following items with which facility staff can assist the individual.

 

i)          cane or dog used in mobility training or a sighted guide.

 

ii)         visual aids.

 

B)        Auditory Disabilities

            The individual requires and receives specialized care due to an auditory disability as defined in Section 144.275(c)(2)(B)(ii).  Aids and appliances for individuals having such disabilities are limited to the following items with which facility staff can assist the individual:

 

i)          Aided augmentative communication system.  Aided modes of communication may include the use of an eye gaze communication board, or an electronic communication device that has speech output or a print tape;

 

ii)         Assistive listening device (hearing aid); or

 

iii)        A hearing dog.

            AGENCY NOTE:  An individual's treatment might need to include being desensitized to tolerate the use of a hearing aid or assistive listening device to prevent the device from being rejected or destroyed.

 

2)         Physical Disabilities

            The individual requires and receives specialized care and training related to a physical disability which prevents or limits mobility.  The individual becomes mobile when employing certain adaptive equipment.  Aids, appliances and other adaptive equipment which promote mobility for individuals with physical disabilities are limited to the following devices which individuals can be taught to apply, or can be applied with assistance from facility staff:

 

A)        Arm brace;

 

B)        Back brace, body jacket;

 

C)        Leg brace;

 

D)        Prosthesis;

 

E)        Splints;

 

F)         Adaptive wheelchair;

 

G)        Walker.

            AGENCY NOTE:  A physical disability is defined as a physical impairment which results in a functional deficit, such as spasticity, poor muscle tone, paralysis, and absence of limbs.  Eligibility under Physical Disabilities requires that the individual needs training in the use of a device or devices in order to achieve some level of independent mobility. An individual who is already independent in mobility and requires adaptive equipment does not qualify.  This includes some individuals who are in training programs for deficits in gross or fine motor functioning, and some individuals who are not in such training programs.

 

c)         Specialized Care, Level II

            The individual is nonmobile, or mobile nonambulatory, requires mobility assistance, and requires services to meet high personal care needs. The individual may also have significant daily medical needs, and/or may have dual sensory deficits (visual and auditory).

 

1)         High Personal Care/Mobility Need (nonmobile)

            The individual requires and receives partial or total assistance in bathing, clothing, grooming and hygiene, eating and toileting/continence. The individual requires and receives mobility assistance, due to a functional deficit (as determined by physical or psychological causes), to transfer from a bed to an alternative positioning device.  He/she also requires and receives assistance with movement/mobility around the facility. The individual may require position changes at two hour intervals, or as specified in the individual program plan, and/or range of motion twice a day or as specified in the individual program plan.

 

2)         Medical Need

 

A)        The individual requires and receives insulin injections daily or more frequently for the management of diabetes which is not stabilized.  Daily monitoring by licensed personnel is required to assess the individual's status, side effects, laboratory work, and to report to the physician as necessary.  The requirement for monitoring pertains also to insulin which is administered on a sliding scale basis.  This monitoring results in adjustments in dosage and/or type of insulin, as indicated by the individual's status.

 

B)        The individual needs and receives ostomy care for a jejunostomy, an ileostomy, or a colostomy.

 

3)         Dual Sensory Deficits

 

            The individual requires and receives services as required, due to both an auditory disability and a visual disability.

            AGENCY NOTE:  Level II services require that an individual meets the criteria in subsection (d) (1) above.  The individual who also meets the criteria in subsection (d)(2) above is eligible for a higher nursing ratio according to Section 144.275(a)(2)(B).

 

d)         Specialized Care, Level III

            The individual is typically nonmobile or mobile nonambulatory, but may be ambulatory, and requires services to meet high medical needs.  High medical needs means one or more of the following:

 

1)         The individual requires and receives intermittent catheterization more than twice a day.

 

A)        Daily recording of intake and output is required.

 

B)        Infection control measures must be carried out as indicated in the facility's catheterization protocol.

 

2)         The individual requires and receives respiratory care which can include tracheostomy care, positive pressure breathing treatments, aerosol therapy, postural drainage with percussion, vibration and/or suctioning.

 

A)        The respiratory status of the individual receiving respiratory care must be frequently assessed as required by the IPP.

 

B)        Infection control measures must be carried out as indicated in the facility's respiratory procedure protocol.

 

3)         The individual requires and receives feeding via a nasogastric or gastrostomy tube, or, the individual has poor sucking and/or swallowing reflexes and requires and receives prolonged oral feeding of two or more hours daily.

 

4)         The individual requires and receives wound care, having been admitted to the facility with a stage III or IV decubitus ulcer, or has deep wounds, infected wounds, extensive burns or extensive lesions requiring treatment in the form of medications, dressings, whirlpool, ultraviolet light and/or irrigations.

 

A)        Decubitus ulcer management includes turning, positioning, nutritional support, range of motion exercises, supportive devices and infection control.

 

B)        The facility protocol for decubitus ulcer prevention must be adhered to.

 

5)         The individual requires and receives intensive physical habilitation due to a functional deficit (as determined by physical or psychological causes).

 

A)        Intensive physical habilitation occurs throughout the individual's working hours to promote skill acquisition, or

 

B)        The individual requires and receives intensive contracture prevention via "hands on" assistance.

 

C)        When staff is meeting functional and service needs of an individual, that time should be used for priority objective/goal attainment.  For example, when the individual has been repositioned, staff stimulation should occur, or the individual is ambulated with assistance to the bathroom or the dining room rather than taken in a wheelchair.

 

            AGENCY NOTE:  Range of motion to all extremities as indicated in the IPP should be incorporated into the individual's daily routine/programs (dressing, bathing, feeding, etc.).

 

(Source:  Amended at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.160  Base Nursing in Facilities Licensed as ICF/DD-16s including Small Scale (4 and 6 bed) ICF/DD-16s

 

a)         Base nursing in ICF/DD-16s staffing and reimbursement recognizes the need for adults with developmental disabilities to have regular health care supports.

 

b)         Base nursing provides for licensed practical nurse services and/or registered professional nurse services and supervision.

 

c)         The addition of base nursing provides for nursing assessments, development and updating of nursing care plans, health risk identification and planning, Tardive Dyskinesia (TD) screening, coordination and implementation of medical services, monitoring of medication effectiveness and side effects, and annual flu immunization.

 

(Source:  Added at 24 Ill. Reg. 13404, effective August 18, 2000)

 

Section 144.165  Medication Administration in Facilities Licensed as ICF/DD-16s including Small Scale Residential Facilities (4 and 6 bed) ICF/DD-16s

 

a)         Medications may be administered by unlicenced staff who have been trained and are supervised by registered professional nurses, in accordance with P.A. 91-0630 and 59 Ill. Adm. Code 116.

 

b)         Reimbursement for the supervision of this medication administration will be provided as described in Sections 144.275 and 144.300.

 

(Source:  Added at 24 Ill. Reg. 13404, effective August 18, 2000)

 

Section 144.175  Functional Needs

 

Functional needs are the basic needs of all persons.  All functional needs of each individual residing in an ICF/MR must be addressed.  The individual's IPP must provide a current assessment of his/her developmental level in each area of functional need.  On the basis of the assessment outcome, the IDT determines if each area of an individual's functional needs can be addressed independently by the person, or is to be addressed as a service need or through a training program.  The IPP specifies the individual's level of dependence/independence, types of assistance needed, and developmental skill interventions (programs) designed to increase functional independence. The IPP shall address skill maintenance if the individual demonstrates any skill regression or loss of functional status.  The individual's preferences shall also be acknowledged (i.e., tub or shower bathing). Additional reimbursement is paid for an individual who needs and receives partial or total assistance in meeting functional needs (Section 144.275(c)(2)).  This reimbursement is provided only when an individual meets the criteria for mobility assistance and/or high personal care under Specialized Care-Health and Sensory Disabilities (Section 144.150(b) and (c)). The functional needs of all individuals are:  

 

a)         Bathing

            Bathing means bathing all, or some part of the body, including the hair, whether the bath occurs in a tub, shower, or bed.

 

b)         Clothing

            Clothing means total dressing and undressing, including stockings or socks and shoes.

 

c)         Eating

            Eating means to consume or assimilate food or nutriments to fulfill nutritional needs.  Eating includes both oral and tube feedings.

 

d)         Grooming/Personal Hygiene

            Grooming/personal hygiene means bodily maintenance including combing hair, cleaning and clipping nails, shaving if applicable, tooth brushing and oral hygiene including denture care, daily deodorant use, hygiene associated with menstruation, makeup application when desirable and appropriate, daily hands and face washing.

 

e)         Toileting/Continence

            Toileting means the appropriate use of a toilet, including related undressing/dressing activities, and necessary follow-up hygiene.

 

f)         Mobility

            Mobility means the power of locomotion and includes transfers/movements which are accomplished by independent ambulation and via the employment of assistive devices such as walkers, wheelchairs, braces, and prostheses.

 

g)         Psychosocial Mental Status

            Psychosocial mental status means the achievement of a sense of well-being and emotional balance in one's relationship with self, other persons, and one's daily environment.

 

(Source:  Amended at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.200  Service Needs - Medical Care (Repealed)

 

(Source:  Repealed at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.205  Service Needs - Medical and Therapy Services (Repealed)

 

(Source:  Repealed at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.225  Individual Rights (Repealed)

 

(Source:  Repealed at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.230  Reconciliation of Resident Funds

 

a)         Upon the death of a resident who has monies which are managed by the facility, the facility is to:

 

1)         convey the resident's funds and a final accounting of those funds to the individual administering the deceased's estate within five business days following the resident's death; and

 

2)         notify the local Public Aid office of the amount of all monies which belonged to the deceased.

 

b)         Upon discharge of a resident who has monies which are managed by the facility, the facility is to:

 

1)         refund any monies belonging to the resident and provide a final accounting of those monies (including all interest earned), to the resident or authorized representative within five business days following the resident's discharge; and

 

2)         notify the local Public Aid office of the amount of all monies, including all interest earned, which belong to the resident.

 

(Source:  Amended at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.250  Discharge Planning/Maximum Growth Potential Plan (Repealed)

 

(Source:  Repealed at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.275  Reimbursement for Program (Active Treatment) Costs in Residential Facilities for Clients with Developmental Disabilities

 

Residential facilities, including distinct parts of facilities, for clients with developmental disabilities (ICF/MR certification with licensure for ICF/DD, ICF/DD-16, SLC, and ICF/MR-SNF/PED license), excluding State-operated facilities for individuals with developmental disabilities, will be reimbursed for an active treatment program for each client.  Facility program reimbursement levels will be derived by the Department from the following four determinants which in combination will result in a total facility program per diem amount.  These four determinants will be determined according to information provided in the most recent Inspection of Care (IOC) conducted by Department of Public Health survey staff.  This IOC information must be validated by the survey staff prior to utilization for payment purposes.  The new reimbursement level will be effective on the first day of the quarter following a facility's IOC.  Where dollar, wage, or salary amounts are used, these shall be inflated to the fiscal year for which reimbursement will be made.

 

a)         Minimum Staffing

 

1)         Direct Services – Facilities must be in compliance with the Health Care Financing Administration's (HCFA) (42 CFR 483.430 (1996)) minimum average daily staffing standards relative to client population according to each individual's overall level of functioning:  

 

Overall Level of Functioning	FTE* Staff:Client Ratio
Mild	1:5
Moderate	1:2.5
Severe or Profound	1:2

 

*FTE = Full Time Equivalent

 

A)        Determination of levels of functioning of clients with mental retardation and related conditions, in accordance with the definition of the American Association of Mental Retardation (Mental Retardation refers to significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period), will include both:

 

i)          an assessment of intellectual functioning as measured by a standardized, full scale, individual intelligence test such as the Stanford Binet and WAIS-R.  Such an assessment must be administered by a psychologist who is registered in Illinois under the Clinical Psychologist Licensing Act (Illinois Department of Professional Regulation); and

 

ii)         an assessment of adaptive behaviors using a nationally standardized, Department approved assessment instrument, such as the Scales of Independent Behavior (SIB) or the Inventory For Client and Agency Planning (ICAP). Such an assessment instrument will be utilized by at least one Qualified Mental Retardation Professional (QMRP) to evaluate each client's functional skills and adaptive behaviors.

 

B)        The final determination of each client's overall level of functioning employs both the assessment of intellectual functioning and the assessment of adaptive behaviors, and will be made according to the criteria set forth in Section 144.Table D and Section 144.Table E of this Part.

 

C)        The amount for Direct Services for these staffing ratios shall be obtained by:  

 

i)          determining the number of clients within each overall level of functioning; dividing each number by the client component of the staff:  client ratio; summing these quotients; multiplying the sum by the aide hourly wage factor, and then by 2080 (52 weeks times 40 hours per week), to obtain a total annual Direct Service cost; and dividing this total by 365 days and then by the number of clients to obtain the amount for Direct Services per client per day. For example, if a facility serves 40 clients in the mild level of functioning, 30 clients in the moderate level of functioning, and 30 clients in the severe/profound level of functioning, the number of FTE Direct Services staff will be (40 divided by 5) + (30 divided by 2.5) + (30 divided by 2) = 35. If the aide hourly wage is $5.00, the total annual cost will be 35 x $5 x 2080 = $364,000. The amount for FTE Direct Services per client per day will then be $364,000 divided by 365 divided by 100 = $9.97.

 

ii)         In ICF/DD-16 facilities, the foregoing calculation is modified such that in step two of subsection (a)(1)(C)(i) of this Section, the facility may receive an amount for up to an additional .5 FTE. Direct Service is determined by multiplying .5 FTE by the proportion found by the ratio of the number of Medicaid eligible clients in the severe/profound level of functioning divided by the total number of eligible clients.

 

2)         Licensed Nurses – Facilities must be in compliance with HCFA (42 CFR 483.460 (1996)) and Illinois Department of Public Health (IDPH) (77 Ill. Adm. Code 350.1230) staffing standards relative to facility type.

 

A)        An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16) licensed for a population of 90 or fewer clients, none of whom require services under Levels II and III of Specialized Care-Health and Sensory Disabilities (Section 144.150(c) and (d)), will be reimbursed for a minimum of 4.8 FTE nurses. A facility with only such a population which has a licensed capacity greater than 90 clients will be reimbursed for additional FTE nurses according to the following Table:

 

Licensed Capacity, Client Type		FTE Nurse:Client Ratio
Greater than 90 clients with no Specialized Care – Health and Sensory Disabilities needs under Level II and III		1:18.7

 

B)        An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16) licensed for a population of 30 or fewer clients, all of whom require services under Level(s) II and/or III of Specialized Care – Health and Sensory Disabilities will be reimbursed for a minimum of 4.8 FTE nurses. A facility with only such a population which has a licensed capacity greater than 30 clients will be reimbursed for additional FTE nurses according to the following Table:

 

Licensed Capacity, Client Type		FTE Nurse:Client Ratio
Greater than 30 clients requiring Specialized Care – Health and Sensory Disabilities under Level(s) II and III		1:6.25

            AGENCY NOTE:  The Omnibus Reconciliation Act of 1987 (P.L. 100-203) requirements prohibit the admission of individuals with a primary diagnosis of mental retardation into non-ICF/MR facilities. Therefore, SNF/PED facilities which meet ICF/MR certification requirements must be certified ICF/MR in order to comply with federal law when admitting individuals with mental retardation. Facilities which undergo certification conversion to ICF/MR will retain State licensure for skilled care (SNF/PED).

 

C)        An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16) which has a licensed capacity of 30 clients or more, some of whom require services under Level(s) II and/or III of Specialized Care – Health and Sensory Disabilities, and some of whom do not require such services, will be reimbursed for a minimum of 4.8 FTE nurses for non Specialized Care individuals plus additional FTE nurses, up to a maximum of a 1:6.25 ratio, according to the following Table:

 

Client Type		FTE Nurse:Client Ratio
Client requiring Specialized Care – Health and Sensory Disabilities under Level(s) II and/or III		1:6.25

 

            For example, for a facility with a licensed capacity of 42 clients, 15 of whom require services under Level(s) II and/or III, and 27 of whom do not require such services, the number of FTE nurses will be (15 divided by 6.25 = 2.40) + (27 divided by 18.75 = 1.44, however, reimbursement will be calculated at the minimum of 4.8) = 7.2.  Utilizing the maximum client ratio allowed, the facility will be reimbursed for 6.72 FTE nurses (42 divided by 6.25 = 6.72).

 

D)        Licensed nurses are not required in an ICF/DD-16 if none of the clients require a physician's medical care plan of treatment.

 

i)          An ICF/DD-16 which has eight or fewer clients with medical care plans of treatment but who do not require services under Specialized Care – Health and Sensory Disabilities, Level(s) II and/or III, will be reimbursed for .5 FTE nurse.  A facility with nine or more such clients will be reimbursed for one FTE nurse.

 

ii)         An ICF/DD-16 with clients requiring medical care plans of treatment and additional medical services under Specialized Care – Health and Sensory Disabilities, Level(s) II and/or III, will be reimbursed according to the method in subsection (a)(2)(D)(i) of this Section, plus additional reimbursement for licensed nurses using an FTE nurse: client ratio of 1:6.25 up to a maximum of the 1:6.25 ratio.

 

E)        The licensed nurse component is computed similarly to the method in subsection (a)(1)(C) of this Section.  To determine the amount for Licensed Nurses, the number of FTE nurses required for each facility type and/or for clients receiving services under Specialized Care – Health and Sensory Disabilities, Level(s) II and/or III, shall be obtained according to subsections (a)(2)(A), (B), (C) and (D) of this Section.  This number is multiplied by the hourly nurse wage factor and then by 2080 (52 weeks x 40 hours).  The product is divided by 365 and then by the number of clients.

 

3)         The total reimbursement amount for Minimum Staffing is the sum of the amount for Direct Staff plus the amount for Licensed Nurses.

 

b)         Active Treatment

 

1)         Qualified Mental Retardation Professional (QMRP) – a person who has at least one year of experience working directly with persons with mental retardation or other developmental disabilities, and is one of the following:  

 

A)        A doctor of medicine or osteopathy.

 

B)        A registered nurse.

 

C)        An individual who holds at least a bachelor's degree in one of the following professional categories:  Occupational Therapist; Physical Therapist; Psychologist. Master's Degree: Social Worker; Recreation Specialist; Registered Dietitian; and Human Services, including but not limited to Sociology, Special Education, Rehabilitation Counseling, and Psychology. (42 CFR 483.430 (1996))

 

D)        The amount for QMRPs assumes that a full-time QMRP is required for every 15 clients. The number of QMRPs shall be obtained by dividing the number of clients in the facility by 15. The obtained number of QMRPs is multiplied by the hourly wage factor and then by 2080. The product is divided by 365 and then by the number of clients to arrive at an amount per client per day.

 

2)         Interdisciplinary Team (IDT)

 

A)        The amount for services rendered by the IDT assumes that each client requires one day of IDT services per year. This amount is computed to be $1.82 per client per day.

 

B)        Interdisciplinary Team – A team which represents the professions, disciplines, or service areas that are relevant to identifying the client's needs and designing programs that meet the client's needs. Appropriate facility staff must participate in interdisciplinary team meetings.  Participation by other agencies serving the client is required (see the Department of Public Aid's rule at 89 Ill. Adm. Code 140.647). Participation by the client, his or her parent (if the client is a minor), or the client's legal guardian is required unless the participation is unobtainable or inappropriate. (42 CFR 483.440 (1996))

 

3)         Additional Direct Service Staff (ADSS)

 

A)        The amount for ADSS assumes an FTE staff:client ratio of 1:7.5.  The total number of clients is divided by 7.5 and a per diem amount is obtained according to the method described in subsection (a)(1)(B) of this Section. In SLC facilities, the foregoing calculation is modified so that the overall level of functioning is distributed proportionately across each living unit (16-18 clients) in step one of the calculation. If dividing the number of clients results in a fraction, it is rounded up to the next whole number in proportion to the number of clients in the severe/profound level of functioning.  The total FTE is obtained by summing the calculation results from each living unit.

 

B)        Additional Direct Services Staff – Staff which is in addition to HCFA's minimum average daily staffing standards (subsection (a)(1) of this Section), and for which the Department will provide reimbursement to ensure the delivery of active treatment. Examples of ADSS include, but are not limited to, staff who provide activity services, dietetic aides, and music therapists.

 

4)         The total reimbursement amount for Active Treatment is the sum of the amounts for QMRP, IDT and ADSS.

 

c)         Specialized Care

            An additional amount shall be paid for clients meeting the requirements for services under Specialized Care. Detailed descriptions of services under Specialized Care are found in Section 144.125 Specialized Care – Behavior Development Programs, and Section 144.150, Specialized Care – Health and Sensory Disabilities. The service Level for each client meeting the criteria of more than one Level under Specialized Care shall be determined according to his/her disability or functional deficit which represents the most intense need for services under Specialized Care, and results in the greatest reimbursement.

 

1)         Specialized Care – Behavior Development Programs

            Behavior development programs are related to maladaptive behaviors which occur with high frequency and/or great severity, and are instituted for the reduction of maladaptive behaviors and/or the increase of adaptive behaviors. The behavior development program shall demonstrate the need for and use of a more intensive staffing pattern (direct care staff) than the regular pattern which is reimbursed for under subsection (a)(1) of this Section. The service Level for a client who meets the requirements for services under Specialized Care - Behavior Development Programs will be identified and validated during the most recent IOC.

 

A)        Level I – .5 hours FTE Direct Service per day.  More intense program services are provided for behaviors which occur with high frequency but moderate severity, such as verbal abuse one or more times per four hours which is hostile in tone and content.

 

B)        Level II – 1.0 hours FTE Direct Service per day.  More intense program services are provided for behaviors which occur with high frequency and are aggressive or destructive, such as purposeful attacks of others which may result in minimal injuries, one or more times per day.

 

C)        Level III – 2.0 hours FTE Direct Service per day.  More intense program services are provided for behaviors which occur with very high frequency such as hyperactivity one or more times per minute, or occur with high frequency and are seriously aggressive, assaultive or destructive and which may result in serious injury.

 

2)         Specialized Care – Health and Sensory Disabilities

            Specialized services for health and sensory disabilities refer to care which some clients must receive in order to attain physical health and development.

 

A)        Definitions

 

i)          Ambulatory – The client is capable of walking without assistance or the aid of adaptive equipment or devices.

 

ii)         Mobile Nonambulatory – The client is capable of locomotion with mobility assistance such as adaptive equipment or devices.

 

iii)        Nonmobile – The client is not capable of locomotion even with mobility assistance.

 

B)        Level I – .5 hours FTE Direct Service per day. The client is ambulatory, mobile nonambulatory, or has the potential to become mobile nonambulatory, and requires services to compensate for a sensory deficit (auditory or visual), or services enabling him or her to be mobile (physical disabilities).

 

i)          Sensory deficits – visual. The client's vision is 20/200 or less in the better eye with the greatest possible correction (Section 2 of the Blind Persons Operating Vending Machines Act [20 ILCS 2420/2]).

 

ii)         Sensory deficits – auditory. The client has a hearing impairment of at least 55 decibels in the better ear, unaided.

 

iii)        Physical disabilities means physical impairments which result in functional deficits requiring the client to receive training in the use of a device or devices, to achieve some level of independent mobility.

 

C)        Level II – 1.0 hours FTE Direct Service per day. The client is nonmobile or mobile nonambulatory, requires mobility assistance, and requires services to meet high personal care needs.  The client may also have significant daily medical needs and/or dual sensory deficits (visual and auditory).

 

i)          Mobility assistance means assistance in transferring from a bed to an alternative position device, and assistance with movement/mobility around the facility.

 

ii)         High personal care means one or more of the following:  assistance with bathing, clothing, grooming and hygiene, eating and continence; position changes at two hour intervals, or as specified in the individual program plan; range of motion twice a day, or as specified in the individual program plan.

 

iii)        Daily medical need means daily insulin injections, drug (insulin) monitoring, and/or ostomy care for a jejunostomy, ileostomy or colostomy.

 

iv)        Dual sensory deficits means both an auditory disability and a visual disability.

 

            AGENCY NOTE:  A client who meets the criteria for Level II services is eligible for the FTE nurse:client ratio according to subsections (a)(2)(B), (C) and (D) of this Section.

 

D)        Level III – 2.0 hours FTE Direct Service per day. The client is typically nonmobile or mobile nonambulatory, but may be ambulatory, and requires services to meet high medical needs. High medical needs mean one or more of the following:  

 

i)          daily intermittent catheterization;

 

ii)         care for wounds including stage III and IV decubitus ulcers, deep wounds, infected wounds, extensive burns, or extensive lesions requiring treatment in the form of medications, dressings, whirlpool, ultraviolet light and/or irrigations;

 

iii)        respiratory care including tracheotomy care, positive pressure breathing treatments, aerosol therapy, postural drainage and percussion, vibration and/or suctioning;

 

iv)        feeding via nasogastric tube, or prolonged oral feeding; and

 

v)         intensive physical habilitation due to a functional deficit as determined by physical or psychological causes.

 

            AGENCY NOTE:  A client who meets the criteria for Level III services is eligible for the FTE nurse:client ratio according to subsections (a)(2)(B), (C) and (D) of this Section.

 

3)         The total reimbursement amount for Specialized Care shall be the sum of the amounts determined under subsections (c)(1) and (2) of this Section, pro-rated over the number of eligible clients identified in the most recent facility reimbursement survey.  For example, if the hourly wage is $5.00, assume a facility with ten residents, two of whom meet the criteria for Specialized Care – Health and Sensory Disabilities Level II, subsection (c)(2)(C) of this Section, with no daily medical needs or sensory deficits, and eight of whom do not meet Specialized Care criteria. The facility will receive an amount of $.81 per client per day (two hours x 1.14 (FTE adjustment factor) divided by eight hours/day = .285 staff; then .285 x (2080 hours/year divided by 365 days/year); then divide by ten clients and multiply by $5.00 to obtain $0.81).

 

d)         Related Costs

 

1)         An amount per client per day will be paid for other program costs, including program – related supplies, consultants and other items necessary for the delivery of active treatment to clients in accordance with their individual program plans.

 

2)         For each facility type, this amount will be determined as follows. Add the amounts determined for subsections (a), (b) and (c) of this Section, but excluding the amount for the IDT (subsection (b)(2) of this Section), and then multiply this sum by the factor determined by the Department for the facility's geographic area (see the Department of Public Aid's rule at 89 Ill. Adm. Code 140.Table B).  The product plus the amount for the IDT (subsection (b)(2) of this Section), is then multiplied by a constant for the facility type, as follows:

 

Facility Type		Constant
ICF/DD		.10
SNF/PED or ICF/DD (An ICF/DD with some clients requiring services under Level(s) II and/or III of Specialized Care – Health and Sensory Disabilities)		.15
ICF/DD-16 and SLC		.20

 

3)         An ICF/DD with some clients requiring services under Level(s) II and/or III of Specialized Care – Health and Sensory Disabilities, and some clients not requiring such services will have the total related cost calculated according to the weighted sum of the number of clients requiring Level(s) II and/or III multiplied by .15, plus the number of clients not requiring such services multiplied by .10.  For example, for a facility with a licensed capacity of 90 clients, 30 of whom require services under Level(s) II and/or III, and 60 of whom do not require such services, the total related cost will be calculated according to subsection (d)(2) of this Section for both groups of clients.  (That is, subsections (a), (b) and (c) of this Section are summed, excluding the amount for the IDT, for clients requiring Level(s) II and/or III and for clients not requiring Level(s) II and/or III.  Each sum is multiplied by the factor determined by the Department for the facility's geographic area, and the products are added to the amount for the IDT.)  Each outcome is multiplied by the appropriate constant (the SNF/PED-ICF/DD constant of .15 or the ICF/DD constant of .10), and then by the number of clients in each group respectively. The two products are summed and then divided by the total number of clients.

 

4)         An amount will also be paid for dental services which are in compliance with HCFA's regulations (42 CFR 483.460(e), (f) and (g) (1996)), for each client age 21 or more.  This amount will be determined by adding the flat per diem of $.40 to the amount calculated according to subsection (d)(2) of this Section.  This per diem will cover the costs of prophylaxis treatment up to once every six months, and periodontal services as needed for each eligible client.

 

5)         An amount will also be paid for base nursing assessments, development and updating of nursing care plans, health risk information and planning. Tardive Dyskinesia (TD) screening, coordination and implementation of medical services, monitoring of medication effectiveness and side effects, and annual flu immunizations in ICF/DD-16s.  A flat per diem of $.57 provides for 12 hours of licensed practical nurse time per person per year and one hour of registered professional nurse time per person per year.

 

6)         An amount will also be paid for supervision of medication administration.  The amount to be reimbursed is based upon a 1:12 ratio of registered professional nurse time at $19.44 per hour (including fringe benefits) to medication administration time.  Medication administration time is based upon the number of medication episodes per day documented by each individual's Medication Administration Record (MAR) and the following:

 

A)        Five Minute Episode – Simple medication preparation, individual self-medication training, administration, and documentation, e.g., up to four medications at one time consisting of oral medications, topical medications, ear drops, creams, and/or lotions.  Medications in this category may be simple pill administration or may require the pill be crushed and mixed with an edible binder such as applesauce or pudding.  This episode type also includes monitoring a person for "cheeking" or spitting out medication.

 

B)        Ten Minute Episode – Advanced medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with set insulin injection, blood pressure and/or pulse checks required prior to medication administration, and/or five or more medications at one time.

 

C)        Fifteen Minute Episode – Complex medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with sliding scale insulin injections, injectable medications, rectal anti-convulsant medications, i.e., Diastat with monitoring.

 

e)         Total Program Per Diem – Total program per diem for each facility will be the sum of the amounts from subsections (a), (b), (c) and (d) of this Section.

 

(Source:  Amended at 24 Ill. Reg. 13404, effective August 18, 2000)

 

Section 144.300  Reimbursement for Program (Active Treatment) Costs in Small Scale Residential Facilities

 

Small scale residential facilities (ICF/MR) with four or six beds for clients with developmental disabilities will be reimbursed for an active treatment program for each client.  Facility program reimbursement levels will be derived by the Department from the following three determinants which in combination will result in a total facility program per diem amount.  These three determinants will be determined according to information provided in the most recent Inspection of Care (IOC) conducted by Department of Public Health survey staff.  This IOC information must be validated by the survey staff prior to utilization for payment purposes.  The new reimbursement level will be effective on the first day of the quarter following a facility's IOC.  Where dollar, wage, or salary amounts are used, these shall be inflated to the fiscal year for which reimbursement will be made.

 

a)         Minimum Staffing

 

1)         Direct Services

 

A)        Reimbursement for direct services is based on a direct service staffing pattern which is specific to small scale ICF/MR facilities.  Facilities must be in compliance with minimum average daily staffing standards relative to client population according to each individual's overall level of functioning.  The overall level of functioning for each client is determined according to the method described in Section 144.275 (a)(1)(A)(i) and (ii), and Sections 144.Tables D and E.  The direct service staffing patterns based on the size of the residential setting and the overall level of functioning of the client population are:

 

Overall Level of Client Functioning		FTE* Staff
4-Person ICF/MR
Mild		2.13
Moderate		3.88
Severe/Profound		5.93
6-Person ICF/MR
Mild		3.2
Moderate		5.02
Severe/Profound		6.84

 

*FTE = Full time Equivalent

 

B)        Reimbursement will be calculated according to the total direct service FTE staff derived from the weighted average of the FTE staff for levels of functioning in the moderate and severe/profound range within the small scale facility.  After the total FTE staff are determined, the per diem amount is obtained according to the method in Section 144.275(a)(1)(C)(i).

 

C)        The reimbursement for a client residing in a small scale ICF/MR who has been found to be ineligible for ICF/MR services, as a result of the facility's Interdisciplinary Team (IDT) process or an IOC determination, will be at the mild level of overall functioning for not more than one year from the quarter following the determination of ineligibility.  If the client has not been discharged in accordance with Section 144.250 by the end of the one year period, reimbursement will be made at the Department's sheltered care rate.  The sheltered care rate will be payment in full for all program, capital and support costs for such clients.

 

D)        Reimbursement for a client admitted to a small scale ICF/MR who is determined to be ineligible, or who is without a determination of eligibility by the preadmission screening process, will be set at the sheltered care rate. The sheltered care rate will be payment in full for all program, capital and support costs.  Payment for services for each client who has not been found eligible for the ICF/MR program upon admission will terminate 30 days following the date of admission.  Reimbursement for residential services for such a client which is paid to the facility beyond the 30 day period following admission will be recouped by the Department from the next facility payment or other contractual time period.

 

E)        The facility rate paid will be the weighted average of the total per diem (including capital and support) calculated for eligible clients with mild, moderate and severe/profound levels of overall functioning and the Department's sheltered care rate for clients admitted without previously determined ICF/MR eligibility, or who are ineligible for ICF/MR services as determined by the IDT or IOC process, and remain in the facility for more than one year following the date of the determination of ineligibility.

 

2)         Licensed Nurses

 

A)        If a client requires nursing services due to a physician's plan of care, reimbursement is calculated according to Section 144.275(a)(2)(D).  The FTE nurse to client ratios which are specified for ICF/MR facilities with 16 or fewer beds, are also used for a set of small scale ICF/MR facilities as identified by the provider agreements (see the Department of Public Aid's rule at 89 Ill. Adm. Code 140.561(a)).

 

B)        The licensed nurse component is computed according to the method in Section 144.275(a)(2)(E).

 

3)         The total reimbursement amount for Minimum Staffing is the sum of the amount for Direct Services staff plus the amount for Licensed Nurses.

 

b)         Active Treatment

 

1)         Qualified Mental Retardation Professional (QMRP) (Section 144.275(b)(1)(A), (B) and (C)).

 

A)        The reimbursement amount paid is based on sixteen clients in an identified set of 4-person and 6-person ICFs/MR.

 

B)        The amount for QMRPs is based on a required full-time QMRP for every 15 clients.  The number of QMRPs shall be obtained by dividing the number of clients in the facility by 15.  The amount paid for QMRPs is computed according to the method in Section 144.275(b)(1)(D).

 

2)         Interdisciplinary Team (IDT) (Section 144.275(b)(2)(B)) – The amount for services rendered by the IDT is based on one day of IDT services per year for each client.  This amount is computed to be $1.82 per client per day.

 

3)         The total reimbursement amount for Active Treatment is the sum of the amounts for QMRP and IDT.

 

c)         Related Costs

 

1)         An amount per client per day will be paid for other program costs, including program related supplies, consultants and other items necessary for the delivery of active treatment to clients in accordance with their individual program plans.

 

2)         For each facility, this amount will be determined as follows.  Add the amount determined for subsections (a) and (b) of this Section, but exclude the amount for the IDT.  Multiply this sum by the factor determined by the Department for the facility's geographic area.  The product plus the amount for the IDT is then multiplied by the constant of .20.

 

3)         An amount will be paid for dental services that are in compliance with the Health Care Financing Administration's regulations (42 CFR 483.460(e), (f) and (g) (1996)) for each client age 21 or more.  This amount will be determined by adding the flat per diem of $.40 to the amount calculated according to subsection (c)(2) of this Section.  This per diem will cover the costs of prophylaxis treatment up to once every six months, and periodontal services as needed for each eligible client.

 

4)         An amount will also be paid for base nursing for assessments, development and updating of nursing care plans, health risk identification and planning, Tardive Dyskinesia (TD) screening, coordination and implementation of medical services, monitoring of medication effectiveness and side effects, and annual flu immunizations in small scale residential facilities licensed as ICF/DD-16s. A flat per diem of $.57 provides for 12 hours of licensed practical nurse time per person per year and one hour of registered professional nurse time per person per year.

 

5)         An amount will also be paid for supervision of medication administration.  The amount to be reimbursed is based upon a 1:12 ratio of registered professional nurse time at $19.44 per hour (including fringe benefits) to medication administration time.  Medication administration time is based upon the number of medication episodes per day documented by each individual's Medication Administration Record (MAR) and the following:

 

A)        Five Minute Episode – Simple medication preparation, individual self-medication training, administration, and documentation, e.g., up to four medications at one time consisting of oral medications, topical medications, ear drops, creams, and/or lotions.  Medications in this category may be simple pill administration or may require the pill be crushed and mixed with an edible binder such as applesauce or pudding.  This episode type also includes monitoring a person for "cheeking" or spitting out medication.

 

B)        Ten Minute Episode – Advanced medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with set insulin injection, blood pressure and/or pulse checks required prior to medication administration, and/or five or more medications at one time.

 

C)        Fifteen Minute Episode – Complex medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with sliding scale insulin injection, injectable medications, rectal anti-convulsant medications, i.e., Diastat with monitoring.

 

d)         Total Program Per Diem – Total program per diem for each small scale residential facility will be the sum of the amounts from subsections (a), (b) and (c) of this Section.

 

(Source:  Amended at 24 Ill. Reg. 13404, effective August 18, 2000)

 

Section 144.325  Capital Rate Calculation

 

a)         Capital rates for ICF/MR facilities with four or six beds will be calculated by the Department according to this Section, which provides calculation methods for rates for various capital categories.  Rate charts will be prepared each year based upon these provisions.  The rate for an individual facility will be selected based upon the following criteria:

 

1)         New construction or remodeled building.  If the facility is a remodeled building the base cost will be used to assign it to a category.

 

2)         Base Year

 

3)         Location

 

b)         The terms used in this Section are defined as follows:

 

1)         "Arm's-length transaction" means a transaction between a buyer and a seller both free to act, each seeking his own best economic interest.  A transaction between related parties as defined in the Department of Public Aid's rule at 89 Ill. Adm. Code 140.537 is not considered to be an arm's-length transaction.

 

2)         "Base Year" refers to the weighted average year of investment in the actual construction of the building.  The Base Year is determined using the components of the building cost, which are included in the Building Base Cost, and the corresponding years of acquisition or construction.  The year of each component of the total investment is multiplied by the cost of each year's investment.  The sum of these products is then divided by the total Building Base Cost to yield an average year of construction.  Any fractional portion of the Base Year derived from this calculation will be truncated.  The Base Year will not change due to sale or lease of the building.

 

3)         "Capital Days" are used to convert all capital items to per diem amounts. A 93% occupancy standard is used in the rate calculation.

 

4)         Building Base Cost refers to the cost to purchase the building to be first licensed as an ICF/DD-16 facility with four or six beds.  Only costs associated with arms-length transactions between unrelated parties will be considered.  The allowable cost of subsequent improvements to the building will be included in the building base cost.  The building base cost will not change due to sales or leases of the facility.

 

5)         "Square feet per bed" is defined as 445 square feet per bed for a four bed facility and 365 square feet per bed for a six bed facility.

 

6)         "New Construction Cost Per Square Foot" is defined as the costs published by the R.S. Means Company, Inc.  Data will come from the most recent edition of the Means Square Foot Costs publication.  The cost used per square foot for new construction is based upon average residential one story construction. Factors are included for wood frame, wood siding, central air, and two bathrooms.

 

7)         Location.  The facilities will be separated into one of the following location groups:

 

A)        Group 1 – Cook, DuPage, Will and Lake counties.

 

B)        Group 2 – Counties 175,000 to 1,000,000 population.

 

C)        Group 3 – Counties below 175,000 population.

 

8)         New building construction refers to construction of a complete building for the purpose of being licensed and operated as an ICF/DD-16 facility with four or six beds.

 

9)         Remodeled buildings refer to buildings which previously existed for some other function and were remodeled to be licensed and operated as an ICF/DD-16 facility with four or six beds.

 

c)         The rates will be calculated for facilities constructed during the current rate year according to the following steps.  These steps will result in six different rate categories.  There is a four bed rate and a six bed rate within each of three different location categories.

 

1)         Preliminary Cost Per Bed – The new construction cost per square foot is multiplied by the square feet per bed to get a preliminary cost per bed.

 

2)         Revised Cost Per Bed

 

A)        The preliminary cost per bed is multiplied by a 120% adjustment factor and is then further increased by factors for a two car garage and for sprinklers as follows:

 

i)          Garage – The R.S. Means Company, Inc. projected cost for an attached two car garage is divided by four or six beds whichever is applicable to obtain a cost per bed.

 

ii)         Sprinklers – A $6,200 sprinkler cost is divided by four or six beds whichever is applicable to obtain a cost per bed.

 

B)        The result of this step is a revised cost per bed for new construction.

 

3)         Localized Cost Per Bed

 

A)        The revised cost per bed is multiplied by a locality adjustor for the applicable area of the State in which the facility is located.  A separate locality adjustor is calculated for the following areas:

 

i)          Cook, DuPage, Will and Lake counties.

 

ii)         Counties 175,000 to 1,000,000 population (excluding DuPage, Will and Lake Counties).

 

iii)        Counties below 175,000 population.

 

B)        The locality adjustors are calculated as the average of all locality factors for each area in the most recent R.S. Means Company, Inc. publication.

 

C)        The result of this step is the localized cost per bed.

 

4)         Total Projected Investment Per Bed – Land is added to the localized cost per bed to arrive at the total projected investment per bed.  Land is based upon $25,000 for facilities located in the Cook, DuPage, Will and Lake counties. Counties with a population of 175,000 to 1,000,000 will use a $18,750 total land cost.  Counties with a population below 175,000 will use a $12,500 total land cost.  The total land cost is divided by four or six beds to determine the land cost per bed.

 

5)         The total projected investment per bed is divided by 339 client days (365 days X 93% = 339) to arrive at a per diem investment.

 

6)         The per diem investment is multiplied by a 11% rate of return and further increased by $3.01 per diem for equipment, working capital costs and vehicles to obtain the rate.

 

7)         The rates for facilities with a base year which is older than the current rate year will be calculated using the same steps as newly constructed facilities in subsection (c) of this Section except for the localized cost per bed in subsection (c)(3).  The localized cost per bed is discounted by a 3% obsolescence for each year between the base year and the current year.

 

8)         A table will be prepared by the Department which will list all applicable rates for each rate year.  The rate for any facility will be looked up based upon the base year, bed size and location of the facility.

 

9)         Rates for Remodeled or Existing Construction

 

A)        To recognize the potentially wide range of investment in existing facilities to be converted into small scale ICF/MR facilities with four or six beds, modifications have been made to the calculation of total projected investment for subsection (c)(4) of this Section.

 

B)        The buildings which were remodeled will be separated into four categories using the lower of the actual land and building purchase price plus remodeling cost per bed, or the appraisal cost of land and building per bed. This assignment to categories is based upon comparison of the facility's cost (lower of actual or appraisal) to the result of the following percentages of the projected investment from subsection (c)(4) of this Section:  (Equipment cost is not included in this comparison.)

 

i)          Category 1 – 77.5% and above

 

ii)         Category 2 – 62.5% to 77.4%

 

iii)        Category 3 – 47.5% to 62.4%

 

iv)        Category 4 – 47.4% and less

 

C)        The total projected investment from subsection (c)(4) of this Section will be multiplied by the following category percentages as applicable, and rates calculated based upon the remaining provisions in subsection (c):

 

i)          Category 1 – 85%

 

ii)         Category 2 – 70%

 

iii)        Category 3 – 55%

 

iv)        Category 4 – 40%

 

d)         Rented facilities will have the capital rates calculated by the same procedures as are used for owned facilities.

 

e)         Property Taxes

 

1)         For four and six bed facilities which can show they will be required to pay property taxes, the Department will have the median property tax rate for their geographic area added to the capital rate.

 

2)         In subsequent years the property tax portion of the capital rate will be calculated in accordance with the Department of Public Aid's rule at 89 Ill. Adm. Code 140.578(b).

 

f)         Combined Rate

 

1)         Small scale ICF/MR facilities are separately licensed facilities. However, reimbursement for capital costs is based on the sixteen person capacity of a set of four 4-person facilities, or one 4-person plus two 6-person facilities (see the Department of Public Aid's rule at 89 Ill. Adm. Code 140.561(b)).  The set of small facilities used in computing the capital rate will be identified in the provider agreements.

 

2)         A separate capital rate will be calculated for each licensed facility in the set of four facilities or one 4-person plus two 6-person facilities. These rates will be combined to arrive at one average capital rate for the set.  The averaging of the capital rates will be weighted according to the number of licensed beds in each of the four facilities in the set.

 

(Source:  Amended at 22 Ill. Reg. 9287, effective May 15, 1998)

Section 144.TABLE A   Overview of Staff Intensity Scale of Maladaptive Behaviors

 

a)         Staff Intensity Scale

 

1)         The Staff Intensity Scale (SIS) is designed to describe behavior problems which are displayed by children and adults who have developmental disabilities.  The rating categories were not "borrowed" from instruments used to describe problems among other disability groups.  Rather, the behavior modification practitioners who designed the SIS focused on the behavior problems of people with developmental disabilities who live in institutions or community settings.

 

2)         The Staff Intensity Scale measures twenty-four major areas of problem behavior.  These areas are denoted within the scale as capitalized and underlined section headings.  The 24 behavior areas include the following:

 

A)        Coercive Sexual Behavior

 

B)        Offensive Bodily Exposure

 

C)        Suicide Attempts and Threats

 

D)        Pica

 

E)        Verbal Abuse

 

F)         Mania

 

G)        Inappropriate Affect

 

H)        Manipulative Behavior

 

I)         Physical Assault

 

J)         Property Theft

 

K)        Substance Abuse

 

L)        Extreme Irritability

 

M)       Hyperactivity

 

N)        Temper Tantrums

 

O)        Wanders, Roams, Runs Away

 

P)         Depression or Excessive Withdrawal

 

Q)        Hallucination

 

R)        Delusions

 

S)         Fire Settings

 

T)         Self-Injurious Actions

 

U)        Handles/Plays with Bodily Waste

 

V)        Property Destruction

 

W)       Resists Supervision

 

X)        Stereotypical Behavior

 

3)         Proper use results in descriptions of three behavioral dimensions. First, the absence or presence of a behavior problem in each of the twenty-four major areas can be indicated.  Second, the rater can describe the severity of the behavior, problem within a major area.  For example, within the major area PHYSICAL AGGRESSION, light slaps directed at another can be differentiated from a range of aggressive behavior including life-threatening attacks.  Third, the rating scale also yields a description of the frequency of a problem along a frequency continuum which is appropriate to the behavior.  For example, since self-stimulatory behavior usually occurs at a much higher rate than coercive sexual behavior, the frequency continua for the two behavioral areas differ accordingly.

 

4)         Beyond providing a basis for comparative information for clinical client evaluation at two or more points in time, the rating scale also allows comparison is an important aspect of the SIS.  If the relative severity of individuals' behavior problems can be measured accurately, then allocation of staffing resources can occur in accord with problem severity.

 

b)         Using the Instrument to Rate a Client

 

1)         The rater should be a psychologist, program unit director, or behavior therapist responsible for the development, implementation and evaluation of the client's behavior programming.  It is best to become thoroughly familiar with the instrument before rating a client.  Read through each of the descriptions associated with the 24 behavioral areas, noting how the frequency continua change from area to area and how the behavioral descriptions span a range of problem severity within each area.  Also note that the position of the behavioral areas of the rating scale follows no pattern.  Position within the list was randomized to decrease changes that rating within an area would be affected by rating in adjacent areas.

 

2)         After examining the whole list of behaviors thoroughly, go back to the first area and begin rating the client's behavior in that area and in each subsequent area in turn.  A rating is expressed by marking an "x" on one of the lines under the frequency column ("once or more per minute, hour, day, etc.") and next to the behavioral definition in the area which best describes the most staff consuming behavior problem displayed by the client within the behavioral area.  If the client does not receive structured data based behavioral programming in an area, do not mark any of the lines for that area.  Similarly, if a client no longer displays maladaptive behavior at the minimal frequency associated with the behavioral area do not mark any of the lines for that area.  If you are currently working with a client who displays a behavioral problem at a frequency higher than that associated with the relevant area of the scale, mark the most frequent occurrence listed.

 

3)         Observing the following rules will eliminate errors in rating interpretation:

 

A)        For each of the 24 major behavior problem areas, all lines should be left blank if the client does not receive a program in the area or the problem occurs at a frequency lower than the lowest frequency category associated with the area.

 

B)        For each of the 24 major behavior areas a single line should be marked with an "x" if the client has a behavior problem in the area and receives a structured behavior management program.

 

C)        The line marked with an "x" should indicate the current frequency of the problem behavior which consumes most staff time within the behavior problem area.

 

D)        None of the 24 major behavior problem areas should be marked with more than one "x".

Section 144.TABLE B   Staff Intensity Scale

 

Client Name		Client Identification
Residential Facility		Client Birthdate
Day Program		Assessment Date
Assessor

 

			Once or More Per:
			Day		Week		Month		Year
a)	Coercive Sexual Behavior
	1)	Touches or grabs others' genitals without their
		consent and/or is aggressively affectionate but will cease engaging in behavior(s) upon request.
	2)	Intimidates (without injuring) another to engage
		in sexual behaviors not including penetration of bodily orifices.
	3)	Intimidates (without injuring) another to engage
		in sexual behaviors including penetration of bodily orifices.
	4)	Injures victim in the course of a sexual attack
		which may or may not include penetration of bodily orifices.

 

			Once or More Per:
			Day		Week		Month		Year
b)	Offensive Bodily Exposure
	1)	Engages in partial or full nudity or genital
		exposure in view of others in inappropriate locations within the treatment setting only.
	2)	Exposes self (not including genitals) in a
		manner offensive to others when outside the treatment setting.
	3)	Exposes self (including genitals) in a manner
		offensive to others when outside the treatment setting.

 

 

			Once or More Per:
			Day		Week		Month		Year
c)	Suicide Threats and Attempts
	(These behaviors imply purposeful suicidal action as opposed to self-injurious actions or pica behavior devoid of conscious suicidal intent.)
	1)	Threatens to commit suicide, may or may not
		be specific how and does not attempt to injure self (e.g., states, "I'm going to kill myself," but does not follow statement with action).
	2)	Purposefully engages in behavior that could be
		fatal, with or without precursory threats, but discontinues behavior upon verbal intervention without injuring self.
	3)	Purposefully engages in behavior that could be
		fatal, with or without precursory threats. Injures self, or is prevented from self-injury only by physical staff intervention.

 

Once or More Per:

Hr.

4 Hrs.

Day

Week

Month

d)

Pica

1)

Mouthing and licking of non-food

objects or compulsive and excessive eating and/or drinking of food and liquids.

2)

Consumption of non-food objects in

volume small enough to be not life-threatening, e.g., small pieces of rubber, plastic or fabric, soil, small nuts and bolts, grass, etc.

3)

Consumption of life-threatening

materials such as paint, cleaning compounds, soap, boiling liquids, sharp objects, large objects that may cause alimentary blockages, or small objects (as in subsection (d)(2) above) in large enough volume to be life-threatening.

 

				Once or More Per:
				Day		Week		Month
e)	Verbal Abuse
	1)		Uses mocking and teasing language.
	2)		Uses language hostile in tone (e.g., sarcastic or
			intimidating) or content, whether obscene or not; may yell or scream threats of violence without designating a specific person as a target.
	3)		Directly and explicitly threatens specific others with
			physical harm or violence.

 

				Once or More Per:
				Day		Month		6 Mo.
f)	Mania
	Engages in constant activity marked by bizarre behavior,
	incoherent speech and a nasty response if ignored or crossed.

 

				Once or More Per:
				Day		Month		6 Mo.
g)	Inappropriate Affect
	Displays emotional tone that is incongruent in general form or
	degree, with the idea, object or thought accompanying it.  Lack of emotional tone ("flat" affect) or incongruent and changing emotional tone ("labile" affect).

 

				Once or More Per:
				Day		Week		Month
h)	Manipulative Behavior
	1)		Circumvents authority by asking successive individuals
			in authority the same question/request until receiving the desired answer or permission.
	2)		Exchanges items of unequal values to own benefit, e.g.,
			trading a candy bar to get a coat.
	3)		Lies about others to get them into trouble or to obtain a
			self-serving goal; or uses another person as an agent to perform unlawful, unacceptable or dangerous acts.

 

 

			Once or More Per:
			4 Hrs.		Day		Week		Month
i)	Physical Assault
	1)	Light striking, kicking, pushing of others that
		is purposeful, but does not appear to cause pain to the target person.
	2)	Purposeful attack of others that causes
		reddening of the skin of the target person.
	3)	Purposeful attack of others that causes
		superficial injury or injuries requiring medical attention.
	4)	Attacks with intent to cause severe injury (e.g.,
		broken bones) using potentially lethal force with or without use of weapon.

 

			Once or More Per:
			Day		Week		Month		6 Mo.
j)	Property Theft
	1)	Takes others' belongings of little or no
		monetary value or importance – may be indicative of hoarding.
	2)	Steals for personal use; or steals belongings
		of moderate or greater monetary value or importance (advance planning is involved); may barter or sell goods taken.

 

						Once or More Per:
						Day		Week		Month
k)	Substance Abuse
	1)		Uses alcohol or non-addictive substances to become
			intoxicated.
	2)		Has an alcohol dependency.
	3)		Is addicted to a controlled substance.
			Persons who use tobacco products or alcohol at levels that do not produce intoxication should not be scored on this item.
			Check box if condition is present regardless of frequency.

 

				Once or More Per:
				Day		Week
l)	Extreme Irritability
	1)		Acts fretful or annoyed in an overly reactive manner to an extent
			that interferes with own social functioning and/or upsets others.
	2)		Displays anger in an overly reactive manner that staff perceive
			as potentially resulting in physical aggression.

 

			Once or More Per:
			Min.		Hour		4 Hrs.		Day
m)	Hyperactivity
	1)	Moves about area continuously in a somewhat
		predictable and moderately-paced manner.
	2)	Moves around area continuously in a seemingly
		random and very rapid manner.
	3)	Bounces up and down or is in and out of chair/
		place/work station continuously.

 

			Once or More Per:
			Day		Week		Month
n)	Temper Tantrums
	1)	Makes inconsequential verbal threats and/or cries loudly,
		jumps up and down or stamps feet when angered.
	2)	Threatens others physically when upset and/or curses
		and kicks or hits objects briefly.
	3)	Yells loudly, thrashes about, kicks, cries and presents
		what appears to be an imminent danger to others.

 

 

			Once or More Per:
			Day		Week		Month		6 Mo.
o)	Wanders, Roams, Runs Away
	1)	Wanders away from immediate supervision
		but returns when called.
	2)	Runs away or wanders out of sight and does
		not return when called even though still within hearing distance.
	3)	Sneaks away for hours or longer.

 

				Once or More Per:
					Week
p)	Depression or Excessive Withdrawal
	1)		Is under-responsive to normal social interactions; inactive;
			may be quiet and unusually passive.
	2)		Rejects contact with others; refuses formerly preferred
			reinforcers; may be inactive, quiet and passive; refuses to eat.

 

			Once or More Per:
			Day		Month		6 Mo.		Year
q)	Hallucinations
	Talks or acts as if experiencing sensory events that
	others do not (e.g., hearing voices) at various times and places and to an extent that it disrupts or interferes with socially adaptive responses.

 

			Once or More Per:
			Day		Month		6 Mo.		Year
r)	Delusions
	Talks about ideas and events that have no basis in
	fact and, in spite of evidence to the contrary, to an extent that it disrupts or interferes with his or her socially adaptive responses.

 

 

Once or More Per:

Day

Week

Month

6 Mo.

Year

s)

Fire-Setting

1)

Plays with matches, open flames

and/or cigarette lighters.  May have accidentally set objects on fire; potential small danger to self or others.

2)

Collects or locates flammable

materials, such as paper or leaves, to use in setting small fire; or starts fires in contained vessels, such as waste-baskets, garbage cans. Overall potential moderate danger to others.

3)

Sets a large fire, such as a bed or

draperies, which has the potential for burning a room or a building; may or may not use an accelerant.

 

			Once or More Per:
			Min.		4 Hrs.		Day
t)	Self-Injurious Actions
	1)	Purposefully inflicts a blow or bite to self that
		causes reddening of the skin.
	2)	Purposefully inflicts a blow or bite to self that
		causes superficial injury requiring medical attention.
	2)	Purposefully inflicts on oneself a blow that causes
		severe injury (e.g., broken bone) or a bite that removes a large amount of tissue.

 

 

			Once or More Per:
			4 Hrs.		Day		Week
u)	Handles/Plays With Bodily Wastes
	1)	Plays or touches rectum or genitals; small amount
		of fecal materials or urine found on hands.
	2)	Smears feces or urine on own clothing and body;
		hoards feces on person or in room.
	3)	Smears feces or urine on others or on nearby
		objects.
	4)	Eats feces or urine.

 

Once or More Per:

Day

Week

Month

6 Mo.

v)

Property Destruction (excluding firesetting).  (Please note that the primary maladaption here is property destruction rather than self-injurious actions or assaults that may also cause property destruction.)

1)

Purposefully damages own or others' property

resulting in a projected negligible or minor repair/replacement cost.

2)

Purposefully damages own or others' property

with a projected major repair/replacement cost.

 

			Once or More Per:
			Day		Week		Month
w)	Resists Supervision
	1)	Will not comply with staff request to act in a considerate
		manner (e.g., plays radio too loud, cuts in line) or refuses to comply with staff instructions to correct behaviors or engage in behaviors affecting self in a minor way (e.g., with not bathe regularly, will not brush teeth).
	2)	Refuses to comply with demands to cease behavior
		or to cooperate, thus significantly disrupting ongoing activities or the living unit in general.
	3)	Refuses to cease behavior constituting imminent and
		significant danger to self or others.

 

			Once or More Per:
			Min.		Hour			4 Hrs.		Day
v)	Stereotypical Behavior
	Repetitive motor or verbal activity, including
	self-stimulation, which does not serve meaningful purposes (e.g., string twirling, bizarre limb or body movements, rocking, repeated verbalizations; DOES NOT INCLUDE self injurious behavior or masturbation.

 

(Source:  Amended at 19 Ill. Reg. 2890, effective February 22, 1995)

 

Section 144.TABLE C  IPP Outcomes (Repealed)

 

(Source:  Repealed at 18 Ill. Reg. 16619, effective October 27, 1994)

 

Section 144.TABLE D   Guidelines for Determining Levels of Functioning

 

 

	COGNITIVE ABILITY IQ SCORE	FUNCTIONAL ADAPTIVE BEHAVIORS	PROBLEMS	IDPA LEVEL OF FUNCTIONING
I.	Mild Moderate Severe/	Moderate or Severe Profound	Behavior	Based on Cognitive Ability with Specialized Service I, II, III, if applicable.
	If a person's assessed adaptive behaviors are lower than the assessed cognitive ability because of behavior, then the overall functioning should be based upon the person's cognitive ability.
II.	Mild Moderate Severe/Profound	Moderate Severe Severe/Profound	Epilepsy Autism Cerebral Palsy	Based upon adaptive level. May also be eligible for specialized service.
	If a person's assessed adaptive behavior is lower than the assessed cognitive ability because of a related condition (epilepsy, autism, cerebral palsy or a seizure disorder which is/are currently active and affect daily living), level of functioning should be based upon the person's adaptive functional behavior.
III.	Mild Moderate Severe/Profound	Moderate or Severe Severe or Profound	None	Based upon the cognitive ability.
	If a person's assessed adaptive behavior is lower than the assessed cognitive ability, but not due to a related condition, then the overall level of functioning is based upon the cognitive ability.
IV.	Mild Moderate Severe/Profound	Mild Mild Moderate	None	Based upon adaptive functional behavior.
	If a person's assessed adaptive behavior is higher than the assessed cognitive ability, then the overall level of functioning is based upon the adaptive behavior.

 

(Source:  Added at 14 Ill. Reg. 17988, effective October 29, 1990)

Section 144.TABLE E   Standardized Adaptive Functional Assessment

 

Mental Age Level Equivalents With Level of Functioning

 

Adult MA Functional Age
Mild	8 years, 6 months to 10 years, 1 month
Moderate	6 years, 1 month to 8 years, 5 months
Severe	3 years, 9 months to 6 years, 0 months
Profound	Below 3 years, 9 months

 

(Source:  Added at 14 Ill. Reg. 17988, effective October 29, 1990)