Current through Register Vol. 48, No. 52, December 27, 2024
a) New and current provider agencies must be
enrolled as a Medicaid provider in the Illinois Medical Program Advanced Cloud
Technology (IMPACT) system with HFS.
b) The provider shall meet Department
standards applicable to the specific services to be provided and shall
demonstrate competency to provide services.
c) Service providers shall:
1) Meet the fiscal, program, and reporting
requirements of the Medicaid HCBS Waiver programs
2) Be willing to serve eligible individuals
from a variety of backgrounds including, but not limited to, former or
potential residents of State-operated facilities or ICF/DDs;
3) Comply with applicable Medicaid provider
requirements, appropriate licensure procedures, and/or standards, as well as
Department operational procedures for purchase of service or grant programs
(see the Department's Rules at 59 Ill. Adm. Code 103, 113, 115 and 119);
and
4) Comply with intake,
assessment, monitoring, and billing procedures established for services under
this Part.
d)
Provider-owned or -controlled residential and non-residential settings must
have all of the following qualities, and other qualities as determined to be
appropriate, based on the needs of the Individual as indicated in their
Personal Plan (42 CFR
441.301(c)(4)):
1) Be integrated in and support full access
of Individuals receiving Medicaid HCBS to the greater community, including
opportunities to:
A) Seek employment and work
in competitive integrated settings;
B) Engage in community life, to the extent
chosen by the Individual;
C)
Control personal resources; and
D)
Receive services in the community, to the same degree of access as Individuals
not receiving Medicaid HCBS.
2) Be selected, with the assistance of the
ISC agency, by the Individual from among setting options including
non-disability specific settings and an option for a private bedroom or unit in
a residential setting. The setting options are identified and documented by the
ISC agency in the Personal Plan and are based on the Individual's needs,
preferences, and, for residential settings, resources available for room and
board. When feasible, the provider agency should offer the option for a private
bedroom or unit in a residential setting.
3) Ensure an Individual's rights to privacy,
dignity and respect, and freedom from coercion and restraint.
4) Optimize, but not regiment, Individual
initiative, autonomy, and independence in making life choices, including, but
not limited to, daily activities, physical environment, and with whom to
interact.
5) Facilitate Individual
choice regarding services and supports and who provides them.
6) Provider-owned or -controlled residential
settings, in addition to the qualities described in subsections (d)(1) through
(d)(5), must meet the following additional conditions:
A) The residential setting is a specific
physical place that can be owned, rented, or occupied under a
legally-enforceable agreement (consistent with the guidelines issued by the
Department) by the Individual receiving services, and the Individual has, at a
minimum, the same responsibilities and protections from eviction that tenants
have under the landlord/tenant law of the State, county, city, and/or other
designated entity. For settings in which landlord/tenant laws do not apply, the
State must ensure that a lease, residency agreement, or other form of written
agreement, as determined by the Department, will be in place for each HCBS
participant, and that the document provides protections that address eviction
processes and appeals comparable to those provided under the jurisdiction's
landlord/tenant law.
B) Each
Individual has privacy in their residential setting.
i) Residential settings shall have entrance
doors lockable by the Individual, with only appropriate staff having keys to
doors.
ii) Individuals sharing a
residential setting shall have a choice of roommates in that setting.
iii) Individuals shall have the freedom to
furnish and decorate their residential setting within the lease or other
agreement.
C)
Individuals have the freedom and support to control their own schedules and
activities and have access to food at any time.
D) Individuals can have visitors of their
choosing at any time.
E) The
setting is physically accessible if required by the needs of any Individuals
served in the setting. Providers should access all available resources, through
the Division and community, to accommodate accessibility needs. All communal
areas must meet standards set forth by the ADA and other federal, State, or
municipal regulations. Providers must ensure sites are certified and have
capacity for a non-ambulatory Individual before offering placement. The
non-ambulatory capacity is indicated in the certification letter given to each
provider by the Department for every site.
F) Any modification of the additional
conditions, under subsections (d)(6)(A) through (E), must be supported by a
specific assessed need and justified in the Personal Plan. The following
requirements must be documented in the Personal Plan and Implementation
Strategy:
i) Identify a specific and
individualized assessed need.
ii)
Document the positive interventions and supports used prior to any
modifications to the Personal Plan.
iii) Document less intrusive methods of
meeting the need that have been tried but did not work.
iv) Include a clear description of the
condition that is directly proportionate to the specific assessed
need.
v) Include regular collection
and review of data to measure the ongoing effectiveness of the
modification.
vi) Include
established time limits for periodic reviews to determine if the modification
is still necessary or can be terminated.
vii) Include the informed consent of the
Individual and guardian.
viii)
Include an assurance that interventions and supports will cause no harm to the
Individual.
e) Providers who deliver authorized services
to Individuals determined eligible under the Medicaid HCBS Waiver Programs
shall be paid by the Department on a monthly basis on submission of service
reports/billing statements.
f)
Providers shall cooperate with:
1) Quality
assurance reviews, monitoring, evaluations, information requests (conducted by
the Department, HFS, or by other entities that are authorized by the Department
or HFS, such as ISC agencies, auditors, or evaluators) and when necessary,
sanctions. Prior to initiating formal action to sanction a provider agency, the
Department will allow the provider an opportunity to take corrective action to
eliminate or ameliorate a deficiency except in cases in which the Department
determines that emergency action is necessary to protect the public or
individual interest, safety, or welfare.
2) Licensure and certification surveys,
monitoring, evaluations and information requests, (conducted by the Department)
and when necessary, sanctions. The Department will conduct onsite surveys of
providers to ensure that they maintain compliance with established rules,
regulations, and standards. Providers who fail to comply with the established
rules, regulations, and standards set forth by the Department shall receive
sanctions that include hold on admissions or payment, decertification of a
site, and licensure revocation. Once a provider comes into compliance, the
sanction shall be lifted, and the Department will proceed with the required
survey process unless the Department has decertified a site or revoked the
license in which case the sanction will not be lifted.
g) Provider agencies shall only use Restraint
as allowed and directed pursuant to statutes and administrative rules
applicable to the program (i.e., 59 Ill. Adm. Code 115, 59 Ill. Adm. Code 119,
77 Ill. Adm. Code 370, 89 Ill. Adm. Code 384, 89 Ill. Adm. Code 401, 89 Ill.
Adm. Code 403, 210 ILCS 35/18, and 405 ILCS 5).
If any type of Restraint not allowed and/or directed by administrative rule
applicable to the program is utilized by an Agency employee, the incident must
be reported via the Critical Incident Reporting and Analysis System (CIRAS) as
well as reported to the Office of the Inspector General.
h) When a provider determines it will reduce,
suspend, or terminate services to an Individual in an HCBS Waiver Program, the
agency must do so according to the following, unless specified otherwise in the
statutes or administrative rules applicable to the program (i.e., 59 Ill. Adm.
Code 115, 59 Ill. Adm. Code 119, 77 Ill. Adm. Code 370, 89 Ill. Adm. Code 384,
89 Ill. Adm. Code 401, 89 Ill. Adm. Code 403,
210 ILCS
35/18, and 405 ILCS 5):
1) A provider agency shall terminate its
services if an Individual or guardian chooses either of the following actions,
both of which are considered voluntary, and the termination is not appealable:
A) An Individual transfers to another
qualified provider; or
B) An
Individual or Individual's guardian withdraws the Individual from the provider
agency's services (with no intention of returning).
2) A provider agency may involuntarily
reduce, suspend, or terminate services to an Individual for the following
reasons:
A) The medical needs of the
Individual cannot be met by the provider agency as documented in the
Individual's record.
B) The
behavioral needs of an Individual cannot be met by the provider agency to
ensure the physical safety of the Individual and/or others as documented in the
Individual's record.
3)
A notice of reduction, suspension, or termination issued by a provider agency,
must:
B) Be sent to the Individual, guardian, and
ISC agency.
C) Include a time frame
for the action. For involuntary terminations, the provider shall issue the
Individual and guardian at least a 30-day notice, except in emergency
situations as described in Section
120.110(i).
D) Provide a clear statement of the action to
be taken.
E) Provide a clear
statement of the reason for the action.
F) Include a complete statement of the
Individual's right to appeal, including the provider's grievance process; it
must also include the Department's informal review process and HFS' hearing
process as described in Section 120.110.
i) Appeals by providers. Provider agencies
may appeal the Department's administrative decisions (i.e., licensure or
certification denial, notice of deficiencies), and request an administrative
hearing as outlined in 89 Ill. Adm. Code 508. Providers may not appeal the
Department's decisions related to discharge, termination, or reduction of
services to an Individual.
1) As the single
State Medicaid agency, HFS is responsible for conducting all provider
administrative hearings and rendering the final administrative decision. The
appeal requirements and process are contained in HFS's rules at 89 Ill. Adm.
Code 104.200 through
104.210.
2) The Department shall conduct informal
reviews of provider appeals to attempt to resolve issues without a formal
administrative hearing.
