Current through Register Vol. 48, No. 38, September 20, 2024
a)
Beginning July l, l996, any individual, except those identified in subsection
(c) of this Section, seeking admission to a nursing facility licensed under the
Nursing Home Care Act [210 ILCS 45 ] for nursing facility services must be
screened to determine his or her need for those services pursuant to this
Section. Any individual, except those identified in subsection (c) of this
Section, who is seeking admission to a nursing facility that operates under the
Hospital Licensing Act [210 ILCS 85 ] must be screened to determine his or her
need for those services except when Medicaid funds will not be used for nursing
facility services for any part of the stay. For the purposes of this Section,
"nursing facility" or "facility" means a location licensed under the Nursing
Home Care Act or the Hospital Licensing Act as a skilled nursing facility or an
intermediate care facility.
b)
Screening Assessment
1) The Level I ID Screen
is the first phase of the preadmission screening process for nursing facility
services described in subsection (a) of this Section. The Level I ID Screen is
conducted to determine if there is a reasonable basis for suspecting that an
individual has developmental disabilities (DD), as defined in subsection
(b)(1)(A) of this Section, or severe mental illness (MI), as defined in
subsection (b)(1)(B) of this Section. This determination is required to assure
that individuals with DD or severe MI are placed into settings which provide
the services they require. Entities authorized to complete the Level I ID
Screen are agents of DPA, Department of Human Services (DHS), Department on
Aging (DoA), Department of Public Health (DPH), hospitals or nursing
facilities.
A) A developmental disability is
a disability that is attributable to a diagnosis of mental retardation (mild,
moderate, severe, profound), or a related condition. A related condition is
attributable to: cerebral palsy or epilepsy, or any other condition, other than
mental illness, 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 persons with mental retardation, and requires
treatment or services similar to those required for persons with mental
retardation. In addition, this condition is manifested before the age of 22; is
likely to continue indefinitely; and results in substantial functional
limitations in three or more of the following areas of major life activity:
i) self-care;
ii) understanding and use of
language;
iii) learning;
iv) mobility;
v) self-direction;
vi) capacity for independent
living.
B) An individual
is considered to have a severe mental illness for the purpose of this Section
if he or she has one of the following diagnoses: schizophrenia; delusional
disorder; schizoaffective disorder; psychotic disorder not otherwise specified;
bipolar disorder I - mixed, manic, and depressed; bipolar disorder II;
cyclothymic disorder; bipolar disorder not otherwise specified; major
depression, recurrent; and due to his or her mental illness exhibits resulting
substantial functional limitations. The functional limitation must be of an
extended duration expected to be present for at least a year, which results in
substantial limitation in major life activities affecting at least two of the
following areas:
i)
self-maintenance;
ii) social
functioning;
iii) community living
activities;
iv) work related
skills.
2) If
the Level I ID Screen indicates that an individual may have DD or severe MI, a
comprehensive assessment, the Level II assessment, except as defined in
subsection (b)(7) of this Section, is conducted by preadmission screening (PAS)
agents designated by the DHS-Office of Developmental Disabilities or DHS-Office
of Mental Health, whichever is applicable, concerning the need for nursing
facility services and the need for specialized services.
3) If the Level I ID Screen does not identify
a reasonable basis for suspecting DD or severe MI, the individual is referred
to DoA (individuals 60 years of age or older) or DHS - Office of Rehabilitation
Services (individuals l8 through 59 years of age) for a Determination of Need
to assess the need for nursing facility services.
4) For applicants of Medicaid services who
are already residing in the facility and were admitted after June 30, 1996, the
Department will review and evaluate a copy of the most recent Minimum Data Set
(MDS) resident assessment instrument. The Department will refer to DoA or DHS,
as appropriate, any light need resident who appears to be a potential candidate
for community placement.
5) A
screening assessment is valid for 90 calendar days from the date of the
assessment. For individuals with DD or severe MI, an existing Level II
assessment may remain valid after 90 calendar days when the designated PAS
agent updates any component of the assessment which is not current, and
confirms the validity of the assessment as reliably reflecting the status of
the individual.
6) Due to
exceptional circumstances, an individual identified as having DD or MI,
following a Level I ID Screen, may be determined to need nursing facility
services. The individual with exceptional circumstances must then receive a
Level II assessment to determine the individual's need for specialized services
related to placement in a nursing facility, except in the specific
circumstances noted in subsection (b)(7) of this Section. Exceptional
circumstances include, but are not limited to:
A) terminal illness with a life expectancy of
six months or less; and
B)
convalescent care (a medically prescribed period of recovery, following acute
care, not to exceed 120 calendar days); and
C) severe physical illnesses, such as coma,
ventilator dependence, functioning at brain stem level or diagnoses such as
chronic obstructive pulmonary disease, Parkinson's disease, Huntington's
disease, amyotrophic lateral sclerosis, and congestive heart failure;
and
D) a diagnosis of dementia,
including Alzheimer's disease or a related disorder, in the case of the
individual with DD.
7)
Level II assessment exemption. Some individuals with DD or severe MI may be
admitted to a nursing facility without receiving a Level II assessment to
determine the need for specialized services by a designated PAS agent.
Individuals exempt from a Level II assessment for specialized services are
provisional admissions pending further assessment in cases of delirium where an
accurate diagnosis cannot be made until the delirium clears. In all other
cases, a determination that specialized services are not needed must be based
on a Level II assessment.
8)
Screening agents shall present alternatives to institutional placement, and
inform individuals of alternative settings before placement into a nursing
facility.
9) Non-Medicaid supported
individuals who choose to be admitted into a nursing facility when the
screening assessment does not justify nursing facility placement will not be
denied access to the facility.
c) A screening assessment does not apply to
an individual who:
1) is receiving or will be
receiving sheltered care services; or
2) transfers from one facility to another,
with or without an intervening hospital stay. It is the transferring facility's
responsibility to ensure that copies of the resident's most recent screening
assessment accompany the transferring resident; or
3) resided in a facility for a period of at
least 60 days and is returning to a facility after an absence of not more than
60 days; or
4) is receiving or will
be receiving hospice services; or
5) is readmitted to a facility after a
therapeutic home visit; or
6) is
readmitted to a facility from a hospital to which he or she was transferred for
the purpose of receiving care; or
7) resided in the facility on June 30,
l996.
d) Nursing
Facility Services
In Illinois, nursing facilities are licensed for intermediate
level nursing care and skilled level nursing care. For guidelines to the type
of services provided by nursing facilities refer to 77 Ill. Adm. Code
300.Appendix A.
e) Date of
Payment
1) No payment for nursing facility
services may be made for individuals who have been determined eligible, or have
applied for Medicaid at the point of admission, unless the screening assessment
documents a need for such care.
2)
Where the assessment does not establish this need, the individual may request
that a licensed physician designated by DPA review the medical reports and any
other evidence the individual wishes to submit, and certify whether there is a
need for nursing facility services in the individual's case. The individual
will be notified of the right to this review.
3) For an individual whose preadmission
screening assessment has been completed prior to admission, DPA will begin
payment:
A) on the date of admission if
Medicaid eligibility has been established, or
B) on the beginning date of Medicaid
eligibility if eligibility starts after the date of admission.
4) For an individual whose
preadmission screening assessment has not been completed prior to admission,
DPA will begin payment on the later of:
A) the
date that the screening assessment requirement is met, or
B) the effective date of Medicaid
eligibility.
5) For an
individual who applies for Medicaid after admission to a facility, DPA will
begin payment on the effective date of Medicaid eligibility.
f) Review Required Upon Change in
DD/MI Resident Condition
Nursing facilities must notify the State mental health
authority or the State developmental disability authority, or their designee as
applicable, when there has been a significant change in the condition of a
Medicaid eligible resident with developmental disability or severe mental
illness as required by 42 USC 396 r(e)(7)(B)(iii) (1999). The nursing facility
shall report in a format established by the applicable State authority, or its
designee, significant changes in a resident's condition. A determination will
then be made whether there has been a significant change requiring a resident
review. For the purposes of this subsection (f), a significant change for a
resident with severe mental illness or developmental disability will be deemed
to have occurred when:
1) An
individual who was determined by PAS to be severely mentally ill, and who has
continuously resided in a nursing facility within the last 12 months, who has
been referred for admission or been admitted to a psychiatric hospital or
psychiatric ward of a general hospital for psychiatric care three or more times
within that 12 month period; or
2)
An individual who was determined by PAS to be severely mentally ill or
developmentally disabled is evaluated by the nursing facility to no longer have
a severe mental illness or developmental disability; or
3) An individual who was determined by PAS
not to be severely mentally ill or developmentally disabled is evaluated by the
nursing facility to have a severe mental illness or developmental disability.
There must be a reasonable basis for believing that the condition may indicate
the presence of a developmental disability prior to the age of 22; or
4) An individual who was determined by PAS to
be severely mentally ill who does not have a medical need for nursing facility
level of care, meets all of the following:
A)
no longer receives any intervention programs for mood, behavior or cognitive
loss;
B) has successfully completed
training skills required to return to the community; and
C) discharge to the community is not planned
within the next 90 days; or
5) An individual who was determined by PAS to
be developmentally disabled no longer receives specialized services;
or
6) An individual with severe
mental illness or an individual with a developmental disability who entered the
nursing facility as an exempted hospital discharge is now found to require more
than 30 days of nursing facility care.
g) Periodic Resident Review
The Department, the Department of Public Health, or their
agents may periodically review some or all Medicaid eligible residents found to
be severely mentally ill or developmentally disabled to evaluate nursing
facilities' compliance with this Section.
