Section 686.10  Personal Assistant (PA) Requirements

 

In order to be employed by a customer as a PA (89 Ill. Adm. Code 676.30), an individual must:

 

a)         have a Social Security number and provide the Department of Human Services (DHS) with documented verification of this number;

 

b)         be a minor between 14 and 16 years of age who is not employed during school hours, has an employment certificate and meets all other requirements of the Child Labor Law [820 ILCS 205] and has an adult who is at least 21 years of age and who is legally responsible for the customer who will supervise the PA; be 16 years of age or older, enrolled in school and not employed during school hours; or be 17 years of age or older and not enrolled in school;

 

c)         have provided to the customer at least two written or verbal recommendations from present or former employers, the recommendation of a Center for Independent Living (CIL), or, if never employed, references from at least two non-relatives;

 

d)         be able to communicate with the customer to the satisfaction of the customer and counselor;

 

e)         be able to follow directions to the satisfaction of the customer and counselor;

 

f)         have previous experience and/or training that is adequate and consistent with the specific tasks required for safe and adequate care of the customer;

 

g)         if the customer has a contagious infectious disease, have a physician, health care institution (i.e., hospital, nursing home, home health agency), or CIL certify, in writing, that he/she has the knowledge of precautionary procedures for the control of contagious infectious diseases, if it is anticipated that he/she will come into contact with bodily fluids, or be evaluated by a Registered Nurse licensed pursuant to the Nurse Practice Act [225 ILCS 65] to determine that he/she has knowledge of those procedures;

 

h)         complete an EMPLOYMENT AGREEMENT between the customer and PA that certifies the PA:

 

1)         shall provide services to the individual in accordance with his/her SERVICE PLAN (IL 499-1049) (89 Ill. Adm. Code 676.30(u));

 

2)         shall submit a bi-monthly calendar listing actual hours worked each pay period (1-15; 16-last working day of the month), as verified by the customer and in accordance with the number of hours authorized by DHS. The PA shall not claim more hours than approved by DHS unless prior approval has been granted by the counselor to address a temporary increased service need;

 

3)         shall make available to DHS and other designated agencies those records described in subsection (h)(2);

 

4)         shall maintain all customer information as confidential and not for release, either in writing or verbally, to anyone other than those designated by DHS in writing;

 

5)         shall not subcontract to any other person, any of the services he/she has agreed to provide;

 

6)         shall provide services only while the individual is in his/her home or during the period covered by Section 684.60 (Provision of Services);

 

7)         shall agree that the customer is responsible for locating, choosing, employing, supervising, training, and disciplining as necessary the PA.  Further, that the State of Illinois does not provide paid vacation, holiday, or sick leave; however, such absences shall be reported to the DHS counselor per the HOME SERVICES TIME SHEET (IL 488-2251) only for the purposes of processing payment;

 

8)         understands that DHS reports all payments made to a PA to the Illinois Department of Employment Security (DES) and that the PA may apply for unemployment benefits, but DES, not DHS, makes the determination as to whether the PA shall receive benefits;

 

9)         understands that he/she may apply for Workers' Compensation benefits through DHS and that some customers may carry such insurance coverage; however, DHS maintains that the customer, not DHS, is the employer for these purposes; and

 

10)       understands that DHS will withhold Social Security tax (FICA) from payments made to him/her. Federal and State income tax shall be withheld if the PA completes and returns to DHS two separate W-4 forms;

 

i)          complete an I-9 Immigration form, which must be retained by the customer;

 

j)          for PAs starting on or after April 13, 1992, complete a PA STANDARDS (IL 488-2112) to be returned to DHS;

 

k)         as of April 13, 1992, at the time of redetermination of eligibility of the customer by which he/she is employed, have completed by the customer, a PERSONAL ASSISTANT EVALUATION (IL 488-2089); and

 

l)          if requested by the customer, give permission and the necessary information for the customer to request a conviction background check from the Illinois State Police.  This permission will require the prospective PA to sign the appropriate form provided by the customer.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.20  Services That May Be Provided by a PA

 

A PA may perform or assist with:

 

a)         household tasks, shopping, or personal care; and

 

b)         incidental health care tasks that do not require independent judgement, with the permission of the customer and/or family; and

 

c)         monitoring to ensure the health and safety of the customer.

 

(Source:  Amended at 38 Ill. Reg. 16978, effective July 25, 2014)

 

Section 686.25  Criminal Background Check

 

a)         A Home Services Customer may require any PA candidate to submit to a criminal background investigation and to successfully complete a criminal background investigation as a condition of being selected as the PA to that Customer.

 

b)         In the event that a customer elects to require a PA candidate to submit to a criminal background investigation, the customer shall be obligated only to inform DHS-Division of Rehabilitation Services (DRS) of his/her decision and DHS-DRS will provide the Customer an appropriate form that the Customer may file with the Illinois State Police to initiate the criminal background investigation.  The results of the criminal background investigation will be sent directly to the customer, and the customer shall have no obligation to share the results of the investigation with DHS-DRS. Nothing contained in this Section shall restrict a customer from extending a conditional offer of employment to any PA candidate pending the results of the background investigation.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.30  Annual Review of PA Performance

 

a)         Pursuant to 686.10(k), annually, at the time of redetermination of the individual's eligibility, a Personal Assistant Evaluation (IL 488-2089) shall be completed, by the customer with assistance of the counselor, for each PA providing services through the Home Services Program (HSP).

 

b)         PAs shall be evaluated based upon:

 

1)         accuracy of work (e.g., ranging from making many errors to few errors);

 

2)         cleanliness of working area (e.g., ranging from very untidy to exceptionally clean);

 

3)         use of work time (e.g., ranging from very wasteful to very efficient);

 

4)         responsibility (e.g., ranging from irresponsible to responsible);

 

5)         attendance (e.g., ranging from frequently absent or late to always prompt); and

 

6)         attitude towards the customer (e.g., ranging from disrespectful to respectful).

 

c)         The outcome of the evaluation shall be mediated by the counselor between the PA and the customer regarding any unresolved issues, up to and including replacement of the PA by the customer, if necessary.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.40  Payment for PA Services

 

a)         PAs shall be paid at the hourly rate set by law, but never less than the current federal minimum wage.

 

b)         PAs shall be paid twice each month for services rendered.  The first payment shall be for any services rendered by the PA, pursuant to the customer's Service Plan, from the first day of the month through the fifteenth day of the month.  The second payment shall be for any services rendered by the PA, pursuant to the customer's Service Plan, from the sixteenth day of the month through the last day of the month.

 

c)         No PA shall be reimbursed by DHS-DRS for services rendered to one or more HSP customers for more than 16 hours in a 24-hour period.  The counselor may grant an exception should an emergency occur that results in the loss of a paid or unpaid primary caregiver who resides with the customer, and there is imminent danger to the health, safety and well being of the customer.  When this occurs, the additional hours may not exceed the annual service cost maximum (SCM). The 16-hour limitation does not apply to PAs providing respite services.

 

(Source:  Amended at 29 Ill. Reg. 16508, effective October 17, 2005)

 

Section 686.100  Adult Day Care (ADC) Provider Requirements

 

a)         Adult Day Care (ADC) Providers (see 89 Ill. Adm. Code 676.40) must either be approved by DHS or by the Illinois Department on Aging (DoA) pursuant to DoA's rules found at 89 Ill. Adm. Code 240, with the exception that the term "the elderly" in 89 Ill. Adm. Code 240.1560(a)(1)(A)(ii) and (a)(2)(A)(iii) should be replaced with the term "individuals with disabilities". 

 

b)         In order to be approved as an ADC Provider by DHS, the ADC Provider must meet all of the conditions specified by DoA, as cited above, and:

 

1)         employ a full-time program director;

 

2)         employ the equivalent of a full-time program coordinator/director;

 

3)         employ a program nurse who is on duty at least a portion of every standard business day;

 

4)         employ a nutrition staff;

 

5)         comply with the provisions of:

 

A)        Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 701), as amended;

 

B)        the Illinois Human Rights Act [775 ILCS 5];

 

C)        the Illinois Accessibility Code (71 Ill. Adm. Code 400);

 

D)        the Americans with Disabilities Act (42 U.S.C. 12101); and

 

E)        the Health Insurance Portability and Accountability Act (42 U.S.C. 1320d);

 

6)         record the administration of all prescribed medications for those Customers served through HSP who are unable to self-administer medication as documented by a physician licensed pursuant to the Medical Practice Act [225 ILCS 60], a registered nurse licensed pursuant to the Nursing Practice Act [225 ILCS 65], or as documented in the individual's Service Plan (IL 488-1049) (89 Ill. Adm. Code 676.30);

 

7)         provide DHS with a record of the amount of pre-service training each employee has;

 

8)         require, and provide DHS documentation of, at least 12 hours of in-service training for each staff person each fiscal year;

 

9)         successfully complete an Adult Day Care Provider Review (IL 488-2129) pursuant to Section 686.120;

 

10)        accept reimbursement at or below the federally-approved Medicaid rates pursuant to the currently active 1915(c) Home and Community Based Services Waiver;

 

11)        maintain adequate records for planning, budgeting, administration and program evaluation and planning.  These records shall be available to DHS and the United States Department of Health and Human Services (HHS), or any entity designated by DHS or HHS, and shall be maintained for a period of at least 5 years or until advised that all State and federal audits are completed. These records must include, but not be limited to:

 

A)        records of all referrals, including the disposition of each referral;

 

B)        all Customer records;

 

C)        administrative records, including:

 

i)          service statistics; and

 

ii)         billing and payment records;

 

D)        personnel records, including:

 

i)          schedules and attendance records for staff and volunteers;

 

ii)         training records for staff and volunteers;

 

iii)        annual performance evaluations for all staff and, as appropriate, all volunteers; and

 

12)        have an Affirmative Action Plan in place which is approved by its governing body.

 

c)         a facility that houses an adult day care program (including satellite sites) shall meet the criteria for the Centers for Medicare and Medicaid Services definition of a home and community-based setting pursuant to 42 CFR 441.301(c)(4) and 42 CFR 441.301(c)(5).

 

d)         if a provider meets the criteria listed in this Section, application to HSP should be made to:

 

Illinois Department of Human Services

Division of Rehabilitation Services

Home Services Program, Program Compliance

100 S. Grand Ave. East

Springfield IL  62794

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.110  Services Which Must Be Provided by ADC Providers

 

In order for an Adult Day Care Provider to be recognized by DHS and used to provide services to individuals receiving services through HSP, each Adult Day Care Center must agree to provide the following services:

 

a)         written and individualized care planning;

 

b)         assistance and arrangement of personal care, hygiene, and self-care training, as appropriate, based on each individual's needs;

 

c)         leisure time and recreation activities;

 

d)         assistance of a medical nature (e.g., medication, assessment, exercise);

 

e)         meals and snacks; and

 

f)         maintenance of a complete record for each individual served through the Adult Day Care Center, including full recording of all required services provided to the customer as listed in subsections (a) through (e), above.

 

Section 686.120  Compliance Review of ADC Providers

 

a)         DHS-DRS shall complete a review of each ADC Provider, at least every two years, to ensure compliance with the criteria set forth in this Subpart.

 

b)         The review shall consist of an on-site review conducted by HSP staff using the Adult Day Care Review form (IL 488-2129).  Written notification shall be provided to the ADC Provider prior to the review.

 

c)         Within 15 days after the completion of the review, a copy of the completed IL 488-2129, along with a letter stating the results of the review, shall be mailed to the ADC.

 

1)         If the ADC Provider is approved, included with the letter shall be an ADC Provider Rate Agreement for execution by the appropriate provider staff and return to DHS-DRS.

 

2)         If the ADC Provider is not approved, the letter shall contain specific information regarding:

 

A)        deficiencies found as a result of the review;

 

B)        the action necessary for the ADC Provider to come into compliance;

 

C)        the time frames within which the ADC Provider must come into compliance; and

 

D)        the information necessary for the ADC Provider to request re-evaluation after the compliance issues are addressed.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.130  Appeal of Compliance Review for ADC Providers

 

a)         ADC Providers determined not to be in compliance with DHS-DRS requirements as a result of the review may appeal the decision to the Bureau Chief of the Bureau of Home Services Program.  The Bureau Chief shall conduct a review of the facts related to the rating and shall, within 15 working days, provide a written decision to the ADC Provider.

 

b)         If the ADC Provider is not satisfied with the decision of the Bureau Chief, the ADC Provider may request review of the Chief's decision by the DHS-DRS Director.  The request must be in writing from the ADC provider and received by the DHS-DRS Director within 10 working days after the date the decision was rendered by the Bureau Chief.  The decision of the DHS-DRS Director shall be final.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.140  Payment for ADC Services

 

a)         DHS shall pay no more than the rate approved by DoA for Adult Day Care Services.  The rate established by DoA shall include meals, snacks, and, in some instances, transportation provided by the ADC Center.

 

b)         Adult Day Care Providers shall submit monthly billings for approved services provided the previous month and progress reports for each customer served by the provider for the month being billed.  Billings may be submitted less frequently at the discretion of the Adult Day Care Provider.

 

Section 686.200  Homemaker Service Provider Requirements

 

In order to provide Homemaker Services under HSP (see 89 Ill. Adm. Code 676.40), a Homemaker Service Provider must be in compliance with all Medicaid provider requirements for the Illinois Department of Healthcare and Family Services (HFS) and DHS.

 

a)         Only Homemaker Service Providers with an approved Homemaker Agreement may be used to provide Homemaker Services to individuals being served through HSP.

 

b)         In order to be approved by HSP, the Homemaker Service Provider must comply with the following, to the satisfaction of HSP:

 

1)         provide a comprehensive array of services that include, but are not limited to, those services described in Section 686.210;

 

2)         assure HSP that all referrals will be responded to within 48 hours after receipt from HSP;

 

3)         have written billing procedures and provide a copy to HSP as part of the compliance review;

 

4)         have documented procedures to cover unexpected absences and emergencies to ensure services will be provided in an adequate and safe manner to all individuals served by the Homemaker Service Provider;

 

5)         have written procedures to respond to customer and counselor complaints regarding services;

 

6)         maintain comprehensive written job descriptions for, at a minimum, the positions of Executive Director or Administrator, supervisory staff, and Homemakers;

 

7)         have established a local presence to ensure regular and on-going contact with HSP and other appropriate community groups;

 

8)         have procedures for regular and on-going recruitment of Homemakers through local resources;

 

9)         be incorporated or provide HSP with a copy of a written statement of purpose and function;

 

10)         maintain adequate records for planning, budgeting, administration and program evaluation and planning. These records shall be available at all times to HSP and the United States Department of Health and Human Services (HHS), or any entity designated by HSP or HHS, and shall be maintained for a period of at least 5 years, or until advised that all State and federal audits are completed.  These records must include, but not be limited to:

 

A)        records of all referrals, including the disposition of each referral;

 

B)        customer records, which include:

 

i)          dates and times services were provided to each individual;

 

ii)         dates and times of supervisor-Homemaker weekly conferences;

 

iii)        semi-annual reports of supervisory visits with each customer served;

 

iv)        monthly service reports for each customer served that document a summary of services, actual or anticipated changes in the customer's condition, recommended changes in the current HSP Service Plan, and all customer contacts;

 

v)         records of all staffings held pertaining to the customer;

 

vi)        records of all financial transactions between the customer and any Homemaker Service Provider employee;

 

C)        administrative records, which include:

 

i)          cumulative service statistics pertaining to any agreement with HSP;

 

ii)         billing and payment records that pertain to HSP;

 

D)        personnel records, which include:

 

i)          attendance records;

 

ii)         schedules for all direct service staff;

 

iii)        documentation regarding each individual's qualification for the position held;

 

iv)        wage rate and effective date for each staff member;

 

v)         job performance evaluations for each staff person that include annual evaluations and at least one probationary evaluation completed within the first six months of employment;

 

vi)        orientation and training attendance information for each staff member, which must include the name of each instructor, the date, the time and the title of each training program attended; and

 

vii)       verification of liability insurance in the amounts of at least $15,000 per person bodily injury, $30,000 minimum per occurrence, and $10,000 in property damage, per occurrence, if the employee will or could be expected to transport customers in the course of his/her work;

 

11)         maintain insurance coverage against any and all liability, loss, damage and/or expense from wrongful or negligent acts of the Homemaker Service Provider or any of its employees and provide HSP with written verification of that coverage;

 

12)         maintain written procedures on reporting loss and damage arising from the wrongful or negligent acts of the Homemaker Service Provider or any of its employees;

 

13)         agree to hold harmless DHS and HSP against any and all liability, loss, damage, cost, or expense arising from wrongful or negligent acts of the Homemaker Service Provider or any of its employees;

 

14)         assist HSP in monitoring and evaluating the Homemaker Service Provider's performance under any agreement with HSP;

 

15)         maintain any and all information regarding individuals referred to the Homemaker Service Provider by HSP as confidential and not for public release without the written consent of HSP and the customer;

 

16)         maintain and have available for review by customers and purchasers of services policies governing:

 

A)        the nature and scope of each service provided by the Homemaker Service Provider;

 

B)        a two-way receipt system for any time an employee of the Homemaker Service Provider handles an individual's money, food stamps or other negotiable items or tender;

 

C)        personnel policies governing salary, leave time, hours of work, employee grievance procedures, and attendance at in and out-service trainings; and

 

17)         have in place an Affirmative Action Plan that is approved by its governing body.

 

c)         At a minimum, each Homemaker Service Provider must employ qualified staff in the positions of:

 

1)         Executive Director or Administrator for each local unit providing services, who is responsible for the administration of the Homemaker Services program and who, at a minimum, has or is making continued progress towards:

 

A)        a Bachelor's degree in health, human services, or a related field;

 

B)        licensure as a Registered Nurse pursuant to the Nurse Practice Act;

 

C)        certification as a home health care administrator, medical clinic administrator, or other health services administrator; or

 

D)        one year of related job experience in social services or in a health agency to replace each year of education required in subsections  (c)(1)(A) through (C), provided that at least one year of experience was in a program that provides services to individuals with disabilities.

 

2)         For the purposes of subsections (c)(1)(A) through (C) "continued progress" shall mean current registration and evidence of successful completion of course work in an accredited junior college, college, or university for a minimum of 2 semesters or 3 quarters of each academic year.  Successful completion shall mean a grade of at least "C" in undergraduate course work or a grade of "B" in graduate course work;

 

3)         Supervisors, in a ratio of no less than the equivalent of one full-time supervisor to the equivalent of every 20 full-time Homemakers, who are responsible for the supervision of Homemaker staff and who, at a minimum, have:

 

A)        a Bachelor's degree with course work in social science, home economics, or nursing;

 

B)        knowledge and skill equivalent to completion of a Bachelor's degree, as described in subsection (c)(1)(A); or

 

C)        a high school diploma or its equivalent plus health service experience including at least 2 years supervisory experience;

 

4)         Homemakers who have:

 

A)        been determined to be in good health;

 

B)        knowledge and skill equivalent to a high school diploma;

 

C)        experience as a homemaker, either in his or her own home or through employment; and

 

D)        knowledge of:

 

i)          nursing care;

 

ii)         first aid;

 

iii)        personal and environmental hygiene;

 

iv)        household budgeting;

 

v)         housekeeping;

 

vi)        nutrition;

 

vii)       food preparation; and

 

viii)      clothing care.

 

d)         Each supervisor and Homemaker must, at a minimum, participate in the following training programs:

 

1)         Orientation, which shall include:

 

A)        the philosophy and purpose of Homemaker Services; and

 

B)        the functions of Homemaker Services;

 

2)         In-service training, directed at increasing the Homemaker Service Provider's knowledge and skills, of not less than 12 hours each year in areas including:

 

A)        disability awareness; and

 

B)        Acquired Immunodeficiency Syndrome (AIDS).

 

e)         The Homemaker Service Provider shall have a written policy and procedures governing a self-evaluation process to evaluate services and case management with an outcome of written recommendations to the governing body of the Homemaker Service Provider to improve the services provided.

 

f)         The Homemaker Service Provider shall abide by provisions of the following federal and State laws and regulations regarding employment practices and compliance:

 

            1)         Laws and Regulations

 

                        A)        Title VI of the Civil Rights Act of 1964 (42 USC 2000d);

 

B)        Section 504 of the Rehabilitation Act of 1973 (29 USC 701);

 

C)        the Americans With Disabilities Act (42 USC 12101);

 

D)        the Illinois Human Rights Act [775 ILCS 5];

 

E)        the Health Care Worker Background Check Act [225 ILCS 46]; and

 

F)         the Health Insurance Portability and Accountability Act (42 USC 1320(d) et seq.).

 

2)         Further, the Homemaker Service Provider shall provide HSP with a letter certifying compliance with the provisions of the laws listed in subsection (f)(1) and a copy of the Affirmative Action Plan for the Homemaker Service Provider.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.210  Services That Must Be Provided by Homemaker Service Providers

 

An approved Homemaker Service Provider must provide professionally directed home management and personal care services through trained Homemaker employees to HSP customers when the customer does not have a responsible person or entity to assist him or her, and the customer requires teaching, performance and/or assistance with:

 

a)         household, financial and time management;

 

b)         nutrition, meal planning and food preparation, which includes specially prescribed diets and snacks;

 

c)         personal care and hygiene that is nonmedical in nature;

 

d)         observation and reporting of a customer's behavior and activities to HSP for the purpose of assessment and service planning; and

 

e)         emergency services to meet an unforeseen need in the areas listed in subsections (a) through (d) when required by the customer and preapproved by HSP.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.220  Compliance Review of Homemaker Service Providers

 

HSP shall conduct a compliance review on all Homemaker Service Providers as a condition of determining compliance, or continued compliance, with the criteria established under this Subpart.

 

a)         A Homemaker Service Provider seeking an HSP rate agreement shall undergo a compliance review as a condition of approval by HSP.

 

b)         A Homemaker Service Provider with a current HSP rate agreement shall undergo a compliance review at least every two years as a condition of determining continued compliance under the program.

 

c)         All Homemaker Service Providers with current HSP rate agreements shall be notified in writing by HSP, at least 10 working days prior to the date of the compliance review.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.230  Appeal Rights of Homemaker Service Providers

 

a)         Homemaker Service Providers not satisfied with a DHS program decision or an HSP compliance review, may submit an appeal request in writing to the Bureau Chief of the Home Services Program.  Appeal requests must be filed within 30 days after the program decision or compliance review.  The Bureau Chief shall conduct a review of the facts and shall, within 15 working days, provide a written decision to the Homemaker Service Provider.

 

b)         If the Homemaker Service Provider is not satisfied with the decision of the Bureau Chief, the Homemaker Service Provider may request review of the Bureau Chief's decision by the Director of DHS-DRS.  The request must be in writing and received by the DHS-DRS Director within 10 working days after the date the decision was rendered by the Bureau Chief.  The decision of the DHS-DRS Director shall be final.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.235  Enhanced Rate for Health Insurance Costs

 

An enhanced rate shall be paid to Homemaker Service Providers that offer health insurance coverage as a benefit to their Homemaker employees who provide services to customers under HSP.

 

a)         For purposes of this Section, "health insurance" means a Type 1 plan or a Type 2 plan as described in subsections (a)(1) and (2).

 

1)         Type 1 Plan

A Type 1 plan must comply with, be comparable to, or exceed required mandated benefits, coverages, and co-payment levels for individuals and group insurance policies and individual and group contracts for health maintenance organizations under the Illinois Insurance Code [215 ILCS 5], the Health Maintenance Organization Act [215 ILCS 125], and 50 Ill. Adm. Code 2001.

 

2)         Type 2 Plan

A Type 2 plan is employer-paid health insurance as part of collective bargaining with unionized Homemaker employees through a Taft-Hartley Multi-employer Health and Welfare Plan.  The Labor Management Relations Act of 1947 (29 USC 141 et seq.) describes the requirements and coverage at 29 USC 186(c)(5).

 

b)         Initial Application

 

1)         An interested Homemaker Service Provider must submit an initial application at least 120 days prior to the end of each State fiscal year.  The application may be obtained from and must be submitted to the Home Services Liaison for Health Insurance, Department of Human Services, 100 South Grand Avenue East, P.O. Box 19429, Springfield, Illinois 62794-9429.

 

2)       Homemaker Service Providers that are found by HSP to have deficiencies may not apply for the enhanced rate until deficiencies are corrected to the satisfaction of HSP.

 

c)         Eligibility

Eligibility requirements include:

 

1)         Verification of a current rate agreement as a Homemaker Service Provider under the HSP.

 

2)         A copy of a health insurance plan or a certification of insurance and the effective date of that document, to establish that:

 

A)        the Homemaker Service Provider provides health insurance at its own expense for its Homemaker employees, which may include coverage for those employees' dependents; or

 

B)        the Homemaker Service Provider will provide for health insurance as part of collective bargaining with unionized Homemaker employees, which may include coverage for those employees' dependents through a Taft-Hartley Multi-employer Health and Welfare Plan.

 

3)         Specification of the total number of employees and the total number of Homemaker employees, together with a certification from a responsible party for the Homemaker Service Provider to the effect that:

 

A)        under a Type 1 health insurance plan:

 

i)          health insurance coverage is offered to all Homemaker employees who have worked at least an average of 20 hours per week for three consecutive months under HSP; and

 

ii)         at least one quarter of the total number of Homemaker employees accept the offer of health insurance.

 

B)        under a Type 2 health insurance plan:

 

i)          health insurance coverage is offered to all of the Homemaker employees subject to the collective bargaining agreement who have worked at least an average of 20 hours per week for three consecutive months under HSP; and

 

ii)         at least one quarter of the total number of Homemaker employees, or any higher percentage required under federal law, accept the offer of health insurance.

 

4)         Submission of any other relevant information requested by HSP for administrative or audit purposes.

 

d)         Notification

It is the responsibility of a Homemaker Service Provider to notify HSP within 7 days of any change in its eligibility status, including, but not limited to, cancellation or termination of the health insurance plan or purchase of a new plan.  A Homemaker Service Provider is only required to monitor participation by Homemaker employees in order to submit the initial application, the Annual Insurance Review required by subsection (e), and required financial reporting.

 

e)         Annual Insurance Review

 

1)         Once a Homemaker Service Provider is determined eligible by HSP and is paid an enhanced rate for health insurance costs, the Homemaker Service Provider must thereafter substantiate its continued eligibility under subsection (c) by submitting appropriate supporting documentation at the same time as its annual financial report under Section 686.250.

 

2)         As part of the Annual Insurance Review, an independent certified public accounting firm for the Homemaker Service Provider must verify the actual, documented expense for health insurance provided for the period listed as part of the required financial reporting under Section 686.250.

 

3)         HSP reserves the right to require a Homemaker Service Provider to engage an independent certified public accounting firm, approved by HSP, to verify the information and data submitted by the Homemaker Service Provider if HSP is in possession of evidence to suggest the information and data submitted is inaccurate, incomplete or fraudulent.  This audit will be performed at the Homemaker Service Provider's expense.

 

4)         HSP shall notify a Homemaker Service Provider in the event of a determination during the Annual Insurance Review that:

 

A)        the Homemaker Service Provider is no longer eligible for continued payment of the enhanced rate for health insurance costs;

 

B)        the total revenue from the enhanced rate for health insurance costs exceeds the actual, documented expenses for health insurance costs for the reporting period;

 

C)        there was an error in eligibility of a Homemaker Service Provider for the prior reporting period;

 

D)        there was an error in the amount of revenue from the enhanced rate for health insurance costs; or

 

E)        there was an error in the amount of the health insurance costs.

 

5)         A Homemaker Service Provider may appeal an adverse eligibility decision regarding continued payment of the enhanced rate for health insurance costs or a repayment decision in accordance with Section 686.230.  HSP will continue to pay the enhanced rate for health insurance costs until the appeal is resolved.

 

6)         Supporting documentation may be subject to release under the Freedom of Information Act [5 ILCS 140] unless an exemption applies for confidentiality, privacy, or other proprietary business purpose and is marked accordingly on the face of any submission.

 

(Source:  Added at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.240  Payment Information for Homemaker Service Providers

 

a)         Payment information for all Homemaker Service Providers

 

1)         Payment for Homemaker Services shall be at the rate specified in the rate agreement signed by HSP and the approved Homemaker Service Provider.

 

2)         Services shall be paid in accordance with the time recorded by the Homemaker employee pursuant to the Service Plan (see 89 Ill. Adm. Code 676.30) developed for the customer.

 

3)         Homemaker Service Providers shall submit monthly billings for approved services provided the previous month and monthly progress reports for each customer served by the Homemaker Service Provider for the month being billed.

 

4)         Payment for Homemaker Services shall be allowed only for those hours services are being provided to the HSP customer.  No payment shall be claimed for those periods that the Homemaker employee spends traveling, in conferences, etc., or for expenses incurred by the Homemaker employee.

 

5)         By accepting any payment under HSP, a Homemaker Service Provider agrees to repay the State of Illinois if:

 

A)        the total revenue from the monthly billings exceeds the actual, approved documented services under this Section for the reporting period;

 

B)        an error occurred in the calculation of the monthly billing submitted to HSP and the provider was overpaid;

 

C)        the Homemaker Service Provider received payment for services during a time the provider was determined ineligible to provide services under HSP; or

 

D)        the Homemaker Service Provider misspent HSP funds or received funding from HSP while participating in fraudulent activity.

 

b)         Additional Payment Information for Homemaker Service Providers with the Enhanced Rate for Health Insurance Costs

 

1)         If a Homemaker Service Provider is determined eligible for the enhanced rate for health insurance costs, HSP will thereafter calculate the appropriate payment based on the number of units of Homemaker Service accepted as billed for the eligible dates of service.

 

2)         A Homemaker Service Provider that makes a switch between a Type 1 and a Type 2 plan is not entitled to any retroactive payments for a period of time preceding the date on which benefits are actually available under the new plan.

 

3)         No Homemaker Service Provider is entitled to a duplicate payment for the same period of time or for the same units of Homemaker Service accepted as billed per contract.

 

4)         By accepting any payment under HSP, a Homemaker Service Provider agrees to repay the State of Illinois if:

 

A)        the total revenue from the enhanced rate for health insurance costs exceeds the actual, documented expenses for its health insurance costs under this Section for the reporting period;

 

B)        an error in eligibility of a Homemaker Service Provider, or the amount of revenue from the enhanced rate for health insurance costs, or the amount of the health insurance costs is subsequently determined by the Homemaker Service Provider or HSP; or

 

C)        the Homemaker Service Provider misspent HSP funds or received funding from HSP for the enhanced rate for health insurance costs while participating in fraudulent activity.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.250  Financial Reporting of Homemaker Service Providers

 

            a)         Homemaker Service Providers shall be required to:

 

1)         complete and submit a Homemaker Cost Certification report that is based upon actual, documented expenditures.

 

A)        The report must be submitted annually, within 60 days after the end of the reporting period, and may be prepared as a part of the Homemaker Service Provider's annual audit.

 

B)        The report may be based on a calendar year or on the Homemaker Service Provider's fiscal year; however, once it is determined which time period is to be used, written approval from HSP shall be required for a change in that determination.

 

C)        The report must demonstrate that the Homemaker Service Provider has expended a minimum of 77% of the total revenues due from HSP, including the customer incurred expense, for Homemaker costs as enumerated in Section 686.280.  For purposes of this report, the phrase "total revenues due from HSP" does not include any amount received as an enhanced rate under Section 686.235 by a qualifying Homemaker Service Provider.

 

D)        The report shall identify the Homemaker Service Provider's expenditures for Homemaker costs of Program support costs, and administrative costs as enumerated in Section 686.280.

 

2)         complete and submit a Homemaker Cost Certification report to document compliance with any rate-based wage increase for Homemaker employees who provide services under HSP.  The report must be submitted within 60 calendar days after issuance of written notification of the increase by HSP.

 

b)         The accuracy of the reports identified in subsections (a)(1) and (2) must be attested to by an authorized representative of the Homemaker Service Provider.

 

c)         HSP reserves the right to require the Homemaker Service Provider to engage an independent certified public accounting firm, approved by HSP, to verify the information and data submitted by the Homemaker Service Provider if HSP is in possession of evidence to suggest the information and data submitted is inaccurate, incomplete or fraudulent.  This audit will be performed at the Homemaker Service Provider's expense.

 

d)         HSP may take appropriate enforcement action in the following instances:

 

1)         a Homemaker Service Provider did not submit a report;

 

2)         a report is inaccurate, incomplete or fraudulent; or

 

3)         a Homemaker Service Provider did not increase the wages paid to its Homemaker employees in the amount required by a rate increase under HSP.

 

e)         Homemaker Services Providers approved for the enhanced rate for health insurance costs:

 

1)         shall not report the enhanced rate for health insurance costs paid by HSP as part of their revenue for purposes of the required financial reporting under this Section; and

 

2)         shall not report health insurance for Homemaker employees as an incurred cost for purposes of the required financial reporting under this Section, except for an amount in excess of the enhanced rate paid by HSP during a reporting period.

 

f)         Enforcement action towards a Homemaker Service Provider includes, but is not limited to the imposition of a corrective action plan, suspension of referrals from HSP, and/or termination of rate agreements with HSP.

                                                                                   

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.260  Unallowable Expenses for Homemaker Service Providers

 

The following Homemaker Service Provider expenses shall not be considered by HSP:

 

a)         expenses resulting from transactions with related parties or parent organizations that are greater than the going market cost of the transactions to the Homemaker Service Provider;

 

b)         non-straightline depreciation;

 

c)         bad debts;

 

d)         special benefits to owners, including owner and key-man life insurance;

 

e)         compensation to non-working owners and officers;

 

f)         discounts, rebates, allowances and charity grants offered by the Homemaker Service Provider;

 

g)         entertainment expenses;

 

h)         fundraising;

 

i)          legal fees for litigation with governmental agencies;

 

j)          awards, grants and gifts to individuals;

 

k)         fines and penalties;

 

l)          contingency funds; 

 

m)        losses on other grants and contracts; and

 

n)         health coverage costs as described under Section 686.250(e)(2).

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.270  Minimum Homemaker Costs for Homemaker Service Providers

 

a)         As provided under Section 686.250(a)(1)(C), Homemaker Service Providers are required to expend a minimum of 77% of the total revenues due from the HSP, to include the customer incurred expense, for Homemaker costs, as enumerated in Section 686.280, during a reporting year.

 

1)         This percentage is to be adhered to on a statewide basis.

 

2)         The remaining 23% of the total revenues may be spent by the Homemaker Service Providers at their discretion on administrative or Program support costs, also delineated in Section 686.280.

 

b)         Failure of the Homemaker Service Provider to meet the requirements in subsection (a) may result in the following:

 

1)         Within 60 days, the Homemaker Service Provider will be required to submit a corrective action plan that shall include Homemaker Service Provider payments to current Homemakers in an amount that will, in total, bring the Homemaker Service Provider into compliance with the requirements in subsection (a).  After HSP's review and approval of the corrective action plan, the Homemaker Service Provider shall implement and observe it.

 

2)         Failure by the Homemaker Service Provider to submit and/or observe a corrective action plan that is acceptable to HSP shall result in termination after 60 days notice.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.280  Cost Categories for Homemaker Services

 

Homemaker Service Providers will provide for cost reporting based on the following categories:

 

a)         Homemaker costs (costs paid to or on behalf of Homemakers) that may include:

 

1)         wages, time paid on behalf of the worker (i.e., vacation, sick leave, holiday and personal leave);

 

2)         health coverage for any Homemaker Service Provider that does not qualify for the enhanced rate for health insurance costs from the HSP or the amount of the cost incurred in excess of the enhanced rate paid to the Homemaker Service Provider during a reporting period, life insurance and disability insurance;

 

3)         retirement coverage;

 

4)         Federal Insurance Contributions Act (FICA) (26 USC 21);

 

5)         uniforms;

 

6)         worker's compensation;

 

7)         Federal Unemployment Tax Act (FUTA) (26 USC 23);

 

8)         travel time and travel reimbursement;

 

9)         unemployment insurance; and

 

10)         other costs approved, in advance, as Homemaker costs by HSP.

 

b)         Administrative Costs:

 

1)         personnel:

 

A)        administrator;

 

B)        assistant administrator;

 

C)        accountant/bookkeeper;

 

D)        clerical;

 

E)        other office staff;

 

F)         supervisor of Homemakers;

 

G)        other personnel expenses;

 

2)         consultant:

 

A)        auditors;

 

B)        management consultants;

 

C)        management fees from the parent organization;

 

D)        other related consultant costs;

 

E)        other consultant expenses;

 

3)         non-personnel:

 

A)        office supplies;

 

B)        office equipment (expense or depreciation based upon company policy);

 

C)        telephone/facsimile;

 

D)        conferences, conventions, meeting expenses;

 

E)        subscriptions and reference materials;

 

F)         postage and shipping;

 

G)        advertising;

 

H)        outside printing and art work;

 

I)         membership dues;

 

J)         moving and recruiting;

 

K)        other general operating expenses;

 

L)        profit;

 

4)         occupancy:

 

A)        depreciation;

 

B)        amortization of leasehold improvements;

 

C)        rent;

 

D)        property taxes;

 

E)        interest;

 

F)         other related occupancy costs.

 

c)         Program support costs that include all allowable costs not specifically made a part of Homemaker costs or administrative costs.  These may include:

 

1)         training expenses;

 

2)         malpractice insurance;

 

3)         Homemaker supervisor costs.

 

(Source:  Amended at 38 Ill. Reg. 11519, effective May 15, 2014)

 

Section 686.300  Electronic Home Response Services (EHRS) Provider Requirements

 

In order for a specific EHRS Provider to be approved for use by DHS in obtaining services for individuals served through HSP, the EHRS Provider must:

 

a)         have, and make available on request:

 

1)         articles of incorporation; or

 

2)         if unincorporated, a statement of purpose and function; and

 

3)         a list of the owners and/or the EHRS Provider's owners and/or directors/officers;

 

b)         have written policies, which are available to DHS and all customers, governing:

 

1)         the type and scope of services provided, which include clear and concise distinctions between services, if more than one service is offered;

 

2)         personnel policies, including:

 

A)        salary schedules;

 

B)        work hours;

 

C)        employee attendance and leave;

 

D)        written job descriptions, which include clear and concise duties and qualifications for each position;

 

E)        grievance procedures; and

 

F)         requirements for staff training and in-service;

 

c)         maintain adequate records for planning, budgeting, administration and program evaluation and planning.  These records shall be available at all times to DHS and the United States Department of Health and Human Services (HHS), or any entity designated by DHS or HHS, and shall be maintained for a period of at least 5 years, or until advised that all State and federal audits are completed. These records must include, but not be limited to:

 

1)         records of all referrals, including the disposition of each referral;

 

2)         customer records, which include:

 

A)        dates and times of all signaling and the name of the responder to each signaling;

 

B)        dates and times of all equipment tests;

 

C)        disposition of all emergency signaling;

 

3)         administrative records including:

 

A)        service statistics; and

 

B)        billing and payment records;

 

4)         personnel records, including:

 

A)        schedules and attendance records for staff and volunteers of the EHRS Provider;

 

B)        staff and volunteer training reports;

 

C)        annual performance review of all EHRS Provider staff;

 

d)         accept all referrals made for services by DHS;

 

e)         maintain and implement written procedures for the evaluation of its programs and services, the outcome of which shall be to make recommendations to its governing body for improving its services;

 

f)         have and agree to maintain adequate liability insurance coverage and provide DHS a copy of the Certificate of Insurance;

 

g)         agree to hold harmless DHS against any and all liability, loss, damage, cost, or expense arising from the wrongful or negligent action of the EHRS Provider or any of its agents, which DHS may sustain, incur, or be required to pay;

 

h)         comply with all local, State, and federal laws, regulations, and standards and DHS regulations and standards pertaining to HSP;

 

i)          maintain as confidential any information obtained regarding a customer of DHS and agree not to release this information without the written approval of the DHS Secretary or the customer;

 

j)          certify that the EHRS Provider and any of its agents have not been convicted of bribery or attempting to bribe an officer or employee of the State of Illinois, nor has the EHRS Provider or any of its agents made an admission of guilt of such conduct which is a matter of record;

 

k)         agree to provide all services listed in Section 686.310; and

 

l)          have in place an Affirmative Action Plan approved by its governing body.

 

Section 686.310  Services Which Must Be Provided by EHRS Providers

 

In order to be a DHS approved EHRS Provider, the EHRS Provider must:

 

a)         have trained employees or volunteers that install the EHRS units in the individual's home.  This service may not be sub-contracted;

 

b)         be able to install the EHRS unit in the individual's home within 48 hours upon referral of an individual by DHS to the EHRS provider;

 

c)         assist the individual in arranging several appropriate responders and provide training to those responders;

 

d)         provide 24-hour monitoring;

 

e)         provide instruction to the individual receiving EHRS services on the proper use of the EHRS unit at the time the unit is installed.  The instruction must include:

 

1)         provisions for monthly testing of the unit and its transmission by the individual receiving the EHRS services; and

 

2)         general care of the home unit; and

 

f)         in the event of unit malfunction, the EHRS Provider must repair or replace the unit within 24 hours of receiving the report.

 

Section 686.320  Minimum Specifications for EHRS Equipment

 

a)         All home units, at a minimum, must meet the requirements of this subsection (a).

 

1)         Home units must be able to be activated from:

 

A)        a wireless remote; and

 

B)        from the telephone, using a predetermined number;

 

2)         The wireless remote activator must have:

 

A)        a crystal or Surface Acoustic Wave (SAW) resonator controlled transmitted frequency for long-term reliability;

 

B)        digital encoding capability for at least 10 combinations;

 

C)        a minimum transmission range of 175 feet;

 

D)        an internal battery with a minimum life of 5 years;

 

E)        low battery signal; and

 

F)         certification under 47 CFR 15.

 

3)         The base unit or communicator unit must:

 

A)        be an integrated unit that connects to the individual's telephone via a modular jack which does not interfere with the normal use of the telephone or be an integrated unit that connects to a stable cellular network available to the individual’s primary residence;

 

B)        connect to a standard home electrical outlet, as its power supply, by use of an Underwriter's Laboratory approved plug;

 

C)        be able to seize the telephone line, even when a telephone in the dwelling is connected via a modular jack and is off the hook, and dial the EHRS Center to transmit an emergency signal;

 

D)        the base unit must have an easily identifiable "Ready" light to verify the unit is on-line with the EHRS Center;

 

E)        the base unit must have an easily identifiable "confirmation" light to indicate that, if activated, the EHRS Center has received the call;

 

F)         disconnect and redial, until the call is received at the EHRS Center, if an emergency call does not reach the EHRS Center;

 

G)        have a simple process by which signals may be aborted, in the event an erroneous signal is sent;

 

H)        have a battery, which is continuously charged while the unit is on, that will maintain a charge for at least 12 hours in the event of an electrical power failure;

 

I)         transmit a message to the EHRS Center signifying maintenance of the unit is required in the event of base unit battery failure; and

 

J)         be certified under 47 CFR 15 and 68.

 

b)         All EHRS Center equipment, at a minimum, must:

 

1)         be capable of automatically receiving all signals and displaying and printing all messages sent from home communicators connected to the EHRS system;

 

2)         have an audible and visual alarm for the notification of all incoming signals;

 

3)         display and print the incoming message, date, time, and Customer identification for each incoming signal;

 

4)         have a battery back-up which will automatically take over should there be a power outage, or a single circuit failure.  This battery back-up must supply sufficient power to operate the entire system for a minimum of 8 hours in the event of an outage;

 

5)         have totally separate and independent primary and back-up receivers.  If the primary receiver should fail, the system must automatically transfer to the back-up receiver to ensure no interruption in services;

 

6)         monitor all connected telephone lines and give an audible signal should one of the connected telephone lines be out of service for a period of longer than one minute;

 

7)         be able to identify each individual Customer account;

 

8)         perform self-diagnostic testing and monitoring to indicate the status of fault conditions, which could interfere with receiving signals and monitoring telephone connections such as power loss, telephone line outages, signals received with no messages, nonoperating transmitters, etc.; and

 

9)         be certified under 47 CFR 15 and 68.

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.330  Compliance Review of EHRS Providers

 

a)         DHS-ORS shall conduct a compliance review of any EHRS Provider seeking an approval from DHS-ORS and at least every two years shall conduct a review of all EHRS Providers that have current approval of DHS-ORS for the purpose of determining compliance or continued compliance with the criteria for approval set forth in this Subpart.

 

b)         DHS-ORS shall, when contacted by an EHRS Provider, or when notified by staff of the need to access the services of a specific EHRS Provider, conduct the review within a period of 60 calendar days.

 

c)         DHS-ORS shall notify all currently approved EHRS Providers, in writing, at least 10 working days prior to the date of the review to determine continued compliance.

 

(Source:  Amended at 24 Ill. Reg. 7501, effective May 6, 2000)

 

Section 686.340  Appeal of Compliance Review for EHRS Providers

 

a)         EHRS Providers determined not to be in compliance with DHS-ORS requirements as a result of the review may appeal the decision to the Chief of the Bureau of Home Services.  The Bureau Chief shall conduct a review of the facts related to the rating and shall, within 15 working days, provide a written decision to the EHRS Provider.

 

b)         If the EHRS Provider is not satisfied with the decision of the Bureau Chief, the EHRS provider may request review of the Bureau Chief's decision by DHS-ORS Associate Director.  The request must be in writing and received by DHS-ORS Associate Director within 10 working days after the date the decision was rendered by the Bureau Chief.  The decision of DHS-ORS Associate Director shall be final.

 

(Source:  Amended at 24 Ill. Reg. 7501, effective May 6, 2000)

 

Section 686.350  Rate of Payment for EHRS Services

 

a)         Installation

            DHS-ORS shall pay up to the rate negotiated as a one time installation fee for the installation of the EHRS unit, plus the charge of the local telephone company for telephone service hook up for those customers who do not have local telephone service at the time EHRS services are initiated.

 

b)         Monthly Service Fees

            DHS-ORS shall pay no more than the rate negotiated for EHRS services, including all fees and charges.  DHS-ORS will not pay the cost of the monthly local telephone services required to have EHRS.

 

(Source:  Amended at 24 Ill. Reg. 10212, effective July 1, 2000)

 

Section 686.400  Maintenance Home Health Provider Requirements

 

DHS shall use Maintenance Home Health Providers which are approved Medicaid providers or licensed by the Illinois Department of Public Health pursuant to the Home Health Agency Licensing Act [210 ILCS 55].

 

Section 686.410  Rate of Payment for Maintenance Home Health Services

 

DHS shall pay Maintenance Home Health Providers the rate established by the Illinois Department of Public Aid through the Medicaid Program for the same service.

 

Section 686.500  Home Delivered Meals Provider Requirements

 

Any entity providing Home Delivered Meals must be certified by the health department in the county in which the program or facility is located and must meet the approval of the customer and counselor.

 

Section 686.510  Rate of Payment for Home Delivered Meals

 

Providers of Home Delivered Meals may be paid up to the amount that would be paid a PA to prepare meals for the customer.

 

Section 686.600  Description

 

Environmental Modification – Services to physically modify the customer's home to accommodate the customer's loss of function in the completion of his/her Activities of Daily Living (ADLs).

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.605  Criteria for the Provision of Environmental Modifications

 

Environmental modifications may be provided to a customer if:

 

a)         the modification will enable the customer to independently perform his/her ADLs,

will result in a decreased need for assistance from another individual in the completion of his/her ADLs, will prevent an anticipated increase in service costs, or will improve the safety of the customer during the completion of his/her ADLs;

 

b)         there are no other resources, public or private, that will provide the modification; and

 

c)         the HSP total cost for purchase of all environmental modifications and assistive equipment purchases, rentals, and repairs (89 Ill. Adm. Code 686.705(d)) does not exceed $25,000 over 5 years.

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.608  Environmental Modification Provider Requirements

 

All Environmental Modification providers must:

 

a)         meet the approval of the customer and counselor;

 

b)         submit a completed 1413 A − Waiver Program Provider Agreement for Participation in the Illinois Medical Assistance Program form;

 

c)         submit a completed W-9 Request for Taxpayer Identification Number and Certificate;

 

d)         carry a minimum of $500,000 in liability insurance, and provide DHS-DRS with a copy of the Certificate of Insurance verifying current coverage;

 

e)         provide proof of appropriate current contractor licenses, as applicable;

 

f)         perform all modifications so that they meet the standards established by the Environmental Barriers Act, the Illinois Accessibility Code [71 ILCS 400] and local zoning ordinances and codes; and

 

g)                  obtain proper building permits as required by local municipalities.

 

(Source:  Renumbered from Section 686.600 to Section 686.608 and amended at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.610  Cost of Environmental Modification (Repealed)

 

(Source:  Repealed at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.615  Environmental Modification Bidding Procedures and Requirements

 

a)         For environmental modification purchases costing $1,500 or less, bids are not required.

 

b)         For environmental modification purchases costing more than $1,500, 3 bids must be obtained using an Invitation to Bid form (IL 488-0293);

 

1)         If an item is available from fewer than 3 sources, the maximum number of bids possible shall be obtained.

 

2)         The lowest bid received from an eligible provider will be accepted.

 

3)         All exceptions must have supervisory approval.

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.620  Permanency of Environmental Modification

 

For environmental modifications that cannot be detached from the dwelling, the home must be owned or mortgage held by the customer.  If the home is not owned by the customer, the customer, with the assistance of the counselor, must obtain written permission of the homeowner/property owner to make the modifications and to ensure that the homeowner/property owner understands the permanency of the modifications and DHS-DRS' inability to return the building to its previous condition.  A Homeowner/Lessor Agreement form (IL 488-0040) must be completed and signed by the homeowner/lessor, customer/lessee, and the counselor prior to the installation of any environmental modifications.

 

(Source:  Amended at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.630  Reason for Denial of Environmental Modification

 

Environmental modifications shall be denied when:

 

a)         the cost of the modifications does not comply with the provisions of Section 686.605(c);

 

b)         the customer has a poor history as a tenant, or is otherwise not expected to remain in the home to be modified for a period of at least 1 year;

 

c)         the past practices or reputation of the landlord is unfavorable; or

 

d)         the modifications are for "value added" or cosmetic purposes.

 

(Source:  Amended at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.640  Verification of Environmental Modification

 

Within 30 days of the date of completion of the environmental modifications, the counselor must make a home visit to inspect the modifications and to ensure customer satisfaction with the modifications.  A signed Receipt for Appliances, Merchandise and Supplies form (IL 488-1694) from the customer shall be required to verify receipt and satisfaction with the modifications.

 

(Source:  Amended at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.700  Description

 

Assistive Equipment − Items necessary to accommodate the customer's loss of function in the completion of his/her Activities of Daily Living (ADLs).  This does not include medical supplies, disposable personal hygiene items, or items necessary for medical treatment.

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.705  Criteria for the Purchase, Rental, or Repair of Assistive Equipment

 

Assistive equipment may be provided to a customer if:

 

a)         the equipment will enable the customer to independently perform his/her ADLs, will result in a decreased need for assistance from another individual in the completion of his/her ADLs, will prevent an anticipated increase in service costs, or will improve the safety of the customer during the completion of his/her ADLs;

 

b)         there is an official communication/documentation in the file of Medicaid denial by the Department of Healthcare and Family Services (HFS) for the requested assistive equipment;

 

c)         there are no other resources, public or private, that will provide the equipment; and

 

d)         the HSP total cost for purchases, rentals, and repairs of all assistive equipment and environmental modifications (89 Ill. Adm. Code 686.605(c)) does not exceed $25,000 over 5 years.

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.708  Purchase, Rental, or Repair of Assistive Equipment

 

A prescription from a physician or licensed therapist is required for all purchases or rentals of medically-oriented assistive equipment.

 

a)         Assistive equipment may be purchased when:

 

1)         the customer is expected to need the equipment for a period to exceed 1 year;

 

2)         the cost of renting the equipment exceeds the purchase price of the equipment; or

 

3)         the equipment is not available for rental.

 

b)         Assistive equipment may be rented when:

 

1)         the customer is not expected to need the equipment for an extended period of time (i.e., less than 1 year); and

 

2)         the rental cost for the equipment for the period the customer is expected to need the equipment is less than the purchase price for the equipment.

 

c)         Assistive equipment may be repaired when:

 

1)         the equipment is already in the possession of the customer;

 

2)         the repair cost is less than the rental or purchase price for the same equipment; and

 

3)         the equipment, when repaired, is expected to have an increased useful life of at least 1 year.

 

d)         If an item is available for purchase, rental, or repair through Medicaid, DHS-DRS will not provide additional funding if an approved provider refuses to accept the Medicaid approved rate.

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.710  Provision of Assistive Equipment (Repealed)

 

(Source:  Repealed at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.715  Assistive Equipment Provider Requirements

 

All assistive equipment providers must:

 

a)         meet the approval of the customer and counselor;

 

b)         submit a completed 1413A − Waiver Program Provider Agreement for Participation in the Illinois Medical Assistance Program form; and

 

c)         submit a completed W-9 Request for Taxpayer Identification Number and Certificate.

 

(Source:  Renumbered from Section 686.700 to Section 686.715 and amended at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.720  Verification of Receipt of Assistive Equipment (Repealed)

 

(Source:  Repealed at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.722  Assistive Equipment Bidding Procedures and Requirements

 

a)         For assistive equipment purchases costing $1,500 or less, bids are not required.

 

b)         For assistive equipment purchases costing more than $1,500, 3 bids must be obtained using an Invitation to Bid form (IL 488-0293);

 

1)         If an item is available from fewer than 3 sources, the maximum number of bids possible shall be obtained.

 

2)         The lowest bid received from an eligible provider will be accepted.

 

3)         All exceptions must have supervisory approval.

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.730  Verification of Receipt of, and Customer Satisfaction with, Assistive Equipment

 

Assistive equipment that is purchased, rented or repaired requires customer contact for verification of equipment/services provided.  A Receipt for Appliances, Merchandise and Supplies form (IL 488-1694) must be completed and signed by the customer within 60 days after the equipment delivery, installation, or repair.

 

(Source:  Added at 31 Ill. Reg. 14238, effective September 27, 2007)

 

Section 686.800  Respite Care Provider Requirements

 

Any individual or agency providing respite services to an individual through HSP must meet the standards set forth in the appropriate Subpart for that service as listed in this Part.

 

Section 686.900  Program Overview

 

The Department of Human Services Division of Rehabilitation Services (DHS-DRS) shall enter into agreements with agencies to provide case management services to persons diagnosed with AIDS, which includes persons with human immunodeficiency virus (HIV) infection, who are eligible for services provided by the AIDS Medicaid Waiver.  For geographical areas in Illinois in which case management agencies are not located, case management shall be provided by DHS-DRS Home Services counselors, utilizing licensed home health nurses, as needed, to comply with the services offered and the requirements contained in Section 686.910(b), (c), (d), and (e).

 

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

 

Section 686.910  Case Management Provider Responsibilities

 

a)         Case Management

 

1)         The case management agency shall receive Customer referrals from hospitals, the Illinois Department of Public Health's AIDS Hotline, HSP Ashburn Unit, other State and local agencies, and other referral services (e.g., doctors and individuals).  The provider shall assign a case manager to each Customer.

 

2)         There shall be two levels of case managers:  provisional case managers and case managers.

 

A)        Case managers are those who have achieved a competency score of 98% or greater for the on-site case reviews done by the HSP Ashburn Unit under Section 686.930(d).  The case manager shall have full responsibility for the determination of HSP eligibility including assessment and implementation of services to be provided.  The case manager shall develop services with Customer participation that are provided in a manner that reflects the Customer's choices, when applicable, and address the Customer's strengths, needs and desired goals.  Assessments, service plans and reassessments completed by case managers may be implemented without consultation with the HSP Ashburn Unit.

 

B)        The case manager shall act as a liaison with the hospital discharge planner, physician, home health agencies, and other medical provider agencies.

 

C)        Provisional case managers are those who have not achieved a competency score of 98% or greater for the on-site case reviews done by the HSP Ashburn Unit, per Section 686.930(d).  Provisional case managers shall submit all developed plans to the HSP Ashburn Unit for approval.  Approval of the plan will be based on a review to determine that:  the Determination of Need Assessment on which the plan is developed is complete and accurate; the plan meets the needs identified by the assessment; the plan does not place the Customer's health and safety at risk; and the plan is cost effective compared to comparable institutional care.

 

b)         The case manager shall provide the following services:

 

1)         initial assessment of eligibility and information gathering (89 Ill. Adm. Code 682);

 

2)         development of a person-centered service plan and implementation (89 Ill. Adm. Code 684);

 

3)         reassessment of level of care at least every 12 months for those cases in formal eligibility, three months for those cases that have been presumptively determined eligible for interim services (89 Ill. Adm. Code 684.80), or at such time when the Customer's financial or physical condition or need for services changes;

 

4)         networking/coordination/brokering services (i.e., referring and assisting the Customer in obtaining other agencies' services);

 

5)         assisting the Customer when Individual Provider and Agency Provider problems develop. Documentation of these problems and the case management team's responses will be kept in the Customer's case file;

 

6)         counseling and advocacy;

 

7)         acting as inter-agency liaison (e.g., with other DHS programs, Managed Care Organizations (MCOs), vendors, hospitals);

 

8)         making required Customer contact at least once a month, with a face-to-face contact bi-monthly, to ensure the Customer's needs are being met;

 

9)         maintaining and updating Customer records; and

 

10)         monitoring the cost effectiveness of the service plan (89 Ill. Adm. Code 679.50).

 

c)         Eligibility for AIDS Waiver

 

1)         Within 10 working days (exceptions being 2 working days for prescreening referrals from cooperating hospitals for interim/emergency services, 5 working days for all other prescreening for interim/emergency services) after receipt of a referral, the case manager shall complete an individual's eligibility determination for the AIDS Waiver program.

 

2)         The case manager shall determine Customer eligibility for the AIDS Waiver by completing an assessment from a home visit or while the applicant is hospitalized (89 Ill. Adm. Code 682).  To determine Customer eligibility, the case manager will utilize the HSP Determination of Need Assessment (89 Ill. Adm. Code 682).

 

3)         The case manager shall assess the Customer's limitations in activities of daily living (ADLs) (e.g., cooking, bathing, shopping) and what resources are available to assist the Customer in performing the ADLs (89 Ill. Adm. Code 682).

 

4)         Notice of eligibility must be mailed to the HSP Ashburn Unit within ten working days after the date on which a completed application is received by the case management agency.

 

d)         The case manager will provide a case action notice to each Customer informing the Customer of the eligibility determination, of all rights and responsibilities under the case management program, including the Customer's right to request an appeal, the appeals procedures promulgated by the Department, the right to receive assistance in filing the request for appeal and information about the services of the Home Care Ombudsman Program (HCOP) and how to reach HCOP.

 

e)         Service Plan

 

1)         If the DON assessment demonstrates a nursing facility level of care need such as the need for intermediate care facility (ICF), skilled nursing facility (SNF), or hospital care because of the disability of AIDS/HIV, the case manager shall develop a person-centered service plan that will allow the Customer to live at home.

 

2)         The service plan will be retained during the time the case is opened and for five years after closure, unless an audit exception has occurred.  In the case of an audit exception, the service plan will be retained until the audit exception has been resolved.  Copies of the service plan will be maintained in the case management team's locations and the HSP Ashburn Unit.  Closed cases will be retained in the HSP Ashburn Unit for two years then archived pursuant to the DHS records retention policy.

 

3)         If implementation of services is delayed beyond required time limits in subsection (c), the case manager must inform the HSP Ashburn Unit and assist the Customer to obtain an alternative provider.

 

f)         Records of contact with the Customer will be entered and maintained in the Customer's confidential case records.  All contacts, verbal or written, with or on behalf of a Customer shall be documented in a confidential case record.  The case manager is responsible for obtaining consents for the release of information as necessary and when required by law or regulation (Confidentiality of Records (42 U.S.C. 290dd-2); Health Insurance Portability and Accountability Act (42 U.S.C. 1320(d) et seq.); AIDS Confidentiality Act [410 ILCS 305]; 89 Ill. Adm. Code 505 (Confidentiality of Information).

 

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

 

Section 686.920  Provider Staffing Requirements, Qualifications, and Training

 

a)         Each case management agency shall designate an individual who will be responsible for the administration of the case management program.  The designated individual shall have or be actively enrolled in a program to obtain:

 

1)         a bachelor's degree in health, human services, or a related field;

 

2)         licensure as a registered nurse pursuant to the Nurse Practice Act [225 ILCS 65]; or

 

3)         at least one year of experience as a home health care administrator, medical clinic administrator, or other health services administrator.

 

b)         The qualifications for case managers shall be as follows:

 

1)         A registered nurse, with a current license and a bachelor's degree in nursing, social work, social sciences, or counseling or one year of case management experience; or

 

2)         A social worker with a bachelor's degree in either social work, social sciences, or counseling.  A Bachelor of Social Work or a Master of Social Work degree from a school accredited by any organization nationally recognized for the accreditation of schools of social work is preferred; or

 

3)         An individual with a Bachelor's Degree in a human services field (including, but not limited to, sociology, special education, or rehabilitation counseling) and with a minimum of one year of case management experience.

 

c)         In addition, it is mandatory that the case manager has:

 

1)         a broad knowledge of community resources and networking, case management, and home care; and

 

2)         experience in working with racial and ethnic minorities, as well as one or more of the following:

 

A)        domestic abuse;

 

B)        the lesbian, gay, bisexual, transgender, queer (LGBTQ+) community;

 

C)        persons living with HIV/AIDS; or

 

D)        persons with substance use disorders.

 

d)         Each full-time case manager shall have no more than 30 fee-for-service customers and 70 Managed Care Organization (MCO) customers, or an appropriately weighted combination of fee-for-service customers and MCO customers that shall not exceed 100 total customers.  For half-time case managers, the full-time requirements may be met proportionately (e.g., 15 fee-for-service customers and 35 MCO customers and shall not exceed 50 total customers).

 

e)         Annually, each case manager shall undergo a minimum of 12 hours of in-service training that shall be:

 

1)         furnished by the case management agency; and

 

2)         relevant to the provision of services to persons with HIV/AIDS (e.g., infectious disease control procedures, sensitivity training, and updates on information relating to treatment procedures).

 

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

 

Section 686.930  Monitoring and Liability of Provider

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

1)         monitor the quality of the reviews conducted annually;

 

2)         provide case reviews of selected cases Statewide; and

 

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

 

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

 

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

 

A)        six fee-for-service initial assessments;

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

e)         Return to Provisional Status

 

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

 

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

 

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

 

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

 

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

 

f)         Liability

 

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

 

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

 

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

 

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

 

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

 

Section 686.940  Provider Compliance Requirements

 

In order to participate in the DHS-DRS program to provide services to persons with HIV/AIDS, the provider agrees to meet the following minimum requirements that shall be reviewed by DHS annually for compliance.

 

a)         Organization and Administration:  The provider shall make available, upon request, its articles of incorporation, or if an unincorporated association (e.g., partnerships and limited partnerships) shall provide a statement of purpose and functions, and the names and addresses of its owners, partners, or general partners.

 

b)         Audits:  DHS reserves the right to audit all records and accounts pertinent to the provision of services and billing at any time within five years after the provider stopped providing services under the HIV/AIDS waiver.

 

c)         Policies and Procedures:  The provider shall have written policies approved by its governing authority (e.g., Board of Directors) and available for review by customers and purchasers of the service.  Such policies shall at a minimum cover:

 

1)         Service Provided:  Policy shall designate the type and scope of service provided.  When more than one type of service is offered, there shall be a clear distinction between each type provided.

 

2)         Personnel Policies:  Policies shall cover salary schedules, hours of work, sick leave, provision for handling employee grievances, and requirements for attendance at work conferences and training sessions.  There shall be written job descriptions identifying required qualifications and duties for each title. Policies shall also include the Centers for Disease Control and Prevention (CDC) recommendations for health care workers for provision of services to persons with HIV/AIDS and any requirements within the Illinois Compiled Statutes regarding HIV/AIDS, including the AIDS Confidentiality Act [410 ILCS 305].

 

d)         State and Federal Statutes

 

1)         All providers shall be subject to compliance with Illinois Compiled Statutes governing conflict of interest [30 ILCS 500/50-13].

 

2)         All providers shall agree to comply with the Civil Rights Restoration Act of 1987 P.L. 100-259), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), the Illinois Human Rights Act [775 ILCS 5], the Constitution of the United States, the 1970 Constitution of the State of Illinois and any laws, regulations or orders, State or federal, that prohibit discrimination on the basis of, including but not limited to, race, color, sex (including sexual harassment), religion, national origin, ancestry, age (40 and over), order of protection status; marital status, sexual orientation (including gender-related identity), physical or mental disability, or unfavorable discharge from military service, pregnancy, citizenship status, employment discrimination based on arrest record, and discrimination in real estate transactions based on familial status or arrest record.

 

e)         Non-compliance:  If the provider is not in compliance with the requirements of this Subpart, corrective actions up to and including termination of the provider as an approved provider shall be taken.

 

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

 

Section 686.1000  Program Overview

 

The Department of Human Services (DHS) shall enter into agreements with community-based organizations to provide case management to persons diagnosed with brain injuries who are eligible for services provided by the Medicaid Waiver for Persons with a Brain Injury.  For geographic areas in Illinois in which case management agencies are not located, case management shall be provided by DHS Home Services counselors.

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1010  Case Management Provider Responsibilities

 

a)         Case Managers

 

1)         The Case Manager shall receive referrals from hospitals, other health providers, and other State and local agencies.

 

2)         The Case Manager shall have responsibility for the implementation of services to be provided.  The services, developed by the HSP Counselor with Customer participation, shall be provided in a manner that reflects the Customer's choice, when applicable, and shall address his/her strengths, needs and desired goals.

 

b)         The Case Manager shall provide the following services:

 

1)         networking/coordination/brokering services (i.e., referring and assisting the Customer in obtaining other agencies' services);

 

2)         counseling and advocacy;

 

3)         contacting the Customer a minimum of one time per month;

 

4)         maintaining and updating Customer records; and

 

5)         monitoring the cost effectiveness of the service plan (89 Ill. Adm. Code 679.50).

 

c)         Service Plan

 

1)         The person-centered service plan will be retained during the time the case is opened and for five years after closure, unless an audit exception has occurred. In the case of an audit exception, the service plan will be retained until the audit exception has been resolved.  Copies of the service plan will be maintained in the Case Manager's location and the HSP office.  Closed cases will be retained in the HSP Central Office.

 

2)         If implementation of services is delayed beyond required time limits in subsection (c), the Case Manager must inform the HSP administration and assist the Customer in obtaining another provider.

 

d)         Records of contact with Customer will be entered and maintained by the Case Manager in the Customer's confidential case record.  All contacts, oral or written, with or on behalf of a Customer shall be documented in a confidential case record.  The Case Manager is responsible for obtaining consents for the release of information as necessary and when required by regulation (89 Ill. Adm. Code 505) and the Health Insurance Portability and Accountability Act (42 USC 1320(d) et seq.).

 

(Source:  Amended at 43 Ill. Reg. 2133, effective January 24, 2019)

 

Section 686.1020  Case Manager Staffing Requirements, Qualifications and Training

 

a)         Every agency providing case management services shall designate an individual who has overall responsibility for the administration of case management services.

 

b)         A Case Manager shall meet one of the following qualifications:

 

1)         a Registered Nurse, licensed pursuant to the Illinois Nursing Act of 1987 [225 ILCS 65];

 

2)         a Certified or Licensed Social Worker, certified or licensed pursuant to the Illinois Clinical Social Work and Social Work Practice Act [225 ILCS 20];

 

3)         a Social Worker with a minimum of a Bachelor's degree in social work, social sciences or counseling. A Bachelor's of Social Work or a Master's of Social Work from a school accredited by any organization nationally recognized for the accreditation of schools of social work is preferred;

 

4)         a Vocational Specialist holding a certification in Rehabilitation Counseling or a minimum of 3 years working with people with disabilities;

 

5)         Licensed Clinical Professional Counselor (LCPC), licensed pursuant to the Professional Counselor and Clinical Professional Counselor Licensing Act of 1998 [225 ILCS 107];

 

6)         Licensed Professional Counselor (LPC), licensed pursuant to the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107];

 

7)         Certified Case Manager (CCM) with certification in case management from an appropriate certifying organization.

 

c)         Each Case Manager shall have no more than 30 customers. Incremental increases may be considered when the Case Manager demonstrates the capacity to competently provide case management services for Brain Injury Waiver cases. Subsequent to this determination, cases may be increased in increments of up to 15 cases.  This capacity will be determined when the Case Manager maintains a competence rate of at least 98% for a period of at least three months at a full caseload size of 30 customers, using the process outlined in 89 ILL. ADM. CODE CH. I SECTION 686.1025(b).

 

d)         Annually, each Case Manager shall receive at least 12 hours of in-service training.  The training must be relevant to the provision of services to persons with brain injuries.

 

(Source:  Amended at 25 Ill. Reg. 6282, effective May 15, 2001)

 

Section 686.1025  Provisional Case Manager

 

a)         There shall be two levels of case management staff: Provisional Case Manager and  Case Manager.  A Provisional Case Manager is one who has not achieved a competency score of 98% or greater on the  case reviews done by the Home Services Program (HSP) administrative staff per Section 686.1030(d). Assessments, service plans and reassessments completed by a Case Manager may be implemented without consultation with the HSP administrative staff.  Provisional Case Managers shall submit all developed plans to HSP for approval. Approval of the plan will be based on a review to determine that: the DON assessment on which the plan is developed is complete and accurate; the plan meets the needs identified by the assessment; and the plan is cost effective compared with comparable institutional care.

 

b)         All Provisional Case Managers will work toward meeting Case Manager standards within six months after receiving the HSP Case Manager Training.  Case Manager status will be granted when six case file reviews attain a competency score of 98-100% using the review process described in this subsection (b).

 

1)         The HSP administrative staff will review three case files within three months from the end date of the Case Manager Training.  The Case Manager will be present and have the Case Manager Training Manual.

 

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

 

3)         Using the Case Manager Training Manual, HSP staff will discuss each deficiency with the Case Manager.

 

4)         A corrective action plan will be developed by HSP staff for the Case Manager to resolve all deficiencies in the case file.

 

5)         The Case Manager will implement the corrective action plan and complete all items prior to the next review of the case files.

 

6)         HSP staff will review all files noted in the corrective action plan for compliance with case management practices.

 

7)         The above process will continue until the cases reviewed for the Case Manager meet a 98-100% compliance score on six case file reviews.

 

c)         Return to Provisional Status

 

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

 

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

 

B)        Within the last year, HSP staff have made five requests for materials that were not submitted on time.

 

2)         Prior to the initiation of action to return a Case Manager to provisional status, the Case Manager will be sent a letter outlining deficiencies and shortcomings. The Case Manager will have 10 days to respond.  The Case Manager will be returned to provisional status unless the Case Manager can prove the Department is incorrect.

 

(Source:  Amended at 38 Ill. Reg. 16978, effective July 25, 2014)

 

Section 686.1030  Monitoring and Liability

 

a)         The HSP staff shall monitor the Case Manager to assure compliance with this Subpart by:

 

1)         reviewing Provisional Case Managers as set forth in subsection (d);

 

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

 

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

 

b)         The HSP supervisory staff shall monitor the service plans of customers served by a Case Manager to ensure that:

 

1)         The Case Manager is monitoring the customer's case by carrying out at least one contact monthly;

 

2)         The Case Manager is reassessing the service plan at least every six months;

 

3)         Each of the reassessments undertaken by the Case Manager is complete and accurate;

 

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

 

5)         The service plan remains cost effective (i.e., the cost of the service plan is equal to or less than the State's costs for nursing facility care).

 

c)         Liability

 

1)         DHS is not liable for actions of the Case Manager and the Case Manager must agree to hold DHS harmless against any and all liability, loss, damage, costs or expenses arising from wrongful or negligent acts of the Case Manager.

 

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

 

3)         The Case Management agency shall remain liable for the performance of any person, organization, unincorporated association or corporation with which it contracts.

 

(Source:  Amended at 38 Ill. Reg. 16978, effective July 25, 2014)

 

Section 686.1040  Provider Compliance Requirements

 

In order to participate in the DHS program for providing services to persons with brain injuries, the provider of case management services agrees to meet the following minimum requirements, which shall be reviewed by DHS annually for compliance.

 

a)         Organization and Administration: The agency providing case management services shall make available, upon request, its articles of incorporation, or if  an unincorporated association, it shall provide a statement of purpose and functions and the names and addresses of its owners, partners or general partners.

 

b)         Audits: DHS reserves the right to audit all records and accounts pertinent to the Agreement at anytime within five years after the final completion date of the Agreement.

 

c)         Policies and Procedures: The provider of case management services shall have written policies approved by its governing authority and available for review by customers and purchasers of the service.  Such policies shall at a minimum cover:

 

1)         Services Provided: the type and scope of services provided. When more than one type of service is offered, there shall be a clear distinction between each type of service.

 

2)         Personnel Policies: salary schedules, hours of work, sick leave, provision for handling employee grievances and requirements for attendance at work conferences and training sessions. There shall be written job descriptions identifying required qualifications and duties for each title.

 

d)         State and Federal Statutes

 

1)         All providers of case management services are subject to compliance with Illinois statutes governing conflict of interest (Sections 50-13 and 50-20 of the Illinois Procurement Code [30 ILCS 500/50-13 and 50-20]).

 

2)         All providers shall agree to comply with Title VI of the Civil Rights Act of 1964 (42 USC 2000d), Section 504 of the Rehabilitation Act of 1973, as amended (29 USC 794), the Illinois Human Rights Act [775 ILCS 5/1-101], the Constitution of the United States, the 1970 Constitution of the State of Illinois and any laws, regulations or orders, State or Federal, that prohibit discrimination on the basis of race, color, sex, religion, national origin, ancestry, age, marital status, inability to speak or comprehend the English language, physical or mental disabilities, or unfavorable discharge from military service.

 

e)         Non-compliance: If the provider of case management services is not in compliance with the requirements of this Subpart, corrective actions up to and including termination of the contract shall be taken.

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1100  Behavioral Services Provider Requirements

 

HSP shall use Behavioral Service Providers that are licensed under the Illinois Clinical Psychologist Licensing Act [225 ILCS 15], the Illinois Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107], or the Illinois Clinical Social Work and Social Work Practice Act [225 ILCS 20].

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1110  Rate of Payment for Behavioral Services

 

HSP shall pay Behavioral Service Providers at rates established per 89 Ill. Adm. Code 545, "Ratemaking".

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1200  Day Habilitation Services Provider Requirements

 

a)         All Habilitation Service Agency providers (hereafter referred to as providers) who provide services to Customers of the DHS-DRS HSP shall have habilitation services accredited by an appropriate accrediting organization or shall be certified by DHS according to the criteria set forth in this Subpart.

 

1)         DHS shall apply its criteria to certify a provider that provides HSP approved services as identified on a Customer's service plan, when the provider has not yet received national accreditation.

 

2)         DHS certification shall be granted for two years, after which time the provider must be accredited for Brain Injury Habilitation Services in accordance with subsection (b).

 

b)         A provider may be accredited by any of the following accreditation organizations:

 

1)         Commission on Accreditation of Rehabilitation Facilities.

 

2)         The Joint Commission.

 

3)         Developmental Training Program under the DHS Division of Developmental Disabilities (59 Ill. Adm. Code 119 (Minimum Standards for Certification of Developmental Training Programs)).

 

c)         A facility that houses a habilitation service program (including satellite sites) shall meet the criteria for the Centers for Medicare and Medicaid Services definition of a home and community-based setting pursuant to 42 CFR 441.301(c)(4) and 42 CFR 441.301(c)(5).

 

d)         If a provider meets the criteria listed in this Section, application to HSP should be made to:

 

Illinois Department of Human Services

Division of Rehabilitation Services

Home Services Program, Program Compliance

100 S. Grand Ave. East

Springfield IL 62794

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1210  Rate of Payment for Day Habilitation Services

 

HSP shall pay Day Habilitation Providers the rate established per 59 Ill. Adm. Code 120, "Medicaid Home and Community-Based Services Waiver Program for Individuals with Developmental Disabilities."

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1220  Certification of Day Habilitation Agency Providers

 

a)         With the submission of an application to HSP, a provider described in Section 686.1200(a)(1) shall be evaluated by representatives of DHS.

 

b)         The provider service program shall be in operation for a period of one year prior to application.

 

c)         DHS shall apply the standards set forth in Sections 686.1230 and 686.1240 to the provider.

 

d)         DHS shall contact the provider to arrange the evaluation date and time that is convenient for all parties, provide written confirmation of that date and time, and explain the on-site evaluation procedure.

 

e)         During the evaluation process, the DHS representative may review case records, program descriptions and documents, and may interview staff and Customers to ensure that standards are being met.

 

f)         DHS shall hold an exit interview with the provider. The interview shall identify areas in which the provider does and does not comply with Sections 686.1230 and 686.1240.

 

g)         A written report of the results of the certification evaluation shall be sent to the provider within 30 calendar days. The results may indicate that remediation is needed to address noncompliance with Sections 686.1230 and 686.1240.

 

1)         If remediation is indicated, the provider shall submit a corrective action plan (CAP) to DHS within 30 calendar days after receipt of the report. The CAP shall identify how the provider will comply with areas of Sections 686.1230 and 686.1240 in which the provider was found noncompliant. The CAP shall include time frames for the remediation.

 

A)        Upon acceptance of the CAP, DHS shall notify the provider of the decision to certify the program and services offered by the provider for two years if compliance with the standards are met.

 

B)        If the provider fails to submit a CAP and/or is unable to institute a plan satisfactorily in compliance with the standards of Sections 686.1230 and 686.1240, DHS shall notify the provider in writing of the decision not to certify the provider.

 

2)         Further application for habilitation certification shall not be accepted by HSP until at least one year after the date of the previous habilitation certification denial.

 

3)         The provider has the right to appeal the certification evaluation by submitting an appeal request in writing to the Bureau Chief of the Home Services Program. Appeal requests must be filed within 30 days after the certification evaluation results are received by the provider. The Bureau Chief shall conduct a review of the facts and shall, within 15 working days, provide a written decision to the provider.

 

4)         If the provider is not satisfied with the decision of the Bureau Chief, the provider may request review of the Bureau Chief's decision by the Director of DHS-DRS. The request must be in writing and received by the DHS-DRS Director within 10 working days after the date the decision was rendered by the Bureau Chief. The decision of the DHS-DRS Director shall be final.

 

(Source:  Added at 43 Ill. Reg. 2133, effective January 24, 2019)

 

Section 686.1230  Provider Standards

 

a)         The provider must be a legally constituted agency or organization, or an entity operated by a state or political subdivision of a state under an appropriate federal, state or local statute.

 

b)         The provider's governing body shall:

 

1)         establish in writing the organization's mission, policies, and necessary financial support;

 

2)         employ a full-time Director and delegate to that person the authority and responsibility for the management of the provider agency in accordance with established policies;

 

3)         meet with its executive committee and Director at least quarterly;

 

4)         review and approve the provider agency budget and the independent, certified audit annually, and the income and expense reports at least quarterly;

 

5)         identify a designated staff member or group that shall be responsible for making admission decisions;

 

6)         include written policy that safeguards against possible conflicts of interest between its members and the operation of the provider agency as part of its constitution or bylaws; and

 

7)         provide documentation of current liability insurance to protect assets and to ensure compensation for staff, individuals with disabilities, volunteers, and the public, in the event compensation would be required for occurrences for which the provider agency is liable.

 

c)         The provider shall employ staff numbers and types to meet the needs of the individuals served in a manner consistent with the purposes and objectives of the organization. Provider employed staff shall receive training in accordance with the provider's policies and procedures.

 

d)         The provider shall provide all services in a safe environment and establish an executive safety committee with clearly defined responsibilities, including the responsibility to:

 

1)         develop a written emergency plan that details staff action and responsibilities in the event of fire, power failure, and natural disasters;

 

2)         maintain an accident prevention program;

 

3)         maintain an accident reporting system that includes a review of the incident reports made and the recommendations for corrective action;

 

4)         ensure staff currently certified in first aid and cardiopulmonary resuscitation are available at all times in all locations where Customers are present in the provider's facilities;

 

5)         ensure test drills are completed at least quarterly and the results of the drills are sent to the executive safety committee;

 

6)         ensure that independent, comprehensive safety education is conducted at least every two years by qualified safety specialists; and

 

7)         ensure that, at least annually, inspections are completed by local or state fire control agencies.

 

A)        A satisfactory rating for each site operated by the provider is required.

 

B)        If an unsatisfactory rating is given, the provider must take immediate corrective action to address the rating.

 

e)         The provider shall have public information materials that identify:

 

1)         the programs and services available;

 

2)         the population to be served;

 

3)         how programs and services can be obtained; and

 

4)         its nondiscrimination policy.

 

f)         The provider shall comply with applicable federal and State regulations.

 

1)         The provider shall offer programs and services that are accessible to persons with disabilities in accordance with section 504 of the federal Rehabilitation Act of 1973, as amended (29 USC 794), the Americans With Disabilities Act (42 USC 12001), and the Illinois Accessibility Code (71 Ill. Adm. Code 400).

 

2)         The provider shall engage in an Affirmative Action Program that provides documentation of its nondiscrimination policy and staff characteristics as required by section 504 of the federal Rehabilitation Act of 1973.

 

3)         The provider shall show evidence of compliance with both federal and State Department of Labor rules and regulations governing wage reimbursement and the Workers' Compensation Act [820 ILCS 305].

 

4)         The provider shall comply with Department of Human Services rules regarding Fiscal/Administrative Recordkeeping and Requirements (89 Ill. Adm. Code 509).

 

(Source:  Added at 43 Ill. Reg. 2133, effective January 24, 2019)

 

Section 686.1240  Program and Service Requirements

 

a)         When HSP refers a Customer to a provider for services, the provider shall notify HSP, in writing, of the disposition of the referral within 15 calendar days after receipt of the referral.  This notification shall include the expected date after admission and any pertinent information regarding the Customer's entry into the program.

 

b)         All Customers referred for services shall receive a personal interview that includes an explanation of why the individual was referred, service opportunities available to the individual, and the right to appeal services under 89 Ill. Adm. Code 510.

 

c)         Customers on waiting lists shall be contacted monthly, apprised of their status, and given sufficient information to decide whether to remain on the waiting list or seek services elsewhere.

 

d)         There shall be clearly written entrance and exit criteria for each service offered by the agency.

 

e)         Customer case records shall be kept secure, confidential, and available only to authorized personnel.  Customers referred for services shall be notified in writing of their acceptance or non-acceptance into the program.

 

f)         Assessment methods, techniques, and work sites shall be relevant to the Customer's needs.

 

g)         Each Customer served by the provider shall receive a Brain Injury Habilitation Assessment and participate in the provider's development of his/her Habilitation Plan.

 

1)         Each Customer shall be provided goal and service options that assist him/her in choosing a habilitation goal.

 

2)         Each Customer shall be enabled to choose his/her habilitation goals and services and express his/her degree of satisfaction with the results achieved.

 

3)         A written report or narrative of the Brain Injury Habilitation Assessment shall include:

 

A)        background information regarding the person;

 

B)        interpersonal/personal observations made by agency staff;

 

C)        a life skills appraisal of the person;

 

D)        a recommended habilitation goal;

 

E)        recommended objectives and services to attain the stated habilitation goal; and

 

F)         a summary of the conference or staffing conducted, including Customer comments.

 

4)         The Habilitation Plan shall identify:

 

A)        a habilitation goal;

 

B)        understandable, measurable objectives to achieve the habilitation goal;

 

C)        services needed to meet the objectives;

 

D)        time frames to achieve the goal and objectives;

 

E)        measures to assess the outcome of objectives, including review dates; and

 

F)         the persons responsible for implementing the plan.

 

5)         All persons involved in the plan development shall receive a copy of the service plan within five State working days after the plan's development.

 

h)         Services purchased by HSP on a full time weekly basis shall offer at least 25 hours of program time per week. The program hours must relate to the Customer's needs and activities as outlined in the Customer's Habilitation Plan.

 

i)          Staffings shall be held on a scheduled basis to allow for review and discussion of the Customer's progress towards achieving his/her habilitation goal and objectives, as follows:

 

1)         at the completion of the Brain Injury Assessment; and

 

2)         at least once every eight weeks for habilitation training services, up to the date of completion of program objectives.

 

j)          All persons identified in the Habilitation Plan shall receive a copy of each staffing report within 10 State working days after the staffing.

 

k)         Customer habilitation trainings shall include individually designed services that meet the Customer's specific needs and desires and enable the Customer to achieve his/her habilitation goal as a direct result of service provided.

 

(Source:  Added at 43 Ill. Reg. 2133, effective January 24, 2019)

 

Section 686.1250  Program Outcomes and Reporting

 

a)         The provider shall complete and submit to HSP an annual written evaluation of all its programs and services that shows evidence of:

 

1)         maintenance of a safe and accessible program;

 

2)         a review of the quality and appropriateness of the services offered;

 

3)         a review of the effectiveness of the services as measured by outcomes achieved; and

 

4)         Customer satisfaction with the services received and habilitation outcomes achieved.

 

b)         The provider shall complete and submit to HSP a monthly Customer Habilitation Training Report that summarizes the following:

 

1)         accomplishment of the objectives;

 

2)         remaining services needed by the Customer to achieve the habilitation goal; and

 

3)         a summary of the staffings conducted, including the Customer's comments.

 

c)         The provider shall submit a monthly Customer Outcome Report on each Customer, based upon successful completion of objectives outlined in the Customer Habilitation Plan.

 

1)         A habilitation outcome is considered successful when:

 

A)        the Customer has a diagnosis of brain injury that, for the individual, causes, or may cause, a substantial impediment to habilitation; has an active HSP service plan; and participates in services offered by the provider as evidenced by habilitation provider billings submitted to HSP;

 

B)        it is consistent with the Customer's abilities, interests and needs;

 

C)        the Customer performs life skill activities effectively and efficiently;

 

D)        the habilitation services are not contraindicated based on the Customer's disability; and

 

E)        the Customer will not jeopardize the health and safety of himself/herself or others while at the program site.

 

2)         Successful habilitation outcomes are determined by the HSP Counselor (see 89 Ill. Adm. Code 676.30).

 

(Source:  Added at 43 Ill. Reg. 2133, effective January 24, 2019)

 

Section 686.1260  Provider Billing and Record Retention

 

a)         The provider shall submit a monthly IL488-1200 Group Billing statement to the HSP field office managing the HSP Customer case within 15 days after the end of the service period.

 

b)         Each statement must be accompanied by a monthly Customer Outcome Report as required under Section 686.1250(c).

 

c)         Expenditures may not exceed the service hours or fees indicated on the active Vendor Authorization for Services form, unless express written approval has been given by the HSP.

 

d)         Supplemental billing for additional hours in a service period that was previously paid, or that is in the process of being paid, is not allowed.  If HSP or the provider determines that the previous billing was in error, all payments received for that billing must be refunded to HSP before submitting a corrected statement for the period.

 

e)         Providers shall keep the following records for a minimum of 5 years:

 

1)         copies of all forms and billings required by, and submitted to, HSP;

 

2)         records of Customer service hours kept by time clock, time cards, or time sheets signed by the Customer;

 

3)         confidential case records (see Section 686.1240(e)); and

 

4)         documentation of credentials and/or licensing for all rendering service staff.

 

(Source:  Added at 43 Ill. Reg. 2133, effective January 24, 2019)

 

Section 686.1270  Compliance Review of Day Habilitation Providers

 

a)         HSP will complete a review of each Day Habilitation Provider, at least every two years, to ensure compliance with the requirements of this Subpart.

 

b)         The review shall consist of an on-site review conducted by HSP staff.  Written notification shall be provided to the provider prior to the review.

 

c)         Within 15 days after the completion, a copy of the completed review shall be sent to the provider.

 

d)         If the provider is found deficient in the review, the written notification shall include:

 

1)         the deficiencies found as a result of the review;

 

2)         the action necessary for the provider to come into compliance;

 

3)         the time frames within which the provider must come into compliance; and

 

4)         the information necessary for the provider to request new review after the compliance issues are addressed.

 

e)         Day Habilitation Providers who are not satisfied with an HSP compliance review may submit an appeal request in writing to the HSP Bureau Chief.  Appeal requests must be filed within 30 days after the compliance review.  The Bureau Chief shall conduct a review of the facts and shall, within 15 working days, provide a written decision to the Day Habilitation Provider.

 

f)         If the Day Habilitation Provider is not satisfied with the decision of the Bureau Chief, the provider may request review of the Bureau Chief's decision by the Director of DHS-DRS.  The request must be in writing and received by the DHS-DRS Director within 10 working days after the date the decision was rendered by the Bureau Chief.  The decision of the DHS-DRS Director shall be final.

 

(Source:  Added at 43 Ill. Reg. 2133, effective January 24, 2019)

 

Section 686.1300  Prevocational Services Provider Requirements

 

HSP shall use Prevocational Services Providers that meet standards as set forth in 89 Ill. Adm. Code 530, Criteria for the Evaluation of Programs of Services in Rehabilitation Facilities.  A facility that houses a Prevocational Service program (including satellite sites) shall also meet the criteria for the Centers for Medicare and Medicaid Services definition of a home and community-based setting pursuant to 42 CFR 441.301(c)(4) and 42 CFR 441.301(c)(5).

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1310  Rate of Payment for Prevocational Services

 

HSP shall pay Prevocational Services Providers rates as established per 89 Ill. Adm. Code 545, Ratemaking.

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1400  Supported Employment Service Provider Requirements

 

HSP shall use Supported Employment Service providers that meet standards as set forth in 89 Ill. Adm. Code 530, Criteria for the Evaluation of Programs of Services in Rehabilitation Facilities.

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1410  Rate of Pay for Supported Employment Services

 

HSP shall pay Supported Employment Service Providers rates as established per 89 Ill. Adm. Code 545, "Ratemaking."

 

(Source:  Added at 23 Ill. Reg. 6457, effective May 17, 1999)

 

Section 686.1500  Definitions

 

Definitions for this Part can be found at 89 Ill. Adm. Code 676.30.

 

(Source:  Added at 41 Ill. Reg.8454, effective August 1, 2017)

 

Section 686.1510  General Overview

 

a)         An Individual Provider working for a Customer under HSP shall not work more than the maximum hours in a work week, as defined within the currently effective Collective Bargaining Agreement (CBA), unless the Customer is approved for an exception under Section 686.1530.  The currently effective Collective Bargaining Agreement is available on the Illinois Department of Central Management Services website.

 

b)         An Individual Provider working for multiple Customers shall not work more than the maximum hours in a work week, as defined within the currently effective CBA, unless a Customer is approved for an exception under Section 686.1530.  The Individual Provider shall apply the following calculations:

 

1)         Add the hours worked for each Customer together; the combined total shall not exceed the maximum hours in a work week, as defined within the currently effective CBA.

 

2)         Add the time spent traveling to the combined total of work time in subsection (b)(1) if the Individual Provider is approved to receive reimbursement for travel time under Section 686.1560.  The combined total of work time and travel time shall not exceed the maximum hours in a work week, as defined within the currently effective CBA.

 

c)         All individual providers must follow the requirements of 89 Ill. Adm. Code 684.60 and 686.40.

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1520  Hiring Individual Providers and Backup Individual Providers

 

a)         Customers must hire sufficient Individual Providers to cover the weekly hours on their Service Plans without incurring unauthorized overtime. 

 

b)         The Customer is required to identify a backup caregiver on their service plan.  The backup caregiver can be a non-paid caregiver, an additional Individual Provider, or agency to cover those times when a regularly-scheduled Individual Provider is unable to work or provide services.

 

c)         Before paid services can be provided to a Customer, all Individual Providers must:

 

1)         meet program requirements for HSP;

 

2)         complete all required enrollment forms that are available through the HSP local offices, the Department’s website, or if applicable, the Customer’s Managed Care Organization (MCO);

 

3)         be enrolled in the program's electronic timekeeping system; and

 

4)         be enrolled in the Illinois Department of Healthcare and Family Services' Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system.

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1530  Overtime Exceptions

 

a)         An Individual Provider working under HSP shall not work more than the maximum hours in a work week as defined within the currently effective Collective Bargaining Agreement (CBA), unless the Customer meets one of the following exceptions described in this Section.

 

1)         Provider Capacity Exception:  A Customer may apply for this exception when an IP no longer works for the Customer, is unfunded, no longer meets qualifications, has expired credentials, and/or there is no qualified IP within 45 miles of the Customer's service location who is able and willing to provide needed services.

 

A)        This exception must be applied for in advance or within two weeks of the Customer's need.

 

B)        This exception will be renewed after one year and automatically renewed for successive one-year periods unless and until HSP determines not to renew the exception pursuant to the CBA.

 

2)         Unique/Complex Needs Exception:  A Customer may apply for this exception when the Customer's health and safety would be compromised by adding additional IPs to the Service Plan, which may include court-ordered service plans, Customers with a DON score at or above 70, Customers who cannot tolerate multiple IPs because of medical or behavioral needs, and Exceptional Care Customers.

 

A)        This exception must be applied for at the time of the Customer's application to HSP or when the exception is first known to the Customer.

 

B)        This exception will be renewed after one year and automatically renewed for successive one-year periods unless and until HSP determines not to renew the exception pursuant to the CBA.

 

3)         Out-of-Town Situations Exception:  A Customer may apply for this exception when the Customer requires care to ensure their health and safety while out-of-town and it is not feasible for the Customer to bring additional IPs.

 

A)        This exception must be applied for in advance of the out-of-town travel date.

 

B)        The Customer may be approved to use this exception up to 14 days per year.  Approval for this exception applies to personal care services as noted in 89 Ill. Adm. Code 684.60(c).

 

4)         Emergency Need Exception:  A Customer must apply for this exception when an urgent need for care arises and working more than the maximum hours defined within the currently effective CBA in a work week is unavoidable without risking the health and safety of the Customer.

 

A)        This exception must be applied for within two weeks of the Customer’s need arising.

 

B)        This exception may be approved up to four times per year for up to 10 hours per pay period.

 

b)         To apply for an exception, the Customer must submit a request for exception form to HSP Central Office Policy Unit.  The Customer will be notified in writing if they are approved or denied for an exception under this Section.  The Customer has the right to appeal the determination under 89 Ill. Adm. Code 510.

 

c)         If a Customer wishes to submit a request for exception form, applications should be submitted by the options listed on the DHS HSP Overtime website page or mailed to the address below:

 

Illinois Department of Human Services

Division of Rehabilitation Services

Home Services Program, Policy Unit

100 S. Grand Ave. East

Springfield, IL 62794

 

d)         If a complete exception form has been submitted and no determination has been made within 30 days, the Individual Provider shall be deemed conditionally approved to work the overtime hours until the determination is made.

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1540  Customer and Individual Provider Responsibilities

 

a)         The Customer and the Individual Provider are responsible for monitoring work hours to ensure that the Individual Provider does not work more than the maximum hours defined within the currently effective Collective Bargaining Agreement (CBA) in a work week unless approved for an exception under Section 686.1530. 

 

b)         Individual Providers who do not comply risk becoming unfunded by the HSP.  Continued noncompliance by a Customer or Individual Provider may result in a change in the Customer's Service Plan to a different Individual Provider or to an agency provider.

 

c)         The Individual Provider and the Customer will be notified in writing of any final determination of overtime found to be unauthorized. 

 

1)         If time worked in excess of the maximum hours defined within the currently effective CBA is found to be an unauthorized use of overtime, Section 686.1570 will apply.

 

2)         Overtime usage will be monitored for abuse or fraud.  Allegations of fraud will be referred to law enforcement authorities for review.

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1550  Individual Providers Working for Multiple Customers (Repealed)

 

(Source:  Repealed at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1560  Travel Time

 

a)         An Individual Provider working for more than one Customer may be paid for travel time. Travel time is the time spent traveling between two different Customer addresses on the same workday that meets the requirements defined in 89 Ill. Adm. Code 676.30.

 

b)         An Individual Provider will not be paid travel time for any trip to or from their home. If an Individual Provider lives with a Customer, they cannot be paid for travel time to another Customer's home if the trip begins or ends at the Individual Provider's home.

 

c)         The combined total of travel time and work time cannot exceed the maximum hours defined within the currently effective Collective Bargaining Agreement (CBA) per work week unless a Customer is approved for an exception under Section 686.1530.

 

d)         If an Individual Provider works for more than one Customer and chooses to claim travel time, they must complete the Home Services Program Travel Agreement form and the Home Services Program Travel Time Sheet form as applicable; the forms are available through the HSP local offices or on the Department's website.

 

1)         The Individual Provider must submit the Home Services Program Travel Agreement form to the HSP local office where the first Customer on the form is served.  The Individual Provider will be notified of the final determination in writing.

 

2)         An Individual Provider with an approved Travel Agreement must complete a Home Services Program Travel Time Sheet form for each work week that travel between Customers occurs on the same workday.

 

A)        The completed Travel Time Sheet form must be attached to the HSP Time Sheet and both forms must be submitted to the HSP local office where the first Customer is served as stated in subsection (d)(1).

 

B)        Incomplete forms will not be considered for reimbursement under this Section.

 

C)        Approved travel time will be processed and paid on the next available pay date.

 

e)         The Individual Provider is responsible for monitoring work time and travel time to ensure they do not work unauthorized overtime.

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1570  Unauthorized Overtime and Sanctions

 

a)         The Customer is required to manage their Individual Provider and both the Customer and the Individual Provider are required to comply with all HSP requirements.  This shall include monitoring of the Individual Provider's work time by both the Customer and the Individual Provider to ensure unauthorized overtime does not occur.

 

b)         Appropriate action will be taken when unauthorized overtime occurs or when a Customer and/or Individual Provider does not comply with HSP requirements.  Unauthorized overtime will result in a documented occurrence of noncompliance (i.e., more than the maximum hours defined within the currently effective Collective Bargaining Agreement (CBA) in a work week not approved for an exception under Section 686.1530).

 

1)         An Individual Provider will be given a written warning for the first three occurrences of unauthorized overtime.  Each written notification of an occurrence of unauthorized overtime shall be valid for a rolling twenty-four (24) month period.

 

2)         If within any rolling 24 month period a fourth occurrence of unauthorized overtime occurs, the Individual Provider will be notified in writing that they are temporarily ineligible for funding from HSP for 3 months.

 

3)         After the Individual Provider has been temporarily ineligible for funding three times pursuant to subsections (b)(1) and (b)(2), the Individual Provider will be notified in writing that they are permanently ineligible for funding from the HSP.

 

4)         If an Individual Provider has been deemed permanently ineligible for funding under subsection (b)(3), the Individual Provider may request a review after 12 months for reinstatement to the HSP, except in cases of substantiated fraud, abuse, neglect, or exploitation.

 

5)         If an Individual Provider is deemed permanently ineligible under this Subpart, the Customer will have the opportunity to replace the Individual Provider with another qualified Individual Provider of the Customer’s choosing or the Customer may change to an agency provider or HSP may amend the Customer’s Service Plan to an agency provider.

 

6)         A Customer who has continued noncompliance with other HSP requirements in addition to the overtime noncompliance may have their Service Plan amended to an agency provider.

 

7)         If any changes to the Customer's Service Plan are made under this Subpart, a Service Notice with the effective date of any changes will be issued.  The Customer has the right to appeal the action under 89 Ill. Adm. Code 510.

 

(Source:  Amended at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1600  Definitions

 

Definitions for this Part can be found at 89 Ill. Adm. Code 676.30.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1610  General Overview

 

a)         Pursuant to the Save Medicaid Access and Resources Together Act (SMART Act) (305 ILCS 5/5-5f(g)), and the 21^st Century Cures Act (42 U.S.C. 1396b), DHS shall implement an Electronic Visit Verification (EVV) system for personal care services and home health care services provided under the Home Services Program (HSP).

 

b)         The EVV system shall be based on global positioning or other cost-effective technology and shall record:

 

1)         the type of service performed;

 

2)         the Customer receiving the service;

 

3)         the date and precise time the service begins and ends;

 

4)         the location of the service delivery; and

 

5)         the worker providing the service.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1620  EVV Requirements for Individual Providers

 

a)         Individual Providers shall use HSP’s Electronic Visit Verification (EVV) system when providing services to a Customer.

 

1)         Once approved by HSP to work for Customers, Individual Providers shall be assigned a unique EVV identification number or other user account information.  Individual Providers shall keep the EVV ID and/or other user account information confidential.

 

2)         Individual Providers shall record the visit start time and visit end time in the EVV system from the Customer’s registered telephone, or other HSP authorized method of recording time worked, at the beginning and end of each service visit.

 

A)        Individual Providers shall enter their assigned EVV ID or other user account information each time they record the start time and record the end time of the visit in the EVV system.

 

B)        Individual Providers shall enter the appropriate task identification number or service information each time that they record the end time in the EVV system.

 

b)         Individual Providers shall be responsible for maintaining timekeeping records which shall include the exact times recorded in the EVV system.

 

c)         At the end of each pay period, Individual Providers and Customers shall review, reconcile, and approve the Provider’s accounting of time worked on a timesheet or other HSP authorized method.

 

d)         The Customer shall review the timekeeping information to ensure that it is complete, accurate, and in accordance with the Customer’s Service Plan and within the Customer’s Service Plan hours.  The Customer shall confirm that the Individual Provider properly recorded time worked in the EVV system for each visit.  The Customer shall discuss any discrepancies with the Individual Provider and work cooperatively with the Individual Provider to correct the timekeeping information in a timely manner.  Once the Customer verifies the accuracy and completeness for all hours worked, the Customer shall approve the timekeeping information in a manner consistent with the policies of HSP.

 

e)         Timekeeping records shall be reviewed by the HSP local office for payment processing.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1630  EVV Requirements for In-home Agency Providers

 

a)         In-home agency providers who provide homemaker services, maintenance home health services, and/or respite services shall utilize their choice of an Electronic Visit Verification (EVV) system that meets the requirements of this section when providing services to HSP Customers and shall:

 

1)         provide documentation to verify implementation and use of the EVV system that meets the requirements of this section;

 

2)         adopt internal policies and procedures regarding the EVV system;

 

3)         provide training and technical assistance to in-home agency field workers who use the EVV system; and

 

4)         submit monthly billing statements to the HSP local office or health plan managing the Customer case within 15 days of the end of the service period.

 

A)        Each statement must correspond to the providers EVV data, as defined in 686.1630(c)(3), for the same time period; and

 

B)        should not exceed the service hours or fees indicated on the active Vendor Authorization for Services form unless express written approval has been given by the HSP.

 

b)         In-home agency providers that employ fewer than 10 field workers may choose to utilize HSP’s EVV system at no cost to the agency provider; all other in-home agency providers must utilize an EVV system at the agency provider’s expense.

 

c)         In-home agency providers who utilize an alternative vendor EVV system shall require their alternative EVV vendor to submit all visit verification data to the HSP’s EVV aggregator component.

 

d)         Minimum EVV System Requirements:

 

1)         Technical Functionality

 

A)        System must capture, identify, and track all relevant service data, including:  the type of service performed, the Customer receiving the service, the date and precise time the service begins and ends, the location of the service delivery, and the agency worker providing the service.

 

B)        System must be accessible to agency workers for input 24 hours a day, 7 days a week.

 

C)        System must support changes in services, Customers, and agency workers.

 

D)        System must allow for multiple shifts per Customer and per agency worker per day including multiple sign in and sign out activities.

 

E)        System must allow for real time data capture.

 

F)         System must identify and track adjustments or edits made to EVV visits after the agency worker has input time worked.

 

2)         Data Storage, Security, and Recovery Standards

 

A)        System must retain all EVV data for up to seven years from the Customer’s last date of service with the agency.

 

B)        Archived data must be retrievable in a timely manner.

 

C)        System must comply with electronic data interchange standards under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification regulations detailed in 45 CFR 160, 162, and 164.

 

D)        System must incorporate a disaster recovery plan, including offsite electronic and physical storage, recovery procedures, defined plan activation prompts, restart capabilities, and backup hardware and operating system software.

 

3)         Data Collection and Aggregator Interface Standards

 

A)        System must collect data in a manner consistent with the HSP EVV aggregator data collection specifications.

 

B)        System must submit all visit verification data to the HSP’s EVV aggregator in compliance with the approved interface and submission data specifications as provided by HSP.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1700  Definitions

 

Definitions for this Part can be found at 89 Ill. Adm. Code 676.30.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1710  General Overview

 

a)         As a condition of enrollment or revalidation in the Department of Human Services, Division of Rehabilitation Services, Home Services Program, Individual Providers shall be enrolled in the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system prior to being paid with funds administered by the State.  As part of enrollment in IMPACT, a background screening shall be completed.  An Individual Provider’s enrollment in the Home Services Program will also be reviewed for continued eligibility, including a background screening.  If such screenings return a result matching the Individual Provider, this Subpart shall apply for Individual Providers paid with funds administered by the State.

 

b)         Notwithstanding anything in this Subpart to the contrary, Individual Providers with misdemeanor convictions not involving bodily harm or fraud may be employed at the Customer’s discretion.

 

c)         The State shall not terminate or defund an Individual Provider from the Home Services Program for any conviction or screening or background check result not referenced in this Subpart.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1720  Waivable Convictions

 

a)         If such screening as stated in Section 686.1710(a) indicates a potential felony criminal conviction for any of the crimes listed in this Section within the five years prior to the date of application for enrollment or revalidation, the State shall provide notification as set forth in Section 686.1740(b).

 

1)         Lewd and lascivious conduct;

 

2)         Assaults;

 

3)         Unlawful restraint;

 

4)         Recklessly endangering another;

 

5)         Frauds, including forgery;

 

6)         Larceny, including thefts and robbery;

 

7)         Burglary;

 

8)         Embezzlement;

 

9)         Extortion;

 

10)       Stalking;

 

11)       Cruelty to children or animals;

 

12)       Kidnapping;

 

13)       Possession of child pornography;

 

14)       Arson;

 

15)       Drug-related;

 

16)       DUI;

 

17)       Firearms violations;

 

18)       All forms of non-intentional homicide;

 

19)       Aggravated crimes not involving bodily harm; or

 

20)       Aggravated crimes involving bodily harm, including but not limited to, aggravated battery, aggravated battery of a senior citizen, aggravated battery of a child, aggravated domestic battery, provided that 10 years or more have passed since the date of conviction or end of incarceration, whichever is later;

 

b)         If the results of the background screening are listed in this Section, the State shall provide the results of the background screening to the Customer and Individual Provider, along with any additional information from the Individual Provider submitted in a form approved by the Department, and allow the Customer the option to consent to or decline working with the Individual Provider with a criminal history.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1730  Non-waivable Convictions

 

a)         If the screening under Subsection 686.1710(a) indicates a potential felony criminal conviction for any of the crimes listed in this Section, the State shall notify the Individual Provider and Customer of the background screening result and give the Individual Provider the opportunity to dispute the screening results and submit additional information as stated in Section 686.1740.

 

1)         Conviction of theft or fraud from a government-funded program.

 

2)         Having been excluded from participation in Medicaid (federal or State) or Medicare programs, or from a similar program in another state, as reflected in sanction/exclusion databases.

 

3)         A substantiated verified record of abuse, neglect, or exploitation of an adult as determined by the Department on Aging pursuant to the Adult Protective Services (APS) Act [320 ILCS 20], resulting in placement on the APS registry and a waiver of such placement has not been granted.

 

4)         All forms of intentional homicide, including but not limited to, solicitation of murder, solicitation of murder for hire, first degree murder, second degree murder.

 

5)         All sexual crimes, including but not limited to, criminal sexual assault, criminal sexual abuse, sexual exploitation of a child, and sexual misconduct with a person with a disability.

 

6)         Aggravated crimes involving bodily harm, including but not limited to, aggravated battery, aggravated battery of a senior citizen, aggravated battery of a child, aggravated domestic battery, provided that less than 10 years have passed since the date of the conviction or end of incarceration, whichever is later.

 

7)         Conviction of abuse, neglect, or exploitation of a child.

 

b)         If the screening under Section 686.1710(a) indicates a potential felony criminal conviction for any of the crimes listed in this section and are verified through the processes stated in Section 686.1740(a), any defunding, termination, or denial of enrollment of an Individual Provider by the State will not be subject to the Customer waiver process described in Section 686.1720(b), but may be appealed through the Illinois Department of Healthcare and Family Services Administrative Hearing process as outlined in 89 Ill. Adm. Code 104, if applicable.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

 

Section 686.1740  Background Screening Dispute

 

a)         If a dispute arises between the Individual Provider and the State regarding the accuracy or correctness of the background screening results, the State shall verify the screening results through a reliable background check process.

 

b)         If the background screening result shows a potential conviction for one of the crimes listed in Section 686.1720(a) or Section 686.1730(a) within the specified time period, the State shall notify the Individual Provider and Customer of the background screening result.  The State shall give the Individual Provider the opportunity to confirm or dispute the accuracy of the background screening results and to submit additional information to the State regarding the criminal conviction no later than 20 days from the date of the notification.  Exceptions to this timeframe may be granted for good cause, which may include but is not limited to, illness or incapacity, family crisis, unexpected emergency, and limitations to an individual’s literacy.

 

c)         The Individual Provider may submit additional information that may supplement their dispute of the background screening results.  The additional information submitted to the State may include, but need not be limited to:

 

1)         Whether the Individual Provider disputes the accuracy or correctness of the screening results;

 

2)         The nature of the seriousness of the offense(s);

 

3)         Circumstances surrounding the offense;

 

4)         Time elapsed since the offense(s);

 

5)         Number or repeated offenses and number of times each offense has been repeated;

 

6)         Age at the time of offense(s);

 

7)         Involvement, since the date of the criminal offense, with the criminal justice system and/or child or adult protective services;

 

8)         Disclosure of the criminal conviction(s) by the prospective worker to the person receiving services, the surrogate, and the legal guardian, if any;

 

9)         Prospective worker’s unique caregiving relationship with the person receiving services;

 

10)       Unavailability of other workers who could reasonably be expected to perform the care required;

 

11)       Any other information the Individual Provider believes will assist in disposing of their application or assisting the Customer in making the decision regarding whether or not to consent to working with the Individual Provider as described below; and

 

12)       Any other information requested by the State or Customer.

 

d)         Failure of the Individual Provider to either confirm or dispute the accuracy of the background screening results may result in termination from the program without penalty and without prejudice to the ability to reenroll in the program upon compliance with this policy.

 

(Source:  Added at 46 Ill. Reg. 20865, effective December 19, 2022)

Section 686.APPENDIX A   Acceptable Human Service Degrees

 

The following degrees will be accepted as human service degrees:

 

Child, Family and Community Services

Early Childhood Development

Guidance and counseling

Home Economics – Child and Family Services

Human Development Counseling

Human Service Administration

Human Services

Master of Divinity

Pastoral Care

Pastoral Counseling

Psychiatric Nursing

Psychiatry

Psychology

Public Administration

Rehabilitation Counseling

Social Science

Social Services/Social Work

Sociology

 

(Source:  Added at 24 Ill. Reg. 18174, effective November 30, 2000)