Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 147 - REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES › Section 147.325 - Resident Reimbursement Classifications and Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) Resident
			 reimbursement classification shall be based on the Minimum Data Set (MDS),
			 Version 3.0 assessment instrument mandated by the United States Department of
			 Health and Human Services, Centers for Medicare and Medicaid Services (federal
			 CMS) that nursing facilities are required to complete for all residents. When
			 later guidance or clarifications are released by federal CMS that contradicts
			 or augments guidance provided in this Section, the more current information
			 becomes the accepted standard and shall become effective as of the date
			 required by federal CMS. The Department shall establish resident classification
			 according to the 48-group, Version IV or RUG-IV model. Resident classification
			 shall be established based on the individual items identified on the MDS and
			 shall be completed according to the RAI Manual.
b) Each resident shall be classified based on
			 the information from the MDS submitted according to the categories as
			 identified in Section
			 147.330
			 and as defined in the RAI Manual.
c) General Documentation Requirements
1) A facility shall maintain resident records
			 on each resident in accordance with acceptable professional standards and
			 practices.
2) Supportive
			 documentation in the clinical record used to validate the MDS item responses
			 shall be dated during the specified look-back period or other timeframe as
			 identified in the RAI Manual. Records shall be retained for at least three
			 years from the date of discharge.
3) Supportive documentation entries shall be
			 dated and their authors identified by signature or initials. Signatures are
			 required to authenticate all documentation utilized to support MDS item
			 responses. At a minimum, the signature shall include the first initial, last
			 name, and title/credentials. Any time a facility chooses to use initials in any
			 part of the record for authentication of an entry, there shall also be
			 corresponding full identification of the initials on the same form or on a
			 signature legend. Initials may never be used where a signature is required by
			 law (i.e., on the MDS). When electronic signatures are used, the facility shall
			 have policies in place to identify those who are authorized to sign
			 electronically and have safeguards in place to prevent unauthorized use of
			 electronic signatures.
4) Each page
			 or individual document in the clinical record shall contain the resident's
			 identification information.
5) A
			 multi-page supportive documentation form completed by one staff member may be
			 signed and dated at the end of the form, provided that each page is identified
			 with the resident's identification information and the dates are clearly
			 indentified on the form.
6)
			 Corrections/Obliterations/Errors/Mistaken Entries. At a minimum, there shall be
			 one line through the incorrect information, the staff's initial, the date of
			 correction was made, and the corrected information. Information that is deemed
			 illegible by Department reviews will not be considered for validation
			 purposes.
7) An error correction in
			 the electronic record applies the same principles as for the paper clinical
			 record. Some indication that a previous version of the entry exists shall be
			 evident to the caregiver or other person viewing the entry.
8) Late entries shall be clearly labeled as a
			 late entry and contain the current date, time and authorized signature.
			 Amendments are a form of late entry. Amendments shall be clearly labeled as an
			 addendum or amendment and include the current date, time and authorized
			 signature.
9) Facilities shall have
			 a written policy and procedures that states who is authorized to make
			 amendments, late entries, and correct errors in the electronic health records
			 (EHRs) and clearly dictate how these changes to the EHR are made.
10) Resident records shall be complete,
			 accurately documented, readily accessible to Department staff, and
			 systematically organized. At a minimum, the record shall contain sufficient
			 information to identify the resident, a record of the resident's assessments,
			 care plan, record of services provided, and progress notes.
11) Documentation from all disciplines and
			 all portions of the resident's clinical record may be used to validate an MDS
			 item response. All supporting documentation shall be produced by a facility
			 during an onsite visit.
12)
			 Documentation shall support all conditions or treatments were present or
			 occurred within the look-back period ending on, and including the ARD period.
			 The look-back period shall include observations and events through the end of
			 the day (midnight) of the ARD. Documentation shall apply to the appropriate
			 look-back period and reflect the resident's status on all shifts.
13) Documentation in the clinical record
			 shall consistently support the item response and reflect care related to the
			 symptom or problem. Documentation shall reflect the resident's status on all
			 shifts.
14) Problems that are
			 identified by the MDS item responses that affect the resident's status shall be
			 addressed on the care plan when deemed appropriate by the interdisciplinary
			 team (IDT) as identified in the RAI Manual.
15) Insufficient or inaccurate documentation
			 may result in a determination that the MDS item submitted was not
			 validated.
16) Documentation shall
			 support that the services delivered were medically necessary.
17) Documentation shall support an
			 individualized care plan was developed based on the MDS and other assessments
			 and addressed the resident's strengths and needs. In addition, documentation,
			 observation and/or interview shall support services were delivered as
			 identified by the care plan.
18)
			 Clinical documentation that contributes to identification and communication of
			 a resident's problems, needs and strengths that monitors his or her condition
			 on an ongoing basis and that records treatments and response to treatment is a
			 matter of clinical practice and is an expectation of trained and licensed
			 health care professional.
19) When
			 there is a significant change in status assessment done, documentation shall
			 include the identification of the significant change in status in the clinical
			 record.