Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 240 - COMMUNITY CARE PROGRAM › Subpart A - GENERAL PROGRAM PROVISIONS › Section 240.160 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Adequate person-centered plan of care" means a
				  person-centered plan of care that provides the minimum services needed to
				  protect the health, safety and welfare of a participant.
"Adjusted rate" means a rate other than the established fixed
				  rate of reimbursement.
"Administrative corrections" means allowable revisions to a
				  proposal permitted and/or performed by the Department in cases of apparent
				  clerical mistakes and in cases where the participant/Department has reason to
				  believe a mistake may have been made and verification from the participant has
				  been provided. These actions shall be taken prior to award.
"Administrative costs" means those allowable costs related to
				  the management and organizational maintenance of the provider.
"Adverse action" means the denial of CCP service; a reduction
				  in dollars in the monthly cost of care according to the Participant Agreement -
				  Person-Centered Plan of Care; a change in service type that could increase the
				  participant's incurred monthly expense for care prior to July 1, 2010; or the
				  termination from CCP service.
"Allegations" means unsubstantiated accusations or
				  statements.
"Allowable costs" means those cost categories, as delineated
				  in Section
				  240.2050,
				  which will be considered in setting a fixed rate.
"Allowable maximums" means the highest authorized allocation
				  available for services per month based upon Determination of Need assessment
				  tool scores or the corollary scores on any successor assessment tool authorized
				  by the Department to determine need for long term services and supports.
"AMD" means automated medication dispenser.
"Appellant" means the participant/authorized representative
				  initiating an appeal as a result of Department action or inaction.
"Assistance with task" means giving aid or support in the
				  performance of a task.
"Assistive device" means crutches, walker, wheel chair,
				  hearing aid, etc.
"Authorized representative" means an agent designated,
				  verbally or in writing, by the participant to be his/her representative, or the
				  participant's legal guardian. In the event that a participant is unable to
				  physically write his/her signature, the CCU may sign for the participant at the
				  participant's verbal request.
"Authorized representative of the provider" means an owner,
				  officer, or employee of the provider agency who has the authority to commit the
				  agency to a financial and/or contractual responsibility.
"Authorized provider" means a provider who holds a valid
				  contract with the Department to provide Community Care Program (CCP)
				  services.
"Available resources" means assistance provided to a
				  participant by family/friends, church, community, etc.
"Best interest" means the determined needs of the participant
				  population are being met.
"Burial merchandise" means gravesites, crypts, mausoleums,
				  urns, caskets, vaults, grave markers or other repositories for the remains of
				  deceased persons, shrouds, etc.
"Calendar year" means from January 1 through December
				  31.
"Capable person" means a person who is qualified to perform
				  the functions required.
"Care Coordinator" means a trained individual who is employed
				  to assess needs, conduct eligibility screenings, and perform care coordination
				  services and care coordination functions under the Community Care
				  Program.
"CCP" means Community Care Program.
"CCU" means Care Coordination Unit.
"CCU in good standing" (See: Contractor in good
				  standing)
"Choices for Care" means a CCP program under which CCUs
				  conduct prescreening or postscreening assessments to determine eligibility of
				  participants age 60 and over for nursing facility placement, supportive living
				  program placement, or the choice of community-based services. Screenings may be
				  conducted in a hospital, nursing facility, supportive living program, or in the
				  community depending on the circumstances.
"Close-out review" means a review performed at the close of
				  the period of time allowed for correction of findings of non-compliance to
				  determine if those corrections have been made and that the newly drawn review
				  sample of participant/provider files reflects on-going compliance.
"Closed caseload" means a caseload restricted to those
				  participants already receiving service and refers only to individual providers;
				  no new participants shall be accepted and current participants who discontinue
				  service for any reason will not be reinstated into this caseload.
"Community-based services" means services provided in an
				  integrated setting in a participant's community.
"Comparable human service program" means a program that
				  offers services that are similar to CCP services (e.g., home health aide, maid
				  service).
"Compliance" means adherence to the CCP rules, policy and
				  procedures and the contract with the Department, and all applicable federal,
				  State and local laws/rules/ordinances.
"Components" means specified parts of the service as defined
				  in the applicable Section.
"Confused and disoriented" means unable to clearly and
				  accurately differentiate as to time, person and/or place.
"Continuous eligibility" means that the participant has met
				  eligibility requirements each time a subsequent redetermination was
				  administered.
"Contractor in good standing" means a CCP contractor who is
				  currently in compliance or within the permitted time frame allotted for remedy
				  to come into compliance with the Department's rules and contract.
"Control date" means a starting point for purposes of
				  calculating a time frame; the count begins the next work or calendar
				  day.
"Cost report" means a report of all categorized allowable
				  costs to a provider that are directly associated with services purchased by the
				  Department for its participants in categories as defined in Section 240.2050.
				  The provider shall use the Direct Service Worker Cost Certification and the
				  Detailed Cost Certification forms.
"Critical event" means any actual or alleged incident or
				  situation that creates a significant risk of substantial or serious harm to the
				  physical or mental health, safety or well-being of a participant. There are 3
				  subcategories that will be reported to the Department:
"Critical Incidents" include anticipated death, unanticipated
				  death, hospitalization, medication error, serious injury, missing person,
				  emergency department visit, property damage, nursing facility placement, fall
				  (with injury), fall (without injury), special circumstance, criminal activity,
				  and law enforcement interaction;
"Service Improvement Program Complaints" or "SIPs" is a
				  complaint based reporting process with the purpose of identifying and resolving
				  problematic issues related to the provision of home and community based
				  services (HCBS); and
"Request for Change of Status" occurs anytime the condition
				  of a CCP participant changes or there is a change in circumstances that affect
				  the ability of the family and/or caregiver to safely provide support and
				  assistance.
"Daily census maximum" means the total square footage of
				  adult day service participant-allotted space divided by 40 sq. ft. equals the
				  daily maximum number of participants that may be served in the adult day
				  service facility.
"Department" means the Illinois Department on Aging.
"Director" means the Director of the Illinois Department on
				  Aging.
"Discontinuance" means the cessation of CCP services provided
				  to a participant for non-payment of incurred expense for care prior to July 1,
				  2010.
"Documentation" means tangible documents or supporting
				  references or records used to record participant contact, determine eligibility
				  or substantiate adherence to rules.
"Documenting" means making written entries on the Case Record
				  Recording Sheet regarding contact with a participant; and/or the viewing or
				  receiving of a document to be placed in participant/worker files to
				  substantiate adherence to rules.
"DON" means the Determination of Need, which is a component
				  of the comprehensive assessment tool, or any successor assessment tool
				  authorized by the Department, used to determine CCP eligibility under this
				  Part.
"Emergency" means a sudden unexpected occurrence demanding
				  immediate action (e.g., participant illness, illness/death of a member of the
				  participant's family).
"Emergency home response service" or "EHRS" means a 24-hour
				  emergency communication link to assistance outside the participant's home based
				  on the participant's health and safety needs and mobility limitations. This
				  service is provided by a 2-way voice communication system consisting of a base
				  unit and an activation device worn by the participant that will automatically
				  link the participant to a professionally staffed support center. The support
				  center assesses the situation and directs an appropriate response whenever this
				  system is engaged by a participant.
"Errands" means performance of services outside the home such
				  as essential shopping, picking up medications, and essential business needs as
				  indicated in the person-centered plan of care.
"Escort" means accompanying those participants who are
				  dependent on personal physical assistance to enable them to reach and use
				  community resources in order to ensure their access to local services and to
				  allow them to maintain independent living as required by the person-centered
				  plan of care.
"Essential" means basic, indispensable or necessary.
"Exit conference" means the meeting at the Illinois
				  Department on Aging between representatives of the Department and the Director,
				  or his/her designee, and of the reviewed agency to resolve the agency's
				  objection to the findings of the Compliance Review Report. These conferences
				  shall be called when the findings indicate evidence of serious
				  participant-related concerns (e.g., Type I findings).
"Face-to-face" means direct communication while physically in
				  the presence of another person or persons.
"Face-to-face review" means an informal review (see Section
				  240.425 )
				  conducted in the appeal process by the Department in the home of an appellant
				  with the participant (and appellant, if appellant is other than the
				  participant) present. (A hearing is conducted by a Hearing Officer - see
				  Section
				  240.450.)
"FUTA" means the Federal Unemployment Tax Act.
"Fiscally sound agency" means a CCU or provider that has on
				  file at the Department documentation that supports that the CCU or provider has
				  adequate financial resources to perform the terms of the contract (e.g., a line
				  of credit from a financial institution).
"Fraudulent information" means purposely erroneous or
				  untruthful information.
"Geographic area" means a physical area (e.g., county) of the
				  State within which a contractor is authorized to provide services to Community
				  Care Program participants.
"Historical costs" means the total allowable costs incurred
				  for all programs the provider provided for the previous reporting year, which
				  are presented via certified report by the provider.
"Home maintenance and repairs" means those non-routine tasks,
				  excluding any work requiring a ladder or requiring specialized skills on the
				  part of the worker, necessary to maintain a safe and healthful environment for
				  the participant as required by the person-centered plan of care (e.g.,
				  defrosting the refrigerator; cleaning the oven; dusting walls and woodwork;
				  cleaning closets, cupboards and insides of windows; changing filters on and
				  cleaning humidifiers; replacing light bulbs; clearing hazards from outside
				  steps and sidewalks if transportation and/or escort is required by the
				  person-centered plan of care).
"Imminent" means likely to occur (e.g., injury or nursing
				  facility care).
"Incomplete proposal" means the written offer to the Request
				  for Proposal (e.g., attachments, appendices) that fails to include all
				  requirements as stated in the Request for Proposal.
"Incurred monthly expense" means the participant's share of
				  the cost of care for CCP services provided during a previous monthly period
				  prior to July 1, 2010.
"Informal review" means the act of determining the facts
				  relating to an appeal in an informal manner by the Department (see Section
				  240.425).
"Informality" means an irregularity that is a matter of form
				  or variation from the exact requirement of the Request for Proposal, the
				  correction or waiver of which would not be prejudicial to other applicants
				  (e.g., failure to return number of copies of signed proposals as required by
				  the Request for Proposal).
"In-home services" means services provided in the
				  participant's residence with the participant present or on behalf of the
				  participant (e.g., homecare aide).
"Intermediate Care Facility" or "ICF" means a facility that
				  provides basic nursing care and other restorative services under periodic
				  medical direction. Many of these services may require skill in administration.
				  ICFs are for residents who have long term illnesses or disabilities that may
				  have reached a relatively stable plateau.
"Licensed Practical Nurse" or "LPN" means a nurse who has
				  graduated from a formally approved program of practical nursing education and
				  has been licensed by the appropriate State authority.
"Mandated time period" means the time frame required by
				  pertinent rule.
"M.D." means medical doctor who is registered in the State of
				  Illinois.
"Memorandum of Understanding" means a written document,
				  executed by the participant/authorized representative, CCU representative and
				  provider representative in which all parties agree to cooperate and in which
				  activities are specified that must be fulfilled by each party.
"Observing participant's functioning" means watching for any
				  change in the participant's needs that could indicate that a redetermination of
				  eligibility and/or a revision in the CCP Participant Agreement -
				  Person-Centered Plan of Care is necessary (e.g., participant is experiencing
				  increasing difficulty in walking; participant is becoming increasingly confused
				  and disoriented; participant's family member is no longer available to prepare
				  meals for the participant).
"Occupancy costs" means the costs of depreciation,
				  amortization of leasehold improvements, rent, property taxes, interest and
				  other related costs.
"On-Notice" means the Department sanction imposed on a
				  provider or CCU requiring that provider or CCU to bring specified services or
				  requirements into compliance.
"Parent organization" means an entity to which the
				  contractual party is a subsidiary.
"Participant" means a person who made a request for services,
				  receives services, or is appealing benefits decisions under the Community Care
				  Program.
"Performance of task" means to carry out an action, function
				  or process.
"Period of stay" means period of time during which
				  implementation of a contract action is temporarily delayed.
"Person-centered planning" means that service planning for
				  participants in the Persons who are Elderly Waiver shall be developed through a
				  person-centered planning process that addresses health and long-term services
				  and supports (paid and unpaid) needs in a manner that reflects participant
				  personal preferences, choices and goals. The person-centered planning process
				  is directed by the participant and may include an authorized representative
				  that the participant has freely chosen to contribute to the process. The
				  planning process, and the resulting person-centered plan of care, will assist
				  the participant in achieving personally defined outcomes in the most integrated
				  community setting, including the assurance of their health, safety and
				  welfare.
"Planning and Service Area" or "PSA" means a designated
				  geographic area.
"Post-screening" means screening performed after a
				  participant has entered a nursing facility due to an emergency situation or
				  oversight without prescreening.
"Potentially" means having the capability of occurring, but
				  not yet in existence (e.g., deterioration in the participant's
				  condition).
"Program support costs" means those allowable costs not
				  included as direct service or administrative costs.
"Proposal" means the written offer made by an applicant in
				  response to Department Request for Proposal.
"Provider Agreement" means purchase of service
				  agreement.
"Provider community experience" means documentation of having
				  provided service within the community in which the provider has applied to
				  provide CCP services.
"Provider in good standing" (See: Contractor in good
				  standing)
"Providers" means those service providers with whom the
				  Department does business through contracts on a reimbursement basis for units
				  of service delivery to specified participants.
"Reasonable" means using and showing reason or sound
				  judgement, sensible, not excessive.
"Reasonable and diligent effort" means perseverance on the
				  part of the participant/client in his/her attempt to dispose of the asset
				  (e.g., as evidenced by copies of the advertisement for the sale of the
				  asset).
"Registered Nurse" or "RN" means a nurse who has graduated
				  from a formal program of nursing education and has been licensed by the
				  appropriate state authority.
"Reinstatement" means the resumption of services, within an
				  established time frame, at the same level provided prior to a
				  suspension/discontinuance of the services.
"Related parties" means any other entities having a legal or
				  contractual relationship with the contractual party.
"Request for Proposal" or "RFP" means a form of invitation to
				  bid that the Department uses to obtain care coordination services and
				  demonstration/research projects under the CCP. The RFP explains the purpose of
				  the invitation to bid, outlines the scope of the work and solicits proposals
				  from provider agencies for the funding of services undertaken by the
				  Department.
"Responsible person" means a capable person who does not
				  appear to be disoriented or confused and is presumed to be acting in the best
				  interest of another individual.
"Risk mitigation" means the process in which events or
				  experiences that place the health, welfare and safety of program participants
				  in jeopardy are evaluated in terms of nature, frequency and circumstance with
				  the intent of providing services and supports aimed at reducing risk and the
				  likelihood of its reoccurrence.
"Rotation plan" means a Department approved plan for the
				  equitable distribution of participants to providers (used only if participant
				  does not indicate a choice of providers).
"Routine procedures" means procedures performed in a hospital
				  that result in no perceptible change in the participant's physical/mental
				  health needs (e.g., tests, blood work-ups, x-rays, dialysis).
"Service area" means any area in which a provider has been
				  awarded a contract to provide CCP services.
"Skilled Nursing Facility" or "SNF" means a group care
				  facility licensed by the Illinois Department of Public Health that provides
				  skilled nursing care, continuous skilled nursing observations, restorative
				  nursing and other services under professional direction with frequent medical
				  supervision. SNFs are provided for patients who need the type of care and
				  treatment required during the post-acute phase of illness or during
				  reoccurrences of symptoms in long-term illness (89 Ill. Adm. Code
				  101.20 ).
"Special diet" means a dietary restriction based upon the
				  health and safety needs of the participant and prescribed by a physician (e.g.,
				  sodium free, fat, protein, diabetic, etc.); whereas a modified diet relates to
				  a diet containing easy to chew foods. A modified diet may be part of a
				  specialized diet.
"State fiscal year" means from July 1 through June 30.
"Supportive Living Program" or "SLP" means the program that
				  provides an affordable assisted living model offering limited personal and
				  health services integrated within apartment-style housing. The SLP operates
				  under the authority of a 1915(c) Home and Community Based Services (HCBS)
				  Waiver. The SLP serves persons who would otherwise need nursing facility (NF)
				  care, but whose individual needs can be met by the SLP. HFS is the operating
				  agency for the SLP Waiver.
"Suspension" means the temporary cessation of the provision
				  of Community Care Program services provided to a participant.
"Suspension of referrals" means closed intake of new
				  participants to a specific contractor.
"Termination" means the permanent cessation of the provision
				  of Community Care Program services and eligibility of services.
"Threat" means the existence of circumstances that indicate
				  the intent of an individual or group to destroy the property of or to injure or
				  punish another individual or group, or the display of a weapon at an adult day
				  services center or home.
"Too highly impaired participant" means a participant who
				  needs 24 hour a day care, for whom CCP cannot develop a person-centered plan of
				  care to protect his/her physical, mental and environmental needs and who does
				  not have sufficient outside support from family, friends, church et. al., to
				  provide for those needs (as determined by Part B - Unmet Need for Care - of the
				  Community Care Program - Determination of Need). (Refer to Section
				  240.715.)
"Unallowable costs" means those costs that will not be
				  considered in determining the fixed rate or in meeting the required minimum
				  direct service expenditure.
"Unit of service" means a measured length of service, such as
				  an hour, a day, a visit, a one-way trip, or some other measurable service
				  component that will enable the Department to determine the amount of service
				  provided individually or in aggregate to or on behalf of a participant.
"Validation of provider community experience" means the
				  documentation of letters from community agencies attesting to experience with
				  the provider within the community.
"Validity of participant billing" means the accuracy of the
				  billing and documentation for participant services.
"Work days" means Monday through Friday at a minimum,
				  excluding provider designated holidays.