Section 147.205  Reimbursement for Ventilator Dependent Residents

a)         Pursuant to Public Act 96-473, effective October 1, 2009, Department of Healthcare and Family Services (HFS) shall begin paying nursing facilities for ventilator dependent residents through a system separate from the Minimum Data Set (MDS) based reimbursement methodology.  For purposes of this Section, ventilators are defined as any type of electrical or pneumatically powered closed mechanical system for residents who are, or who may become, unable to support their own respiration.  It does not include Continuous Positive Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BIPAP) devices.

b)         Payment shall be made for each individual resident receiving ventilator services through the Medicaid Management Information System (MMIS).  The rate shall include the facility specific support, capital and nursing components plus the geographic area average ventilator minutes from the MDS and $150 supply cost.

c)         Other services coded by a facility on the MDS for a ventilator dependent resident shall continue to be applied toward the nursing component of the nursing facility rate.

            d)         Staffing

1)         A minimum of one RN on duty on the day shift, seven days per week (as required by the Department of Public Health (DPH) in 77 Ill. Adm. Code 300.1240 or 250.910(e) and 250.910(f)(1), as appropriate).  Additional RN staff may be determined necessary by HFS, based on HFS' review of the ventilator services.

2)         A minimum of the required number of LPN staff (as required by DPH in 77 Ill. Adm. Code 300.1230, 300.1240 or 250.910(e) and 250.910(f)(1), as appropriate), on duty, with an RN on call, if not on duty on the evening and night shifts, seven days per week.

3)         A certified respiratory therapy technician or registered respiratory therapist shall be available at the facility or on call 24 hours a day.

4)         A certified respiratory therapist shall evaluate and document the respiratory status of the ventilator resident on a weekly basis.

5)         At least one of the full-time licensed nursing staff members must have successfully completed a course in the care of ventilator dependent individuals and the use of ventilators, conducted and documented by a certified respiratory therapy technician or registered respiratory therapist or a qualified registered nurse who has at least one year experience in the care of ventilator dependent persons.

6)         All staff caring for ventilator dependent residents must have documented in-service training in ventilator care prior to providing that care.  In-service training must be conducted at least annually by a certified respiratory therapy technician or registered respiratory therapist or a qualified registered nurse who has at least one-year experience in the care of ventilator dependent persons.  In-service training documentation shall include name and qualification of the in-service director, duration of presentation, content of presentation and signature and position description of all participants.

            e)         Physical Plant

The Provider shall have and maintain physical plant adaptations to accommodate the necessary equipment, such as, an emergency electrical backup system.

            f)          Notification to HFS

A provider shall notify HFS, in writing, when a ventilator dependent resident is admitted and discharged from the facility.  Notification in either instance shall occur within five days after the admission or discharge.  Discharge is defined as the resident leaving the facility with no intention of returning.  It does not mean an admission to a hospital.

            g)         Accessibility

The provider must make accessible to HFS and/or DPH all provider, resident and other records necessary to determine that the needs of the resident are being met and to determine the appropriateness of ventilator services.

(Source:  Added by emergency rulemaking at 33 Ill. Reg. 14350, effective October 1, 2009, for a maximum of 150 days; Section modified in response to the objection of the Joint Committee on Administrative Rules at 34 Ill. Reg. 1421, effective January 5, 2010, for the remainder of the 150 days; emergency expired February 27, 2010; added at 34 Ill. Reg. 3786, effective March 14, 2010)