TITLE 89: SOCIAL SERVICES
CHAPTER II: DEPARTMENT ON AGING
PART 240 COMMUNITY CARE PROGRAM
SECTION 240.160 DEFINITIONS


 

Section 240.160  Definitions

 

"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.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)