TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.10 PURPOSE
Section 125.10 Purpose
a) The intent of this Part is to define and describe the role of
the Department of Human Services once the decision has been made by direct
service personnel that a recipient is a candidate for discharge from a
State-operated facility. A person shall not remain in a State-operated
facility after it has been clinically and professionally determined that
therapeutic services as defined within the Mental Health and Developmental
Disabilities Code [405 ILCS 5] are no longer needed by the recipient. Adequate
discharge planning, linkage and aftercare within an appropriate setting with
individualized follow-up services will be provided for each recipient.
Recipients will not be discharged from State-operated facilities without
assurance that linkage will occur, unless the recipient refuses individualized
follow-up services.
b) The policies and procedures within this document are
consistent with the statutes which contain the Mental Health and Developmental
Disabilities Code and the Mental Health and Developmental Disabilities
Administrative Act [20 ILCS 1705] and provide uniform direction to Department
employees beginning with the decision to discharge a recipient and continuing
through the follow-up process. The approach contained in this Part should
enhance the quality of delivery of services to recipients and provide for
improved public accountability.
c) This Part shall be used to assist in the orientation and
training of staff as well as to provide guidance which may be necessary on a
day-to-day basis. It is written in such a way that the policy expectations of
the Department in terms of the roles and responsibilities of those involved in
the discharge/linkage/aftercare process are addressed, including:
1) Central Office personnel;
2) Department facility and regional personnel;
3) Follow-up staff; and
4) Community providers.
d) The Department has always placed a special emphasis upon the
necessity of continuity of care among service providers. Evidence of
collaborative interagency agreements which assure prompt access to needed
services is a requirement for the receipt of Department of Mental Health and
Developmental Disabilities grant funds. Nationally recognized accreditation
organizations have also emphasized the importance of this area through the
development of standards concerning discharge planning, linkage and aftercare
services.
e) The programmatic issue of assuring linkage of a recipient of
services to the receiving agency/facility as distinguished from the monitoring
and tracking of the recipient through the system has been given special
consideration. Consequently, the Department's primary emphasis is to assure
this linkage. The contents of this Part reflect this emphasis.
f) The provision and delivery of aftercare services to the recipient
are the responsibility of the receiving agency/facility. The assurance that
the services are appropriate and continue to be provided are the responsibility
of the case coordinator and/or the designated mandated follow-up staff.
g) Facilitating the linkage of each recipient to a receiving
agency while at the same time respecting the individual's rights as set forth
in the Mental Health and Developmental Disabilities Confidentiality Act [740
ILCS 110] requires that any recipient identifying information contained in the
Department's automated linkage system be maintained on a time limited basis.
Confirmation of linkage for a time period, not exceeding 180 days from the date
of absolute discharge from a state-operated facility is maintained in the automated
linkage system. An exception to this practice will exist for those recipients
placed by the Department into licensed long-term care facilities. In these
cases, the Department will maintain recipient identifying information for a
minimum of one year in order to fulfill the mandated follow-up responsibility
specified in Sections 15 through 16 of the Mental Health and Developmental
Disabilities Administrative Act [20 ILCS 1705/15 through 16].
h) The policies and procedures contained in this Part articulate
specific activities which must be accomplished. Further, terminology used in
this Part has been standardized to facilitate its usefulness as well as gain
greater clarity in communications among responsible personnel.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.15 DEFINITIONS
Section 125.15 Definitions
For purposes of this Part, the
following terms are defined:
"Aftercare." The continuation of needed care and
services of a recipient discharged from a state-operated facility within an
appropriate setting with individualized follow-up services.
"Case coordination." The provision of assistance
and advocacy services to a recipient for the purpose of assuring and/or
coordinating the provision of necessary services and support.
"Code." The Mental Health and Developmental
Disabilities Code [405 ILCS 5].
"Community agency/facility." A locally-operated
organization which provides treatment/habilitation services to persons who are
dysfunctional due to mental illness, developmental disability or alcohol
abuse. An agency/facility may have an agreement with the Department to provide
services in consideration of payment through a grant or purchase care funding
mechanism. A grant funded agency must be in compliance with Grants (59 Ill.
Adm. Code 103) and report its activities through the extramural information
reporting system.
"Department." The Department of Human Services.
"Individualized services plan." A written plan for
persons who are dysfunctional due to mental illness, developmental disability
or alcohol abuse. This plan includes an assessment of the recipient's
treatment/habilitation needs, a description of the services recommended
for treatment/ habilitation, the goals of each type of the element of
service, the role of the family in the implementation of the plan, when
indicated, an anticipated timetable for the accomplishment of the goals, and
the name of the person or persons responsible for the implementation of the
plan (Sections 3-209 and 4-309 of the Code [405 ILCS 5/3-209 and 4-309]).
"Licensed long-term care facility." A private
home, institution, building, residence, or other place as defined by the
Nursing Home Care Act [210 ILCS 45] whether operated for profit or not; a
county home for the infirm and chronically ill which provides personal care,
sheltered care, or nursing for three or more persons not related to the
applicant or owner by blood or marriage; or an out-of-state facility meeting
Illinois standards. Facilities included are those that are licensed by the
Department of Public Health for skilled nursing, skilled/pediatric nursing,
intermediate care, intermediate care for the developmentally disabled (ICF/DD),
intermediate care for the developmentally disabled with 15 beds and under,
sheltered care, and facilities for individuals under age 22.
"Linkage." Person to person contact between a
recipient being discharged from a State-operated facility and the staff of a
community agency/facility which has agreed to provide necessary aftercare
services following the recipient's discharge. Linkage may include, but is not
limited to, the recipient's pre-discharge visit to the receiving
agency/facility; the receiving agency/facility pre-discharge visit with the
recipient at a State-operated facility; and/or post discharge initiation of
service delivery.
"Mandated follow-up." The statutorily-required
monitoring of recipients placed by the Department in licensed long-term care
facilities utilizing on-site visits to the facility for the purpose of
observing the health, well-being and adjustment of the recipient as well as the
appropriateness of the services and the suitability of the facility. This
monitoring activity must be provided for twelve months following placement,
including weekly visits during the first month, or for longer periods as
required (see Section 15 of the Mental Health and Developmental Disabilities
Administrative Act [20 ILCS 1705/15]).
"Placement." The act of Departmental staff, based
upon the finalization of appropriate plans for discharge, linkage, and
aftercare, in securing residential services in a licensed long-term care
facility for a recipient discharged from a state-operated facility for whom
Sections 15, 15a, 15b, and 16 of the Mental Health and Developmental
Disabilities Administrative Act [20 ILCS 1705/15, 15a, 15b and 16] mandates
follow-up monitoring services.
"Recipient of services" or "recipient."
A person who has received or is receiving treatment or habilitation
(Section 1-123 of the Code [405 ILCS 5/1-123]).
"State-operated facility." A mental health and/or
developmental center operated by the State of Illinois, under the jurisdiction
of the Department, which provides treatment/habilitation services for
recipients who are mentally ill, developmentally disabled or those alcohol
abusers who are a danger to themselves or others.
"Termination." The formal discontinuance of
mandated follow-up monitoring of recipients placed in licensed long-term card
facilities and/or the discontinuance of case coordination for recipients who
were previously served in state-operated facilities.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.20 RECIPIENT RIGHTS
Section 125.20 Recipient
rights
a) The rights of recipients of mental health and developmental
disabilities services in the public as well as the private sector are set forth
in Sections 2-100 through 2-111 of the Code [405 ILCS 5/2-100 through 2-111].
b) The observation and protection of recipient rights, as
specified in the statute, are applicable to all sections of this Part.
c) As a general rule, individuals lose none of their rights,
benefits, or privileges because they receive mental health or developmental
disabilities services. For example, a recipient does not lose the right to
vote, attend religious services or any other rights guaranteed by federal and
State constitutions and laws.
d) A summary of rights to which the recipients of services are
entitled include the following:
1) Adequate and humane care and services in the least restrictive
environment and an individualized services plan.
2) To communicate with other people in private, without
obstruction or censorship by the staff at the facility. This right includes
mail, telephone calls, and visits. There are limits upon this right, e.g.,
communication by these means may be reasonably restricted by the facility
director, but only to protect the recipient or others from harm, harassment or
intimidation. All letters addressed by a recipient to the Governor, members of
the General Assembly, Attorney General, judges, state's attorneys, officers of
the Department, or licensed attorneys at law must be forwarded at once to the
persons to whom they are addressed without examination by the facility
authorities. Letters in reply from the officials and attorneys mentioned above
must be delivered to the recipient without examination by the facility
authorities.
3) To receive, possess, and use personal property unless it is
determined that certain items are harmful to the recipient or others. On
discharge all lawful property must be returned to the recipient.
4) To use money as a recipient chooses, unless the recipient is
under 18 or under a court imposed restriction, including the appointment of a
guardian.
5) To deposit money in a bank or place it for safekeeping with
the facility. If the facility deposits a recipient's funds, any interest
earned will be the recipient's. Neither the facility nor any of its employees
may act as payee to receive any payment or assistance directed to a recipient,
including Social Security and pension, annuity, or trust fund payments without
informed consent of the recipient/guardian.
6) To be paid for work a recipient was asked to perform which
benefits the facility; the recipient may be required to do personal
housekeeping chores without being paid.
7) To refuse services, including medication. If refused, the
recipient will not be given such services except when necessary to prevent
serious harm to self or others.
8) To have restraints used only to protect the recipient from
physically harming self or others, or as a part of a medical/surgical
procedure.
9) Seclusion used only to prevent the recipient from physically
harming self or others.
10) A recipient will not receive electro-convulsive therapy
(electroshock) without informed consent as provided for in Section 2-110 of the
Code [405 ILCS 5/2-110].
11) Any unusual, hazardous, or experimental services require the
recipient's written and informed consent.
12) Except in emergencies, medical or dental services will not be
provided without informed consent of the recipient/guardian.
13) If recipient rights are restricted, the facility must notify
the following (using form MHDD-4, "Notice Regarding Rights of Recipient"):
A) Recipient and the person of the recipient's choice;
B) Parent or guardian, if the recipient is under age 18;
C) Court-appointed guardian for adult recipient;
D) The Guardianship and Advocacy Commission, if so designated (see
Section 2-201 of the Code [405 ILCS 5/2-201]).
SUBPART B: SYSTEM COMPONENTS
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.30 OVERVIEW
Section 125.30 Overview
a) Department facilities are primarily intensive
treatment/habilitation resources which provide therapeutic services to
recipients unable to adjust to community settings. As recipients respond to
the intensive services provided in Department facilities, they are encouraged
to attain greater degrees of independence in alternate living situations
within the community, either in their homes, or in residential facilities.
b) The optimal transition of recipients from State-operated
facilities requires active interaction among public and private sector service
providers. The components described in this Part, including the regional
discharge/linkage/aftercare (DLA) plan, discharge planning, and interagency
agreements, are designed to facilitate such interaction. Full implementation
of these components should result in the enhancement of the quality of the
service system and provide improved public accountability.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.40 REGIONAL DLA PLAN
Section 125.40 Regional DLA
plan
a) Each region shall develop a regional DLA plan which
articulates how the region will implement the policies and procedures contained
in this Part.
b) The plan must be developed to assure the quality,
effectiveness and continued appropriateness of aftercare services for each
recipient discharged from state-operated facilities and to provide an audit
trail which includes documentation and records to identify and track
recipients, to evaluate quality and quantity of services delivered, to monitor
fiscally and for compliance with related statutes and regulations as well as
compliance with responsibilities and functions outlined in this Part.
c) The content of the plan shall include:
1) Discussion of the regional DLA network, its strengths,
deficiencies and direction, and identification of those portions of the network
with which there will be written interagency agreements.
2) Designation of DLA staff responsibilities in the regional
office, at state-operated facilities and/or community agencies for functions
required by this Part.
3) Designation of case coordinator model(s) to be used in the
region.
4) Assessment of licensed long-term care facility staff training
needs and training plans to address these needs.
5) Procedures for handling mandated follow-up monitoring,
transfers and terminations.
6) Interagency agreements.
7) Procedures for reporting, with recipient consent, to the
referring agency/facility that a recipient is not referred for aftercare
treatment/habilitation services.
8) Process for developing and maintaining required records and
reporting.
9) Procedures for the dissemination of regional DLA plan.
10) Time frame for implementation of the DLA plan.
d) The regional DLA plan shall be submitted, within 60 days after
the effective date of the adoption of this Part, to the associate directors for
the Secretary's approval. The plan must assure regional compliance with this
Part. The Plan shall be reviewed annually and significant changes including
but not limited to changes in the regional network, dropped or added
interagency agreements, case coordinator model changes and available services
shall be submitted to the associate directors for the Secretary's approval.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.50 DISCHARGE PLANNING
Section 125.50 Discharge
planning
a) During the earliest treatment/habilitation planning activities
within a State-operated facility, active consideration must be given to the
current and anticipated needs of the recipient. While formal as well as
informal planning is conducted with the recipient, the individualized services
plan is recorded, as it evolves, in the recipient's record consistent with
professional judgment and the provisions set forth in the Code, and
Departmental and facility policy. Establishing and maintaining the recipient's
record is first and foremost a necessary practice which contributes to planning
for and providing the most appropriate services. In addition, recordkeeping
establishes the necessary documentation which provides an audit trail which is
used for a variety of accountability purposes such as securing facility
certification and accreditation, responding to judicial inquiries and the
assurance of general public accountability.
b) As the facility related treatment and habilitation goals
contained in the individualized services plan come closer to realization,
greater attention must be paid to numerous DLA related considerations. Prior
to making the decision to discharge and refer a recipient, the recipient's
readiness for that move must be assessed as well as the recipient's desire and
agreement to participate. In this assessment, consideration must be given, not
only to the desires of the recipient and the recommendations of State-operated
facility treatment/habilitation staff, but also the desires and recommendations
of the recipient's guardian, family, follow-up monitoring staff, community
agency staff previously involved with the recipient or likely to provide
services after discharge, and staff of other involved State agencies (such as
Department of Public Aid, Department of Children and Family Services, State
Board of Education and the Department of Corrections).
Agency note: Recipients who are drug abusers shall be referred to the
state Office of Planning and Program Development, Dangerous Drugs Commission.
The Commission shall participate in DLA planning and shall be responsible for
assuring the treatment/habilitation services, placement and/or follow-up are
provided to meet the individual recipient's aftercare needs.
c) The following general areas must be addressed for all
recipients regardless of the aftercare setting to which the recipients may be
discharged:
1) The need of the recipient for various services as detailed in
the individualized services plan.
2) The readiness and desires of the recipient or the recipient's
guardian.
3) The recipient's area of origin and/or location of social
supports.
4) The effectiveness of any previous individualized services
plans or other services the recipient may have received in the community prior
to the last admission to the State-operated facility.
5) A general assessment of the recipient's intellectual and
emotional state including the recipient's behavior.
6) Medication needs of the recipient.
7) Special procedures which must be followed related to the legal
status of the recipient due to the relationship of the recipient to the
criminal justice system. This includes recipients who are legally classified
as:
A) Not guilty by reason of insanity (NGRI);
B) Guilty but mentally ill;
C) Unfit to stand trial, to plead or be sentenced;
D) Hold order from the court.
AGENCY NOTE: These recipients can only be released pursuant to the
provisions of the Unified Code of Corrections [730 ILCS 5]. Further
clarification on this subject is found in the publication entitled
"Responsibilities of DMHDD for Persons Admitted as Unfit to Stand Trial,
To Plead or Be Sentenced in Accordance With Public Act 81-1217", December,
1981.
8) The availability of financial resources for recipients
discharged from State-operated facilities including:
A) Consideration of the recipient's ability to be self-supporting;
B) Consideration of other sources of personal or family income;
C) Assisting the recipient who does not return to independent or
semi-independent living in accessing necessary financial support, e.g.,
Supplemental Security Income (SSI), Department of Public Aid, and/or other
applicable funding;
D) Reasonable assistance in accessing financial support for
recipients returning to independent or semi-independent living.
9) After considering the factors listed above, a decision may be
made to discharge and refer the recipient to available and appropriate
aftercare services.
10) Before the actual discharge is completed the applicable items
listed below on the discharge planning check list need to be completed:
A) Secure the recipient's informed consent on form DMHDD-146,
"Authorization for Release of Information", in order to communicate
and share records with individuals and organizations regarding the recipient.
B) Identify the location, when possible, of the aftercare living
situation. For a recipient being placed in long-term care, the licensed
facility shall be identified.
C) Facilitate appropriate contact and linkage with family and/or
other individuals who can provide extended social support to the recipient (see
Section 125.50(b)).
D) Assist the recipient in accessing necessary financial
resources. Special emphasis must be given to this activity when the recipient
is not returning to independent or semi-independent living. In these cases,
applicable funding approval, such as the SSI approval letter or Department of
Public Aid point count, shall be forwarded to the receiving facility.
E) Refer the recipient to available support services including
social, psychological, vocational and transportation, and assist in the actual
linkage contact between the aftercare service provider(s) and the recipient.
F) Notify the recipient, guardian, attorney or person who
executed the application for admission of the intent to discharge. Special
attention as outlined in Section 125.50(c)(7) must be given to the discharge
notification process for recipients who are associated with the criminal
justice system.
G) Notice of discharge has been given and any and all written
objections relating to it have been heard and an administrative decision has
been rendered.
H) Complete part one of form DMHDD-20, "Discharge
Summary", by the date of discharge and part two of DMHDD-20, within 48
hours following discharge. For recipients placed in a licensed long-term care
facility, the DMHDD-20 must be transmitted at the time of placement.
I) Forward as necessary, any relevant medical or dental reports
to the appropriate aftercare agency/facility.
J) Assure the provision of an adequate supply of medication
sufficient to last until the first scheduled aftercare visit as contained in
the recipient's DLA plan.
K) Forward a copy of the guardianship papers to the aftercare
service provider(s) if the recipient is legally incompetent.
L) Assist the recipient in securing personal clothing, property
and funds.
M) Complete parts one and two of form DMHDD-189, "Recipient
Transfer Summary", for all recipients being placed in a long-term care
facility and transmit both parts of the form to the facility at the time of
placement.
N) Notify designated mandated follow-up staff of the placement of
the recipient in a licensed long-term care facility.
O) Transmit to the ICF/DD facility a copy of a psychological
assessment completed within the past 36 months for recipients who are being
placed there.
P) Provide placement notification, when such agencies are the
funding agencies, to the Department of Public Aid and the Social Security
Administration, stating the recipient's name, address of the facility and date
of placement.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.60 DISCHARGE NOTIFICATION AND OBJECTION PROCESS
Section 125.60 Discharge
notification and objection process
a) Written notice of discharge shall be given to the
recipient, if 12 years of age or older; to the attorney of record and guardian,
if any; and to the person who executed the application for admission. This
notice shall include the reason for the discharge and a statement of the right
object (Section 3-903 of the Code).
b) Whenever possible, notice of the discharge shall
be given at least seven days prior to the intended discharge date from
a mental health facility and 14 days prior to discharge from a
developmental disabilities facility (Sections 3-903 and 4-704 of the Code).
c) The recipient, if 12 years of age or older, may
object to discharge, or the attorney or guardian of a recipient or the
person who executed the application may object on behalf of a recipient.
Prior to discharge, a written objection shall be submitted to the director of
the facility in which the recipient is located. Upon receipt of
an objection, the facility director shall promptly schedule a hearing, with
the utilization review committee, to be held at the facility within
seven days (Sections 3-207, 3-903, 4-209 and 4-704 of the Code).
d) No discharge shall proceed pending a hearing on an objection,
unless the person objecting to the discharge consents to discharge pending the
outcome of the hearing (Sections 3-903 and 4-704 of the Code).
e) At the hearing, the Department shall have the burden of
proving that the recipient meets the standard for discharge under the Code
and under Section 15 of Mental Health and Developmental Disabilities
Administrative Act (Sections 3-903 and 4-704 of the Code).
f) Within three days after the conclusion of the hearing, the
utilization review committee shall submit its written recommendations to the
facility director. A copy of the recommendations shall be given to the
recipient and the objector. (Sections 3-903 and 4-704 of the Code)
g) Within seven days after receipt of the recommendations, the
facility director shall provide written notice to the recipient and objector of
either acceptance or rejection of the recommendations and reasons therefor.
h) If the facility director rejects the recommendations, or if
the recipient or objector requests a review of the facility director's
decision, the facility director shall promptly forward a copy of the decision,
the recommendations, and the record of the hearing to the Secretary of the
Department for final review. The decision of the facility director or the decision
of the Secretary of the Department, if his review was requested, shall be
considered a final administrative decision.
i) Any person affected by a final administrative decision of
the Department may have such decisions reviewed only under and in accordance
with the Administrative Review Law [735 ILCS 5/Art. III]. The
Administrative Review Law, and the rules adopted pursuant thereto,
apply to and govern all proceedings for the judicial review of final
administrative decisions of the Department (Section 6-101 of the Code).
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.70 INTERAGENCY AGREEMENTS
Section 125.70 Interagency
agreements
a) Recipients shall be referred from state-operated facilities to
supportive community programs in ways which insure the continuity of needed
services. Interagency coordination then is an essential element for improving
the capacity of the services system to provide necessary support. Written
interagency agreements facilitate the establishment, as well as the
understanding and observance of the agreements by various personnel associated
with the organizations.
b) Each Department region and/or State-operated facility must
maintain current written linkage agreements as part of its DLA plan with
appropriate community agencies involved in the network of services in that
region. The following elements are suggested for consideration in the
development of these interagency agreements.
1) Clear statement of the purpose of the agreement between
parties, identifying specific programs to be effected, with delineation of
goals and measurable objectives for the terms of the agreement.
2) Definitions of any terms that could be ambiguous between the
parties.
3) Specific actions, roles and responsibilities of each party to
the agreement as well as mutual responsibilities.
4) Designation of staff position(s) within each agency
responsible for:
A) Implementing the agreement as specified;
B) Monitoring the implementation;
C) Negotiating change when necessary to update agreement;
D) Resolving disagreements.
5) General administrative procedures for parties affected by the
agreement (i.e., specified time period for agreement, mechanism for
updating/revising, scheduling meetings, confidentiality safequards, referral
mechanisms, information sharing, and other assurances).
6) Evaluation design specified and agreed upon by all parties to
be used in monitoring implementation of agreement; identification of person(s)
responsible for evaluating and sanctions agreed on to assure its
implementation.
c) It is important that each region and/or facility maintain
these agreements and provide adequate staff to implement the provisions. This
may involve meeting regularly with staff from community agencies/facilities as
well as including community agency/facility staff on state-operated
treatment/habilitation teams. Alcoholism agencies must be in conformance with
59 Ill. Adm. Code 107.50.
d) Agencies which are performing mandated follow-up services for
the Department shall enter into an agreement which, in essence, establishes the
principle that mandated follow-up services are a statutory responsibility of
the Department. While performance of the function may be delegated to a
community agency, responsibility for the function cannot be delegated.
Therefore, the community agency acts as an agent of the Department in complying
with this legal mandate.
e) Additional policies and procedures required of community
agencies receiving financial support from the Department are contained in
Grants (59 Ill. Adm. Code 103) and in purchase of care program guidelines.
Designated regional staff are assigned to work with each community agency to
facilitate compliance with the requirements.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.80 RECIPIENT FINANCIAL SUPPORT
Section 125.80 Recipient
financial support
a) During DLA planning, financial support for the recipient's
continued treatment/habilitation services and other needs must be considered.
Designated staff will assist the recipient, family or guardian in understanding
their respective liabilities for treatment/habilitation and in accessing
available financial resources. The required authorizations to investigate or
access assets, income or benefits must be secured.
b) Sources to contact for information are the recipient, family
or guardian at admission, during treatment/habilitation or prior to discharge.
Sources which may be considered include insurance carriers, funding agencies,
e.g., Social Security offices, federal fiscal intermediaries (Blue Cross/Blue
Shield or E.D.S. Federal Corporation), and the Department of Public Aid (the
single State agency for Medicaid and administering agency for public assistance
and the State supplement), and township assistance agencies.
c) Resources which may be available for support based on
recipient eligibility include:
1) Private funding
A) Recipient's personal funds, e.g., assets which are negotiable
or can be liquidated;
B) Income, from employment, from assets, estates, trusts, and
facility trust funds;
C) Family funds, e.g., voluntary or due to legal liability.
2) Third party payments
A) Private insurance (disability and/or medical) carried by the
recipient or family;
B) Health maintenance organization plans (HMOs);
C) Black lung disease benefits (30 U.S.C.A. 924 (1981));
D) Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS/CHAMPVA) (38 U.S.C.A. 601 (1981));
E) Medicare, which is short-term hospital and medical insurance
(42 U.S.C.A. 1395b-1 (1981));
F) Medicaid, which is public medical assistance for the aged,
blind and disabled (42 U.S.C.A. 1396a (1981)).
3) Federal/state/local benefits/other
A) Social Security Retirement and Survivors Benefits (SSDI) (42
U.S.C.A. 401 (1981)) which is based on wage earners and employers
contributions;
B) Supplemental Security Income (SSI) (42 U.S.C.A. 1381 (1981)), a
federal income maintenance program for aged, blind and disabled, which also
requires documentation to establish disability for the blind and disabled by
the Department's Bureau of Disability Adjudication Services;
C) Railroad Retirement benefits (45 U.S.C.A. 231 (1981)) and
Veterans' Administration benefits (38 U.S.C.A. 521, 541, and 542 (1981)).
D) General/township assistance, state supplemental payments and
Bureau of Employment Security Benefits, Department of Labor.
E) Private industry professional groups, labor unions and other
organizations.
4) Local school district services or funding
When a
recipient aged 3 to 21 years is handicapped as defined in Section 14-1.02 of
the School Code [105 ILCS 5/14-1.02] and has not been graduated from high
school, the recipient is probably eligible to receive special education
services from a local school district. The parent or guardian should be
assisted in obtaining these services or funding.
5) Department sources
There is a
variety of purchase of care programs for the mentally ill, developmentally
disabled or alcohol abusers for which individuals may qualify.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.90 COMPETENCY
Section 125.90 Competency
a) A recipient age 18 or over is presumed legally competent. A
recipient is considered incompetent upon the filing of a petition with the
court where the court adjudges a recipient to be a disabled person. At the
time of the hearing a guardian may be appointed. (See Sections 11a-2 and 11a-3
of the Probate Act of 1975 [755 ILCS 5/11a-2 and 11a-3])
b) Guardianship is ordered only to the extent necessitated by the
recipient's actual mental, physical and adaptive limitations.
c) A guardian may be appointed for a recipient, if, because of
disability, there is a lack of sufficient understanding or capacity to make or
communicate responsible decisions concerning personal care. A guardian may be
appointed for the estate of a disabled recipient, if, because of disability,
the recipient is unable to manage an estate or financial affairs.
d) The appointment of a limited guardian does not constitute a
finding of legal incompetence. The appointment of a plenary guardian
constitutes a finding of legal incompetence (see Section 11a-14 of the Probate
Act of 1975 [755 ILCS 5/11a-14]).
e) The Code does not require the appointment of a guardian prior
to discharge.
SUBPART C: INFORMATION SYSTEMS PROCEDURES
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.100 OVERVIEW
Section 125.100 Overview
a) Public accountability of the Department's efforts to assist
recipients of mental health, developmental disability, or alcoholism services
in accessing appropriate levels of aftercare according to their needs is
achieved by documenting the process for discharge planning, linkage and
aftercare services. Depending on the types of community agencies/facilities
involved, this documentation is accomplished at the present time through an
information system which is either automated or manual. The uniform method of
reporting to be used by all receiving Department organizational units and grant
agencies is the Department's extramural system and its subsystem, the aftercare
linkage system (ACL). The description of this system and reporting instructions
are found in the Department's extramural systems manual, revised July 1, 1980.
This current computer system does not allow for recording of the referral to
more than one provider. Therefore, it is necessary to indicate the primary
agency/facility to whom the recipient is being referred for aftercare
treatment/habilitation services even though the discharge plan calls for
multiple service providers. The primary agency/facility for a recipient being
placed in a licensed long-term care facility must be that designated agency/facility
or Department organizational unit which has responsibility for the mandated
follow-up monitoring services.
AGENCY NOTE: For the purpose of documenting the linkage and
mandated follow-up monitoring services provided to recipients being placed in a
licensed long-term care facility, the receiving agency to whom the recipient is
referred shall be either the designated Department organizational unit or the
designated grant agency. The linkage of the recipient to the licensed
long-term care facility is documented through noting the home code of the
facility in which the recipient is placed, using form DMHDD-1001,
"Inpatient Statistical Reporting Form".
b) For referral to non-grant agencies or non-state-operated
facilities the method of reporting is similar but the documentation is effected
through other reporting mechanisms set forth in this Part.
c) Accurate recording of the discharge/linkage/aftercare status
for each person discharged from Department facilities is fundamental to the
effective management of the DLA system. The process explained in this Part is
absolutely necessary to document the successful linkage and provision of
aftercare services to the discharged recipient to be documented within the
Department.
d) When the discharge plan has been completed and the recipient
is ready for discharge, documentation is necessary to indicate the recipient's
agreed upon referral according to the following categories:
1) Referred for aftercare treatment/habilitation services
A) To a Department grant agency;
B) To a Department organizational unit;
C) To a Department purchase care facility;
D) To a non-Department funded agency;
E) To a licensed, registered, or certified private practitioner;
F) To a Veterans Administration (VA) facility;
G) Remanded by the court to another setting; or
H) Transferred to another state.
2) Not referred for aftercare treatment/habilitation services
A) Recipient refused aftercare services;
B) Aftercare, provided within the formal human service system
structure, is not required; or
C) Left against staff advice.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.110 REPORTING RESPONSIBILITIES AND METHODS
Section 125.110 Reporting
responsibilities and methods
The duties and responsibilities
of all Department DLA staff and the responsibilities agreed to by the receiving
agency/facility shall be broadly outlined within the regional DLA plan. Active
participation includes, but is not limited to representation on a discharge
planning team and participation in the development of the individualized
services plan, by communication and consultation with designated follow-up
staff, of the community agency/facility in discharge planning is highly
desirable as linkage can be more readily achieved and the recipient may be more
willing to follow through on the discharge plan. Outlined below are those
responsibilities which must be incorporated into and provided for in the
regional DLA plan.
a) Designated DLA staff responsibilities for referral to agencies
reporting through the extramural system consist of ensuring the accomplishment
of the following functions:
1) Securing recipient's agreement for linkage to an agency for
aftercare treatment/habilitation services and consent for release of
information confirming that the recipient has received initial service in
accordance with the discharge plan (form DMHDD-146, "Authorization for
Release of Information").
2) Communication with the proposed receiving agency to achieve the
following:
A) Obtaining the agency's identification (ID) number for the
recipient (current number if an open case); or the ID number for a recipient
whose case has been closed and is now being reopened; or the new ID number
assigned to a recipient being opened to the agency for the first time;
B) Active participation by the receiving agency in the development
of the discharge plan;
C) Definite appointment for the recipient (day, time, location,
and the name of the staff person the recipient is to see) to receive the
initial service indicated in the discharge plan;
D) Prompt completion and dispatch of the completed parts one and
two of form DMHDD-20, "Discharge Summary", within 48 hours after
discharge, excluding Saturdays, Sundays and holidays.
3) Communication with proposed receiving licensed long-term care
facility for those recipients being placed in such settings to achieve the
following:
A) Active participation in the development of the discharge plan;
B) Confirmation of the date of placement;
C) Copies of the completed form DMHDD-20, parts one and two,
"Discharge Summary", and form DMHDD-189, parts one and two,
"Recipient Transfer Summary", must accompany the recipient at the
time of placement.
4) Retention of all Department forms used in the discharge
process in the recipient's State-operated facility medical record.
b) Designated DLA staff responsibilities for referral to
agencies/facilities not reporting through the system consist of ensuring the
accomplishment of the following functions:
1) Recipient's agreement for linkage to an agency/facility for
aftercare treatment/habilitation services and consent for release of
information confirming that recipient has received initial service in
accordance with the discharge plan (form DMHDD-146, "Authorization for
Release of Information").
2) Communication with proposed receiving agency/facility to
achieve the following:
A) Active participation by the receiving agency/facility in the
development of the discharge plan;
B) Definite appointment for the recipient (day, time, location,
and the name of the staff person the recipient is to see) to receive the
initial service indicated in the discharge plan;
C) Prompt receipt (within 48 hours after discharge, excluding
Saturdays, Sundays and holidays) of copies of the completed form DMHDD-20,
"Discharge Summary", parts one and two;
D) Confirmation of the initial service provided to the recipient
after discharge.
3) Notification of the Department's Bureau of Information
Services of recipient information, including confirmation of receipt of initial
service after discharge, on the form DMHDD-1001 series, "Inpatient
Statistical Reporting Form".
4) Retention of all Department forms used in the discharge
process in the recipient's State-operated facility medical record.
c) Responsibilities of receiving agency reporting through the
extramural system ensuring the accomplishment of the following functions:
1) Recipient's authorization for release of information to the
Department discharging facility for the confirmation of linkage and initial
service delivery after discharge.
2) Communication with the discharging facility to achieve the
following:
A) Providing the agency's ID number for the recipient (current
number if an open case); or the ID number for a recipient whose case had been
closed and is now being reopened; or the new ID number assigned to a recipient
being opened to the agency for the first time;
B) Active participation in the development of the discharge plan;
C) Definite appointment for the recipient (day, time, location,
and the name of the staff person the recipient is to see) to receive the
initial service indicated in the discharge plan.
3) Confirmation and accounting for services provided to the
recipient through the extramural system and the aftercare linkage system.
d) Responsibilities of receiving agency/facility not reporting
through the extramural system consist of ensuring communication with the
discharging facility to achieve the following:
1) Active participation in the development of the discharge plan.
2) Definite appointment for the recipient (day, time, location,
and the name of the staff person the recipient is to see) to receive the
initial service indicated in the aftercare services plan.
3) Confirmation of the initial service provided to the recipient
after discharge.
SUBPART D: FOLLOW-UP SERVICES
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.120 OVERVIEW
Section 125.120 Overview
This Subpart describes the
process by which the Department and/or designated staff assures the quality,
the effectiveness and the continued appropriateness of aftercare services for
each DLA recipient needing case coordination and/or mandated follow-up monitoring
services which are intended to assure the following:
a) The recipient's rights and desires have been taken into
consideration through mutual planning, if feasible.
b) The recipient's family has been included in the placement
process, whenever possible, consistent with confidentiality requirements.
c) The receiving agency/facility is best able to meet the
recipient's needs.
1) An individualized services plan has been completed by the
discharging facility and accepted by the receiving agency/facility.
2) Firm recipient referral has been effected and the recipient is
being served by the receiving agency/facility.
3) The joint planning process for the recipient's progress
provides for the continuity of services within the services network.
d) On an ongoing basis, a recipient is not being abused,
neglected, or improperly cared for, and health needs are being met.
e) The designated staff will offer appropriate
treatment/habilitation alternatives as clinically indicated and assists, as
appropriate, in transfers.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.130 CASE COORDINATION
Section 125.130 Case
coordination
a) Case coordination is a mechanism for assuring and coordinating
services to meet the needs of those recipients who require this service. It
provides the necessary advocacy function to facilitate the linkage of a
recipient who has identified service needs to the available resources. The
case coordinator principally focuses on the service delivery system from the
vantage point of the individual recipient in need of the service, and engages
in resource identification and linkage.
b) Case coordination attends to the practical level of
synchronizing the efforts of multiple service providers and other supportive
resources which enable the recipient to live successfully in a community
setting. However, the case coordination function does not displace the responsibility
of other service providers to work directly with the recipient or with the
family, community supportive resources or other service organizations as
provided for in the individualized services plan. Rather, the case
coordinating function complements and integrates the usual services for those
recipients whose need is so substantial so as to require an extraordinary level
of service attention. Case coordinators rely, in large part, on:
1) Working knowledge of the nature and consequences of the recipient's
disability;
2) Functional knowledge of the service delivery system, recipient
eligibility requirements and procedures;
3) A working understanding of potential recipient resources,
particularly those available through federal, State and local governmental
agencies; and
4) The ability to work cooperatively with the many individuals
and organizations which can provide services and assistance to the recipient.
c) Typical settings – Case coordination shall be provided through
various organizational entities:
1) By the Department;
2) Through an entity which also provides direct recipient
services or other indirect services; or
3) Through a free-standing entity whose sole function is the
provision of case coordination services.
d) Typical activities – Activities a case coordinator engages in
may include:
1) Assessment of service need: Participates with direct service
staff in assessing an individual's needs and readiness to move into alternate
services or settings, utilizing clinical evaluation of intellectual, emotional
and functioning levels. Where appropriate, standardized assessment
instruments, such as the Illinois Client Information System (ICIS) for
developmentally disabled recipients, will be used in conjunction with the
professional evaluation of need.
2) Development of recipient individualized services plan:
Participates with responsible program staff in developing a plan for the most
effective and appropriate continuum of generic and specialized services.
3) Arrangement for service delivery: Assists recipient in
identifying appropriate providers of care, screening and assistance in the
eligibility process for Department or Department-supported programs as well as
other public or private programs, and facilitating the linkage of recipients to
service provider(s), and case coordination in a new location, if appropriate.
4) Coordination and advocacy with service providers: Is
responsible for enabling continuity, accessibility and the most effective
delivery of services as prescribed in the individualized services plan
including the facilitation of coordination activities among multiple providers.
5) Follow-up: Conducts scheduled activities to monitor and
evaluate the recipient's progress toward established service goals, and the
need for continuing services. While follow-up activities focus on recipient
status, they also may provide commentary on service irregularities or
deficiencies and provide recommendations on the status and quality of care
provided by the service delivery system.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.140 MANDATED FOLLOW-UP MONITORING SERVICES
Section 125.140 Mandated
follow-up monitoring services
a) Provisions contained within Sections 15 through 16 of the
Mental Health and Developmental Disabilities Administrative Act [20 ILCS
1705/15 through 16] mandate specific types of follow-up services for recipients
who are being discharged from Department State-operated facilities and placed
in licensed long-term care facilities, as defined by Section 1-113 of the
Nursing Home Care Act [210 ILCS 45/1-113].
b) Before discharge from a state-operated facility can be
considered, a clinical and professional decision must have been made that a
recipient will derive benefits from a proposed placement, is legally competent
(or is in the process of having legal competency restored), has a guardian if
declared legally incompetent (or is in the process of having a guardian
appointed), and requires the medical and personal care and/or supervision as
described in the Nursing Home Care Act. The lack of a guardian, however, shall
not inhibit discharge planning and placement once it has been deemed that
continuing State-operated treatment/habilitation services will no longer be of
benefit to a recipient. Department staff will do all that is possible to
obtain suitable guardians; however, if these efforts prove to be unsuccessful
the regional office of the Guardianship and Advocacy Commission shall be
contacted and all appropriate information, such as but nor limited to, the
recipient, the recipient's condition, the inability to locate a person to serve
as guardian and the need for guardianship, forwarded.
c) Mandated follow-up services may be delegated by the Department
to community agencies. This delegation shall be based on but not limited to
caseload needs, availability of staff and available resources. This
arrangement, however, will require a special contract between the Department
and the agency. This contract establishes that the community agency acts as an
agency of the Department and is bound by this Part. In addition, employees of
any community agency that has a long-term care monitoring contract with the
Department, is subject to the same conflict of interest rule as Department
employees (59 Ill. Adm. Code 101.80).
d) As required by the Mental Health and Developmental
Disabilities Confidentiality Act the recipient's confidentiality shall be
protected.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.150 PRE-PLACEMENT GUIDELINES
Section 125.150
Pre-placement guidelines
a) In order to fulfill statutory directive as well as providing
due process for persons placed in licensed long-term care facilities,
designated DLA staff shall assure that requirements of the Mental Health and
Developmental Disabilities Code summarized in Section 125.40 and of the Nursing
Home Care Act are followed.
b) Consideration shall also be given to the interests and the
needs of the recipient and the capacity of the facility to address those needs.
1) Out-of-region placement of recipients is permissible and
requires written approval between the designated regional staff of the regions
involved. Approval will be based on criteria in Section 125.160(f)(1).
2) The Department shall not place discharged recipients in
facilities located outside of the State of Illinois unless appropriate
facilities are not available within the State, or if placement in a contiguous
state results in locating a recipient in a facility closer to home or family.
3) When it becomes necessary for arrangements to be made for
placement in a state other than Illinois, the designated DLA staff shall notify
the appropriate regional administrator who approves of the transfer based on
criteria in Section 125.160(f)(1), and who shall notify the Department's
Interstate Services Branch.
4) The Department is responsible for providing follow-up services
to all recipients placed residentially in out-of-state facilities and shall
indicate the regional DLA plan how follow-up services will be provided. A
recipient cannot be placed in an out-of-state facility if it is not licensed by
the state in which the facility is located. Subsequent to placement, if an
appropriate facility within the State becomes available at a distance equal to
or closer to the recipient's home or family, the recipient shall be returned
and placed at this facility.
AGENCY NOTE: Three months after an out-of-state placement has been made,
the Department must send copies of visitation reports to the recipient's
parent(s), guardian or nearest responsible relative (see Section 15.1 of the
Mental Health and Developmental Disabilities Administrative Act [20 ILCS
1705/15.1]).
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.160 FOLLOW-UP MONITORING GUIDELINES
Section 125.160 Follow-up
monitoring guidelines
Designated mandated follow-up
staff shall assure compliance with the provisions of the Mental Health and
Developmental Disabilities Administrative Act and compliance with the following
Departmental policies.
a) Recipient monitoring
1) Provide or contract for the provision of individual monthly
monitoring of recipients placed in a licensed long-term care facility for at
least 12 months, including visits on a weekly basis during the first month.
2) Interview the recipient during the course of follow-up visits
and discuss program involvement and/or other needs with staff in the licensed
long-term care facility.
3) Observe, review and document the following:
A) The recipient's comments and concerns;
B) The recipient's overall adjustment to the facility; and
C) The adequacy of the recipient's current individualized services
plan as maintained by the facility.
4) The adequacy of the programs and services available in the
facility and in the community for meeting the needs of the recipient which may include,
but are not limited to:
A) Activities;
B) Social (re)habilitation;
C) Restoration nursing;
D) Diagnostic testing; and
E) Psychological and social services.
5) Sufficiency of the nursing and medical services to meet the
physical health needs of the recipient.
AGENCY NOTE: For the conditionally discharged recipient, designated
staff must visit or consult with the recipient and the family on the condition
of the recipient and advise the family of care that will be most favorable for
the recipient. This visitation and contact requirement shall remain in effect
while the recipient is on conditional discharge and shall terminate when such
status is terminated.
b) Reporting and records
1) Reports of deaths, accidents and unusual occurrences
A) All deaths of recipients, or accidents and unusual occurrences,
such as reports of abuse, neglect and improper care, involving a recipient,
shall be reported by the facility by telephone within twelve hours to the
designated mandated follow-up staff, guardians (including the Office of the
State Guardian, where appointed) and next of kin and confirmed in writing no
later than the next working day with a complete statement of circumstances.
The facility must promptly notify the coroner of all deaths pursuant to Section
3-3013 of the Counties Code [55 ILCS 5/3-3013].
B) Designated staff shall close cases in which death occurs in the
Department's extramural reporting system by filing form DMHDD-1006, "Case
Information".
2) Monthly facility report – Designated staff shall report on the
results of their onsite visits to each facility on the monthly evaluation
report for long-term care facilities. Copies of this report shall be submitted
to the licensed long-term care facility and to the designated regional staff,
with a copy being retained by the designated mandated follow-up staff.
3) Semiannual facility report
A) The regional administrator will submit to the associate
directors, semiannually, a summary of the monthly facility reports for each
facility within the region.
B) These reports may be used for the evaluation and continued
approval or denial of placements in licensed long-term care facilities.
4) Monthly and annual information report
Monthly and annually a report shall be produced for Central
Office and regional use by the Department's Bureau of Information Services
including the following information by disability:
A) The total number of facilities serving the Department's
mandated follow-up recipients;
B) The total number of Department recipients placed during the
current month and year-to-date;
C) The total number of Department mandated follow-up recipients in
each facility;
D) The total number of Department mandated follow-up recipients
being monitored on a weekly and monthly basis;
E) The number of mandated follow-up recipients readmitted to state-operated
facilities from licensed long-term facilities for the current month and
year-to-date;
F) The number of mandated follow-up recipients transferred to
another licensed long-term care facility, to a State-operated facility, to
independent living for the current month and year-to-date;
G) The number of deaths of Department mandated follow-up
recipients for the current month and year-to-date; and
H) The total number of drug abusers for the current month and
year-to-date.
c) Program development and monitoring
1) When necessary, designated mandated follow-up staff may
provide training as outlined in Section 15 of the Mental Health and
Developmental Disabilities Administrative Act as outlined to assist facilities
in meeting the unique needs of persons previously served by the Department.
2) Designated mandated follow-up staff will assist a facility in
arranging for resources to program for these populations, e.g., activity
programs, treatment/habilitation programs and other specialized programs. These
program development functions may include:
A) Providing time limited direct services in an effort to train
facility staff;
B) Providing workshops on special programs or procedures;
C) Consulting with program staff or licensed long-term care
facilities regarding the development of individualized services plans;
D) Developing methods of implementation; and
E) Evaluating programs available in the licensed long-term care
facility.
3) At least annually, the Department must review facility
training records prescribed by Department of Public Health standards for
licensure of long-term care facilities (Minimum Standards for the Licensure of
Long-Term Care Facilities for the Developmentally Disabled (77 Ill. Adm. Code
350); Minimum Standards for the Licensure of Long-Term Care Facilities – Persons
Under Twenty-Two (22) Years of Age (Divisions 1 through 73); Minimum Standards
for the Licensure of Long-Term Care Facilities – Sheltered Care Facilities (77
Ill. Adm. Code 330); and Minimum Standards for the Licensure of Long-Term Care
Facilities – Skilled Nursing Facilities and Intermediate Care Facilities (77
Ill. Adm. Code 300)) and make recommendations regarding future training needs.
Specific recommendations regarding orientation and inservice staff training
must be included in the semiannual facility report. This report must also
contain a judgment as to the sufficiency and capability of the staff in the
facility.
4) Program development and monitoring activities must be
documented and maintained in a file readily available to the appropriate region
office.
AGENCY NOTE: Designated mandated follow-up staff shall not provide
consulting services for the purpose of meeting Department of Public Health
licensure requirements, nor can fees be charged for the program development
services provided by the Department or its contracted agents performing
follow-up monitoring services.
d) Termination from mandated follow-up services
1) Termination of follow-up monitoring services occurs after the
12-month period, except in cases of death, discharge to other than a licensed
long-term care facility, or discharged for leaving against staff advice.
Termination which is an individualized programmatic and clinical decision is
based on the following criteria:
A) A clinical determination has been made that mandated follow-up
services to the recipient are no longer necessary to maintain adjustment in the
licensed long-term care facility.
B) Appropriate and necessary linkage to community resources have
been established which will enable the recipient to function independently.
C) The developmentally disabled recipient is receiving specialized
programmatic services to meet the objectives for further personal development
as contained in the individualized services plan, and that procedural
continuity is established which is essential to maintain adaptive levels and/or
to prevent behavioral/developmental regression.
D) The recipient has substantially achieved the objectives
outlined in the individualized services plan.
E) The facility has demonstrated its ability to provide the
necessary continuing support and appropriate programming to the recipient.
AGENCY NOTE:
When the decision to terminate has been made, designated staff shall check the
follow-up notes and recipient records to insure that the recipient's recorded
progress clinically supports the decision to terminate. In cases of
developmentally disabled individuals on conditional discharge, who are being
considered for termination from mandated follow-up services, a copy of the
community placement termination summary will be forwarded to the regional
administrator or designee as the recommendation for termination. The regional
administrator or designee must give approval before the termination is
effected.
2) The termination of recipients from mandated follow-up
services, however, does not necessarily mean that contact with these persons
shall cease. Statutorily required follow-up monitoring services and reporting
shall cease, services including but not limited to those covered in the
individualized services plan may continue to be provided. Supportive services
and/or case coordination, if appropriate, should be provided based on the
recipient's on-going needs.
e) Continuing mandated follow-up status
Monthly comments will be forwarded to the designated
Department region staff on each community placement recipient who exceeds one
year in continuing mandated follow-up status. Comments will relate to
specifics pertaining to inadequate adjustment of the recipient or any other
cause considered significant enough to maintain the case in mandated status.
f) Transfers of recipients
1) Transfers, when necessary, from one long-term care facility to
another may be to assure the recipient's health and well being. Primary
attention shall be given to the needs and choices of the individual recipient
(a recipient cannot be moved against the recipient's will except in an
emergency). A transfer is indicated if the facility cannot meet the current
needs of the recipient; or the recipient has been neglected, abused or
improperly cared for; or if the facility is not in substantial compliance with
previously cited licensure standards or has not developed an acceptable plan of
correction as determined by the Illinois Department of Public Health.
2) If a transfer is indicated, designated staff shall cooperate
in the transfer of mandated follow-up recipients from one licensed long-term
care facility to another. The regional DLA plan shall specify how transfer
activities shall be coordinated with involved State agencies.
3) In times of disaster or emergency, designated staff may need
to be involved in the transfer of recipients who have been terminated from
mandated follow-up monitoring services.
AGENCY NOTE: Designated staff must document all transfer
activities and maintain the documentation in the recipient's record.
4) Routine transfers
A) All recipients shall be transferred insofar as possible, in or
near the communities in which the recipients reside or in which the recipients'
families or significant others, such as a guardian or a friend, reside. The
same considerations and procedures followed for the initial planning for
discharge/linkage/aftercare shall apply (see Section 125.40).
B) Transfers may be initiated at the request of the recipient or
legally responsible party. Transfers may also be initiated by the long-term
care facility's administrator. Under such situations, designated staff will
work with the Department of Public Aid and other involved agencies.
5) Inter-region transfers
Recipients may be moved between regions provided there is a
prior agreement with both regional administrators or their designated agents
involved in the transfer.
6) Emergency transfers
A) The Department of Public Health under Sections 3-401 through 3-423
of the Nursing Home Care Act [210 ILCS 45/3-401 through 3-423] and the
Department under Section 15 of the Mental Health and Developmental Disabilities
Administrative Act are empowered to take specific action to transfer recipients
who are not receiving appropriate services and/or when conditions exist in a
facility which imperil the health or pose a serious and imminent threat to the
life or safety of those recipients.
B) Both Departments must make all reasonable efforts to eliminate
any threats to the safety and well-being of any recipient, through
consultation with the facility, the attending physician, and the recipient,
spouse, parents, responsible relative or guardian (see Section 15 of the Mental
Health and Developmental Disabilities Administrative Act).
C) The Department of Public Health is given broad statutory
authority and primary responsibility to transfer any individual who is not
receiving appropriate services in licensed long-term care facilities. The
Department's legal authority deals specifically with individual recipients who
have been placed by the Department in these facilities.
D) The Department must work in close cooperation with the
Department of Public Health to effect the transfer of recipients whose life or
safety is in imminent danger. However, the Department may, in the proper
exercise of its statutory mandate, initiate action to provide for the health
and welfare of mandated follow-up recipients residing in a facility.
| TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 125
RECIPIENT DISCHARGE/LINKAGE/AFTERCARE
SECTION 125.170 STAFF ACTION IN EMERGING OR EXTRAORDINARY CIRCUMSTANCES
Section 125.170 Staff action
in emerging or extraordinary circumstances
a) Designated mandated follow-up staff shall personally observe
the recipient, review individual progress and adjustment within the placement
setting, and review the following considerations:
1) The recipient's rights and desires have been taken into consideration;
2) The receiving agency/facility continues to meet recipient
needs;
3) The individualized services plan is being constantly updated
by staff of the receiving agency;
4) Joint planning for the recipient's progress continues; and
5) On an on-going basis, the recipient has not been abused,
neglected or improperly cared for.
b) As mandated follow-up or other visits are made, designated
staff shall review for:
1) Prolonged understaffing;
2) Suspected abuse/neglect;
3) Inappropriate level of care;
4) Unattended medical needs;
5) Unexplained weight loss or gain;
6) Filth, dirt and odors; and
7) Inquiries from family, media or elected officials.
c) If these or other untoward or extraordinary situations such as
room temperature extremes, contagious diseases and natural catastrophes are
noted, the following steps shall be undertaken and fully documented:
1) Consultation with the licensed long-term care facility
administrator and/or appropriate staff shall occur to discuss any deficient
conditions. This consultation and any actions agreed to shall be fully
documented. If resolution is achieved, further steps need not be taken.
Regional offices of the Department of Public Health shall be kept informed.
2) If resolution is not reached, immediate verbal reports to the
regional and central offices of the Department of Public Health, as well as to
the regional administrator and appropriate associate directors of the
Department must be made, followed by written confirmation within 24 hours.
3) Initiate regional interagency review with involved state
agencies and formulate necessary action to resolve the situation. The right to
a neutral hearing as provided for in Sections 3-703 through 3-802 of the
Nursing Home Care Act [210 ILCS 45/3-703 through 3-802] and Sections 2-704,
3-207, 3-903, 4-209 and 4-709 of the Code must, however, be observed.
4) If a regional solution is not reached, the appropriate associate
directors are notified and requested to facilitate resolution with the
appropriate state agencies.
5) If resolution is not reached, the region will be instructed to
initiate transfer by:
A) Consulting with each recipient potentially involved in the
transfer and documenting the recipient's response and notifying family or legal
guardian;
B) Locating and arranging for suitable alternative placement;
C) Coordinating the transfer with the Department of Public Health
and applicable funding agencies;
D) Assuring that records required in this Part are maintained and
personal effects are properly safeguarded; and
E) Submitting a follow-up report to the associate directors.
d) Report of abuse or neglect of a recipient by an owner,
licensee, administrator, employee, or agent of a facility shall be made to
local law enforcement officials as provided in the Abuse and Neglected Long
Term Care Facility Residents Reporting Act [210 ILCS 30].
AUTHORITY: Implementing and authorized by Section 5-104 of the Mental Health and Developmental Disabilities Code [405 ILCS 5/5-104] and Sections 5, 15, 15.1, 15a, 15b and 16 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705/5, 15, 15.1, 15a, 15b and 16].
SOURCE: Adopted and codified at 7 Ill. Reg. 11234, effective August 31, 1983; emergency amendment at 16 Ill. Reg. 2672, effective February 1, 1992, for a maximum of 150 days; recodified from the Department of Mental Health and Developmental Disabilities to the Department of Human Services at 21 Ill. Reg. 9321.
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