TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 147 REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES
SECTION 147.335 ENHANCED CARE RATES
Section 147.335 Enhanced Care Rates
An additional enhanced rate is applied for certain categories of residents that are in need of more resources.
a) Ventilator Services – The following criteria shall be met to be eligible for enhanced rates.
1) Ventilators are defined as any type of electrical or pneumatically powered closed mechanical system for residents who are, or who may become, unable to support their own respiration. It does not include Continuous Positive Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP) devices. When ventilators are used to deliver CPAP or BiPAP they shall not be counted as ventilator services for enhanced rates.
2) Ventilators set to PEEP or CPAP to aid in weaning a resident from the ventilator are included. The weaning process shall be documented in the clinical record. Ventilators used to deliver CPAP or BiPAP services for the resident with Sleep Apnea are not included.
3) Nursing facility shall notify the Department using a Department designated form that includes a physician order sheet that identifies the need and delivery of ventilator services. A facility shall also use the designated form to notify the Department when a resident is no longer receiving ventilator services. In addition, a Section S item response of the MDS may be used.
4) The following criteria shall be met in order for a facility to qualify for ventilator care reimbursement.
A) A facility shall establish admission criteria to ensure the medical stability of patients prior to transfer from an acute care setting.
B) Facilities shall be equipped with technology that enables it to meet the respiratory therapy, mobility and comfort needs of its patients.
C) Clinical assessment of oxygenation and ventilation-arterial blood gases or other methods of monitoring carbon dioxide and oxygenation shall be available on-site for the management of residents. Documentation shall support clinical monitoring of oxygenation stability was completed at least twice a day.
D) Emergency and life support equipment, including mechanical ventilators, shall be connected to electrical outlets with back-up generator power in the event of a power failure.
E) Ventilators shall be equipped with internal batteries to provide a short term back-up system in case of a total loss of power.
F) An audible, redundant ventilator alarm system shall be required to alert staff of a ventilator malfunction, failure or resident disconnect. A back-up ventilator shall be available at all times.
G) Facilities licensed under the Nursing Home Care Act [210 ILCS 45] shall have a minimum of one RN on duty for 8 consecutive hours, 7 days per week, as required by 77 Ill. Adm. Code 300.1240. For facilities licensed under the Hospital Licensing Act, an RN shall be on duty at all times, as required by 77 Ill. Adm. Code 250.910. Additional RN staff may be determined necessary by the Department, based on the Department's review of the ventilator services.
H) Licensed nursing staff shall be on duty in sufficient numbers to meet the needs of residents as required by 77 Ill. Adm. Code 300.1230. For facilities licensed under the Nursing Home Care Act, the Department requires that an RN shall be on call, if not on duty, at all times.
I) No less than one licensed respiratory care practitioner licensed in Illinois shall be available at the facility or on call 24-hours a day to provide care, monitor life support systems, administer medical gases and aerosol medications, and perform diagnostic testing as determined by the needs and number of the residents being served by a facility. The practitioner shall evaluate and document the respiratory status of a ventilator resident on no less than a weekly basis.
J) A pulmonologist, or physician experienced in the management of ventilator care, shall direct the care plan for ventilator residents on no less than a twice per week basis.
K) At least one of the full-time licensed nursing staff members shall have successfully completed a course in the care of ventilator dependent individuals and the use of the ventilators, conducted and documented by a licensed respiratory care practitioner or a qualified registered nurse who has at least one-year experience in the care of ventilator dependent individuals.
L) All staff caring for ventilator dependent residents shall have documented in-service training in ventilator care prior to providing such care. In-service training shall be conducted at least annually by a licensed respiratory care practitioner or qualified registered nurse who has at least one-year experience in the care of ventilator dependent individuals. Training shall include, but is not limited to, status and needs of the resident, infection control techniques, communicating with the ventilator resident, and assisting the resident with activities. In-service training documentation shall include name and title of the in-service director, duration of the presentation, content of presentation, and signature and position description of all participants.
M) Documentation shall support the resident has a health condition that requires medical supervision 24-hours a day of licensed nursing care and specialized services or equipment.
N) The medical records shall contain physician's orders for respiratory care that includes, but is not limited to, diagnosis, ventilator settings, tracheostomy care and suctioning, when applicable.
O) Documentation shall support the resident receive tracheostomy care at least daily.
5) To be eligible to receive ventilator add-on, facilities shall also be required to implement the established written protocols on the following areas:
A) Pressure Ulcers. A facility shall have established policies and procedures on assessing, monitoring and prevention of pressure ulcers, including development of a method of monitoring the occurrence of pressure ulcers. Staff shall receive in-service training on those areas.
i) Documentation shall support the resident has been assessed quarterly for their risk for developing pressure ulcers.
ii) Documentation shall support that interventions for pressure ulcer prevention were implemented and include, but are not limited to, a turning and repositioning schedule, use of pressuring reducing devices, hydration and nutritional interventions and daily skin checks.
B) Pain. A facility shall have established policies and procedures on assessing the occurrence of pain, including development of a method of monitoring the occurrence of pain. Staff shall receive in-service training on this area.
i) Documentation shall support the resident has been assessed quarterly for the presence of pain and the risk factors for developing pain.
ii) Documentation shall support an effective pain management regime is in place for the resident.
C) Immobility. A facility shall have established policies and procedures to assess the possible effects of immobility. These shall include, but not be limited to, range of motion techniques, contracture risk. Staff shall receive in-service training on this area.
i) Documentation shall support the resident's risk for contractures were assessed quarterly and interventions are in place to reduce the risk.
ii) Effects of immobility will be monitored and interventions implemented as needed.
D) Risk of infection. A facility shall have established policies and procedures on assessing risk for developing infection and prevention techniques. These shall include, but are not limited to proper hand washing techniques, aseptic technique in delivery care to a resident, and proper care of equipment and supplies. Staff shall receive in-service training on this area.
i) Documentation shall support the resident was given oral care every shift to reduce the risk of infection.
ii) Documentation shall support the facility has a method to monitor and track infections.
E) Social Isolation. A facility shall have a method of assessing a resident's risk for social isolation. Interventions shall be in place to involve a resident in activities when possible.
F) Ventilator Weaning. A facility shall have a method of routinely assessing a resident's weaning potential and interventions implemented as needed. Documentation shall support the weaning process and the use of mechanical ventilation for a portion of each day for stabilization.
G) Policies shall include monitoring expectations of the ventilator resident, routine maintenance of equipment and specific staff training related to ventilator settings and care.
H) In order to maintain quality standards and reduce cross contamination, the facility shall have a policy for cleaning and maintaining equipment.
6) Department staff shall conduct on-site visits on a random or targeted basis to ensure both facility and resident compliance with requirements. All records shall be accessible to determine that the needs of a resident are being met and to determine the appropriateness of ventilator services. In addition to the requirements of this subsection (a), Department review shall include, at a minimum, the following:
A) The tracking of Ventilator Associated Pneumonia;
B) Documentation to track hospitalizations, reason for hospitalizations, and interventions aimed at reducing hospitalizations for ventilator residents;
C) Ventilator weaning.
7) An enhanced payment shall be added to the rate determined by the methodology currently in place:
A) Payment shall be made for each individual resident receiving ventilator services;
B) The rate add-on for ventilator service is $208 per day.
b) Traumatic Brain Injury (TBI) – The following criteria shall be met to be eligible for enhanced rates.
1) A facility shall meet all the criteria set forth in this subsection for TBI care to a resident in order to receive the enhanced TBI reimbursement rate identified.
2) TBI is a nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.
3) The following criteria shall be met in order for a facility to qualify for TBI reimbursement.
A) The facility shall have written policies and procedures for care of the residents with TBI and behaviors that include, but are not limited to, monitoring for behaviors, identification and reduction of agitation, safe and effective interventions for behaviors, and assessment of risk factors for behaviors related to safety of residents, staff and staff shall be in-serviced on these policies.
B) The facility shall have staff to complete the required physical (PT), occupational (OT) or speech therapy (SP), as needed. Additionally, a facility shall have staffing sufficient to meet the behavior, physical and psychosocial needs of the resident.
C) Staff shall receive in-service for the care of a TBI resident and dealing with behavior issues identifying and reducing agitation, and rehabilitation for the TBI resident. In-service training shall be conducted at least annually. In-service documentation shall include name and title of the in-service director, duration of the presentation, content of presentation, and signature and position description of all participants.
D) The facility environment shall be such that it is aimed at reducing distractions for the TBI resident during activities and therapies. This shall include, but not be limited to, avoiding overcrowding, loud noises, lack of privacy, seclusion and social isolation.
E) Care plans on all residents shall address the physical, behavioral and psychosocial needs of the TBI residents. Care plans shall be individualized to meet the resident's needs, and shall be revised as necessary.
F) The facility shall use the "Rancho Los Amigos Cognitive Scale" to determine the level of cognitive functioning. The assessment shall be completed quarterly by a trained rehabilitation registered nurse. Based on the level of functioning, and the services and interventions implemented, a resident will be placed in 1 of 3 tiers of payments. Tier 3 is the highest reimbursement. By completing a Department designated form, facilities will be responsible for notifying the Department of the applicable tier in which a resident is placed.
G) Documentation found elsewhere in the resident records shall support the scoring on the Rancho Los Amigos Scale as well as the delivery of coded interventions.
4) Admission Criteria
A) Documentation by a neurologist that the resident has a severe and extensive TBI diagnosis.
B) The diagnosis meets RAI Manual requirements for coding.
C) There shall be documentation the diagnosis has resulted in significant deficits and disabilities that required intense rehabilitation therapy. In addition, documentation from the neurologist shall identify the resident has the ability to benefit from rehabilitation and a potential for independent living.
D) Diagnostic testing shall support the presence of a severe and extensive TBI as a result of external force as defined in subsection (b)(2).
E) Documentation the resident was assessed using the Rancho Los Amigos Cognitive Scale and scored a Level IV through X. Residents scoring a Level I, II or III on the Rancho Los Amigos Cognitive Scale shall not be eligible for TBI reimbursement.
F) Documentation the resident is medically stable and has been assessed for potential behaviors and safety risk to self, staff and others.
5) Documentation supports the Tier I requirements are as follows:
A) Tier I shall not exceed 6 months.
B) The resident shall have previously scored in Tier II or Tier III.
C) The resident has received intensive rehabilitation and is preparing for discharge to the community. The resident shall receive intervention and training focusing on independent living skills, prevocational training and employment support. This includes, but is not limited to, community support options, substance abuse counseling, as appropriate, time management and goal setting.
D) Resident scores a Level VIII through X on the Rancho Los Amigos Cognitive Scale (Purposeful, Appropriate, and stand-by assistance to Modified Independence).
E) No behaviors or Behaviors present, but less than 4 days (E0200A-C<2 AND E0500A-C=0 AND E0800< 2 and E1000A+B=0). If behaviors are present, resident receives behavior management training to address the specific behaviors identified.
F) Cognition. Brief Interview for Mental Status (BIMS) is 13 through 15 (Cognitively intact, C0500).
G) Activities of daily living (ADL) functioning. All ADL tasks shall be coded less than 3 (Section G).
H) An assessment shall be completed quarterly to identify the resident's needs and risk factors related to independent living. This assessment shall include, but is not limited to, physical development and mobility, communication skills, cognition level, food preparation and eating behaviors, personal hygiene and grooming, health and safety issues, social and behavioral issues, ADL potential with household chores, transportation, vocational skills and money management.
I) Discharge Potential. There is an active discharge plan in place (Q0400A=1) or referral has been made to the local contact agency (Q0600=1). There shall be weekly documentation by a licensed social worker related to discharge potential and progress. This shall include working with the resident on community resources and prevocational employment options.
J) The resident shall receive interventions and/or training related to their specific discharge needs.
6) Documentation supports the Tier II requirements are as follows:
A) Tier II shall not exceed 12 months.
B) Resident has reached a plateau in rehabilitation ability, but still requires services related to the TBI. Resident shall have previously scored in Tier III. The resident continues to receive restorative nursing services.
C) Resident scores a Level IV throughVII on the Rancho Los Amigos Cognitive Scale (Confusion, may or may not be appropriate).
D) Cognition. BIMS is less than 13 (C0500) or Cognitive Skills for decision making are moderately to severely impaired (C1000=2 or 3).
E) Resident has behaviors (E0300=1 or E1000=1) and these behaviors impact resident (E0500A-C=1) or impact others (E0600A-C=1). Behaviors shall be tracked daily and interventions implemented. There shall be documentation of weekly meetings with interdisciplinary staff to discuss behaviors, effectiveness of interventions and to implement revisions as necessary.
F) ADL function (Section G) 3 or more ADL require limited or extensive assistance.
G) Resident is on 2 or more of the following restorative: Bed Mobility (O0500D=1), Transfer (O0500E=1), Walking (O0500F=1), Dressing/Grooming (O0500G=1), Eating (O0500H=1) or Communication (O0500J=1).
H) Resident receives either Psychological (O0400E2>1) or Recreational Therapy (O0400F2>1) at least 2 or more days a week. Documentation shall include a summary of the sessions, resident's progress and potential goals, and identify any revisions needed.
I) Documentation shall support one to one meeting with a licensed social worker at least twice a week to discuss potential needs, goals and any behavior issues.
J) Documentation of at least quarterly oversight of care plan by a neurologist.
K) Documentation the resident has received instruction and training at least twice per week that includes, but is not limited to, behavior modification, anger management, time management goal setting, life skills and social skills.
L) Behavioral rehabilitation assessment and evaluations shall be completed quarterly and shall include cognition, behaviors, interventions and outcomes.
M) Documentation shall support the residents requires intensive counseling, behavioral management and neuro-cognitive therapy. The resident behaves in such a manner as to indicate an inability, without ongoing supervision and assistance of others, they would be unable to satisfy the need for nourishment, personal care, medical care, shelter, self-protection and safety.
7) Documentation supports the Tier III requirements are as follows:
A) Tier III shall not exceed 9 months.
B) The injury resulting in a TBI diagnosis must have occurred within the prior 6 months to score in Tier III.
C) Includes the acutely diagnosed resident with extensive deficits in physical functioning and identifies intensive rehabilitation needs.
D) Resident scores an IV through VII on the Rancho Los Amigos Cognitive Scale.
E) Cognition. BIMS is less than 13 (C0500) or Cognitive Skills for decision making are moderately to severely impaired (C1000=2 or 3).
F) Documentation shall support the facility is monitoring behaviors and has implemented interventions to identify the risk factors for behaviors and to reduce the occurrence of behaviors.
G) Resident receives Rehabilitation therapy (PT, OT or ST) at least 500 minutes per week and at least one rehabilitation discipline 5 days per week (O0400). The therapy shall meet the RAI Manual guidelines for coding. The resident shall continue to show the potential for improvement in the therapy programs.
H) The facility shall have trained rehabilitation staff on-site working with the resident on a daily basis. This shall include a trained rehabilitation nurse and rehabilitation aides. The resident requires a minimum of 6 to 8 hours per day of one-to-one support as a result of functional issues.
I) Documentation shall support there are weekly meetings of the interdisciplinary team to discuss the resident's rehabilitation progress and potential.
J) Resident receives Psychological Therapy (O0400E2>1) at least 2 days per week. Documentation shall include a summary of the sessions, resident's progress and potential goals, and identify any revisions needed.
K) There shall be documentation to support monthly oversight by a neurologist.
L) A comprehensive medical and neuro-psychological assessment is done upon admission and quarterly. It shall include, but is not limited to, the following:
i) Physical ability and mobility;
ii) Motor coordination;
iii) Hearing, vision and speech;
iv) Behavior and impulse control;
v) Social functionality;
vii) Safety and medical needs; and
viii) Communication needs.
8) Rates of payment for each Tier are as follows:
A) The payment amount for Tier I is $264.17 per day.
B) The payment amount for Tier II is $486.49 per day.
C) The payment amount for Tier III is $767.46 per day.
9) Effective for services on or after January 1, 2015, facilities licensed by the Department of Public Health under the Nursing Home Care Act and meeting all the care and services requirements of this Part will receive a per diem add-on of $5.00 for each resident scoring as TBI on the MDS 3.0 but otherwise not qualifying for Tier 1, 2 or 3.
(Source: Amended at 38 Ill. Reg. 23778, effective December 2, 2014)