Section 115.230  Interdisciplinary process


Agencies licensed to certify CILAs shall comprehensively address the needs of individuals through an interdisciplinary process.


a)         Through the interdisciplinary process, the CST shall be responsible for preparing, revising, documenting and implementing a single individual integrated services plan for each individual.


b)         The following shall be included in the interdisciplinary process:


1)         The individual or his or her legal guardian, or both;


2)         Members of the individual's family unless the individual is not legally disabled and does not desire the involvement of the family or the family refuses to participate;


3)         Significant others   chosen by the individual;


4)         The QMRP or the QMHP; and


5)         Other members of the CST.


c)         As needed to meet the individual's needs, the following shall be included in the interdisciplinary process:


1)         Persons in addition to the CST who provide habilitation, treatment or training; and


2)         Professionals who assess the individual's strengths and needs, level of functioning, presenting problems and disabilities , service needs and who assist in the design and evaluation of the individual's services plan.


d)         Upon the individual's entry into a CILA, the QMRP or the QMHP shall:


1)         Document in the record those services being provided to the individual until an individual integrated services plan is developed; and


2)         Explain all rights enumerated in Section 115.250 and document in the individual's record that this has been done.


e)         The agency shall assure that each individual receives an initial assessment and reassessments that shall be documented in the individual's record and the results explained to the individual and guardian.


1)         The assessments shall determine the individual's strengths and needs, level of functioning, the presenting problems and disabilities, diagnosis and the services the individual needs.


2)         Assessments shall be performed by employees trained in the use of the assessment instruments.


3)         Through the selection of the assessment instruments and the interpretation of results, all assessments shall be sensitive to the individual's:


A)        Racial, ethnic and cultural background;


B)        Chronological and developmental age;


C)        Visual and auditory impairments;


D)        Language preferences; and


E)        Degree of disability.


4)         Initial assessment for individuals with a mental disability shall include:


A)        A physical and dental examination, both within the past 12 months, which shall include a medical history;


B)        Previous and current adherence to medication regime and the level of ability to self-administer medications or participate in a self-administration of medication training program;


C)        A psycho-social assessment including legal status, personal and family history, a history of mental disability and related services, evaluation of possible substance abuse, and resource availability such as income entitlements, health care benefits, subsidized housing and social services;


D)        An assessment with form DMHDD-1215, "Specific Level of Functioning Assessment and Physical Health Inventory," (SLOF) for individuals with a mental illness and with the Inventory for Client and Agency Planning (ICAP) (Riverside Publishing Co., 425 Spring Lake Drive, Itasca IL 60143 (1986)) or the Scales of Independent Behavior-Revised (SIB-R) (Riverside Publishing Co., 425 Spring Lake Drive, Itasca IL 60143 (1996) ) for individuals with a developmental disability;


E)        An educational and/or vocational assessment including level of education or specialized training, previous or current employment, and acquired vocational skills, activities or interests;


F)         A psychological and/or a psychiatric assessment; both must be conducted for individuals with both a mental illness and a developmental disability;


G)        A communication screening in vision, hearing, speech, language and sign language; and


H)        Others as required by the individual's disability such as physical therapy, occupational therapy and activity therapy.


5)         Annual reassessments for individuals with a mental disability shall include:


A)        A physical and dental examination including a review of medications;


B)        The SLOF for individuals with a mental illness or ICAP or SIB for individuals with a developmental disability;


C)        An annual psychiatric examination for individuals with a mental illness;


D)        Other initially-assessed areas, as necessary.


f)         Within 30 days after an individual's entry into the CILA program, a services plan shall be developed that:


1)         Is based on the assessment results;


2)         Reflects the individual's or guardian's preference as indicated by a signature on the plan or staff notes indicating why there is no signature and why the individual's or guardian's preference is not reflected;


3)         Identifies services and supports to be provided and by whom; and


4)         States goals and objectives. Objectives shall:


A)        Be measurable;


B)        Have timeframes for completion; and


C)        Have an employee assigned responsibility.


g)         The individual integrated services plan shall identify the CILA site chosen with the individual's and guardian's participation and shall indicate the type and the amount of supervision provided to the individual.


h)         The services plan shall address goals of independence in daily living, economic self-sufficiency and community integration.


i)          The services plan shall include the names and titles of all employees and other persons contributing to the plan.


j)          The services plan shall be signed by the QMRP and the QMHP and the individual or guardian.


k)         The individual or guardian shall be given a copy of the services plan.


l)          The services plan shall become a part of the individual's record.


m)        At least monthly, the QMRP and  QMHP shall review the services plan and shall document in the individual's record that:


1)         Services are being implemented;


2)         Services identified in the services plan continue to meet the individual's needs or require modification or change to better meet the individual's needs; and


3)         Actions are recommended when needed.


n)         The CST shall review the services plan as a part of the interdisciplinary process at least annually for individuals with developmental disabilities and semi-annually for individuals with mental illness and shall note progress or regression which might require plan amendment or modification.


o)         All services specified in the services plan, whether provided by an employee of the licensed agency, consultants, or sub-contractors, shall be provided by or under the supervision of a QMRP or a QMHP, as appropriate, based on the individual's primary disability.


p)         The provider agency must ensure that current copies of individuals' service plans are kept at the individuals' residences.  The provider agency must also ensure that direct care workers (including employees, contractual persons, and host family members) are knowledgeable about the individuals' service plans, are trained in their implementation, and maintain records regarding the individuals' progress toward the goals and objectives of the individual service plans.


q)         Through the interdisciplinary process the CST shall be responsible for determining an individual's ability to transition from continuous supervision or support to an intermittent level of supervision or support.


1)         If a determination is made that the individual is appropriate for a less restrictive environment, documentation shall be included in the individual's plan identifying time frames for transition.  The individual's QMRP or QMHP shall be responsible for monitoring the individual's transitional plan and for documenting the individual's progress toward intermittent supervision and supports.


2)         If a determination is made that an individual with a developmental disability is appropriate for intermittent supervision and supports, the PAS agency in conjunction with the provider agency must submit a completed CILA rate determination packet to the Department for development of a rate to support the intermittent supervision and supports.


3)         For individuals with a developmental disability, funding will remain at the individual's current level of funding for the first three months.  At the end of the first three months, the QMRP or QMHP shall convene the CST to assess the individual's attainment of his or her goal for less restrictive supervision and supports.  If the CST determines that the individual requires additional time to complete a successful transition, a request shall be made in writing to the Department for an extension not to exceed a total of six months. If the CST determines that the individual has not met, and is not likely to meet, his or her goal for less restrictive supervision and supports, the individual will continue to receive continuous supervision or support.


r)          An individual who requires continuous supervision or support indefinitely may stay alone or access the community independently under specific circumstances.  The CST must determine that the individual has the ability and desire to stay alone safely for brief periods of time, or access specified locations in the community independently, or with supervision and support other than that provided by agency employees.  The individual service plan must state the periods of time and restrictions on activities when at home, and locations and time frames for accessing the community.  The individual will successfully complete an assessment demonstrating the skills necessary to assure his or her safety, and this must be part of the individual's record.  This should occur only as part of the individual's habilitation/treatment process, and not to accommodate staffing concerns.


(Source:  Amended at 27 Ill. Reg. 5376, effective March 17, 2003)