TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 120 MEDICAID HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAM FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES
SECTION 120.110 APPEALS AND FAIR HEARINGS
Section 120.110 Appeals and fair hearings
For appeals initiated by an individual concerning services, the following procedures apply:
a) The individual, parents, or guardian or the individual's representative may appeal the following actions:
1) Refusal to accept a request for services;
2) Failure to act on a request for services within the mandated time period;
3) Denial of service; or
4) Suspension, termination or reduction of services.
b) The appeal shall be filed with, and received by, the Department's Hearing and Appeals Unit, 401 Stratton Building, Springfield IL 62765 within 10 working days after the date the individual or guardian receives the notice of action following the agency grievance process.
c) Within 30 working days after the notice of appeal is received, the Department shall conduct an informal review of the appealed action and reverse, modify or leave unchanged the decision. The appellant, the appellant's representative (if any) and the service providers shall be notified in writing of the Department's action within 10 working days after the informal review. The written notification shall include:
1) A clear statement of the action to be taken;
2) A clear statement of the reason for the action;
3) A specific policy reference which supports such action; and
4) A complete statement of the individual's right to appeal the decision to the Department of Public Aid (DPA).
d) The appeal shall be filed with, and received by, the DPA Assistance Hearings Section, 624 South Michigan Avenue, Chicago IL 60605-1906 within 10 working days after the date the individual or guardian receives the written notification from the Department.
e) The hearing shall be conducted by an impartial hearing officer appointed by the Department of Public Aid (DPA).
f) The hearing shall be held at the DPA office nearest the appellant's home, unless the appellant, the Department's Hearing and Appeals Unit, and the DPA Assistance Hearings Section agree to hold it elsewhere.
g) DPA's hearing rules for assistance appeals, as set forth at 89 Ill. Adm. Code 104, shall apply, except that subsection (c) of this Section shall apply rather than any similar DPA rule.
h) Following the hearing, the Director of the Department of Public Aid shall issue a final administrative decision in accordance with DPA's rule at 89 Ill. Adm. Code 104.70. Copies of the decision shall be mailed to the appellant, the appellant's representative (if any), the service provider, and the Supervisor of the Department's Hearing and Appeals Unit.
i) The receipt of the request for an appeal shall stay the decision pending the final administrative decision or the withdrawal of the appeal. If the decision being appealed is suspension, termination or reduction of services, services shall not be suspended, terminated or reduced until the appeal is resolved, except as described below.
1) Services may be suspended, terminated or reduced before the final administrative decision only if all of the following conditions are met:
A) The physical safety of the individual or others is imminently imperiled;
B) Appropriate services are not available at the provider agency;
C) The provider agency has documented attempts to identify and ameliorate the probable causes of maladaptive behaviors and to seek staff training or technical assistance to meet the individual's needs; and
D) The PASSAR agent has:
i) Reviewed the individual's record;
ii) Gathered the necessary clinical information;
iii) Reviewed the actions of the provider;
iv) Met with the individual; and
v) Determined that a delay in termination, suspension or reduction in services would imminently imperil the physical safety of the individual or others and has documented that fact in the individual's record.
2) If all the requirements of subsection (i)(1) of this Section have been met, services to the individual may be terminated, suspended or reduced and the notice of action shall be given in accordance with Section 120.100(d) of this Part as soon as possible, but in no case later than 48 hours after the termination, suspension or reduction in services.
3) The provider shall hold the individual's place open until the appeal is resolved.
(Source: Amended at 20 Ill. Reg. 4762, effective March 8, 1996)