TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.642 SCREENING ASSESSMENT FOR NURSING FACILITY AND ALTERNATIVE RESIDENTIAL SETTINGS AND SERVICES
Section 140.642 Screening Assessment for Nursing Facility and Alternative Residential Settings and Services
a) Beginning July l, l996, any individual, except those identified in subsection (c) of this Section, seeking admission to a nursing facility licensed under the Nursing Home Care Act [210 ILCS 45] for nursing facility services must be screened to determine his or her need for those services pursuant to this Section. Any individual, except those identified in subsection (c) of this Section, who is seeking admission to a nursing facility that operates under the Hospital Licensing Act [210 ILCS 85] must be screened to determine his or her need for those services except when Medicaid funds will not be used for nursing facility services for any part of the stay. For the purposes of this Section, "nursing facility" or "facility" means a location licensed under the Nursing Home Care Act or the Hospital Licensing Act as a skilled nursing facility or an intermediate care facility.
b) Screening Assessment
1) The Level I ID Screen is the first phase of the preadmission screening process for nursing facility services described in subsection (a) of this Section. The Level I ID Screen is conducted to determine if there is a reasonable basis for suspecting that an individual has developmental disabilities (DD), as defined in subsection (b)(1)(A) of this Section, or severe mental illness (MI), as defined in subsection (b)(1)(B) of this Section. This determination is required to assure that individuals with DD or severe MI are placed into settings which provide the services they require. Entities authorized to complete the Level I ID Screen are agents of DPA, Department of Human Services (DHS), Department on Aging (DoA), Department of Public Health (DPH), hospitals or nursing facilities.
A) A developmental disability is a disability that is attributable to a diagnosis of mental retardation (mild, moderate, severe, profound), or a related condition. A related condition is attributable to: cerebral palsy or epilepsy, or any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental retardation, and requires treatment or services similar to those required for persons with mental retardation. In addition, this condition is manifested before the age of 22; is likely to continue indefinitely; and results in substantial functional limitations in three or more of the following areas of major life activity:
ii) understanding and use of language;
vi) capacity for independent living.
B) An individual is considered to have a severe mental illness for the purpose of this Section if he or she has one of the following diagnoses: schizophrenia; delusional disorder; schizoaffective disorder; psychotic disorder not otherwise specified; bipolar disorder I – mixed, manic, and depressed; bipolar disorder II; cyclothymic disorder; bipolar disorder not otherwise specified; major depression, recurrent; and due to his or her mental illness exhibits resulting substantial functional limitations. The functional limitation must be of an extended duration expected to be present for at least a year, which results in substantial limitation in major life activities affecting at least two of the following areas:
ii) social functioning;
iii) community living activities;
iv) work related skills.
2) If the Level I ID Screen indicates that an individual may have DD or severe MI, a comprehensive assessment, the Level II assessment, except as defined in subsection (b)(7) of this Section, is conducted by preadmission screening (PAS) agents designated by the DHS-Office of Developmental Disabilities or DHS-Office of Mental Health, whichever is applicable, concerning the need for nursing facility services and the need for specialized services.
3) If the Level I ID Screen does not identify a reasonable basis for suspecting DD or severe MI, the individual is referred to DoA (individuals 60 years of age or older) or DHS - Office of Rehabilitation Services (individuals l8 through 59 years of age) for a Determination of Need to assess the need for nursing facility services.
4) For applicants of Medicaid services who are already residing in the facility and were admitted after June 30, 1996, the Department will review and evaluate a copy of the most recent Minimum Data Set (MDS) resident assessment instrument. The Department will refer to DoA or DHS, as appropriate, any light need resident who appears to be a potential candidate for community placement.
5) A screening assessment is valid for 90 calendar days from the date of the assessment. For individuals with DD or severe MI, an existing Level II assessment may remain valid after 90 calendar days when the designated PAS agent updates any component of the assessment which is not current, and confirms the validity of the assessment as reliably reflecting the status of the individual.
6) Due to exceptional circumstances, an individual identified as having DD or MI, following a Level I ID Screen, may be determined to need nursing facility services. The individual with exceptional circumstances must then receive a Level II assessment to determine the individual's need for specialized services related to placement in a nursing facility, except in the specific circumstances noted in subsection (b)(7) of this Section. Exceptional circumstances include, but are not limited to:
A) terminal illness with a life expectancy of six months or less; and
B) convalescent care (a medically prescribed period of recovery, following acute care, not to exceed 120 calendar days); and
C) severe physical illnesses, such as coma, ventilator dependence, functioning at brain stem level or diagnoses such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, and congestive heart failure; and
D) a diagnosis of dementia, including Alzheimer's disease or a related disorder, in the case of the individual with DD.
7) Level II assessment exemption. Some individuals with DD or severe MI may be admitted to a nursing facility without receiving a Level II assessment to determine the need for specialized services by a designated PAS agent. Individuals exempt from a Level II assessment for specialized services are provisional admissions pending further assessment in cases of delirium where an accurate diagnosis cannot be made until the delirium clears. In all other cases, a determination that specialized services are not needed must be based on a Level II assessment.
8) Screening agents shall present alternatives to institutional placement, and inform individuals of alternative settings before placement into a nursing facility.
9) Non-Medicaid supported individuals who choose to be admitted into a nursing facility when the screening assessment does not justify nursing facility placement will not be denied access to the facility.
c) A screening assessment does not apply to an individual who:
1) is receiving or will be receiving sheltered care services; or
2) transfers from one facility to another, with or without an intervening hospital stay. It is the transferring facility's responsibility to ensure that copies of the resident's most recent screening assessment accompany the transferring resident; or
3) resided in a facility for a period of at least 60 days and is returning to a facility after an absence of not more than 60 days; or
4) is receiving or will be receiving hospice services; or
5) is readmitted to a facility after a therapeutic home visit; or
6) is readmitted to a facility from a hospital to which he or she was transferred for the purpose of receiving care; or
7) resided in the facility on June 30, l996.
d) Nursing Facility Services
In Illinois, nursing facilities are licensed for intermediate level nursing care and skilled level nursing care. For guidelines to the type of services provided by nursing facilities refer to 77 Ill. Adm. Code 300.Appendix A.
e) Date of Payment
1) No payment for nursing facility services may be made for individuals who have been determined eligible, or have applied for Medicaid at the point of admission, unless the screening assessment documents a need for such care.
2) Where the assessment does not establish this need, the individual may request that a licensed physician designated by DPA review the medical reports and any other evidence the individual wishes to submit, and certify whether there is a need for nursing facility services in the individual's case. The individual will be notified of the right to this review.
3) For an individual whose preadmission screening assessment has been completed prior to admission, DPA will begin payment:
A) on the date of admission if Medicaid eligibility has been established, or
B) on the beginning date of Medicaid eligibility if eligibility starts after the date of admission.
4) For an individual whose preadmission screening assessment has not been completed prior to admission, DPA will begin payment on the later of:
A) the date that the screening assessment requirement is met, or
B) the effective date of Medicaid eligibility.
5) For an individual who applies for Medicaid after admission to a facility, DPA will begin payment on the effective date of Medicaid eligibility.
f) Review Required Upon Change in DD/MI Resident Condition
Nursing facilities must notify the State mental health authority or the State developmental disability authority, or their designee as applicable, when there has been a significant change in the condition of a Medicaid eligible resident with developmental disability or severe mental illness as required by 42 USC 396r(e)(7)(B)(iii) (1999). The nursing facility shall report in a format established by the applicable State authority, or its designee, significant changes in a resident's condition. A determination will then be made whether there has been a significant change requiring a resident review. For the purposes of this subsection (f), a significant change for a resident with severe mental illness or developmental disability will be deemed to have occurred when:
1) An individual who was determined by PAS to be severely mentally ill, and who has continuously resided in a nursing facility within the last 12 months, who has been referred for admission or been admitted to a psychiatric hospital or psychiatric ward of a general hospital for psychiatric care three or more times within that 12 month period; or
2) An individual who was determined by PAS to be severely mentally ill or developmentally disabled is evaluated by the nursing facility to no longer have a severe mental illness or developmental disability; or
3) An individual who was determined by PAS not to be severely mentally ill or developmentally disabled is evaluated by the nursing facility to have a severe mental illness or developmental disability. There must be a reasonable basis for believing that the condition may indicate the presence of a developmental disability prior to the age of 22; or
4) An individual who was determined by PAS to be severely mentally ill who does not have a medical need for nursing facility level of care, meets all of the following:
A) no longer receives any intervention programs for mood, behavior or cognitive loss;
B) has successfully completed training skills required to return to the community; and
C) discharge to the community is not planned within the next 90 days; or
5) An individual who was determined by PAS to be developmentally disabled no longer receives specialized services; or
6) An individual with severe mental illness or an individual with a developmental disability who entered the nursing facility as an exempted hospital discharge is now found to require more than 30 days of nursing facility care.
g) Periodic Resident Review
The Department, the Department of Public Health, or their agents may periodically review some or all Medicaid eligible residents found to be severely mentally ill or developmentally disabled to evaluate nursing facilities' compliance with this Section.
(Source: Amended at 27 Ill. Reg. 14799, effective September 5, 2003 )