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)         Facility Approval for Ventilator Services Enhanced Care Rate.  Requests for the ventilator services enhanced care rate must be submitted within 45 calendar days of the requested start date in accordance with 89 Ill. Adm. Code 140.513. Renewal requests for the ventilator services enhanced care rate shall be submitted every 12 months (365 days from last approval date). Renewal requests must be submitted within 45 days prior to the end of the 12-month period or may be subject to suspension or discontinuation of the ventilator services enhanced care rate.  A facility must comply with the requirements of this subsection (a) to be eligible for the ventilator services enhanced care rate.

 

1)         Services that Qualify for Ventilator Services Enhanced Care Rate

 

A)        The ventilator services enhanced care rate provides reimbursement for residents requiring mechanical ventilation through a functioning tracheostomy. "Invasive mechanical ventilation" is defined as any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respiration. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator.

 

B)        Residents must have a functioning tracheostomy and be dependent on the use of invasive mechanical ventilation as defined in subsection (a)(1)(A) for a minimum of 10 hours daily, 7 days a week.

 

2)         Services that Do Not Qualify for Ventilator Services Enhanced Care Rate

 

A)        "Non-invasive Ventilation" (NIV) or "Non-invasive Positive Pressure Ventilation" (NIPPV) is defined as any type of respiratory support device that prevent airways from closing by delivering slightly pressurized air continuously or via electronic cycling throughout the breathing cycle. This includes, but is not limited to, Continuous Positive Airway Pressure (CPAP), Bi-level Positive Airway Pressure (BiPAP), Pressure Support Ventilation (PS or PSV) or Volume Support (VS). Non-invasive ventilator mode and devices enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike invasive ventilation that delivers a controlled breath for the individual.

 

B)        Ventilator or respiratory devices used to deliver non-invasive modes of ventilation such as CPAP and its various settings, BiPAP and its various settings, PSV or VS shall not be eligible for the ventilator services enhanced care rate, with the exception of Department-approved active weaning from invasive mechanical ventilation that meets the minimum requirement of 10 hours daily on invasive mechanical ventilation as defined in subsection (a)(1)(A).

 

C)        Non-invasive ventilation modes utilized during the day, with ventilator use at night, are not eligible for the ventilator services enhanced care rate with the exception of Department- approved active weaning from invasive mechanical ventilation that meets the minimum requirement of 10 hours daily on invasive mechanical ventilation as defined in subsection (a)(1)(A).

 

D)        The ventilator services enhanced care rate is not available for those residents requiring mechanical ventilation during sleep hours only.

 

E)        Sleep apnea, obesity, or other non-ventilator dependent diagnoses are not eligible for the ventilator services enhanced care rate.

 

F)         Residents that transition into hospice coverage are not eligible for the ventilator services enhanced care rate.

 

G)        Physician Order Sheets with orders such as "PRN" or "as needed", or standby ventilator orders are not eligible for the ventilator services enhanced care rate.

 

3)         Ventilator Weaning Requirements for Ventilator Services Enhanced Rate Approval

 

A)        The weaning process is eligible for the ventilator services enhanced care rate with Department-approved active weaning from invasive mechanical ventilation to a non-invasive ventilation mode. Residents are considered actively weaning when the facility is making active attempts to liberate the resident from invasive mechanical ventilation. Non-invasive ventilation used in active ventilator weaning may be considered for the ventilator services enhanced care rate with required documentation.  Documentation shall support that the weaning process meets the minimum requirement of 10 hours daily on invasive mechanical ventilation as defined in subsection (a)(1)(A).

 

B)        Weaning shall be documented daily in the clinical record and submitted with the request for payment. Requirements for eligible weaning must include, but are not limited to:

 

i)          Continuous pulse oximetry.

 

ii)         Daily spontaneous breathing trials.

 

iii)        Daily weaning log or documentation showing ventilator weaning start time and weaning end time.

 

iv)        Daily documentation of successful ventilator weaning or failed weaning attempts.

 

v)         Daily documentation of barriers to weaning or lack of weaning progression during the weaning process.

 

vi)        Daily documentation of significant change from maximum ventilator settings to lower ventilator settings.

 

C)        A resident must be weaning on the ventilator to be eligible for approval of ventilator weaning. Weaning such as, but not limited to, trach collar, high-flow oxygen, nasal cannula, trach capping, speaking valve trials (PMV) or weaning for decannulation are not eligible for the ventilator services enhanced care rate.

 

D)        All physician and provider progress notes must clearly identify active ventilator weaning from invasive mechanical ventilation to non-invasive ventilation.

 

E)        Ventilator or respiratory devices used to deliver non-invasive modes of ventilation such as, but not limited to, CPAP and its various settings, BiPAP and its various settings, PSV or VS without clear documentation that distinguishes active weaning from invasive mechanical ventilation are not eligible for the ventilator services enhanced care rate.

 

4)         Resident Approval Requests for Ventilator Services Enhanced Care Rate

 

A)        Authorized facilities shall notify the Department using a Department-designated form for all ventilator services enhanced care rate start and discontinue requests and shall provide all required documentation with the start or discontinue requests. Start and discontinue requests must be submitted within the time frame specified in this subsection (a)(4). The form and supporting documentation must be Health Insurance Portability and Accountability Act (HIPAA) compliant and submitted through email.

 

B)        Notification of admission and changes in resident status shall be submitted in accordance with 89 Ill. Adm. Code 140.513.  The effective date for approval requests submitted more than 45 calendar days after the request start date will be the date the Department received the approval request.

 

C)        The ventilator services enhanced care rate start request must include Physician Order Sheets signed by a pulmonologist or physician experienced in the management of ventilator care that identify the need for and delivery of eligible ventilator services. The effective date of the order must correspond to the ventilator services effective start date requested on the form. Physician Order Sheets must be written, signed, and dated within 24 - 72 hours of the order date. The order must identify the ventilation mode, settings, parameters, and duration and include diagnosis, tracheostomy care and suctioning. Physician orders must be current and within 90 days of the requested start date. In addition, all other required documentation specified on the form must be included with the request.

 

D)        All respiratory therapy (RT) documentation must also correspond exactly to the ventilator services effective start date requested. Documentation must clearly and accurately document full ventilator services (including mode, settings, treatments, etc.). It must also document actual (correct) times placed on and removed from the ventilator. RT documentation must also correspond exactly to the Physician Order Sheet and other directives documented in the clinical record. If the resident is weaning from the ventilator, the start request must include a weaning order with full weaning directives. Inconsistent or incomplete documentation of ventilator use is subject to denial.

 

E)        Additional information may be requested for completion of the review. Authorized facilities must submit all additional documentation by the required due date. A facility will be given no more than 10 business days to provide the requested information.

 

F)         If anytime during the approval process, the resident is discharged to the hospital and returns after 24 hours, a new Physician Order Sheet is required with an effective date that corresponds to the return date in addition to all supporting documentation.

 

G)        In the case where a ventilator services enhanced care rate start request is submitted for a resident who was only in the facility for one day prior to discharging to a hospital, the request will be held until the resident returns from the hospital or until a discontinuation form is submitted. A new Physician Order Sheet is required with an effective date that corresponds to the return date in addition to all supporting documentation.

 

H)        In the case where a ventilator services enhanced care rate start request is submitted for a resident that is discharged to a hospital during the approval process, the start request will be held until the resident returns from the hospital or until a discontinuation form is submitted. A new Physician Order Sheet is required with an effective date that corresponds to the return date in addition to all supporting documentation. Ventilator services enhanced care rate start requests will not be held more than 30 days pending a hospital return. If a resident is discharged to the hospital with return anticipated and does not return within 30 days after discharge or the resident returns and discharges again, the ventilator services enhanced care rate start request will be determined based on the information provided and only through the last day that the resident meets the ventilator services enhanced care rate requirements found in this Section. The facility can reapply if the resident returns to the facility and meets the ventilator services enhanced care rate requirements found in this Section.

 

I)         A facility shall also use the designated form to notify the Department when a resident is no longer receiving ventilator services. Authorized facilities are required to submit a discontinue request within the time frame described in subsection (a). All required documentation specified on the form must be included with the discontinue request. Additional information may be requested for the review, and authorized facilities must submit all additional documentation within the 10 business days required by the Department.

 

J)         A submission with a same-day start request and hospital discontinuation is not eligible for ventilator services enhanced care rate.

 

K)        The discontinue date is always the last date the resident was in the facility and met the ventilator services enhanced care rate requirements found in this Section.

 

L)        All ventilator start and discontinue requests will be compared to Minimum Data Set (MDS) assessment admit, discharge, and Medicare dates. The MDS assessment reference data and the relevant Section O and Section S item response data must document that the resident was in the facility and met the ventilator services enhanced care rate requirements found in this Section for the requested date.

 

M)       If the Department's review determines that the ventilator services enhanced care rate start request does not meet the requirements of this Section, the request will be denied. Providers will be emailed a letter specifying the reasons for the denial and will be given 30 calendar days to submit a written appeal and supporting documentation for review, except in cases where the requested additional information was not received. A response to the appeal will be returned within 120 calendar days after the date the appeal was received by the Department, except in cases where the Department requires additional information from the facility. In such case, the 120-day clock is paused until the additional information is received, and then restarts upon receipt of the additional information. A facility must provide the requested information within 10 business days.  The denial of a request for the ventilator services enhanced care rate will stand if the facility fails to submit a timely appeal or request for information, or fails to document compliance with the requirements of this Section.

 

N)        Ventilator services enhanced care rate requests that result in denial due to information not received are not eligible for appeal and the denial will be final.

 

5)         Process for Facility to Become Authorized for Ventilator Services Enhanced Care Rate.  Facilities must be authorized by the Department as a ventilator services facility to submit requests for ventilator services enhanced care rates for residents that meet the requirements of this Section. To become authorized for ventilator facility status, the facility must submit a request for an application; this is required for both new facility applicants (not previously authorized) and for the new owner(s) of a previously authorized facility that has had a change of ownership (CHOW). New facility applicants must have a fully functioning ventilator unit at the time of application, and all requirements of this Section must be met prior to the effective date requested for ventilator facility status. CHOW applicants must attest to meeting the requirements of this Section at the time of the application.

 

A)        The initial application and all required documentation must be submitted to the Department within 45 calendar days after receipt of the application.  The Department will review the application and determine if the requirements of this Section have been met, or if additional or missing documentation is required to complete the review.

 

B)        On-site reviews will be conducted when a new facility application is submitted and every one to three years thereafter. Facilities will be notified by the Department prior to the on-site review.

 

C)        Facilities must provide documentation that clearly and accurately identifies the facility's name on company letterhead. The use of another facility's policies, procedures, protocols, or documentation will not be accepted.

 

D)        Facilities that fail to provide documentation that demonstrates full compliance with this Section in the time period prescribed in subsection (a)(5)(A) will not be approved.

 

E)        The facility's requested authorized effective date may also be adjusted to correspond with the date the Department determines the facility provided a complete application documenting compliance with this Section. This will be determined by the dates the provider application fully documents compliance with all rule requirements, including but not limited to approved and dated policies, procedures, and all required in-service trainings as specified in this rule. The authorized effective date can be no sooner than 30 calendar days from the application submission date.

 

F)         Once the facility is authorized for the ventilator services enhanced care rate, existing resident requests and all required documentation must be submitted within 45 calendar days of the facility's authorized effective date.  The effective date for existing resident requests submitted more than 45 calendar days after the requested start date will be the date the Department received the existing resident requests.

 

6)         Process to Appeal a Facility Denial of Authorization for Ventilator Services Enhanced Care Rate.  Facilities may file an appeal within 30 calendar days of the date the facility was notified of the denial or the start date adjustment and of the reason for the denial or adjustment. The facility must include a cover letter detailing the specific reasons for the appeal and must provide all documentation required to support the appeal. A response to the appeal will be returned within 120 calendar days after the date the appeal was received by the Department, except in cases where the Department requires additional information from the facility. In such cases, the 120-day clock is paused until the additional information is received, and then restarts upon receipt of the additional information. A facility will be given no more than 10 business days to provide the requested information.

 

A)        If the facility fails to submit an appeal as required within 30 calendar days, or if the facility fails to provide any additional required documentation, the denial or start date adjustment will stand.

 

B)        A facility that was denied authorization may submit a new application request no sooner than 90 days after the date of the Department's denial.

 

C)        A facility that was denied and does not submit an appeal may request a new application no sooner than 90 days from the date of the Department's original denial letter.

 

D)        Once a facility application is denied, resubmission of a new facility application will not be backdated to the previous application date of noncompliance.

 

E)        Once a facility application is denied, documentation submitted with a previously denied application cannot be reprocessed with a new application submission. All required documentation must be submitted with a new facility application.

 

7)         Criteria for Facility Authorization to Bill for Ventilator Services Enhanced Care Rate.  The following criteria shall be met for a facility to qualify for the ventilator services enhanced care rate reimbursement.

 

A)        The facility shall be equipped with technology that enables it to meet the respiratory therapy, mobility and comfort needs of its ventilator dependent residents.

 

B)        The facility shall have clinical assessment of oxygenation and ventilation-arterial blood gases or other methods of monitoring carbon dioxide and oxygenation available on-site for the management of ventilator dependent residents.  Clinical monitoring of oxygenation stability must be completed at least twice a day and must be documented.

 

C)        The facility's dated emergency policies and procedures must clearly document the continued operation of all equipment needed to maintain the health and safety of ventilator dependent residents in the event of all emergency situations, including a power failure.  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.  Facilities shall also comply with 77 Ill. Adm. Code 300.2940.

 

D)        The facility shall have dated policies, procedures, and documented transfer agreements ensuring the safe transfer of ventilator dependent residents.  The transfer agreement must be with local qualified hospitals or nursing facilities capable of providing the ventilator care required to maintain and ensure the safety of these residents in the event of an emergency.

 

E)        The facility shall have dated policies, documentation, and agreements in place to ensure maintenance and testing of the back-up generator, as well as access to a supplemental generator in the event the back-up generator fails to operate. Facilities shall comply with the requirements of 77 Ill. Adm. Code 300 regarding emergency power requirements.

 

F)         Facilities must have an audible ventilator alarm system to alert staff of a ventilator malfunction, failure or resident disconnect. The alarm system shall be connected to a centralized notification system located at a 24-hour monitored location such as the nursing staff desk on the ventilator unit and may include additional notifications connected to staff phones or beepers. Backup ventilators shall be available at all times to ensure continuous ventilation in case of a power failure or equipment failure. The exact number of backup ventilators shall be based on the facility's size and the number of ventilated patients. The facility must ensure the backup ventilators are fully serviced and maintained properly.

 

G)        Facilities licensed under the Nursing Home Care Act [210 ILCS 45] shall comply with 77 Ill. Adm. Code 300.1230 and 300.1240 regarding registered nurse (RN) staffing and licensed nurse staffing.

 

H)        No less than one Illinois licensed respiratory care practitioner (RCP) shall be available on duty on every shift seven days per week.

 

I)         The respiratory care practitioner shall fully assess, evaluate, and document the respiratory status of a ventilator dependent resident on no less than a weekly basis. All care and treatments given to every ventilator dependent resident shall be fully documented on each shift by the respiratory care practitioner. Full weaning documentation, including all successful and failed weaning attempts, shall be documented on every shift where the respiratory care practitioner attempted to wean the ventilator dependent resident from the ventilator.

 

J)         Documentation shall support the ventilator dependent resident receives tracheostomy care at least daily.

 

K)        A pulmonologist, or physician experienced in the management of ventilator care, shall direct the care plan for ventilator dependent residents on no less than a weekly basis and this must be documented in the clinical record.  Any changes to the resident's ventilator dependent status, including weaning directives, must be kept current and updated in the clinical record. Physician orders for ventilator services must be kept current.

 

L)        At least two of the current, 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 registered nurse who has at least one year experience in the care of ventilator dependent individuals. This must be a regularly scheduled course, such as a continuing education class, and must include training materials, post-training assessment or exam, and a certificate documenting successful completion of the course.

 

M)       All staff caring for ventilator dependent residents shall have documented in-service training in ventilator care prior to providing such care as described in subsection (a)(8).

 

8)         Ventilator Approved Facilities – Policies and Training Requirements.  To be eligible to receive the ventilator services enhanced care rate, facilities shall implement written and dated facility-specific policies and protocols, as well as related in-service trainings in the areas listed in this subsection (a)(8).  Staff assigned to care for ventilator dependent residents shall receive in-service training in the areas described prior to providing care and annually thereafter. All in-service training must be provided by a licensed respiratory care practitioner or registered nurse who has at least one year experience in the care of ventilator dependent individuals.  In-service training documentation shall include at minimum: the name and title of the in-service director; the duration of the presentation; the content of presentation; and the printed name, signature, and position description of all participants. The in-service trainings require a minimum of 30 minutes per topic and all materials provided to participants and used in the training must be provided upon request to the Department. The required areas are:

 

A)        Pressure Ulcers.  A facility shall have dated policies and procedures on assessing, monitoring and prevention of pressure ulcers, including development of a method of monitoring the occurrence of pressure ulcers for the ventilator dependent resident.  These policies shall require documentation to support that:

 

i)          The ventilator dependent resident has been assessed weekly for their risk for developing pressure ulcers.

 

ii)         Interventions for pressure ulcer prevention were implemented and include, but are not limited to, a turning and repositioning schedule every 2 hours according to best medical practices, use of pressuring reducing devices, hydration and nutritional interventions and daily skin checks.

 

B)        Pain.  A facility shall have dated policies and procedures on assessing the occurrence of pain, including development of a method of monitoring the occurrence of pain for the ventilator dependent resident.  These policies shall require documentation to support that:

 

i)          The ventilator dependent resident has been assessed daily for the presence of pain and the risk factors for developing pain.

 

ii)         An effective pain management regimen is in place for the resident.

 

C)        Immobility.  A facility shall have dated policies and procedures to assess the possible effects of immobility for the ventilator dependent resident. These shall include, but not be limited to, range of motion techniques and contracture risk.  These policies shall require documentation to support that:

 

i)          The ventilator dependent resident's risk for contractures were assessed on admission within 14 days and thereafter weekly and interventions are in place to reduce the risk.

 

ii)         Effects of immobility will be monitored, and interventions implemented as needed.

 

iii)        The policy shall also require that a physician, registered nurse, licensed practical nurse, physical therapist, or occupational therapist perform the assessment of contractures.

 

D)        Risk of infection.  A facility shall have dated policies and procedures on assessing risk for developing infection and prevention techniques for the ventilator dependent resident.  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.  These policies shall require documentation to support that:

 

i)          The ventilator dependent resident was given oral care every shift to reduce the risk of infection.

 

ii)         The facility has a method to monitor and track infections.

 

E)        Social Isolation.  A facility shall have dated policies and procedures as well as a method of assessing a ventilator dependent resident's risk for social isolation. Interventions shall be in place to involve the resident in activities when possible.

 

F)         Communication.  A facility shall have dated policies and procedures on assessing communication needs and techniques for the ventilator dependent resident.  These shall include but are not limited to Passy-Muir Valve (PMV) use as well as methods for non-verbal communication.

 

i)          The policy shall require documentation to support that the ventilator dependent resident is assessed on admission and will receive a follow-up assessment within 14 days to determine needs and goals.

 

ii)         The policy shall also require that the assessment be completed by a Speech Therapist and interventions are in place to assist with communication and swallow status.

 

G)        Status and Needs.  A facility shall have dated policies and procedures to include monitoring expectations of the ventilator dependent resident, routinely assessing the resident's status and needs, and specific staff training related to ventilator settings and care.

 

H)        Equipment.  A facility shall have dated policies and procedures to maintain quality standards and reduce cross contamination. The facility shall have a dated policy for cleaning and maintaining all ventilators and related equipment required for the care of the ventilator dependent resident.

 

9)         Ventilator Service Facility Audits.  Department staff shall conduct desk audits and on-site visits on a random or targeted basis to ensure both facility and resident ventilator services enhanced rate requests comply with requirements in this Section.  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), the Department's review shall include, at a minimum, the following:

 

A)        The tracking of Ventilator Associated Pneumonia (VAP);

 

B)        Documentation to track hospitalizations, reason for hospitalizations, and interventions aimed at reducing hospitalizations for ventilator dependent residents; and

 

C)        Ventilator weaning.

 

10)       Ventilator Services Enhanced Care Rate

A ventilator services enhanced care rate shall be added to the facility's daily rate.

 

A)        Payment shall be made for each individual ventilator dependent resident receiving ventilator services that meet the requirements of this Section.

 

B)        Effective January 1, 2024, the ventilator services enhanced care rate is $481 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 Resident Assessment Instrument (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 through VII 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 restoratives: 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;

 

vi)        Cognition;

 

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 50 Ill. Reg. 4212, effective March 9, 2026)