Follow-up monitoring guidelines

Section 125 Section 125.160  Follow-up monitoring guidelines Designated mandated follow-up staff shall assure compliance with the provisions of the Mental Health and Developmental Disabilities Administrative Act and compliance with the following Departmental policies. a)         Recipient monitoring 1)         Provide or contract for the provision of individual monthly monitoring of recipients placed in a licensed long-term care facility for at least 12 months, including visits on a weekly basis during the first month. 2)         Interview the recipient during the course of follow-up visits and discuss program involvement and/or other needs with staff in the licensed long-term care facility. 3)         Observe, review and document the following: A)        The recipient's comments and concerns; B)        The recipient's overall adjustment to the facility; and C)        The adequacy of the recipient's current individualized services plan as maintained by the facility. 4)         The adequacy of the programs and services available in the facility and in the community for meeting the needs of the recipient which may include, but are not limited to: A)        Activities; B)        Social (re)habilitation; C)        Restoration nursing; D)        Diagnostic testing; and E)        Psychological and social services. 5)         Sufficiency of the nursing and medical services to meet the physical health needs of the recipient. AGENCY NOTE:  For the conditionally discharged recipient, designated staff must visit or consult with the recipient and the family on the condition of the recipient and advise the family of care that will be most favorable for the recipient.  This visitation and contact requirement shall remain in effect while the recipient is on conditional discharge and shall terminate when such status is terminated. b)         Reporting and records 1)         Reports of deaths, accidents and unusual occurrences A)        All deaths of recipients, or accidents and unusual occurrences, such as reports of abuse, neglect and improper care, involving a recipient, shall be reported by the facility by telephone within twelve hours to the designated mandated follow-up staff, guardians (including the Office of the State Guardian, where appointed) and next of kin and confirmed in writing no later than the next working day with a complete statement of circumstances.  The facility must promptly notify the coroner of all deaths pursuant to Section 3-3013 of the Counties Code [55 ILCS 5/3-3013]. B)        Designated staff shall close cases in which death occurs in the Department's extramural reporting system by filing form DMHDD-1006, "Case Information". 2)         Monthly facility report – Designated staff shall report on the results of their onsite visits to each facility on the monthly evaluation report for long-term care facilities.  Copies of this report shall be submitted to the licensed long-term care facility and to the designated regional staff, with a copy being retained by the designated mandated follow-up staff. 3)         Semiannual facility report A)        The regional administrator will submit to the associate directors, semiannually, a summary of the monthly facility reports for each facility within the region. B)        These reports may be used for the evaluation and continued approval or denial of placements in licensed long-term care facilities. 4)         Monthly and annual information report Monthly and annually a report shall be produced for Central Office and regional use by the Department's Bureau of Information Services including the following information by disability: A)        The total number of facilities serving the Department's mandated follow-up recipients; B)        The total number of Department recipients placed during the current month and year-to-date; C)        The total number of Department mandated follow-up recipients in each facility; D)        The total number of Department mandated follow-up recipients being monitored on a weekly and monthly basis; E)        The number of mandated follow-up recipients readmitted to state-operated facilities from licensed long-term facilities for the current month and year-to-date; F)         The number of mandated follow-up recipients transferred to another licensed long-term care facility, to a State-operated facility, to independent living for the current month and year-to-date; G)        The number of deaths of Department mandated follow-up recipients for the current month and year-to-date; and H)        The total number of drug abusers for the current month and year-to-date. c)         Program development and monitoring 1)         When necessary, designated mandated follow-up staff may provide training as outlined in Section 15 of the Mental Health and Developmental Disabilities Administrative Act as outlined to assist facilities in meeting the unique needs of persons previously served by the Department. 2)         Designated mandated follow-up staff will assist a facility in arranging for resources to program for these populations, e.g., activity programs, treatment/habilitation programs and other specialized programs. These program development functions may include: A)        Providing time limited direct services in an effort to train facility staff; B)        Providing workshops on special programs or procedures; C)        Consulting with program staff or licensed long-term care facilities regarding the development of individualized services plans; D)        Developing methods of implementation; and E)        Evaluating programs available in the licensed long-term care facility. 3)         At least annually, the Department must review facility training records prescribed by Department of Public Health standards for licensure of long-term care facilities (Minimum Standards for the Licensure of Long-Term Care Facilities for the Developmentally Disabled (77 Ill. Adm. Code 350); Minimum Standards for the Licensure of Long-Term Care Facilities – Persons Under Twenty-Two (22) Years of Age (Divisions 1 through 73); Minimum Standards for the Licensure of Long-Term Care Facilities – Sheltered Care Facilities (77 Ill. Adm. Code 330); and Minimum Standards for the Licensure of Long-Term Care Facilities – Skilled Nursing Facilities and Intermediate Care Facilities (77 Ill. Adm. Code 300)) and make recommendations regarding future training needs.  Specific recommendations regarding orientation and inservice staff training must be included in the semiannual facility report. This report must also contain a judgment as to the sufficiency and capability of the staff in the facility. 4)         Program development and monitoring activities must be documented and maintained in a file readily available to the appropriate region office. AGENCY NOTE:   Designated mandated follow-up staff shall not provide consulting services for the purpose of meeting Department of Public Health licensure requirements, nor can fees be charged for the program development services provided by the Department or its contracted agents performing follow-up monitoring services. d)         Termination from mandated follow-up services 1)         Termination of follow-up monitoring services occurs after the 12-month period, except in cases of death, discharge to other than a licensed long-term care facility, or discharged for leaving against staff advice. Termination which is an individualized programmatic and clinical decision is based on the following criteria: A)        A clinical determination has been made that mandated follow-up services to the recipient are no longer necessary to maintain adjustment in the licensed long-term care facility. B)        Appropriate and necessary linkage to community resources have been established which will enable the recipient to function independently. C)        The developmentally disabled recipient is receiving specialized programmatic services to meet the objectives for further personal development as contained in the individualized services plan, and that procedural continuity is established which is essential to maintain adaptive levels and/or to prevent behavioral/developmental regression. D)        The recipient has substantially achieved the objectives outlined in the individualized services plan. E)        The facility has demonstrated its ability to provide the necessary continuing support and appropriate programming to the recipient. AGENCY NOTE:  When the decision to terminate has been made, designated staff shall check the follow-up notes and recipient records to insure that the recipient's recorded progress clinically supports the decision to terminate.  In cases of developmentally disabled individuals on conditional discharge, who are being considered for termination from mandated follow-up services, a copy of the community placement termination summary will be forwarded to the regional administrator or designee as the recommendation for termination.  The regional administrator or designee must give approval before the termination is effected. 2)         The termination of recipients from mandated follow-up services, however, does not necessarily mean that contact with these persons shall cease.  Statutorily required follow-up monitoring services and reporting shall cease, services including but not limited to those covered in the individualized services plan may continue to be provided.  Supportive services and/or case coordination, if appropriate, should be provided based on the recipient's on-going needs. e)         Continuing mandated follow-up status Monthly comments will be forwarded to the designated Department region staff on each community placement recipient who exceeds one year in continuing mandated follow-up status.  Comments will relate to specifics pertaining to inadequate adjustment of the recipient or any other cause considered significant enough to maintain the case in mandated status. f)         Transfers of recipients 1)         Transfers, when necessary, from one long-term care facility to another may be to assure the recipient's health and well being.  Primary attention shall be given to the needs and choices of the individual recipient (a recipient cannot be moved against the recipient's will except in an emergency).  A transfer is indicated if the facility cannot meet the current needs of the recipient; or the recipient has been neglected, abused or improperly cared for; or if the facility is not in substantial compliance with previously cited licensure standards or has not developed an acceptable plan of correction as determined by the Illinois Department of Public Health. 2)         If a transfer is indicated, designated staff shall cooperate in the transfer of mandated follow-up recipients from one licensed long-term care facility to another.  The regional DLA plan shall specify how transfer activities shall be coordinated with involved State agencies. 3)         In times of disaster or emergency, designated staff may need to be involved in the transfer of recipients who have been terminated from mandated follow-up monitoring services. AGENCY NOTE:  Designated staff must document all transfer activities and maintain the documentation in the recipient's record. 4)         Routine transfers A)        All recipients shall be transferred insofar as possible, in or near the communities in which the recipients reside or in which the recipients' families or significant others, such as a guardian or a friend, reside. The same considerations and procedures followed for the initial planning for discharge/linkage/aftercare shall apply (see Section 125.40). B)        Transfers may be initiated at the request of the recipient or legally responsible party.  Transfers may also be initiated by the long-term care facility's administrator.  Under such situations, designated staff will work with the Department of Public Aid and other involved agencies. 5)         Inter-region transfers Recipients may be moved between regions provided there is a prior agreement with both regional administrators or their designated agents involved in the transfer. 6)         Emergency transfers A)        The Department of Public Health under Sections 3-401 through 3-423 of the Nursing Home Care Act [210 ILCS 45/3-401 through 3-423] and the Department under Section 15 of the Mental Health and Developmental Disabilities Administrative Act are empowered to take specific action to transfer recipients who are not receiving appropriate services and/or when conditions exist in a facility which imperil the health or pose a serious and imminent threat to the life or safety of those recipients. B)        Both Departments must make all reasonable efforts to eliminate any threats to the safety  and well-being of any recipient, through consultation with the facility, the attending physician, and the recipient, spouse, parents, responsible relative or guardian (see Section 15 of the Mental Health and Developmental Disabilities Administrative Act). C)        The Department of Public Health is given broad statutory authority and primary responsibility to transfer any individual who is not receiving appropriate services in licensed long-term care facilities.  The Department's legal authority deals specifically with individual recipients who have been placed by the Department in these facilities. D)        The Department must work in close cooperation with the Department of Public Health to effect the transfer of recipients whose life or safety is in imminent danger.  However, the Department may, in the proper exercise of its statutory mandate, initiate action to provide for the health and welfare of mandated follow-up recipients residing in a facility.