Reimbursement for Program (Active Treatment) Costs in Small Scale Residential Facilities

Section 144 Section 144.300  Reimbursement for Program (Active Treatment) Costs in Small Scale Residential Facilities Small scale residential facilities (ICF/MR) with four or six beds for clients with developmental disabilities will be reimbursed for an active treatment program for each client.  Facility program reimbursement levels will be derived by the Department from the following three determinants which in combination will result in a total facility program per diem amount.  These three determinants will be determined according to information provided in the most recent Inspection of Care (IOC) conducted by Department of Public Health survey staff.  This IOC information must be validated by the survey staff prior to utilization for payment purposes.  The new reimbursement level will be effective on the first day of the quarter following a facility's IOC.  Where dollar, wage, or salary amounts are used, these shall be inflated to the fiscal year for which reimbursement will be made. a)         Minimum Staffing 1)         Direct Services A)        Reimbursement for direct services is based on a direct service staffing pattern which is specific to small scale ICF/MR facilities.  Facilities must be in compliance with minimum average daily staffing standards relative to client population according to each individual's overall level of functioning.  The overall level of functioning for each client is determined according to the method described in Section 144.275 (a)(1)(A)(i) and (ii), and Sections 144.Tables D and E.  The direct service staffing patterns based on the size of the residential setting and the overall level of functioning of the client population are: Overall Level of Client Functioning FTE* Staff 4-Person ICF/MR Mild 2.13 Moderate 3.88 Severe/Profound 5.93 6-Person ICF/MR Mild 3.2 Moderate 5.02 Severe/Profound 6.84 *FTE = Full time Equivalent B)        Reimbursement will be calculated according to the total direct service FTE staff derived from the weighted average of the FTE staff for levels of functioning in the moderate and severe/profound range within the small scale facility.  After the total FTE staff are determined, the per diem amount is obtained according to the method in Section 144.275(a)(1)(C)(i). C)        The reimbursement for a client residing in a small scale ICF/MR who has been found to be ineligible for ICF/MR services, as a result of the facility's Interdisciplinary Team (IDT) process or an IOC determination, will be at the mild level of overall functioning for not more than one year from the quarter following the determination of ineligibility.  If the client has not been discharged in accordance with Section 144.250 by the end of the one year period, reimbursement will be made at the Department's sheltered care rate.  The sheltered care rate will be payment in full for all program, capital and support costs for such clients. D)        Reimbursement for a client admitted to a small scale ICF/MR who is determined to be ineligible, or who is without a determination of eligibility by the preadmission screening process, will be set at the sheltered care rate. The sheltered care rate will be payment in full for all program, capital and support costs.  Payment for services for each client who has not been found eligible for the ICF/MR program upon admission will terminate 30 days following the date of admission.  Reimbursement for residential services for such a client which is paid to the facility beyond the 30 day period following admission will be recouped by the Department from the next facility payment or other contractual time period. E)        The facility rate paid will be the weighted average of the total per diem (including capital and support) calculated for eligible clients with mild, moderate and severe/profound levels of overall functioning and the Department's sheltered care rate for clients admitted without previously determined ICF/MR eligibility, or who are ineligible for ICF/MR services as determined by the IDT or IOC process, and remain in the facility for more than one year following the date of the determination of ineligibility. 2)         Licensed Nurses A)        If a client requires nursing services due to a physician's plan of care, reimbursement is calculated according to Section 144.275(a)(2)(D).  The FTE nurse to client ratios which are specified for ICF/MR facilities with 16 or fewer beds, are also used for a set of small scale ICF/MR facilities as identified by the provider agreements (see the Department of Public Aid's rule at 89 Ill. Adm. Code 140.561(a)). B)        The licensed nurse component is computed according to the method in Section 144.275(a)(2)(E). 3)         The total reimbursement amount for Minimum Staffing is the sum of the amount for Direct Services staff plus the amount for Licensed Nurses. b)         Active Treatment 1)         Qualified Mental Retardation Professional (QMRP) (Section 144.275(b)(1)(A), (B) and (C)). A)        The reimbursement amount paid is based on sixteen clients in an identified set of 4-person and 6-person ICFs/MR. B)        The amount for QMRPs is based on a required full-time QMRP for every 15 clients.  The number of QMRPs shall be obtained by dividing the number of clients in the facility by 15.  The amount paid for QMRPs is computed according to the method in Section 144.275(b)(1)(D). 2)         Interdisciplinary Team (IDT) (Section 144.275(b)(2)(B)) – The amount for services rendered by the IDT is based on one day of IDT services per year for each client.  This amount is computed to be $1.82 per client per day. 3)         The total reimbursement amount for Active Treatment is the sum of the amounts for QMRP and IDT. c)         Related Costs 1)         An amount per client per day will be paid for other program costs, including program related supplies, consultants and other items necessary for the delivery of active treatment to clients in accordance with their individual program plans. 2)         For each facility, this amount will be determined as follows.  Add the amount determined for subsections (a) and (b) of this Section, but exclude the amount for the IDT.  Multiply this sum by the factor determined by the Department for the facility's geographic area.  The product plus the amount for the IDT is then multiplied by the constant of .20. 3)         An amount will be paid for dental services that are in compliance with the Health Care Financing Administration's regulations (42 CFR 483.460(e), (f) and (g) (1996)) for each client age 21 or more.  This amount will be determined by adding the flat per diem of $.40 to the amount calculated according to subsection (c)(2) of this Section.  This per diem will cover the costs of prophylaxis treatment up to once every six months, and periodontal services as needed for each eligible client. 4)         An amount will also be paid for base nursing for assessments, development and updating of nursing care plans, health risk identification and planning, Tardive Dyskinesia (TD) screening, coordination and implementation of medical services, monitoring of medication effectiveness and side effects, and annual flu immunizations in small scale residential facilities licensed as ICF/DD-16s. A flat per diem of $.57 provides for 12 hours of licensed practical nurse time per person per year and one hour of registered professional nurse time per person per year. 5)         An amount will also be paid for supervision of medication administration.  The amount to be reimbursed is based upon a 1:12 ratio of registered professional nurse time at $19.44 per hour (including fringe benefits) to medication administration time.  Medication administration time is based upon the number of medication episodes per day documented by each individual's Medication Administration Record (MAR) and the following: A)        Five Minute Episode – Simple medication preparation, individual self-medication training, administration, and documentation, e.g., up to four medications at one time consisting of oral medications, topical medications, ear drops, creams, and/or lotions.  Medications in this category may be simple pill administration or may require the pill be crushed and mixed with an edible binder such as applesauce or pudding.  This episode type also includes monitoring a person for "cheeking" or spitting out medication. B)        Ten Minute Episode – Advanced medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with set insulin injection, blood pressure and/or pulse checks required prior to medication administration, and/or five or more medications at one time. C)        Fifteen Minute Episode – Complex medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with sliding scale insulin injection, injectable medications, rectal anti-convulsant medications, i.e., Diastat with monitoring. d)         Total Program Per Diem – Total program per diem for each small scale residential facility will be the sum of the amounts from subsections (a), (b) and (c) of this Section.