TO: Licensed or Certified Community Provider Agencies
FROM: Cathy Cumpston, BALC
DATE: July 1, 2009
RE:Recent discussions and changes
I continue to write this quarterly memo to provide information about changes in interpretations and requirements or about long-standing, unchanged practices that remain unclear. I hope it helps you in your efforts to comply with licensure and
certification requirements. Please direct any comments or questions to me at 217/557-9282 or firstname.lastname@example.org
Fire Clearance Renewals
BALC handles requests for fire code inspections by the Office of the State Fire Marshall of existing CILA, DT and MMH sites. All agency-controlled and host family CILA sites must have fire clearances once every three years. Developmental Training
sites must have fire clearances annually. Medicaid Community Mental Health services sites must have fire clearances once every three years. BALC submits the requests to the OSFM for these inspections several months prior to the program expiration date.
The OSFM is then responsible for scheduling the inspections.
CILA Site Reviews
When BALC conducts a full CILA licensure review - prior to the expiration of the license, all agency-controlled and host family sites must be seen by the reviewers. If for any reason, the provider being surveyed asks that a particular site not be
seen, that site will not be approved for use when the license is renewed.
New CILA and DT Interpretive Guidelines
A reminder - effective July 1, 2009 the revised interpretive guidelines for CILA and DT will begin to be used. No rule standards have changed and the same standards will be granted deemed status. The tools are available on the DHS website at:
These guidelines will be used for all surveys beginning July 1.
If Your Agency Is Not Nationally Accredited
Remember that if you are funded by the DHS Division of Developmental Disabilities and choose to not be nationally accredited, BALC will apply the non-deemed status survey tool(s) to your program(s).
BALC Interpretation of Quarterly and Annually
Rule 115.240f) states: "A physician or registered professional nurse shall evaluate the ability of the individual to self-administer medications. Ability to self-administer medication shall be reassessed at least quarterly for individuals with mental
illness (including those dually diagnosed with a mental illness and a developmental disability and at least annually for individuals with a developmental disability." and - Rule 115.300c)3) states: For agency-controlled CILA sites, "There shall be
documentation that living arrangements are inspected quarterly by the licensed CILA agency to ensure safety, basic comfort and compliance with this Part."
Quarterly is interpreted by BALC, after consultation with the Division of Developmental Disabilities, to mean every three months and annually is interpreted to mean every twelve months.
Correction to Medicaid Mental Health (Rule 132) Interpretation of Off-Site Documentation
In the past Medicaid Community Mental Health services providers have been told to document off-site services very specifically, e.g., giving the address and name of a restaurant, school or library where off-site services were provided. After clinical
review and checking on federal requirements, it is agreed that such specific documentation is not required. Documentation such as at "Burger King" or "Lincoln Park" would be acceptable.
Another Rule 132 Clarification
In a recent response to a provider, DHS clarified the need to include "individual" and "group" on the treatment plan for the following services: therapy/counseling (also must include if "family" is to be provided), community support, community
support-residential, psycho-social rehabilitation (PSR), and medication training.