Table of Contents
- Section 1: Introduction
- Section 2: Dictionary
- Section 3: General Information
- 3.1 Geographic Responsibility
- 3.2 Qualifications of Individual Service Coordinators
- 3.3 Mandated Reporting
- Section 4: PUNS for Persons with Developmental Disabilities
- 4.1 Questions and Problems
- 4.2 Individual Assurances
- 4.3 Educating
- 4.4 Screening
- 4.5 For Whom to Complete a PUNS Form
- 4.6 For Whom NOT to Complete a PUNS Form
- 4.7 Special Form Completion Circumstances
- 4.8 Guidelines for Completing the PUNS Process
- 4.9 Instructions for Completing the PUNS Form
- 4.10 Updating, Changing and Closing PUNS Records
- 4.11 Maintaining Local PUNS Records
- 4.12 Dependents of Military Service Members
- Section 5: Pre-Admission Screening
- Section 6: Person Centered Planning
- 6.1 Discovery
- 6.2 Personal Plan
- 6.3 Implementation Strategies
- Section 7: Service Request, Submission and Authorizations- This section is currently unavailable
- Section 8: General Service Coordination
- Section 9: Individual Service and Support Advocacy
- 9.1 Annual Review and Update of the Plan
- 9.2 ISSA Monitoring Activities
- 9.3 Medicaid Benefit Enrollment and Medical Renewal Process
- 9.4 Level of Care Redeterminations
- 9.5 Rights and Advocacy
- 9.6 Critical Incident Reporting and Analysis System (CIRAS)
- Section 10: Bogard Consent Decree
- 10.1 Bogard Class Members Residing in an ICF/DD
- 10.2 Bogard Class Members Residing in Other Non-Waiver Settings
- 10.3 Bogard Class Members Residing in a Medicaid Waiver Setting
- Section 11: Addressing and Resolving Issues or Concerns
- 11.1 Principles of the Resolution Process
- 11.2 Protocol for Resolving Issues or Concerns
- 11.3 Time Frames
- 11.4 Documentation
- Section 12: Referral for Monitoring and Technical Assistance
- Section 13: Service Terminations and Bedhold Request
- Section 14: Appeal Process
- Section 15: General Administrative Requirements
- 15.1 Data Collection
- 15.2 Reporting and Billing
- 15.3 Maintenance of ISC Records
- Section 16: Monitoring of Independent Service Coordination Agencies
- Section 17: Appendix
Section 1: Introduction
Independent Service Coordination (ISC) agencies contract with the Illinois Department of Human Services, Division of Developmental Disabilities (IDHS, DDD) to perform their duties under the authority of, and in compliance with, all applicable federal and state laws, rules and regulations, including but not limited to: Illinois Administrative Codes and Rules, the Developmental Disabilities Manuals, the Person Centered Planning Policy and Guidelines for DD Waiver Services, the DDD Medicaid Waivers and the Centers for Medicare & Medicaid Services (CMS) - Regulations & Guidance. The Centers for Medicare and Medicaid Services (CMS) published Home and Community Based Services (HCBS) Regulations on January 16, 2014. These Regulations became effective on March 17, 2014 and impact all 1915c HCBS Waivers. The Regulations include Person Centered Planning, Conflict of Interest in case management and Settings.
The CMS HCBS Conflict of Interest Free regulation requires States to separate case management functions from service delivery. As such, case management cannot be done by a relative of the person served, a direct provider of service, someone who has a financial interest in a provider or who is employed by a provider. ISC agencies are the Conflict of Interest case management entity and are essential to Illinois Developmental Disability service system. In this manual, case management will be referred to as service coordination and includes maintaining the PUNS database, conducting Pre-Admission Screens, providing Individual Service and Support Advocacy to people in a DDD Waiver and providing service coordination to Bogard class members. It also includes, but is not limited to, conducting outreach, serving as the front line for information and assistance to help individuals and families navigate the system, ensuring informed choice, developing and monitoring a person's Plan, linking individuals to services and addressing problems related to outcomes and quality. ISC agencies provide accurate individual information for statewide planning, as well as collaborate with service providers to ensure individual's health, safety, welfare, well-being, and satisfaction with services funded by DDD. They encourage individuals and families to make informed decisions, exercise choice, and have maximum control over their lives. ISC agencies do not provide direct services but serve as the primary connection between individuals (and guardians) who are seeking or receiving developmental disability services and the IDHS/DDD. The purpose of this manual is to outline the policies and procedures to be followed by ISC agencies when performing their duties on the behalf of the IDHS/DDD.
Section 2: Dictionary
Note: For a definition and description of DD services, please refer to the Developmental Disabilities Program Manual and the DD Waiver Manual.
|Adult Protective Service
||A program within the Illinois Department on Aging that investigates abuse, neglect, or financial exploitation of adults age 60 or older and adults age 18-59 with disabilities living in the community.
||Illinois' comprehensive health insurance program for children. The program covers doctor visits, hospital stays, prescription drugs, vision care, dental care, eyeglasses, regular check-ups and immunizations (shots). All Kids also covers special services like medical equipment, speech therapy, and physical therapy for children who need them.
|Centers for Medicare and Medicaid Services
||The federal agency within the Department of Health and Human Services, which reviews, approves and monitors State Medicaid Waiver plans.
|Community Reporting System
||The PC-based system designed to be used for collecting and submitting required data to the Department of Human Services (DHS) by those community providers who have contracted with the Department to provide services for individuals.
|Department of Children and Family Services
||State agency that is responsible for protecting children who are reported to be abused or neglected. DCFS also works to increase families' capacity to safely care for their children; provide for the well-being of children in their care; provide appropriate, permanent families as quickly as possible for those children who cannot safely return home; support early intervention and child abuse prevention activities.
|Department of Human Services
||State agency that community health and prevention programs, oversees interactive provider networks that treat persons with developmental disabilities, mental health and substance abuse challenges and provides rehabilitation services. This agency also aids eligible, low-income individuals and families with essential financial support, locating training and employment opportunities and obtaining child care in addition to other family services.
|Department on Aging
||State agency responsible for helping older adults live independently in their own homes and communities.
||An intellectual disability or related condition that is manifested before age 18 or 22 respectively, is likely to continue indefinitely and results in substantial functional limitations in major life activity.
||The first component of the DD Person Centered Planning process. The Tool is used to gather information about a person's preferences, interests, abilities, preferred environments, activities, and supports needed.
|Division of Developmental Disabilities
||A Division within the Department of Human Services that provides services and supports for individuals with developmental disabilities and their families.
|Division of Mental Health
||A Division within the Department of Human Services that serves at the State's Mental Health Authority. This Division is responsible for assuring that children, adolescents and adults, throughout Illinois, have the availability of and access to public-funded mental health services for those who are diagnosed with a mental illness or emotional disturbance and who have an impaired level of functioning based on a mental health assessment.
|Division of Rehabilitation Services
||A Division within the Department of Human Services that serves as the state's lead entity responsible for assisting individuals with disabilities to prepare for, locate and maintain employment. This Division also ensures that people with disabilities make informed choices to achieve full community participation through employment, education, and independent living opportunities.
|Family and Community Resource Center
||The local office (under the Department of Human Services/Division of Family & Community Services) that process Medicaid Benefits applications such as Cash, SNAP and/or medical assistance.
|Governor's Office of Management and Budget
||The Governor's Office of Management and Budget prepares the Governor's annual State budget and advises the Governor on the availability of revenues and the allocation of those resources to agency programs.
|Grant Accountability and Transparency Unit
||A unit of the Governor's Office of Management and Budget that is tasked with administering the Grant Accountability and Transparency Act.
|Healthcare and Family Services, Illinois
||The single Illinois state Medicaid agency that oversees Waiver programs. This agency is responsible for providing healthcare coverage for adults and children who qualify for Medicaid, and for providing child support services to help ensure that Illinois children receive financial support from both parents.
|Home and Community Based Services Waivers
||Services that prevent or delay a person from living in a long-term care facility or institution. The Division of DD operates three HCBS Waivers for people with developmental disabilities: The Adult Waiver, the Children's Residential Waiver and the Children's Support Waiver.
|Independent Service Coordination
||Entities contracted with the Division of Developmental Disabilities that provide case management/service coordination which includes maintaining the Division's waiting list, determining clinical eligibility, assisting with identifying providers of choice, developing the Personal Plan and monitoring the Plan. ISC agencies serve as the front line for information and assistance to help individuals and families make informed choices and to navigate the system.
|Integrated Eligibility System
||Eligibility system for Medicaid, SNAP and Cash Assistance shared between DHS and HFS. The IES has two main components, ABE (the public facing application process) and the worker portal, in which eligibility decisions are made and maintained.
|Inventory for Client and Agency Planning
||An instrument that assesses adaptive and maladaptive behavior and gathers additional information to determine the type and amount of special assistance that people with disabilities may need. Created to be used for determining eligibility, planning services, evaluating, reporting progress, and for use in funding reports.
|Individual Service and Support Advocacy
||Service coordination or case management to persons who are enrolled in a DD Home and Community Based Service Waiver and to Bogard class members who live in an ICF/DD. Through the provision of ISSA, the ISC monitors whether services are being provided as outlined in the person's Plan as well as monitors the person's welfare, health and safety. ISCs also ensure continued eligibility for DD Waiver services.
|Individual Support Plan
||A document that prioritizes and structures the delivery of all services (including generic and Medicaid State Plan) and supports across environments. The document should include relevant and timely assessment information, including individual preferences, abilities and needs. The Plan must be based on principles of community inclusion and self-determination and includes functional goals and methods to measure progress toward those goals. ISPs are developed for individuals in ICFs/DD and other non-waiver settings.
|Medical Management Unit
||An entity within the Department of Human Services/Division of Family & Community Services that was created to streamline the maintenance of medical only cases and more effectively manage the redeterminations. This office was created out of 2 existing Family and Community Resource Centers and replaces the services formerly provided by the Illinois Medicaid Redetermination Project.
|Office of Inspector General
||The Office of the Inspector General, within the Department of Human Services, investigates all reports of abuse, neglect and exploitation, to foster humane, competent, respectful and caring treatment of individuals with physical, developmental and/or mental disabilities. It also assists State agencies and facilities in prevention efforts.
|Office of State Guardian
||A state entity that handles the personal, financial, and legal affairs of people with developmental disabilities, mental illness and elderly persons with disabilities.
|Omnibus Reconciliation Act
||A bill, first enacted in 1987, to improve the quality of care in nursing homes for the health and safety of nursing home residents. This legislation significantly strengthened federal standards, inspections and enforcement of nursing home quality.
A single, comprehensive personal vision for a person's life. This document is developed through a person-centered process and focuses on the individual's strengths, preferences, needs and desires. This Plan is developed by ISC agencies in conjunction with the individual, guardian, family, and providers. The Personal Plan contains desired outcomes, documents choices of qualified providers, reflects what is important to the person regarding delivery of services in a manner which ensures personal preferences, health and welfare. It must also include risk factors and plans to minimize them.
A Personal Plan is required for all individuals in a DD Waiver program.
|Person Centered Planning
||The process through which each waiver participant's needs, goals and preferences are identified and strategies are developed to address those needs, goals and preferences. It is the process through which the people in a waiver exercises choice and control over services and supports and through which risks are assessed and planned for.
||A process used to determine whether an individual has a developmental disability and, if so, to determine whether the individual needs 24-hour nursing care and/or active treatment as well as the type of services needed.
||Division of Developmental Disabilities statewide database that registers individuals who want or need DDD Waiver services. As funding becomes available, this database is used to invite individuals to apply for DDD Waiver services.
|Qualified Intellectually Disability Professional
||A professional staff that who is responsible for a variety of duties such as integrating, coordinating and monitoring services for individual's with developmental disabilities. QIDP must possesses the qualifications according to the 42 CFR 483.430
||The process, usually every 12 months, of reassessing a person's eligibility for Medicaid benefits. Also referred to as Medicaid Renewals.
|Reporting of Community Services
||A computer-based system within the Community Reporting System that collects and processes service reporting data to DHS. This data is used by DHS to monitor services, supports and funding.
|Scales of Independent Behavior
||A comprehensive assessment of adaptive and maladaptive behavior used to determine a person's level of functioning in key behavior areas; usually used for either diagnosis or program planning.
Section 3: General Information
Through the provision of service coordination, Independent Service Coordination (ISC) agencies assist individuals and families in obtaining and maintaining developmental disability services. Only individuals who have a developmental disability are eligible for services within the DD service system. A person is determined to have a developmental disability if the person has an Intellectual Disability or a Related Condition as defined in Section 5.5 of this Manual.
All ISC duties must be carried out in a culturally sensitive manner. This includes respecting differences related to ethnicity, race, religion, age, gender, sexual orientation, abilities, and communication preferences. Where needed or requested, ISC agencies should secure interpreter services to promote the full inclusion of persons seeking or receiving services, their legal guardian, and their family members.
ISC agencies are available 24 hours a day, 365 days of the year for individuals in crisis.
3.1 Geographic Responsibility
Each Independent Service Coordination (ISC) agency is responsible for a specific geographic area of the State. The ISC agency located in the geographic area in which the individual resides is the designated ISC agency for that individual. If an individual is receiving day program services from a provider agency located outside the ISC agency's area, the ISC agency in the geographic area in which the individual's resides will still be the responsible entity. An ISC agency cannot decline an individual residing in their designated area. The Independent Service Coordination Agency Map is useful in identifying geographic areas and the corresponding ISC Agency.
3.2 Qualifications of Individual Service Coordinators
Individual Service Coordinators must possess the Qualified Intellectual Disability Professional (QIDP) credentials as defined in Federal regulations. This requirement applies regardless of whether they provide services full-time or part-time. Service coordinators/QIDPs must update their job skills and knowledge annually, including earning 12 Continuing Education Units annually in job-related training.
Service Coordinators should possess the following skills:
- The ability to coordinate all elements of the Person Centered Planning process, including conducting formal and informal assessments; developing outcomes, producing a Plan, reassessment and revision of the service plan.
- The ability to work within a team process, including such skill areas as facilitating meetings and providing follow up.
- The ability to facilitate communication, including the ability to interpret non-verbal communication, especially as presented by persons with developmental disabilities; the ability to empathize with others' points of view, and the ability to assist others in expressing their own viewpoints and opinions.
- The ability to assist with conflict resolution, including the abilities to facilitate communication, to develop alternative strategies and to help restore normalcy.
- The ability to present information succinctly, both verbally and in writing, without bias, that addresses the level of interests of its intended audience. This includes the ability to interpret technical information to persons inexperienced in the use of technical language.
- The ability to identify, utilize and develop resources that are important for the developmental disability service planning process and for developmental disability service delivery.
- The ability to utilize professional assessments and service reports in the determination of eligibility for services, especially services provided through the Home and Community-Based Waiver.
- The ability to organize one's professional activities so that deadlines are met, appointments are kept and non-productive time (travel and personnel reports) is minimized.
- The ability to maintain a professional demeanor that presents a positive approach to service issues.
3.3 Mandated Reporting
Individual Service Coordinators will report any allegations or observations of suspected abuse, neglect and financial exploitation directly to:
- Office of the Inspector General (OIG) at 1-800-368-1463 for individuals residing in a Community Integrated Living Arrangement (CILA) or incidents that occur at Community Day Services (CDS).
- Adult Protective Services (APS) at 1-866-800-1409 for adults age 18 and over, who reside in their own home or family's home.
- Department of Children and Family Services at 1-800-252-2873 (Voice), 1-800-358-5117 (TTY) for children under the age of 18 or for anyone residing in a Child Group Home or Child Care Institution
- Department of Public Health at 1-800-252-43-43 email at DPH.CCR@Illinois.gov for individuals residing in a Community Living Facility (CLF).
A. Office of the Inspector General, Abuse, Neglect and Exploitation Observations and Reporting
Independent service coordinators are considered "required reporters" under The Illinois Administrative Code Title 59, Part 50 (Rule 50 or OIG Rule) and must report all or suspected cases of abuse, neglect, exploitation or other incidents specifically included in this Rule. When the ISC makes a report to OIG, he/she is considered the "complainant". As necessary, the ISC should inform the DDD Region staff and keep them apprised of the situation.
Rule 50 establishes specific guidelines to follow from the initial reporting of abuse, neglect and exploitation through final action which would result from any subsequent investigation. The Illinois Administrative Codes, Title 59 Part 115 (for Community-Integrated Living Arrangements) and Part 119 (for Community Day Services) also contain language requiring reporting to OIG. OIG is responsible for such investigations in all DDD Waiver settings, except Community Living Facilities, which are licensed by the Department of Public Health.
B. Adult Protective Services
When the ISC is made aware of an Adult Protective Services (APS) investigation, they will contact the identified APS staff or supervisor and offer assistance and information. The ISC must not intervene in the investigation. When the ISC is made aware of an Adult Protective Services (APS) substantiated and verified case, the ISC will work with the APS to resolve issues related to this case. In these situations, the ISC will receive a Substantiation Decision Summary and a Report of Substantiated Decision. For those who are not already in DDD Waiver services, the ISC should determine if the person is eligible for DDD Waiver services and if they meet the crisis criteria or should be placed on the PUNs (see Section 4). For those who are already enrolled in DDD Waiver services, the ISC must determine if the person needs additional services. In some cases, it may be necessary for the ISC to develop a safety plan until permanent arrangements have been made. The ISC must keep the Division informed of their course of action.
Section 4: PUNS for Persons with Developmental Disabilities
The PUNS Form Completion Manual was developed in partnership with Celia S. Feinstein and James A. Lemanowicz, CFA, Inc., the Illinois Department of Human Services/Division of Developmental Disabilities and the Illinois Council on Developmental Disabilities. As of the publishing of the ISC Manual, the PUNS Form Completion Manual is no longer considered the appropriate guidelines for the PUNS process. The PUNS categories, criteria, forms and instructions for completing the form have been revised and now reflect a more streamlined approach to the process. These changes were necessary to (1) reduce confusion, (2) increase transparency, and (3) make the selection process more predictable for the individuals with developmental disabilities and their families. This section of the ISC Manual reflects the most recent information regarding PUNS.
PUNS is a database that registers individuals who want or need DDD Waiver services. People that are interested in receiving services through an ICF/DD should work with the ISC agency to explore potential ICF/DD providers. Individuals can still seek placement on PUNS while exploring ICF/DDs. At the time of enrollment into the database, the ISC must explain all service options available to the person. ISCs can use the Illinois PUNS Form - Enrollment Tool. The ISC will enroll individuals in the PUNS database based on the categories listed below.
The Seeking Services category is for people who currently need or desire supports and are in any of the following situations:
- Persons whose caregiver is clearly progressing toward being unable to provide care for any number of reasons (age of the caregiver, physical/psychological/health condition of caregiver, health or other situation of the individual). The individual and/or family are coping for now but supports are needed.
- The individual him/herself has a deteriorating situation, which requires formal supports.
- Cases where, although the caregiver and person with developmental disabilities have not been directly affected, a death in the family (especially of a care giver's spouse or other family member who may have assisted in providing care) or other circumstance has affected their situation requiring a need for additional support.
- Situations where the caregiver(s) must work to provide income to pay the rent, etc. If services are not provided, the caregiver(s) would have to remain at home to provide support, and effectively be unable to continue working.
- Persons who have (or will shortly) graduate from school and will need day supports (i.e., there are no other employment or other day support options available/planned).
- Person is dissatisfied with current setting and would like to have DD residential services.
- Person prefers to live in his/her own home rather than in a funded residential setting but would need supports to do so.
- Person currently lives in out-of-home residential setting that is not funded by the Division of DD and wishes to return to their family home (and family concurs). The family is capable of providing care but would like support to return this person to the home.
The Planning for Services category is for people who do not currently want or need supports but may in the future. It is helpful to know about these situations even though the person/family is not seeking services now. The Planning for Services category is for persons who are not currently seeking services but will be seeking if something happens to the caregiver (e.g. caregiver becomes ill or passes away) or other family circumstances change. It is also appropriate for persons who currently receive funding or services through entities other than DD, and whose eligibility will be terminating primarily due to the age of the individual. This person is not in crisis and does not have a current need or desire for DD services. This might include, but is not limited to, persons who are funded through:
- Early, Periodic Screening, Diagnosis and Treatment (EPSDT) program
- Medically Fragile/Technology Dependent Children's Waiver
- Individual Care Grant supports through the mental health system
- Illinois State Board of Education or public school system.
PUNS selections for Waiver services will occur as funding is available. Selections will be based on a person's cumulative length of time in the Seeking Services Category after age 18. Selections will not be made from the Planning for Services category. If the individual enrolled in PUNS before turning age 18, the length of time begins calculating on the individual's 18th birthday provided that they are in the Seeking service category. In order to move from one category to the other, individuals and/or guardian must notify their ISC. Movement from one category to the other is not automatic.
Children may be enrolled on PUNS beginning at age 2.5. Children should be placed in the category appropriate to their situation-Seeking Services or Planning for Services. If funding is identified to do a PUNS selection for the children's waivers, selection will be based on a child's cumulative length of time in the Seeking Services category prior to age 18; again, selections will not be made from the Planning for Service category.
4.1 Questions and Problems
Feedback is very important. If any data entry field or explanation is not clear or if ISCs have questions about what should be reported, they may contact the Division of Developmental Disabilities' Program Development Unit at (217) 785-6171 for clarification.
4.2 Individual Assurances
The ISC agency must ensure that people with developmental disabilities and their guardians/caregivers understand that completion of the PUNS form and the inclusion of the information in the IDHS database does not guarantee that the individual is eligible or will receive services.
The information collected through the PUNS form is confidential. The individual, guardian, family and/or caregiver(s) are to be advised of the form's confidentiality and that person-specific information or other personally-identifying data will not be released.
Note: Summary data will be made available via the Department of Human Services' (IDHS) website and upon request. These data will be aggregated and will not disclose information that could be tied to a specific individual.
Among its roles, the ISC agency is to educate individuals of all ages and families that present themselves by informing them of and explaining all the services and support options available. By doing so during the screening process, the ISC agency ensures that all individuals and families make informed decisions about their need for services or supports. This educational role is particularly important when individuals or families do not initially foresee a need for services or supports within the next five years.
If after fully exploring the service and support options, the individual and family state that their need for any services or supports is more than five years away, the ISC should enroll this person in the Planning for Services category. Although PUNS selections will not occur from this category, the Division needs to be aware of these individuals for planning and budgeting purposes.
The ISC agency is to use the guidelines put forward in the Level I Pre-Admission Screen (PAS) process to ensure there is a reasonable basis to believe the person has a developmental disability. A reasonable basis would include that the person has an intellectual disability (with onset before age 18); or cerebral palsy, epilepsy, or other conditions, such as Autism Spectrum Disorder, that fall within the Related Condition category (see Section 5). Any of the latter conditions must have an age of onset prior to the age of 22.
The ISC agency is not expected to routinely complete a Level II PAS for all individuals who request enrollment in PUNS. However, if the ISC agency finds it is necessary to proceed with a Level II PAS before enrolling certain individuals in PUNS, then the screening must be treated as a full Level II PAS and the individual/guardian must be informed of the results. If the Level II PAS determines an individual would not be eligible for services, the individual must be informed about his/her appeal rights and should be referred to alternative services, if appropriate (e.g., aging, mental health).
4.5 For Whom to Complete a PUNS Form
The ISC agency should only complete a PUNS form for children and adults within the ISC agency service area for whom there is a reasonable basis to believe that they have a developmental disability. In addition, the ISC should complete the PUNS form on:
- Adults, age 18 and over, who desire DDD Waiver services (this may include individuals who currently reside in ICF/DDs) and do not meet the descriptions outlined in section 4.6.
- Children, age 2.5 years or older, who desire DDD Waiver services and do not meet the descriptions outlined in section 4.6. PUNS is not a database for Early Intervention (EI) services. Children receiving or seeking EI services should have a PUNS form completed no earlier than the age of 2.5 years.
- Dependents of military service members who are absent from the State due to the member's military service. Upon request, the person can be enrolled in PUNS to indicate the need for services upon return to the State. These persons should not meet the criteria outlined below.
4.6 For Whom NOT to Complete a PUNS Form
The ISC agency should not complete a PUNS form on individuals:
- For whom there is no reasonable basis to believe the presence of a developmental disability.
- Who are already receiving services funded through a DDD Waiver.
- Who do not want DDD Waiver services now or in the future.
- Who, upon assessment, the ISC determines they meet the Crisis Criteria (homelessness, abuse, or neglect). In these cases, the ISC should continue to assess and process all situations that rise to the Crisis level, without placing the individual on PUNS.
- Who are transitioning from State-Operated Developmental Centers into a DDD Waiver service.
- Who are transitioning from State-Operated Mental Health Centers and found to be appropriate for DDD Waiver services.
- Who are transitioning from the Department of Children and Family Services into a DDD Waiver service.
- Who are a part of an ICF/DD Downsizing agreement with DDD and have chosen to go into a DDD Waiver service.
4.7 Special Form Completion Circumstances
- Out of State Guardian/Family: For individuals whose guardian/family lives out of state or outside the ISC agency's assigned geographic area, schedule completion of the PUNS form when the guardian/family visits the individual. If no visit is likely to occur before a PUNS form is necessary, complete the PUNS form with the individual with developmental disabilities with the participation of the guardian/family by telephone.
- Individuals who are Wards of the Office of State Guardian: For individuals who are wards of the Office of State Guardian, schedule completion of the PUNS form to coincide with scheduled visits by the OSG representative or work with the OSG representative to schedule his/her visit at the same time the ISC agency completes the PUNS form if it can be arranged and is timely. If a coordinated face-to-face interview cannot be arranged in a timely fashion, the OSG representative may participate by telephone. A copy of the completed PUNS form can then be sent to the OSG representative for confirmation and signature.
- Children and Adolescents: Individuals ages 12 and older should be encouraged to participate in the PUNS completion meeting.
4.8 Guidelines for Completing the PUNS Process
The completion of the PUNS form is to occur when the person first contacts the ISC agency, at any time the individual's needs change significantly after enrolling in PUNS, and annually to make sure the individual's information is current. The PUNS form and database entry must be closed when an individual becomes enrolled in a DDD Waiver service or when an individual withdraws from the database.
Whenever the form is completed, it should be completed as a result of a conversation between the individual, his/her guardian(s), and ISC agency staff. Other individuals, as desired by the person with the developmental disability and/or guardian may also be involved. The PUNS form should be completed in its entirety. Anyone who participates in completing the PUNS form should sign the form.
The ISC must conduct a face-to-face interview with the person, guardian and family (as applicable) when completing the initial PUNS form. The initial PUNS form should never be sent to an individual, guardian, caregiver, family member, or others for him/her to fill out. The ISC must schedule and reschedule, if necessary, the PUNS meeting to a time and date that will accommodate attendance by the individual and guardian, as well as family members and primary caregivers. The face-to-face meeting must be held at the location of the individual's or guardian's choosing.
ISC agency staff should remind those involved in completing the PUNS form, the individual, guardians, parents and/or caregiver(s) that it is important to bring all relevant and supporting documentation of the individual's medical condition(s) and living situation to the interview. This information will help to ensure that the person's need desires for services and supports is determined accurately.
4.9 Instructions for Completing the PUNS Form
- Individual Data. In this section, record basic information such as the reason for completing the form, the name of the individual requiring services, the service coordinator, caregiver, provider, guardian, etc. Please do not leave any blank fields. If information is not applicable to the individual or is unknown, indicate this by entering NA or UNK as applicable.
- Effective Date - Enter the eight-digit (8) date (MM/DD/YYYY) that the initial or updated form was completed. This entry is important because it is used to trigger the 30-day notice to ISC agencies that the annual update is due as well as the priority order in which the person will be enrolled into the database.
- Person's name - Enter the first name, middle initial, and last name of the person requesting services.
- Social Security Number - Enter the social security number being enrolled in PUNS. Please be sure it is entered correctly as the number will be used for tracking purposes over time.
- Reason for PUNS or PUNS Update - Check one and only one reason for completing the form.
- Primary Caregiver - Enter the name, date of birth and address of the family member with whom the person with developmental disabilities is living and who serves as the primary caregiver. If there is not a primary caregiver or if the person is in a residential placement, enter "NA." Paid staff members are not primary caregivers for the purposes of this question.
- Secondary Caregiver - Enter the date of birth of the family member with whom the person with developmental disabilities is living and who serves as the secondary caregiver. This would be the case, for example, for someone living with both parents and one parent is the primary caregiver and the other is the secondary caregiver. If there is not a secondary caregiver or if the person is in a residential placement, enter "NA." Paid staff members are not secondary caregivers for the purposes of this question.
- Is the individual in school? Select yes or no. If yes, enter the projected graduation date.
- Be sure to read the paragraph regarding confidentiality and eligibility to the individual and/or his/her family.
- Signatures - The name of the service coordinator, individual, family member and/or guardian should be printed legibly, and their signatures obtained.
- Client Case Registration and Client Developmental Disability Information. The data fields that will be completed in this section of the PUNS form are taken directly from the IDHS Community Reporting System (CRS) manual Reporting of Community Services (ROCS) screens. These screens contain demographic and clinical information. If the data have been previously entered through the ROCS system by the ISC agencies, and if it is still current and accurate, it need not be reentered. Service coordinators should make sure that the client data displayed in the ROCS system are current at the time of the interview. The demographic field descriptions are available through the IDHS CRS manual. It is recommended that ISC agencies access this manual through the IDHS website periodically to ensure that field descriptions have not changed. This information is available through at IDHS Community Reporting System manual
- PUNS Categories. On the PUNS Form/Screens, the ISC must select only one of the two categories below:
- Seeking Services (people who currently need or desire supports)
- Planning for Services (people who do not currently want or need supports but may in the future).
- Supports Needed. On the PUNS Form/Screens, ISC is to check supports identified by the individual or family as needed by the individual. All needed supports identified should be checked. If the person does not need a particular support as identified below, this option should be left blank.
||Check (?) if applicable
|Personal Support (include habilitation, personal care, intermittent respite)
|Respite Supports (24 hours or more)
|Behavioral Supports (includes behavioral intervention, therapy, counseling)
|Adaptations to Home or Vehicle
|Nursing Services in the Home, provided intermittently
|Other Individual Supports
||Check (?) if applicable
|Transportation (include trip/mileage reimbursement)
|Other Transportation Service
|VOCATIONAL OR OTHER STRUCTURED SUPPORTS
||Check (Y) if applicable
|Support to work at home (e.g., self-employment or earnings at home)
|Support to work in the community
|Support to engage in work/activity in a disability setting
|Attendance at activity center for seniors
||Check (?) if applicable
|Out-of-home residential services with less than 24-hour supports
|Out-of-home residential services with 24-hour supports
4.10 Updating, Changing and Closing PUNS Records
The ISC agency is responsible for updating, changing and closing PUNS records as described below to ensure the information in the database accurately reflects the person's need and/or desire.
- Annual Updates to PUNS Records
The ISC agency is required to update PUNS records at least annually to ensure that the individual and/or guardian is still interested in DDD Waiver services and to assess whether their situation has changed from one category to the other. ISCs should remind all persons involved in the annual update to provide documentation of the individual's medical condition and living situation. The ISC must also remember to give everyone who signed the updated PUNS form a copy of the signed form. Failure to update the PUNS form annually will result in the individual's information being identified as "Closed" in the database. Before the individual's information is identified as "Closed" in the database, the ISC will document completion of the steps outlined in the "Closing PUNS Records" section. The ISC is primarily responsible for PUNS updates, but this is a shared responsibility with the individual, guardian, family members and/or primary caregivers (as applicable). All parties should be knowledgeable of the process described below and take appropriate action to ensure annual updates are completed timely.
Annual updates to the PUNS information:
- Can be conducted by phone for persons in either category as long as the opportunity for a face to face discussion was offered.
- Requires a face-to-face discussion if an ISC starts an update by phone and determines a change to the category exists. In these cases, the PUNS update should stop and must be completed at a face-to-face meeting.
- Requires a face-to-face discussion if requested by the individual and/or guardian.
When no changes to the current information are to be reported, the service coordinators should check the Annual Update box, complete the form by marking the same items as the previous PUNS Form, and send a copy of the "Annual Update" PUNS Form to the individual/guardian for signature.
- For those updates completed over the phone, the ISC will send the individual or guardian a written or electronic copy of the updated enrollment. The date of the update will be that on which the phone interview occurred. The signatures may not pre-date the phone call. The individual or guardian (or parent in the case of an individual aged 18 or younger) must sign and return a copy of the form to the ISC agency.
- The ISC agency will be notified at least 90 days before the date that the annual update is due for all PUNS-enrolled individuals it serves. At the end of each month, the IDHS Community Reporting System will generate a listing for the ISC agency that will identify each individual whose annual update is due in the next 90-120 days. The names on the listing will be based on the date entered in the "Date Form Completed and Signed by All Parties" on the most recent PUNS form recorded in the database. Letters will also be generated simultaneously to the individual and guardian of record to alert them to prepare for the annual update of the PUNS record. These notifications are intended to assist the individuals, guardians, and ISC providers; however, the annual update requirement is the joint responsibility of the individual, guardian, and ISC provider.
- When practical and if applicable, the ISC agency should coordinate the completion of annual updates with regularly scheduled visits by OSG representatives.
- Changes to PUNS Records (outside of the annual update)
ISC agencies are required to update PUNS records whenever an individual's situation changes significantly from what was reported by the previous PUNS form. This can be whether the previous PUNS form was an initial one, an annual update or one that also reported a previous significant change. The ISC agency should complete an update within 30 days of becoming aware of the change in the individual's situation and remember to give everyone who signed the updated PUNS form a copy of the signed form. Signature by the individual or guardian is not required in circumstances of moved to another state, deceased, or unable to locate.
- Closing PUNS Records
In order to ensure everyone has fair and equal access to Medicaid Waiver services, and that the Department has accurate information for planning and budgeting purposes, PUNS records must be kept current. To that end, the following steps will be taken if annual updates are not completed timely.
- Families will be notified by the Department 90 days before the date that the annual update is due.
- The ISC agency will be aware of the due date through the monthly reports discussed under "Annual Updates to PUNS Records".
- The ISC must then contact the individual or guardian to complete the annual update. If the individual or guardian does not respond to the notice or contact, the ISC agency must take the following steps prior to closing the PUNS record.
- The ISC completes a first phone call or text to the individual or guardian 60 days prior to the PUNS annual update due date.
- If there is no response and an update session is not scheduled, the ISC completes a second phone call or text one to two weeks following the first phone call, varying day and time of the call.
- If there is still no response or plan for updating the PUNS record, the ISC completes and sends the first letter or e-mail to the individual or guardian 45 days prior to the PUNS annual update due date stating that the person's record will be closed if there is no response within 30 days.
- If there is no response, the ISC completes and sends a second letter or e-mail two weeks after the previous letter stating the enrollment will be closed if there is no response by the date specified in the two letters.
- If there is no response after two weeks following the second letter, the ISC will close the PUNS enrollment record.
[Note: Days and time periods referenced in this section represent calendar days.]
An example of time frames for the above actions would be as follows for an annual PUNS update due on June 1st:
- April 1, first phone call or text.
- April 7 through 14, second phone call or text.
- April 15, first letter or e-mail indicating the PUNS enrollment will be closed if the individual/guardian does not respond by May 15.
- May 1, second letter or e-mail indicating the PUNS enrollment will be closed if the individual/guardian does not respond by May 15.
- June 1, PUNS enrollment is closed.
Once the ISC closes the PUNS record and electronically reports that to the Department, the Department will send a notice of the closure to the individual or guardian at the last known address reported by the ISC.
4.11 Maintaining Local PUNS Records
Copies of all completed PUNS forms (initial, changes, annual updates) are to be maintained by the ISC agency in the individual's file.
Whenever a PUNS form is completed or updated, the ISC is to give a copy of the signed PUNS form to the individual and any other person who signed the PUNS form (i.e., guardian, primary caregivers, etc.) for their information and records. Exception: If a guardian or primary caregiver who lives with the individual specifically requests not to receive a separate copy of the PUNS form, the service coordinator should note that request on the agency's copy of the PUNS form.
4.12 Dependents of Military Service Members
People who are dependents of military service members, absent from the State due to the member's military service and who have been selected from the PUNS database to receive services will have 6 months, from the date of the selection notification, to apply for services. This person then has another 6 months to commence using such services. Once this person begins receiving DD waiver services, they no longer need to be on PUNS.
Section 5: Pre-Admission Screening
Pre-Admission Screening (PAS) information and process
Section 6: Person Centered Planning
Person Centered Planning addresses the balance between what is important to a person and what is important for a person in service planning. The process focuses on outcomes that are identified by the person in collaboration with their guardian and family. The ISC will document those desired outcomes, assist in identifying the barriers that currently prevent the outcomes, and assist the individual/family to locate and select agencies that are willing and qualified to provide the needed supports. Person Centered Planning is required for individuals who are or will be funded through a DDD Waiver. Person Centered Planning does not mandate goals in independence in daily living, economic self-sufficiency, community integration or self-administration of medication.
Person Centered Planning:
- Must be driven by the person
- Ensure services are delivered in a manner that reflects personal preferences and choices
- Must include evidence that setting is chosen by the individual
- Assist to achieve personally defined outcomes in the most integrated setting
- Contributes to the assurance of health and welfare of the person receiving services
- Must include opportunities to seek employment and work in competitive integrated settings
- Must include opportunities to engage in community life, control personal resources, and receive services in the community to same degree of access as those not receiving Medicaid Home and Community Based Services
- Includes risk factors and measures to minimize risk
- Should be written in plain language that can be understood by the person who receives services and their guardian
- Reflects cultural considerations
- Include strategies for solving disagreements
Person Centered Planning process includes three main documents: The Discovery Tool, the Personal Plan and Implementation Strategies, each of these are described in detail below. In most cases, the initial Person Centered Planning documents will be completed prior to a person entering DD Waiver services. Once a person has began receiving services, these documents must be updated at least annually (see Section 9.1 of this manual).
Discovery is the first component of Person Centered Planning. The Discovery process is designed to gather information about a person's preferences, interests, abilities, preferred environments, activities, and supports needed. The ISC agencies will be responsible for facilitating the Discovery process and documenting what they gather in the Discovery Tool. The Discovery process is not a one-time event, but a series of information gathering activities. The ISC will gather information through discussions (face to face, phone, and electronic), observations, and record reviews (evaluations, assessments, case notes). This process should begin with the individual and then include the guardian, advocate or family, and others chosen by the individual. It must also include current providers. The information captured during this process is used to develop the Personal Plan which summarizes key and critical areas of the person's life.
A. Independent Service Coordinator (ISC) Responsibilities
The ISC is responsible for the completion of the Discovery process and Tool. This must be done in conjunction with the person and his/her guardian. The ISC must complete the initial Discovery process for children and adults newly transitioning to a DDD Waiver, including Ligas Class members. The Discovery process must be completed after the person has been determined eligible but prior to developing the Plan or searching for a provider. This does not include individuals in Crisis.
The ISC must continue to complete and submit the Crisis Transition Plan and Funding Request form for individuals who are considered to be in Crisis (homeless, abuse or neglect). The ISC then has 30 calendar days after the date the person begins DDD Waiver services to complete the Discovery process and develop the Personal Plan.
The ISC should not complete the Discovery Tool/process for:
- Individuals who are Bogard class members living in an Intermediate Care Facility for individuals with Developmental Disabilities (ICF/DD). These individuals are not involved in the Person Centered Planning process and will continue to have an Individual Service Plan developed by the ICF/DD provider.
- Individuals who are 100% State funded.
B. The Process
- In preparing for the Discovery process, the service coordinator must consider the individual's desired preference for the manner, location(s) and time(s) to gather the information.
- The ISC must facilitate the discovery process and complete the Discovery Tool.
- The ISC should ask the individual who they want to participate in the initial discussions. The person should consider inviting people that know, support, and respect them.
- If possible, the discovery process should include a face to face discussion with the individual/guardian (if applicable). In situations where the guardian is unable to be present, the ISC must document how information was received from the guardian.
- The ISC must obtain information from provider agencies currently serving the individual (if applicable).
- The ISC can also obtain information from family members, Personal Support Workers, teachers, therapists, friends, child care providers, and others who know the person well.
- The Discovery process is fluid and should be conducted over a period of time instead of in a single meeting.
- The completion date of the Discovery Tool cannot be more than six (6) months from the date of the Personal Plan.
- For those who become enrolled in a DDD Waiver, the Discovery Tool should be updated at least annually as described in Section 9.1 of this manual.
C. Sources of Information
- The questions in the Discovery Tool are meant to guide conversations. It is not necessary to ask every question in each section, but it is necessary to address each section of the Tool.
- Prior to talking to the individual, the ISC should consider what supports may be needed to promote the person's full participation (visual aids such as graphics/pictures to understand concepts, pen, paper, sign language interpreter, etc.).
- ISC can obtain information in various ways: conversations (face to face, phone, e-mails), record reviews, assessments/evaluations, provider agency notes and summaries.
- If the individual is currently enrolled in other services (e.g. residential service funded by a local school district), the ISC agency must obtain information from the current provider agency(s). If information will be obtained face to face, the ISC staff must ensure agency staff has the appropriate authorization to leave their work responsibilities to participate. Agency staff should not participate in Discovery discussions without consulting with or informing the appropriate provider agency management.
- When addressing risk, the ISC must gather information from a variety of sources including the individual, guardian, family, staff, record review, and observation. Then, they must use the information gathered to document why the concern currently presents a risk or when the concern has presented significant risk in the past.
- A separate risk assessment is not required but if an ISC chooses to use one it must include the following domains: health/medical, safety at home, in the community and in the workplace, finances and behavioral supports.
D. Guiding Conversations
- When gathering information:
- Speak with the person using first person language and open ended questions, such as "What do you…"
- Communicate with the individual/family using words that are easy to understand. Refrain from canned language and acronyms.
- If conducting a discussion with multiple people, ask the individual for input before asking others present to respond.
- Allow sufficient time for the individual to formulate thoughts and answer.
- Encourage/support multiple styles of communicating thoughts and ideas (pictures, drawing, symbols and words).
- The ISC should consider having a separate discussion with the individual prior to gathering information from other sources.
- If the individual is unable to communicate in a way for the ISC to understand, ISCs will have to rely on caregivers/those who know the person best to complete the discovery process. You may also rely upon caregivers when conducting the Discovery process with young children.
E. Documenting the Information
- The Discovery Tool should be typed using the form provided. Using bullet points is preferred.
- The Tool must be completed by the ISC staff and therefore will not be written in first person.
- The ISC should provide a copy of the Discovery Tool to the individual/guardian once the Tool is considered complete (each section addressed and with the ISC signature).
- The most recent copy of the Discovery Tool should be kept on file with the ISC.
- The ISC should provide a copy of the Discovery Tool and Plan, as a part of the complete referral packet, to the provider agency selected by the individual/guardian. This should occur after the person has selected the provider(s) and given consent to make a detailed referral for services.
- The ISC must update the Discovery Tool at least annually but can do so more often if the preferences, abilities or needs of the person changes.
- The completed Discovery Tool will not require a review/approval from the Division of Developmental Disabilities.
6.2 Personal Plan
The Personal Plan is the single, comprehensive personal vision for a person's life. This document focuses on the individual's strengths, preferences, needs and desires. The ISC agencies will be responsible for developing the Personal Plan in conjunction with the individual, guardian, family, and providers. The Personal Plan will not only contain the outcomes that the person requires in their life, but also documents choices of qualified providers, reflect what is important to the person regarding delivery of services in a manner which ensures personal preferences, health and welfare. It must also include risk factors and plans to minimize them. This document is developed through a person centered process and serves as a mechanism for sharing this information with others who are or will be involved in supporting the person to achieve his/her desired life. The Personal Plan provides the basis for receiving services, service monitoring and quality evaluation. The Plan should be completed based on what was learned during the Discovery process and can only be developed after the Discovery process is complete. The Plan must be completed prior to searching for a provider agency and initiating DDD Waiver services (except for individuals who are in crisis).
A. Developing the Plan
- The ISC is responsible for developing the outcomes and ensuring the completion of the Plan.
- The Personal Plan is based on information gathered during the Discovery process.
- The ISC must develop the Personal Plan for children and adults newly transitioning to a DDD Waiver. This must be completed prior to initiating DDD Waiver services, with the exception of Crisis cases.
- For individuals who are considered to be in Crisis (homeless, abuse, or neglect), the ISC must complete the Crisis Transition Plan and Funding Request form. The ISC then has 30 calendar days after the date the person begins DD Waiver services to conduct the Discovery process and develop the Personal Plan.
- The ISC will use the Personal Plan form as the official Plan. Alternative formats of the Plan may be generated and distributed to the individual/guardian as needed.
- The contents of the Plan must reflect the key aspects of a person's life as outlined on the form. If there is no outcome listed in a section, the ISC should still complete the remaining statements/questions of that particular section as appropriate.
- It should be recognized that some individuals will have multiple desired outcomes, all of which may not be addressed at this time. In such cases, the ISC should assist the person to prioritize outcomes and select providers that meet the "top" priorities. The ISC should document the outcome(s) that are currently on hold and the reason why.
- The ISC must ensure the Plan accurately reflects the outcomes, preferences, strengths and support needs of the individual.
- The Plan must also discuss risk and strategies to minimize these risks.
- The Personal Plan is considered complete when the individual and guardian approve the services, identified outcomes and supporting information in the Plan. The individual, guardian (if applicable) and ISC must sign the Personal Plan. The last signature date of these three parties becomes the annual renewal date for the Personal Plan.
- If the individual is unable or unwilling to sign the Personal Plan, the ISC must document the reason why and the date the ISC reviewed the Plan with the person.
- If the guardian:
- Is unable to sign the Plan, the ISC must obtain verbal approval from the guardian and document the method and date the approval was received.
- Is unwilling to approve and sign the Plan, the ISC must first work to resolve any disagreement(s) and document in the Plan how the disagreement(s) was addressed. If the guardian is still unwilling to approve and sign the Plan, the ISC must document the reasonable measures taken to obtain their approval/signature.
- Is unresponsive to requests for their approval and signature, the ISC must document the reasonable measures taken to obtain this information and that the individual's guardian has failed to respond.
- Does not sign and date the Personal Plan, the last signature date of the individual or ISC becomes the annual renewal date for the Personal Plan.
The completed Plan shall become a part of the individual's record.
B. Dissemination of the Plan and Provider Selection
- The individual/guardian directs the ISC to disseminate the Personal Plan to provider organizations that he/she is considering as a possible service provider for the purpose of determining organizations' ability to meet the desired outcomes and/or provide services identified in the Plan.
- Organizations that believe they can meet outcomes and/or provide services identified in the Plan can request additional information from the ISC (i.e. Discovery Tool, medical and social histories, psychological evaluation(s), etc.) and work with the ISC who will facilitate the provider selection process.
- In cases where a current provider is unable or unwilling to assist the person to work towards any desired outcome or provide services:
- This provider should not sign a Provider Signature Page.
- The ISC should assist the individual to locate other qualified and willing providers. Until a qualified and willing provider(s) is located, the ISC should document progress toward finding an appropriate service provider and document the outcome(s) that is currently on hold and the reason(s) why.
- It is crucial for all stakeholders to understand that the outcomes listed in the personal plan are those expressed by the individual through the discovery process. Service providers who are aware of the need to change the Plan should notify the ISC of the person's need or desire to change their plan.
It is expected that each individual in DD Waiver services has at least 1 outcome. This may reflect something the individual desires that is not currently present or it may reflect something that is already present and they want to maintain. When developing outcomes in the Personal Plan, remember that outcomes:
- Can only be developed after identifying what is important to the person.
- Should include what is important for the person. The outcome statement should reflect "in order to" or "so that". See examples below.
- May have to be prioritized.
- Are not services and supports; see examples below.
- Should make sense for a person without an intellectual/developmental disability.
- Must be written in present tense and plain language.
- Should not be written in first person.
- Do not have to be present in each section of the Plan. Outcomes should only be identified for sections that the individual expressed a desire or preference.
Examples of Outcomes Statements:
- Mary volunteers at a day care center so that she gets to spend time with children and knows that she is needed.
- Bernice sings with the choir on Sundays so that she stays active.
- Ron enjoys rock music while bathing so that he can relax and feel refreshed.
- Bree watches Animal Planet when she is assisted to stretch so that she feels safe and relaxed during her exercise time.
- John delivers mail at the hospital in order to gain job skills.
When documenting risk in the Personal Plan:
- Provide narrative information (including brief overview of current skills as well as potential and known risks) sufficient to guide a provider.
- Consideration should be given to both the risks associated with current activities of the individual as well as potential risks which inhibit the individual from pursuing his/her goals and fully participating in integrated settings.
- All safeguards, supports, education and training necessary to mitigate identified risks should be included.
- Discuss with the individual/guardian, if applicable, if they are willing to accept some situations with risks to facilitate choice, independence, and community integration.
- Identify safeguards that are already in place to minimize identified risks and outline additional needed actions to reduce other risks which pose a real or potential threat to the individual's health, safety and/or welfare.
- Identify who will be responsible for each of the needed safeguards and actions.
If conflict arises during Personal Plan development, the ISC should:
- Determine what needs to change, what needs to remain the same for the person.
- Consider what makes sense or what is working in the individual's life?
- Consider what doesn't make sense or what is not working in the individual's life?
- Allow each person to contribute his/her perspective.
- Use the information gathered as the basis of thought for the development of an outcome.
F. Summary of Services & Supports Page
The Summary of Services & Supports page of the Personal Plan is to be completed by the ISC agency. The ISC must document all services, as applicable to each individual, on this page Plan under the column titled Service/Support. ISC agencies must ensure that all Medicaid Waiver services to be provided to an individual (including the services' scope, amount, frequency and duration) must be listed in the individual's Personal Plan. This should include Individual Service & Support Advocacy. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided. It is not necessary for ISCs agencies to document the details of the services that will be provided (i.e. provide assistance with meal preparation) on this page. Provider agencies who are aware of the need to change services (i.e. add Supported Employment), should notify the ISC to ensure that this service is requested by the individual/guardian and included in the Personal Plan.
G. Provider Signature Page
The Provider Signature Page of the Personal Plan should only be completed and signed by provider agencies that will render services or work toward outcomes listed on Summary of Services and Supports page of the Personal Plan. This page will not be completed or signed by families, guardians or those serving as the HBS Employer of Record. Prior to delivering any services through the Medicaid Waivers, provider agencies should ensure they have a copy of the final and completed Plan. The Summary of Services & Supports page of the Plan must contain the service(s) the provider will deliver. All paid services that are applicable to the individual must be identified on this page. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided.
- After receipt of a Personal Plan, provider agencies that will support any of the services or outcomes listed on the Plan should document the particular service(s) and outcomes they will address on the Provider Signature Page of the Personal Plan. It is not necessary for provider agencies to document the details of these services (i.e. providing assistance with hygiene) on this page. The details of how the service will be provided should be outlined in an Implementation Strategy.
- A provider agency must not change the services or outcomes contained in the Plan. Provider agencies who are aware of the need to revise or edit the Plan, should notify the ISC.
- Provider agencies have 10 calendar days to complete, sign and return the Provider Signature Page. The completed and signed page becomes a part of the individual's Personal Plan.
6.3 Implementation Strategies
The information identified in the Personal Plan must be addressed and accounted for in the Implementation Strategy. An Implementation Strategy must detail the supports and services that will be provided on a day-to-day basis. Implementation Strategies are developed by provider agencies that have agreed to provide services and/or by the Home Based Services (HBS) Employer of Record. Implementation Strategies will be evaluated to assure consistency between the stated desires and activities/support.
A. Implementation Strategies developed by Provider Agencies
After the provider agency's signature on the Provider Signature Page of the Personal Plan, the provider agency will develop an Implementation Strategy that includes the details of how the service(s) will be provided. Prior to delivering any services through the Medicaid Waivers, providers should ensure they have a copy of the final and completed Plan. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided.
Provider agencies who will develop an Implementation Strategy can determine their own tool/format, but it must at least contain the following:
- Basic descriptive, diagnostic, demographic and medical information
- Outcomes identified in the Personal Plan that the provider has agreed to work toward.
- A description of how supports and services assist the individual to engage in community life and maintain control over personal resources.
- Opportunities to seek employment and work in competitive integrated employment if desired.
- Functional goals/training areas and methods to measure progress.
- Documentation that services and supports are linked to individual strengths, preferences and assessed clinical and support needs.
- Risks included in the Personal Plan and any others subsequently identified; strategies that will be used to mitigate risk and identify who is responsible for implementing these strategies.
- All services and supports to be provided regardless of provider or funding source, including type, methods if applicable, frequency, duration and staff assigned if applicable.
- Justification for any restriction(s) or modifications that limit the person's choice, access or otherwise conflict with HCBS standards.
- Documentation for any situation where a person lives in a residential setting owned or controlled by a service provider and modifications to the community settings are requested.
When an individual is using the same provider agency for both CILA and CDS services, a provider agency is not required to develop 2 different Strategies. However, if the strategies for CILA and CDS are significantly different, and the provider determines that separate Implementation Strategy documents would be more "user friendly" for the staff, the use of separate documents is acceptable. Regardless of whether the provider opts to use separate or combined strategies, each the Implementation Strategy document must contain all the necessary components described above. The provider should keep a copy in both locations so that staffs are aware of the supports and services they are to provide.
- Provider Agencies have 20 calendar days to develop their Implementation Strategy. The 20 calendar days begins with the provider's signature date on the Provider Signature Page of the Personal Plan.
- Provider agencies must provide the Individual/guardian and the ISC a copy of the Implementation Strategy.
- Individual/guardians must review the proposed strategies. If approved, the individual/guardian is required to sign the provider's Implementation Strategy. The ISC will not sign or approve Implementation Strategies.
- Provider agencies must ensure that all services being billed are identified in the Personal Plan. Provider agencies who are aware of the need to change services (i.e. add Supported Employment), should notify the ISC to ensure that this service is requested by the individual/guardian and included in the Personal Plan.
- Implementation Strategies must reflect ongoing review, monitoring and updating when necessary. Implementation Strategies must also be updated to reflect changes in the Personal Plan at least annually and more often if warranted by circumstances, a change in functional status or at the request of the individual.
Provider types listed below, who have agreed to render services and/or work toward outcomes, should develop Implementation Strategies as outlined below:
|The following provider types are required to develop Implementation Strategies:
||The following provider types can develop Implementation Strategies OR use current Assessment/Treatment Documents:
||The following provider types are not required to develop an Implementation Strategy:
- Adult Day Care
- Agency-based Personal Support Worker (Home Based Support Program (HBS) only)
- Child Group Home
- Community Integrated Living Arrangement (CILA)
- Community Day Services (CDS, formerly known as Developmental Training)
- Community Living Facility (CLF)
- Supported Employment Program (SEP)
- Behavior Counseling
- Nursing (HBS only)
- Occupational Therapy
- Physical Therapy
- Speech Therapy
- Adaptive Equipment
- Assistive Technology
- Home Modifications
- Non-Medical Transportation (HBS only)
- Self Direction Assistant (SDA, HBS only)
- Vehicle Modifications
B. Employer of Record Implementation Strategy
Individual's, family, and others who act as the Employer of Record in HBS, must develop an Implementation Strategy when they will arrange any service (i.e. hiring PSWs or purchasing Self Direction Assistance (SDA)) or work on any outcome from the Personal Plan. It is the responsibility of the ISC agency to notify the individual, family guardian of this and to direct them to the form. The Employer of Record will complete the Employer of Record Implementation Strategy form [IL462-1240] and use the Instructions for Completing the Employer of Record Implementation Strategy [IL462-1241]. If the Employer of Record wants or needs help completing the form, they can purchase SDA. The ISC agency should help individuals and families locate an agency that provides SDA.
The Employer of Record's Implementation Strategy must:
- Be completed using the Employer of Record Implementation Strategy form according to the instructions provided.
- Be completed by the HBS Employer of Record for the person receiving DD Waiver services or a SDA hired by the individual, family or guardian.
- Be completed when the individual or family has chosen to arrange or oversee services and/or outcomes from the Personal Plan. This might include when services are being delivered by a family member, Personal Support Workers (PSW) privately hired, Special Recreation Association programs, private day programs, or professionals/therapists who do not accept Medicaid. When an individual or family has chosen agency based services only (i.e. Community Day Access, agency based Personal Support Workers), it is not necessary to complete this form.
- Contain all the outcomes from the Personal Plan that the individual, family or guardian has agreed to work on or arrange.
- Contain any of the services that the individual, family or guardian has or will arrange. This includes: PSWs hired directly by the individual, family or guardian; Adaptive Equipment, Assistive Technology, Home Modifications, Non-Medical Transportation, Self Direction Assistant and Vehicle Modifications.
- Be updated at least every year. It can be updated more often if the individual/guardian's needs or desires change.
The Employer of Record Implementation Strategy does not replace the Home-Based Support Service Agreement. The Employer of Record must keep the completed Strategy on hand. They must also provide a copy to their Independent Service Coordination (ISC) agency and SDA if they have hired one. It should be available to the Division of Developmental Disability staff as requested. The Employer of Record must also ensure that all services and supports are provided and/or billed according to your HBS Service Agreements, Service Authorizations and Implementation Strategy.
Section 7: Service Request, Submission and Authorizations- This section is currently unavailable
Section 8: General Service Coordination
ISC agencies provide general service coordination for children and adults with developmental disabilities who are not in a DDD Waiver funded service and who are not a part of the Bogard Class. General service coordination provides:
- Initial eligibility and linkage
- Referral and linkage to both generic and specialized services
- Transportation to facilitate referrals and linkage
- Planning (only in those instances where not otherwise provided by other programs)
- Crisis intervention
Service Coordination includes participation in planning efforts for adolescents aging out of the public school system. It also includes completion and update of PUNS information, as outlined in Section 4 of this Manual, for all individuals in the assigned geographic area who seek inclusion in the database.
The Independent Service Coordination agency, upon request from an individual or guardian, shall do the following as initial eligibility and linkage:
- Complete the OBRA 1 Initial Screen to determine if there is a reasonable basis to suspect the individual has a developmental disability or follow up on the OBRA 1 documents received by the ISC agency.
- If there is a reasonable basis to suspect a developmental disability exists, the ISC completes a Pre-admission Screening (PAS) Level II screen.
- If there is a reasonable basis to suspect there is not a developmental disability, provide information and linkage to the Department of Aging, Division of Mental Health and the Division of Rehabilitation Services.
- For persons for whom there is a reasonable basis to believe a developmental disability exists, review service options, including Medicaid entitlement (ICF/DD, CLF, etc.) and Home and Community Based waiver services (HCBS).
- Refer to appropriate interim services (e.g. DRS, Respite), for persons with a developmental disability who opt to go on PUNS database.
Section 9: Individual Service and Support Advocacy
Individual Service and Support Advocacy (ISSA) is service coordination or case management to persons who are enrolled in a DDD Home and Community Based Service Waiver. This will include some individuals who are:
- Living at home and are receiving intermittent support services through Community Integrated Living Arrangement (CILA) or Home Based Services;
- In a variety of community-based residential settings, including CILA, Community Living Facilities (CLF) and Child Group Homes.
- Receiving Community Day Services (CDS).
ISSA is also provided to Bogard class members who live in an ICF/DD (see Section 10.1 of this manual). Through the provision of ISSA, the ISC represents the Department's interests in determining whether program services are being provided as outlined in the Personal Plan as well as monitoring the person's welfare, health and safety. ISSA is not optional; individuals, guardians or families must not refuse ISSA.
9.1 Annual Review and Update of the Plan
For those enrolled in a DDD Waiver, the Discovery Tool and Personal Plan must be updated annually to ensure they continue to reflect the person's preferences and support needs. The Plan must be updated within 365 calendar days of the previous Plan. This includes obtaining the individuals/guardian's signatures. The Discovery Tool should always align with the information in the Personal Plan. The ISC should provide a copy of updated Discovery Tools and Plans to current provider agencies serving the individual.
- For annual reviews and updates to the Plan, the ISC agency must obtain information from the current provider agency(s). Provider agencies must send the ISC requested information/ documents within 14 calendar days of receiving a request. ISCs should request information from or coordinate discussions through provider's management staff. If the individual/guardian has identified a specific provider staff (i.e. a direct care staff) to be involved, the ISC should make management at the provider agency aware of the request. Agency staff should not participate in Discovery discussions without consulting with or informing the appropriate provider management.
- The Personal Plan can be revised or edited more often than annually if the person's desires or needs change. Individuals, guardians, families or service providers who are aware of the need to revise or edit a Plan should notify the ISC. Revisions and edits to the Plan must be done using the following guidelines:
- Revising the Personal Plan:
- If there is a significant change in the individual's wellbeing (medical or behavioral), the ISC must review and revise the Discovery Tool and Personal Plan to ensure that these documents accurately reflect the current preferences, desires, abilities and support needs of the individual.
- On page 1 of the Personal Plan, under Check type of Plan, the ISC must select Revision.
- A Revision requires new signatures (and dates) from the individual, guardian(s) and ISC.
- The last signature date of the individual, guardian(s) and ISC becomes the annual renewal date for the Personal Plan.
- A new Provider Signature Page(s) should be completed along with a new Implementation Strategy.
- Edits to the Personal Plan:
- When the ISC becomes aware of the need to add or subtract an outcome or service the Plan can be edited.
- The Discovery Tool should be reviewed and updated as needed (if discrepancies are identified).
- It is not necessary to obtain new signatures from the individual, guardian(s) or ISC when the Plan is edited.
- An edit to the Plan does not reset the annual renewal date.
9.2 ISSA Monitoring Activities
As the case management entity, the ISC agency is responsible for monitoring the implementation of the Plan as well as the health, welfare and safety of the individual receiving DD services. The following guidance should be used when conducting monitoring visits and other monitoring activities.
A. Minimum required annual visits
- The ISC agency will conduct a minimum of two face to face ISSA visits per year to each person in a DDD Waiver program and will consist of the following:
- At least one annual visit must be conducted to update the Discovery Tool and Personal Plan. The person's Discovery Tool and/or Personal Plan will serve as the required documentation for this visit. The ISC can conduct additional visits to complete the Tool and Plan if necessary.
- A minimum of one annual monitoring visit must be conducted to the individual's residence to assess the individual's satisfaction with the outcomes and services as well as to monitor their health, safety and welfare (whether or not it is a private home). The annual monitoring visit should occur in the person's home/residence; this includes licensed settings (i.e. CILAs, CLFs, child group homes) as well as non-licensed settings (individual's own or family homes). The ISC Individual Monitoring and Interview Notes [IL462-4465] will provide documentation for this visit.
- Prior to completing the annual required monitoring visit, contact must be made with the guardian, family member or friend (if allowed by the individual) to determine if there are issues or concerns that they would suggest for consideration in the forthcoming visit. The ISC must consider and plan for the amount of time needed to make contact with the guardian prior to a visit and begin the process as early as necessary. At a minimum, the ISC's effort to contact the guardian, family member and/or friend should consist of at least the following efforts:
- One telephone call during daytime hours
- One telephone call during non-business hours
- One written communication (text, e-mail, or letter)
- The minimum annual required monitoring visit should occur 4-6 months:
- After the initiation of DDD Waiver services for individual who are new to the DDD Waivers.
- After the person moves into a new residential setting (e.g. moving from a child group home to a CILA, moving from 24-hour CILA to Family CILA or moving from provider A to provider B). This can also include persons changing homes within the same provider. If the move from one home to another within the same provider agency was due to a significant issue, then the ISC should conduct an additional visit.
- After the Personal Plan date for individuals currently receiving DDD Waiver services and are not changing their residential location.
B. Additional Monitoring Visits
- Separate from the minimum required monitoring visit and the visit for the Discovery and Personal Plan, the ISC should conduct additional monitoring visits (face to face) any time there are significant issues or emergencies with the person receiving waiver services. When necessary, the ISC should use the Monitoring Note to capture the Additional Monitoring Visit. In situations where a revised Discovery Tool and Personal Plan are required, service coordinators are not required to complete a Monitoring Note also. All sections of the Monitoring Note may not be relevant when conducting Additional Monitoring Visits.
- The number of monitoring visits should be conducted based on the person's needs. Additional monitoring visits can occur in the person's residence or in other locations. The location (i.e. day program site, hospital, home) should be based on the situation or reason for monitoring. In most cases, the ISC should conduct Additional Monitoring visits within 30 calendar days of becoming aware of an issue. The exact timing of the visit should be based on the urgency of the situation and the potential risks to the person receiving services. The ISC should use their professional judgement, seek guidance from their Executive Director, and if necessary consult with Division staff when direction is still needed. It is best to err on the side of caution and conduct needed "next steps" sooner rather than later.
- Many factors contribute to the determination of whether an individual has sufficient supports, protections, or personal abilities to be in a safe and healthy environment. ISC agencies must direct their resources based on the needs of the Participants at any given point in time. The following are a list of circumstances which may require at least one additional face to face visit. ISC agencies should complete an additional face to face visit to address the specific circumstance or adequately document the individual's record to justify the reason for not completing a visit. Documentation should include confirmation that the events related to the circumstance no longer present a risk to the individual.
- Police involvement [with or without court action]
- Investigative findings of egregious neglect, abuse, and/or exploitation
- Status after a hospitalization
- Significant life changes/transitions
- Significant behavioral issues/concerns that could change the individual's Personal Plan or Implementation Strategy
- Significant medical issues/concerns
- Death of family or close supports that have a potential to adversely affect the individual's services and/or supports
- Changes in level of care needs within the Waiver
- Guardian's interests conflict with the person's desires that adversely affect the individual's services and/or supports
- Unresolved individual/guardian issues and concerns that adversely affect the individual's services and/or supports
- Other situations which create concerns related to health, well-being, and service provision
- Danger of losing current placement
- Involvement of Service and Support Teams (SST), Short-term Stabilization Homes (SSH), and/or Clinical and Administrative Review Team (CART)
C. Visits to Private Homes
The State has the responsibility to ensure the general health and well-being for persons in the waiver, including individuals in their own homes; therefore, individuals who choose to participate in waiver residential support programs, including Intermittent CILA, Supported Living Arrangements and host family settings, must provide access to their homes for on-site visits. For individuals requesting waiver-funded services, ISC Agencies must inform families prior to enrollment that ISC visits will take place in the family homes. Families are more likely to be receptive and cooperative if this necessity is explained to them from the beginning. At least one annual monitoring visit by service coordinators will be made to the individual's home. These visits should typically occur during evening and weekend hours (i.e., not during the individual's day program or working hours).
For visits to individuals residing in private homes, the ISC must take into consideration cultural and economic factors that may affect particular situations. Standards that apply in provider-supported residential settings may not be appropriate standards when visiting a person's own home. For example, in evaluating whether the setting is clean, the ISC should recognize that individuals and families vary from day to day in their interest and capacity to adhere to any one set of standards for what is considered "clean." When the ISC has questions in this area, the ISC should address whether the individual's health, safety and well-being are supported by the setting. Another consideration relates to fairness. The ISC should consider whether everyone within the home shares the same standards for cleanliness, or whether a double standard exists, so that the individual being visited does not benefit equally from standards existing elsewhere in the home. Considerations like the above should be utilized when determining if, "The individual appears to be well groomed and appropriately dressed."
D. Guidelines for Completing the Individual Monitoring and Interview Notes
The ISC Individual Monitoring and Interview Notes and the Interpretive Guidelines [IL462-4465] assist the service coordinators in accurately and consistently recording information gathered during a monitoring visit to individuals receiving DDD Waiver services. The priority is to address issues of health, safety, and welfare of the individual, as well as services being provided according to the Personal Plan and Implementation Strategy. ISCs are required to complete a Monitoring Note for the minimum required monitoring visit. In addition, the Monitoring Notes can be used to document any additional monitoring visits as outlined in B. of this section. In situations where a revised Discovery Tool and Personal Plan are required, service coordinators are not required to complete a Monitoring Note also.
ISC are not required to send Monitoring Notes to the Division on a routine basis; however, ISC agencies will forward their Monitoring Notes when submitting the Referral to Department of Human Services for Monitoring and/or Technical Assistance form (see Section 12) to DDD, or upon request from the Division. Copies of completed Monitoring Notes must be shared with the individual and/or the guardian and the waiver service providers within 10 calendar days following the completion of the monitoring visit. All Monitoring Notes must be typed or printed and must be legible. The following guidance is provided to assist service coordinators in completing each section of the form.
- General Information: This section contains basic information about the person receiving Waiver services, the provider agency, the parent/guardian and the ISC agency.
- Purpose of visit: Document that this is an "Annual Monitoring Visit" or an "Additional Monitoring visit to address…" (see B. Additional Monitoring Visits).
- Location of visit: The minimum annual monitoring visit should occur in the person's home/residence. Additional monitoring visits can occur in the person's residence or in other locations based on the situation or reason for monitoring.
- Residential Program Type: Example responses include, but are not limited to, 24 Hour Community Integrated Living Arrangement (CILA), Host Family CILA, Child Group Home. If the person is authorized for day program only or HBS, indicate "own home" or "family home".
- Provider Agency Name: List the primary provider. If the person:
- Is in DDD residential services, this agency is the primary provider.
- Is enrolled in a day program only, the day program agency is the primary provider.
- Is enrolled in HBS with agency based services, any of the agencies can serve as the primary provider.
- Is enrolled in HBS and does not have any agency involved, enter "self-directed".
- Sources of Information Used During Visit: In this section, use the grid to document the sources of information that was used for the monitoring visit. Although the primary source of information will come from face to face interviews, the ISC can gather additional information through observations, telephone interview, etc. Regardless of the source, record the information in this section.
- Interests of Guardian, Family, Friends: Provide a brief narrative of any interests, concerns, or issues expressed by the guardian prior to or during this visit. In cases where there is no guardian, provide a brief narrative of any interests, concerns, or issues expressed by significant family or friends if the individual has given permission for those persons to be contacted.
- Key Elements of Accomplishment/Attainment: In addition to the Monitoring Notes, the Interpretive Guidelines should be used when conducting the individual interviews. These are probing questions and are provided as a guide to prompt conversation and encourage dialogue. Use as many or as few questions as needed for each key element. The ISC must be sure to be sensitive to the communication style for each person they will interview. Take time to seek support from someone who knows the person best when communication styles differ from your own. Ensure that the person has whatever communication supports (for example: interpreter, communication device, visual supports) that are used in their daily life available to them at the time of the interview. For each statement/question in the Key Elements of Accomplishment/Attainment section, mark yes, no, or not applicable. A narrative must be completed for each question. The Narrative section should reflect presence or absence of evidence to support each key element. For Example, Key Element #1: ISC has received all Implementation Strategies for this person.
- If the response is YES:
- The Narrative(s) should address the presence of evidence to support this key element.
- The Narrative might read: John has three implementation strategies, and all received within the required time frame.
- If the response is NO:
- The Narrative(s) should address the absence of evidence to support this key element.
- The Narrative might read: Two of three implementation strategies are present at time of review, follow up needed.
- General Observations, Comments, Unusual Circumstances. In this section, ISCs will record:
- Their overall impressions and summary information.
- Whether the individual appears to be well groomed and appropriately dressed.
- Any concerns or issues specific to the person receiving Waiver services.
- Whether previous issues have been addressed and if the person is satisfied with the solution or result.
- Any special efforts or achievements by the person being visited, providers or other entities that might be commended.
- Suggested Follow-Up: The ISC must determine if follow-up action is needed based on what they found during the interview process. If follow-up action is needed, the ISC must complete each item in this section (Issue, Suggested Action, By Whom, Suggested Target Date and Follow-up Actions Response). Follow-up Action may include suggestions to providers, modification of the Personal Plan or Implementation Strategies, securing additional assessments or other action needed by persons other than the ISC. The service coordinator will not always be the person responsible for completing the Suggested Action; it might be the individual, family/guardian, and/or the provider. In cases where there is no follow-up action needed, then there is no need to complete this section.
- Lastly, the service coordinator must sign and date (date Monitoring Note was completed) the document.
E. Other ISSA Monitoring Activities
The ISC shall perform additional monitoring activities as needed to ensure the health, welfare, safety, satisfaction and continued Waiver eligibility of the individual. This could include telephone calls, face to face discussions or electronic communications with families, guardians or provider agencies; this also includes reviews of records and other documentation. The ISC must determine if the activity is considered significant thereby requiring a Monitoring Note. If the activity is not significant, documentation can be completed with a case note.
F. Visits to Bogard Class Members Living in an Intermediate Care Facility for persons with Developmental Disabilities
ISC agencies conduct ISSA activities for Bogard class members who live in ICF/DDs, per the Bogard Consent Decree. For Bogard class members only, the ISC must conduct a minimum of 4 quarterly visits a year (instead of a minimum of 2). ISC agencies must record their visits using the Individual Service and Support Advocacy (ISSA) Visiting Notes; the ISSA Visiting Notes Interpretive Guidelines should be used for guidance. ISC agencies will not develop a Personal Plan for Bogard class members who live in ICF/DDs; the provider will continue developing an Individual Service Plan (ISP).
9.3 Medicaid Benefit Enrollment and Medical Renewal Process
As the case management entity, the ISC agency plays an important role in the Medicaid Benefit and Medical Renewal Process for Medical, Cash and SNAP. This includes assisting individuals and families who will be entering a DDD Waiver to apply for Medicaid Benefits. It also includes assisting the individual/ family who is already in a DDD Waiver with their annual redetermination process.
A. Approved Representatives
In order for the ISC to receive Medicaid Benefit information on behalf of someone enrolled in a DDD Waiver, the individual/guardian must first designate the ISC as an Approved Representative. An approved representative is a person who has been given permission by a client to apply for benefits and receive notices; it is not the same as a Representative Payee. A person can designate more than one approved representative if they desire. ISCs are not required to be an Approved Representative; being designated as such allows an ISC to act on a person's behalf with the Department of Healthcare and Family Services or the Department of Human Services for Cash, SNAP and Medical benefits. The ISC enrolling as the Approved Representative is particularly beneficial when serving people in a DDD Waiver that do not have a service provider as it ensures that the ISC will receive all correspondence from DHS. This also allows the ISC to represent the person in a DDD Waiver at a local DHS office/FCRC, over the phone or by e-mail. If the ISC will serve as an Approved Representative, they must be involved in the enrollment process along with the individual/guardian. Enrollment can be done online at https://abe.illinois.gov or by completing and submitting the Approved Representative Form [IL444-2998]. The ISC is still responsible for assuring people who are enrolled in a DD Waiver service maintain financial eligibility for Medicaid even if the ISC is not designated as an Approved Representative.
B. Medicaid Benefit Enrollment for Children Authorized for a DDD Children's Waiver
Children who are determined DD clinically eligible, who have been given an Award Letter for the Children's Support Waiver or the Children's Residential Waiver and who are under the age of 19 can apply for Medicaid under special eligibility rules. The special eligibility rules can waive family income for families who would not otherwise qualify for Medicaid benefits for their child because of the parent's income. When children meet the criteria above, the ISC agency will follow the procedures below to help the family apply for Medicaid benefits and to ensure that the child's Medicaid application is prioritized. The ISC will send the Child's Medicaid application to the Illinois Department of Healthcare and Family Services (HFS) All Kids Unit which is responsible for processing medical applications for persons under the age of 18 years old.
- When sending an application to All Kids, please write: DD WAIVER in red on the envelope and on the first page of the application. The Illinois Department of Human Services Family and Community Resource Center (FCRC) Medical applications sent to the All Kids Unit must include:
- A cover letter;
- The DD Waiver service award letter;
- Proof of parent's income (Proof of income is still required despite being waived), and;
- all other required verifications.
- For Children already receiving Medicaid medical benefits please send a copy of the DD Waiver service award letter with a cover letter to the All Kids Unit attention Jennifer Frescura at Jennifer.Frescura@illinois.gov.
C. Expedited Medicaid Benefit Process
The ISC will send Medicaid applications directly to HFS for persons who are enrolled or planning to be enrolled in a DDD Waiver in order to expedite Medicaid enrollment or to resolve a lapse in benefits. This assistance is provided to:
- Children entering a DDD Waiver; as described in part A.
- Young adults who are turning 19 (transitioning to adult Medicaid).
- Any individual selected from the PUNS list that is not enrolled in Medicaid or whose case has lapsed more than 90 days.
These cases will be sent to Jennifer Frescura at Jennifer.Frescura@illinois.gov
D. Redetermination of Medicaid Benefits, Medical Renewal
An individual, guardian or approved representative is responsible for maintaining uninterrupted eligibility for Medicaid benefits in order to continue receiving DDD Waiver services. As such, a Redetermination process occurs every year for each person receiving benefits. The process will be either manual or automatic, as described below:
- Medical Automatic Redetermination (Auto-REDE) process: Healthcare and Family Services (HFS) and the Department of Human Services (DHS) now use the Integrated Eligibility System (IES) to conduct Automatic Redeterminations (auto-REDE) of Medicaid Benefits. This process is completed internally within HFS and DHS prior to sending any notification to the individual/family. For a case to be selected for auto-REDE process, the case must be eligible and the financial and non-financial information must be verified electronically during a clearance process. If the income found electronically for an individual is within the income standard, the IES will proceed with auto-REDE for the case. For these cases, individuals/families receive a notice stating the REDE was processed and approved; there is no follow up for the person or for the ISC. The ISC should retain this notification in the individual's file. If HFS or DHS was unable to verify the information during the clearance or if the case is not eligible for the auto-REDE process, then the person will receive notice regarding the standard or Manual Redetermination process.
- Medical Manual Redetermination (REDE) process: For cases not qualified for the auto-REDE process, the individual, guardian or approved representative will receive two Illinois Medicaid Redetermination notices in the mail every year. The notices contain a return address from the Department of Human Services, Family and Community Resource Center (commonly known as FCRC or local office) or the Department of Healthcare and Family Services (HFS). These are the two Illinois entities which handle Redeterminations. It is crucial that the individual, guardian or approved representative complete and return the Medical Renewal Form within the specified time frames in order to avoid interruption or loss of Medicaid status and Waiver services.
- The first mailing is a notice that the redetermination date is approaching and the Illinois Medicaid Redetermination, Medical Renewal Form will arrive in approximately two weeks.
- The second mailing contains the actual Illinois Medicaid Redetermination, Medical Renewal Form. This form will already contain the individual's name and date of birth; it will also contain a barcode in the upper right-hand corner. To complete the redetermination process the individual, guardian or approved representative must
- Complete the Illinois Medicaid Redetermination, Medical Renewal Form.
- Attach any verifications and/or documentation requested.
- Sign the form.
- Return the form and any verifications and/or documentation by the date indicated on page 3, #11 of the form.
- The ISC shall assist persons enrolled in a DDD Waiver with the Medicaid benefit redeterminations as to avoid any interruption in eligibility or coverage. For everyone enrolled in a DDD Medicaid Waiver service, the ISC should:
- Remind the individual, guardian or approved representative, as well as any residential provider of the annual re-determination date if known.
- Remind the individual, guardian or approved representative, as well as any residential provider that they will (or inquire if they already have) received a Illinois Medicaid Redetermination, Medical Renewal Form as described above.
- Help resolve cancelled Medicaid cases. Any time the ISC becomes aware that the individual is not eligible, or the Medicaid case has been cancelled the following steps must be taken:
- Identify the reason for cancellation.
- If the case is cancelled and the re-determination has been sent in, contact the FCRC/local office liaison identified by DDD.
- If the case is cancelled and the re-determination has not been sent in, the ISC must contact the FCRC/local office liaison identified by DDD to request that a new Illinois Medicaid Redetermination, Medical Renewal Form is issued.
- If there is no resolution to the Medicaid redetermination issues contact the identified Medicaid benefits liaison within the DDD.
- If the individual, guardian or approved representative is unable to successfully complete the Illinois Medicaid Redetermination, Medical Renewal Form the ISC should assist as needed. A provider agency can also assist the individual, guardian or authorized representative in completing and returning the form.
The Notice of DHS Community-Based Services form/HFS 2653 (commonly known as the Spenddown form) must be completed by a provider agency or the Home Based Services Employer of Record. The Estimated Monthly Cost to be filled in on this form can be found on the DHS/DDD Rate sheets, which is the second page of the DDD Award Letter. The provider must forward a copy of the form to the ISC agency. It is the ISC agency's responsibility to provide assistance and information as needed to the provider agency or the Home Based Services Employer of Record. The ISC is not required to send this form into DHS but should maintain the Notice of DHS Community-Based Services form/HFS 2653 in the individual's file.
F. Medicaid Benefit Contacts:
- State Agency Contacts
- HFS Contact for processing Medicaid applications: Jennifer Frescura at Jennifer.Frescura@illinois.gov
- DDD Contact for Medicaid benefit assistance: Jay Bohn, (217) 558-1361 or at Jay.Bohn@Illinois.gov
- For Medical only cases, a more streamlined contact process between the FCRC staff of the local offices and the staff at the Medical Management Unit (MMU) has been created. The MMU, Office 155, can now be contacted via email at DHS.MMU@Illinois.gov
Medical Management Unit (Formerly Homewood IMRP)
- 1055 W. 175th Street Suite 201
- Homewood, IL 60430
- Phone (708) 957-8352
Medical Management Unit (Formerly Hunter IMRP)
- 527 S. Wells
- Chicago, IL 60607
- Phone (312) 793-2152
- Fax (312) 814-1651
9.4 Level of Care Redeterminations
At least annually, a service coordinator will conduct a level of care/Waiver eligibility redetermination for continuing eligibility of services to everyone in the DDD Waivers. This redetermination is for waiver claiming and is summarized and documented on the Redetermination of Medicaid DD Waiver Eligibility form [IL462-0952], formerly the DD-1213.1. The annual level of care redetermination can be performed during the time of the annual review of the Discovery or Person Plan; however, the redetermination may never be allowed to expire. If the redetermination and the PCP process cannot be scheduled during the same time, the ISC must perform the redetermination on or before its next due date, regardless of the timing of the PCP process. The timeliness of the redetermination is of critical importance, as it will be monitored by the federal government: Centers for Medicare & Medicaid Services (CMS), and state government: The Illinois Department of Healthcare and Family Services (HFS) and The Illinois Department of Human Services (DHS) Division of Developmental Disabilities (DDD). No redetermination may be allowed to become out of date, it must be completed within 365 days of the date on the most recent Determination of Intellectual Disability or Related Condition & Associated Treatment Needs (DDPAS-5) form [IL462-4428] or the Redetermination of Medicaid DD Waiver Eligibility form [IL462-0952], documenting the need for an ICF/DD level of service (sometimes referred to as active treatment for developmental disability). The IL462-4428 or IL462-0952 must be maintained in the individual record. Not only will the ISC complete and document the Level of Care Redetermination (formerly referred to as Redetermination of Waiver Programmatic Eligibility), the ISC must also report the annual redeterminations in the Reporting of Community Services (ROCS) system.
The criteria for continuing waiver eligibility are the same as the criteria for initial waiver eligibility, contained in Section 5 Pre-Admission and Screening of this Manual. The following assessments and programmatic information must be completed or reviewed in re-determining the level of care:
- Inventory for Client and Agency Planning (ICAP) or Scales of Independent Behavior (SIB): An existing ICAP or SIB functional assessment instrument may be used if it is not more than six months old. The redetermination date may be adjusted as needed to coordinate with the previous ICAP or SIB that was completed as long as the 365-day time limit is met. The ISC is responsible for ensuring the ICAP or SIB is updated in a timely manner. The Completion of the ICAP or SIB is the responsibility of a QIDP at the ISC agency and can be shared with provider agencies.
- Other documentation: individual redeterminations should also be based on a review of the Personal Plan, other formal and informal assessments, all available case notes, individual progress reports, medical information and the individual's status.
- The Release of Information form [IL462-1214] is needed to extend consent for release of individual information for Medicaid waiver purposes for a further time period. This form must also be maintained in the individual record.
9.5 Rights and Advocacy
Annually, upon request or when changes in services occur, the ISC agency must inform individuals (or the guardian of the individual, if applicable) of rights under the Waiver using the Rights of Individuals form [IL462-1201]. The ISC must also provide him or her a copy of the form. This form must also be filed in the individual's clinical record.
Independent Service Coordination Agencies conduct the following advocacy activities for individuals receiving DDD Waiver services. As appropriate, service coordinators should refer to Section 3.3 - Mandated Reporting, Section 11- Addressing and Resolving Issues or Concerns, and Section 12 - Referral for Monitoring and Technical Assistance for guidance.
- Assist the individual in self-advocacy with providers of waiver services and will assist with conflict resolution.
- Conduct necessary problem-solving activities as issues arise regarding implementation of the Plan, coordination of services, or general health and well-being.
- Work cooperatively with service providers to implement improvements in the responsiveness and appropriateness of the services received by the individual according to the individual's Personal Plan.
- Refer any recurring, unresolved issues or serious problems affecting the individual's health and welfare to DDD so the Division can monitor or provide technical assistance as needed.
- Conduct necessary evaluations and assessments of individual service needs.
- Assist individuals with linkage and applications for any non-Waiver services; provide any necessary coordination of services.
- Assemble and submit any necessary applications for changes in DDD Waiver services, including those that require prior approval.
- Assist individuals with appeals resulting from discharges, suspension or terminations of DDD Waiver services as outlined in Section 14 of this Manual.
- Inform individuals of all willing and qualified providers.
- Explain and provide information to individuals about reporting allegations of abuse, neglect, and exploitation, as well as filing other complaints and grievances. The following entities are available to individuals and guardians for advocacy services:
- Equip for Equality
- Main Office Chicago: (800) 537-2632 (Voice), (800) 610-2779 (TTY)
- Central Illinois Region: (800) 758-0464 (Voice), (800) 610- 2779 (TTY)
- Northwestern Illinois Region: (800) 758-6869 (Voice), (800) 610-2779 (TTY)
- Southern Illinois Region: (800) 758-0559 (Voice), (800) 610-2779 (TTY)
- Online at https://www.equipforequality.org/
- Illinois Guardianship and Advocacy Commission (Regional offices are located throughout the state)
- Statewide General Info: (866) 274-8023 (Voice), (866) 333-3362 (TTY)
- Legal Advocacy Service: Chicago General Office (312) 793-5900
- Office of State Guardianship: Springfield General Office (217) 785-1540
Note: Geographic areas of the State may offer specific county and local resources and providers of advocacy services.
9.6 Critical Incident Reporting and Analysis System (CIRAS)
The Division of Developmental Disabilities (DDD) has developed the Critical Incident Reporting and Analysis System (CIRAS) to capture electronic reports from ISC agencies as well as providers of certain incidents involving participants in the State's Medicaid Waiver programs for individuals with developmental disabilities. The types of incidents to be reported are listed and defined in the CIRAS Manual which is available on the DHS website. The DDD will use the information reported through CIRAS to:
- Inform ISC agencies of potential issues involving the participants whose general health and well-being the ISCs are monitoring,
- Ensure incidents are addressed appropriately, and
- Analyze potential systemic issues and take steps to enhance overall system quality.
CIRAS is not a reporting system for alleged incidents of abuse, neglect, or exploitation. Alleged cases of abuse, neglect or exploitation should continue to be reported to the Department of Human Services' Office of the Inspector General (OIG), Department of Children and Family Services (DCFS), Department on Aging / Adult Protective Services (APS), and/or Department of Public Health as appropriate and required in accordance with the type of service involved.
As ISCs are informed of critical incidents, they will be the primary responder, will perform the appropriate follow-up and notify the Division of its findings. The ISC agencies are also CIRAS incident reporters. Being a reporter will allow ISC agencies to enter the incident in CIRAS, making the report complete and keeping the Division aware of all CIRAS incidents. ISCs should refer to the CIRAS Manual for guidelines on enrolling, reporting and follow-up.
Section 10: Bogard Consent Decree
The Department of Human Services is required to follow the Bogard Modified Consent Decree signed July 25, 2000 for individuals identified as a Bogard class member. Bogard class members are defined in the modified Bogard Consent Decree, Page 1, Section A., as "all persons 18 years of age or older, with developmental disabilities, who, on or after March 23, 1986, resided in an Intermediate Care Facility or Skilled Nursing Facility in Illinois as a Medicaid recipient for a period of more than 120 days in the aggregate. No person first admitted to an Intermediate Care Facility or a Skilled Nursing Facility on or after April 1, 1994, can be a member of the class." Bogard class members are designated by the Department of Human Services/Division of Developmental Disabilities.
Class members receive a specific form of case coordination directly related to their residential setting. These class members live in nursing facilities, nontraditional DD settings such as State Operated Mental Health Centers, shelter care homes, their own or family homes, apartments without DD services, and State Operated Developmental Centers. Bogard class members who are receiving waiver services such as Community Integrated Living Arrangements (CILA), Community Day Services (CDS) or Home-Based Support Services (HBS) as well as class members living in an Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD), not including State-Operated Developmental Centers, receive Individual Service and Support Advocacy. (For a description of ISSA, see Section 9 of this Manual.)
It is expected that Bogard class members develop new skills and maintain existing ones through specialized services or active treatment, receive adaptive equipment as appropriate, live in appropriate community-based residential settings if they so choose, and receive case coordination on a regular basis.
Independent Service Coordination (ISC) agency staff serve as the case coordinator for Bogard class members and are required to be a Qualified Intellectual Disabilities Professional (QIDP).
10.1 Bogard Class Members Residing in an ICF/DD
Bogard class members residing in an Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD) will be provided all Individual Service and Support Advocacy (ISSA) activities except for the level of care redetermination and the Person Centered Planning process. The level of care redetermination and Person Centered Planning are not required for Bogard Class members residing in an ICF/DD.
For Bogard class members residing in an ICF/DD, the Independent Service Coordination (ISC) agency will provide assistance to both individuals and their providers to enhance the delivery and effectiveness of services. The ISC will:
- Attend interdisciplinary team meetings to provide input into the ISP.
- Ensure individuals have adequate and appropriate assessments and reassessments of needs and abilities.
- Complete a minimum of four monitoring visits per year (approximately one per quarter), first informing the guardian (if applicable) and according to the following guidelines. All visits must occur when the individual is present at the site.
- One visit for participation in the development of the Individual Service Plan (ISP). The person's ISP will provide documentation for this visit.
- One visit either to the individual's residence or day program (if the individual participates in a day program). The ISSA Visiting Note will provide documentation for this visit.
- One visit each to the individual's residence and day program (if the individual participates in a day program). The ISSA Visiting Notes will provide documentation for this visit.
- One or two visits to the location of the individual's choice. The ISSA Visiting Notes will provide documentation for this visit.
- Complete additional visits beyond what is outlined above, if necessary, to resolve issues or in times of crisis. The ISC must document in the record the reason for the additional visit(s). For example, additional visits may be needed for a class member who is unable to communicate with spoken words, when the guardian does not participate, if there are serious medical or behavior issues and/or there is suspected abuse.
- Prior to each visit the ISC must contact the guardian to determine if there are issues or concerns they have for consideration during the visit. At a minimum, the ISCs effort to contact the guardian should consist of at least the following, unless successful before the next step:
- One telephone call during daytime hours
- One telephone call during non-business hours
- One email or letter
- Ensure facilitation and collaboration, with service providers, of conflict resolution for matters of concern to the individual and/or guardian and provider, including satisfaction, health, safety, well-being, and the development and implementation of the ISP.
- Recommend to the provider that an interdisciplinary team meeting be convened if service planning and implementation do not appear to be adequate.
- Work cooperatively with service providers to implement improvements in the responsiveness and appropriateness of services received by the individual according to the individual's satisfaction, preferences and unique perspectives.
- Refer any reoccurring, unresolved or serious issues affecting the individual's health and welfare to DHS/DDD for possible technical assistance and/or monitoring, as needed.
- Screen for and report any allegation or observation of suspected abuse and neglect to the Department of Public Health at 800-252-4343.
10.2 Bogard Class Members Residing in Other Non-Waiver Settings
- Bogard class members residing in the following type of non-waiver settings will receive Bogard Service Coordination from the ISC agency:
- Nursing Facility.
- State Operated Mental Health Center, Shelter Care Home, their own or family home and apartment without DD services.
- State Operated Developmental Center.
- Under Bogard Service Coordination, the ISC will:
- Ensure completion of adequate and appropriate assessments and reassessments of needs and abilities.
- Coordinate the Individual Service Plan (ISP) development.
- Ensure the individual and guardian provided input in the ISP.
- Facilitate and broker Specialized Services for persons in nursing facilities.
- Advocate for the development of natural supports.
- Conduct activities to maintain or improve availability, accessibility, and quality of services.
- Assist with the procurement of adaptive equipment through the Department of Healthcare and Family Services.
- Complete, at a minimum, one monthly service coordination monitoring visits with the individual.
- Monitor the implementation of the ISP, as well as the individual's health, safety and well-being, through site visits to residential and day programs.
- Utilize problem-solving procedures to achieve conflict resolution.
- Provide crisis intervention supports, as needed.
- Ensure the provision of transportation to facilitate the selection of employment and residential services among other options.
- Advocate for individuals in securing services, exercising rights and identifying their choice.
10.3 Bogard Class Members Residing in a Medicaid Waiver Setting
Bogard class members residing in a Community Integrated Living Arrangement (CILA), Community Living Facility (16 beds or less) or receiving Community Day Services through the Medicaid waiver program, will receive ISSA. ISSA activities are outlined in Section 9 of this Manual.
Section 11: Addressing and Resolving Issues or Concerns
In the course of their work with individuals, providers and ISC agencies will become aware of issues and concerns. The Division has developed a process to address these, with time frames that comply with expectations from the Centers for Medicare and Medicaid Services.
11.1 Principles of the Resolution Process
This resolution protocol is based on five foundational principles. These principles include:
- Issues or concerns are best resolved at the level where they originate and should be elevated to higher levels of an organization only when they resist a concerted effort at initial level resolution.
- Direct, problem solving communication must occur between those directly involved with the problem.
- Evaluation of the problem to higher levels of organizations should not allow those initially involved with the problem to avoid responsibility for either the problem or resolution.
- Creative, collaborative solutions should not be allowed to compromise the quality of supports provided to individuals served by provider agencies.
- Communication and problem-solving activities should work to resolve the problem and help build relationships, respect, and trust.
11.2 Protocol for Resolving Issues or Concerns
ISCs are to ensure an initial response to complaints or otherwise identified problems within two business days. Time frames to resolve the identified issues involved are outlined below. ISC agencies are also to ensure that services continue while resolution of the issues is pending. See four levels listed below:
- Initial Level Resolution: Worker to Worker
- Issues or concerns, identified during the course of any ISC contact with individuals, guardians, family members, provider agencies, or other advocates, will initially be addressed with the person responsible for oversight of daily program implementation (provider agency QIDP, house lead, ISC worker, etc.). The ISC and the agency staff will develop an action plan, acceptable to both, for addressing the issues or concerns.
- If there is a medical or safety need, then appropriate, prompt action is required of the ISC. Likewise, problems that require reporting to OIG or some other regulatory body must first be handled per those requirements, and then, if appropriate, submitted to the Resolution of Issues or Concerns process. If the identified issues or concerns are perceived to be significantly serious, then the ISC will immediately utilize the second or third level.
- If no action plan is developed after 30 days, the issue shall be moved to the second level.
- Second Level Resolution: Worker to Worker and Supervisor to Supervisor
- If seriousness warrants, the matter is not resolved per the action plan, or if the parties fail to create a mutually acceptable action plan, the ISC and/or the agency staff will immediately contact his/her supervisor to inform the supervisor of the unresolved issue or concern. Additional efforts at resolving the issue or concern will be promptly undertaken using the following guidelines:
- Both the ISC and the provider agency program level staff person must provide a written statement of the issue or concern, as each sees it, and their recommended solution. These written statements will be shared with the other party prior to any additional problem solving discussions.
- Continuing problem solving discussions will include all four participants (ISC and supervisor, agency program level staff person and agency program director).
- Copies of resolution plans will be forwarded to the agency Executive Director and the ISC Executive Director. If no action plan is reached within 14 days, the issue shall move to the third level.
- Third Level Resolution - Worker to Worker, Supervisor to Supervisor, and Executive Director to Executive Director
- If the matter remains unresolved, then the Executive Director of the ISC agency and the Executive Director of the agency will be brought into the problem-solving discussions (discussions will now have six participants).
- If resolution cannot be reached within 7 days, the issue shall move to level four.
- Fourth Level Resolution: Involvement of the Division of Developmental Disabilities
- If the matter is not resolved under Levels 1 through 3, the ISC Executive Director will contact the Division of Developmental Disabilities within 2 business days following completion of Level 3 via the Referral for Monitoring and Technical Assistance Tool. Please also see: Instructions for Completing Referral Form regarding completion and submission. The Division will collect all available information regarding those involved and will work with the parties to bring about a final resolution to the problem.
- In the event the parties are unable to reach agreement, then the Division will issue a final and binding decision.
11.3 Time Frames
The time frames specified above are to be considered maximum time frames. If it becomes clear, for example, on day five that resolution cannot be reached under Level 1, then the parties should proceed immediately to Level 2. Individuals served may contact the Division directly at any time during the process if they so choose.
Documentation of the conflict resolution process will be maintained in the individual's ISC record. The ISC agency will document that it has provided the individual and guardian with the status and progress of the resolution process. This documentation (that the information was provided to the individual and guardian) and the status/progress of the process must be maintained in the individual's ISC record.
Section 12: Referral for Monitoring and Technical Assistance
The Division of Developmental Disabilities has developed a referral form for use of ISC agency staff when they are unable to resolve service issues at the local level.
- The formal Referral for Monitoring and Technical Assistance Tool is sent to the Division for consideration of technical assistance and/or additional monitoring. For assistance in completing the form, refer to the Instructions for Completing Referral Form. Note: This form is not used for suspected cases of abuse, neglect, or financial exploitation which are reported immediately to the appropriate investigative body.
- Upon receipt, the referral will be assigned to the appropriate Bureau within the Division for appropriate follow up.
- The assigned Bureau Chief is responsible for ensuring appropriate and timely follow up.
- Depending on the nature of the concern being raised by the ISC, the Division may involve additional resources, such as the Support Service Team (SST) and, the Bureau of Accreditation, Licensure and Certification (BALC).
The Division maintains a database to capture information about service issue referrals so that routine reports may be produced for monitoring and management purposes. Reports are also shared with the Department of Healthcare Services (HFS).
Section 13: Service Terminations and Bedhold Request
The ISC agency will ensure that Service Termination Approval Request (STAR) [IL462-2028] and Bed Hold Extension Request [IL462-2027] forms are complete and submitted to the Division when necessary. The STAR form is applicable to all individuals receiving services funded through the DDD including Community Integrated Living Arrangement, Purchase of Service programs, Home Based Supports and/or Community Day Services.
- The provider agency is responsible for initiating the STAR form. The provider should complete Sections A-C, and the provider information in Section D no later than five (5) business days after the individual leaves or ceases receiving services from the service provider. The provider must then forward the form to the ISC agency that provides service coordination to that individual.
- The ISC agency should review and ensure the STAR is complete. The ISC agency must sign the STAR and forward it to the appropriate Region staff within the DDD.
- When an individual, guardian or personal representative files an appeal of termination from Waiver services (see Section 14 of this Manual), the individual cannot be terminated until a final decision of the appeal is rendered, or the appeal has been withdrawn. If the ISC agency receives a STAR form for an individual who is appealing termination of services, then the ISC should return the STAR form to the service provider. The reader can also refer to the Illinois Administrative Code Title 59, Part 120 for more detailed information.
- When a CILA provider is requesting bedhold, a Bed Hold Extension Request form and two (2) required supporting documentation statements MUST be attached to the individual's STAR form. The DDD shall consider approval of up to 60 days of bed hold for an individual enrolled in CILA services when a complete bed hold request is received with a STAR form.
- Upon the DDD's processing and data entry of a STAR form the termination date will not be changed to a later date unless there was an error on the part of the DDD or ISC agency.
- The division reserves the right to modify any date reported on the STAR form when it does not match official service reporting by the service provider or information obtained through the IDHFS.
Additional guidelines for STAR and bedhold forms and processes are available on the DHS website at Service Termination Authorization Request (STAR) Process and at Bed Hold Request Process.
Section 14: Appeal Process
Any individual requesting or receiving Medicaid waiver-funded services has the right to appeal the following actions: a denial (including a determination of eligibility), termination, suspension, or reduction of the waiver-funded services.
- The ISC, DDD or provider agency, whichever entity took the above-mentioned action, will notify the individual and/or guardian in writing of the action taken and the process to appeal.
- The individual and/or guardian will be provided with a notice that includes the action, whether or not services will continue and a copy of the Notice of Individual's Right to Appeal Medicaid Waiver Determinations [IL462-1202].
- If the individual and/or guardian decide to appeal the action, the ISC agency is responsible for submitting:
- A complete appeal checklist,
- The Documentation For Medicaid Waiver Appeals form [IL444-0171], and
- An appeal packet of documentation/information that will be used in the informal review process for a determination regarding the specifics of the appeal case.
- The appeal packet must include a signed written request to appeal by the individual and/or guardian.
- The appeal packet must be submitted within 60 calendar days of the notice received of the actions listed above. The 60 calendar day limitation does not apply if the DD provider agency, the ISC, DDD, whichever entity or agency took the action, fails to notify the individual in writing of the action or the time limit.
- The Division has 30 working days to complete an informal review of the appeal case. The DDD must then notify the individual and/or guardian of the informal review decision within 10 working days of that determination. Should the individual and/or guardian disagree with the determination by the DDD, they have the option of requesting within 10 days, an administrative hearing with the Department of Healthcare and Family Services (HFS) to review the DDD's informal review decision.
Details of the grounds for appeal, notification requirements and appeal process are contained in the Administrative Rule: Medicaid Home and Community-Based Services Waiver Program for Individuals with Developmental Disabilities, Section 120.110 Appeals and Fair Hearings (59 Ill. Adm. Code 120.110).
Section 15: General Administrative Requirements
Independent Service Coordination agencies must follow contractual requirements as outlined by the Department, the DDD Program Manual, the Community Services Agreement and Attachment.
In addition, ISC agencies will:
- Participate in webinars, trainings, outreach, pilot projects and/or initiatives as directed by the Division.
- Ensure each ISC representative completes all required training, both initial and continuing education.
- Comply with any formal requests for desk reviews and audits, by the Division and other entities.
- Respond to general inquiries and requests for information by the Department of Human Services.
- The ISC applicant must comply with Medicaid Waiver qualifications, as delineated in the federally approved Waiver. The Waiver can be found on the DHS website under Medicaid Waivers - Approved.
- Maintain eligibility to be an ISC provider in accordance with the waiver.
- Provide prompt notice to the Division, including plans to remediate issues, when issues arise that may jeopardize eligibility.
- Be available 24-hours per day, 365 days per year for individuals in times of crisis.
- Enter into a Corrective Action Plan with the Division to remediate issues and achieve compliance if the Department determines the ISC agency is out of compliance. Determinations will be based on the Division's review tools published on the DHS website under Quality Review and Related Documents.
15.1 Data Collection
- ISC agencies are required to document service provision and maintain accurate, comprehensive service records for all persons seeking or receiving services in the assigned service area(s). ISC agencies will provide periodic reports to the Division to demonstrate compliance with all performance measures as well as provide ad hoc reports as requested by the Division.
- Quarterly reporting will be completed utilizing the Periodic Performance Report (GOMBGATU-4001) and Periodic Financial Report (GOMBGATU-4002) including all deliverables noted in Exhibit B of the Uniform Grant Agreement. Quarterly reports will be submitted no later than 15 days after end of each period.
- 1st Quarter Reports are due NLT October 15th
- 2nd Quarter Reports are due NLT January 15th
- 3rd Quarter Reports are due NLT April 15th
- 4th Quarter Reports are due NLT July 15th
- Under the terms of the Grant Funds Recovery Act (30ILCS 705/4.1), "Grantor agencies may withhold or suspend the distribution of grant funds for failure to file required reports." If the report is more than 30 calendar days delinquent, without any approved written explanation by the grantee, the entity will be placed on the Illinois Stop Payment List. Refer to the Grantee Compliance Enforcement System for details about the Illinois Stop Payment List. Additional information can be found on the Grant Accountability and Transparency Act webpage.
- The ISC agency is required to meet compliance reporting status to comply with consent decrees, compliance reporting and other legal requests to the appropriate parties (i.e. Ligas compliance reporting status to the Ligas Court Monitor.)
- Monthly service delivery reporting through the ROCS data base or alternative systems determined by the Division is required.
- ISC agencies must submit complete and accurate service reports the month following the month in which services were delivered. Grant payments may be suspended if service reports are not submitted in the proper format and accepted by the Department within sixty (60) calendar days following the end of the service month.
- In addition, the ISC agency must submit all data required by rule or requested by the Department concerning the operation of its funded programs. The Provider must submit data in a timely manner in a format prescribed by the Department. The Provider shall complete and transmit service reporting accurately and timely in accordance with Title 59, Ill. Adm. Code, Part 103.
15.2 Reporting and Billing
When reporting or billing for services, the complete name, Social Security number, and Recipient Identification Number (if one has been assigned), are required for each person.
A. Individual Service and Support Advocacy (ISSA)- Program 51A - 51L
The ISC agency will bill ISSA as a fee for service program in ROCS. Each ISC agency will bill the service code that is appropriate for their geographic area: Area A (51A), Area B (51B), Area C (51C), Area D (51D), Area E (51E), Area F (51F), Area G (51G), Area H (51H), Area I (51I), Area J (51J), Area K (51K) or Area L (51L). ISSA will be reimbursed at an hourly rate established by DHS. The agency will have a pool of hours based on 26 hours per year per client receiving ISSA. The ISC agency will have the flexibility to manage these hours to ensure that clients receive the appropriate level of support. The ISC is not allowed to exceed the total amount of hours awarded in the pool unless they receive written authorization from the Division.
Billing and payment procedures should be followed through the Community Reporting System (CRS) as outlined in Chapter 700 of the DDD Waiver Manual. Specific instructions are listed, including proper forms to utilize along with time lines for completion.
Billable ISSA hours consist of time spent on behalf of the individual waiver recipient and include:
- Conducting necessary evaluations and assessments (i.e. Inventory for Client and Agency Planning, risk assessment).
- Completing Vocational Rehabilitation (VR) referrals for individuals who have documented such services and supports in their Person Centered Plan.
- Reviewing/Updating the Discovery Tool and Personal Plan.
- Conducting monitoring visits for individuals served through the DD Waiver programs; including travel time involving ISC visits and documentation time to support ISSA billings.
- Conducting other monitoring activities for individuals served through the DD Waiver programs.
- Reviewing, verifying and submitting service request to the Division.
- Reporting allegations of abuse, neglect, and exploitation per Division guidelines and regulations.
- Completing annual level of care redeterminations.
- Reporting and providing follow up on critical incidents for waiver participants.
- Informing individuals, annually, of their rights as a waiver participant.
- Ensuring the appeals process for individuals receiving waiver services is followed as appropriate, including serving as a representative for the Division when attending the hearings.
- Ensuring the health, safety, and welfare of individuals involved with Adult Protective Services (APS).
- Assisting HBS participants with finding alternative personal support if DDD requires agency-based services.
- Coordinating the transition between and within DDD Waivers.
- Resolving rejected billings related to Medicaid benefits and level of care re-evaluation.
- Participating in consultations and providing follow-up as necessary related to individuals including but not limited to: Support Services Team (SST), Short-Term Stabilization Home (SSH), State Operated Developmental Center (SODC), and State Operated Mental Health Hospital (SOMH).
- Responding to general and/or emergency inquiries and complaints from sources such as: hospitals, emergency rooms, jail, other states and community agencies specific to persons receiving waiver services.
- Ensuring that STAR (Service Termination Approval Request) and Bedhold request forms are completed and submitted to the Division.
- Providing service coordination to Bogard class members residing in a Community Integrated Living Arrangement (CILA), Host Family or Community Living Facility (67D).
B. General Service Coordination (PUNS, Initial Eligibility and Linkage) -Program 500
ISC agencies must report grant activities under program 500. Guidance on the types of activities to be conducted and reported as part of this programs include the following:
- Completing the OBRA 1 screening.
- Providing information and linkage to the Department of Aging, Division of Mental Health and the Division of Rehabilitation Services.
- Reviewing service options, including Medicaid entitlements (ICF/DD, CLFs that are larger than 16 beds, etc.) and Home and Community Based waiver services (HCBS).
- Completing the PUNS database forms/enrollment.
- Completing annual update of PUNS information.
- Making appropriate referrals for interim services (e.g. DRS, Respite), for persons with a developmental disability who opt to go on PUNS.
C. Pre-Admission Screening -Program 780
ISC agencies must report activities under grant program 780 (PAS). Guidance on the types of activities to be conducted and reported as part of this program includes:
- Conducting a PAS Level II Screen and providing notice of Screening results.
- Educating individuals, guardians, and families about service options.
- Making referrals to all service providers and presenting all available service options.
- Conducting the Discovery process and develop a Personal Plan.
- Submitting service and funding requests to the Division.
- Monitoring the transition of the individual (for four weeks) following initiation of waiver services.
- Securing a service provider and completing a safety plan for persons who are in a crisis.
- Complying with Ligas Consent Decree requirements.
D. Bogard Service Coordination -Program 781
ISC agencies must report activities under program 781 (Bogard). Activities to be conducted and reported as part of this program include:
- Providing assistance to enhance the delivery and effectiveness of service provision.
- Completing service coordination monitoring visits.
- Ensuring collaborative facilitation of conflict resolution for matters of concern to the individual and/or guardian and provider.
- Completing referrals to the DDD Regional staff for monitoring and/or technical assistance.
- Providing Service Coordination to Bogard class members residing in other non-waiver settings:
- Ensuring completion of assessments and reassessments of needs and goals.
- Coordinating the Individual Service Plan (ISP) development.
- Facilitating and brokering Specialized Services for persons in nursing facilities.
- Advocating for the development of natural supports
- Conducting activities to maintain or improve availability, accessibility, and quality of services
- Assisting with the procurement of adaptive equipment.
- Completing monthly service coordination monitoring visits with the individual.
- Monitoring the implementation of the ISP, as well as the individual's health, safety and well-being, through site visits.
- Utilizing problem-solving procedures to achieve conflict resolution.
- Providing crisis intervention supports.
- Providing transportation to facilitate the selection of employment and residential services.
- Ensuring the Bogard choice process.
15.3 Maintenance of ISC Records
- Independent Service Coordination (ISC) agency records are subject for review by monitoring entities to include HFS, DHS and DDD. ISC agency records should include:
- Documentation of DDD payments to the ISC agency
- Audit report and consolidated year-end financial report
- For person receiving DDD Waiver services, ISCs must maintain ISSA records which must include, but are not limited to, the following information:
- Completed and updated Discovery Tool and Personal Plan.
- Documentation to support the annual level of care redetermination.
- The completed Individual Monitoring and Individual Interview Note(s) to support the minimum monitoring requirement.
- Documentation to support additional monitoring activities to the individual.
- Correspondence with provider agencies regarding issues related to the individual.
Section 16: Monitoring of Independent Service Coordination Agencies
ISC agencies are monitored by the Division of Developmental Disabilities to ensure compliance with the Uniform Grant Agreement (performance measures, performance standards, and deliverables identified), the Administrative Code Part 7000 Grant Accountability and Transparency Act and contractual requirements. In addition, ISC agencies are monitored to carry out established standards to include PAS, ISSA, Bogard Service Coordination, PUNS and Person Centered Planning. The Division will also assess ISC agency staff's qualifications/training and 24-hour accessibility for emergencies.
- At least annually, the DDD's Bureau of Quality Management (BQM) will conduct an unannounced visit to each ISC agency. During the annual unannounced visit, BQM will review a sample of individual records to determine:
- PUNS records including annual updates
- Accuracy of PAS determinations
- Timeliness of the annual Level of Care redetermination
- Quality and accuracy of Discovery Tools and Personal Plans
- Evidence of individual's right
- Accuracy and timeliness of monitoring visits and documentation
- The DDD's Bureau of Quality Management's (BQM) annual visit will be a part of DDD's waiver compliance review. ISC agencies will be notified in writing of any deficiencies and are required to submit a plan of correction, including time frames for completion. Division staff will review the plan of correction, and if acceptable, approve the corrective action. When the performance of an ISC agency is found to be less than adequate or they fail to comply with applicable regulations, IDHS may terminate contracts, reduce the scope of contracts or impose administrative sanctions. The Division will provide additional monitoring and technical assistance as needed.
- BQM will also conduct face-to-face and phone interviews with Persons receiving DDD Waiver services to assess their satisfaction with service delivery, as documented by the National Core Indicator survey data. Although the ISC does not play a direct role in the interviews, their service delivery will be measured by the information collected.
- The Division's Medicaid Waiver Unit will also conduct periodic reviews of Medicaid Waiver compliance. These Mobius based reviews will determine if service coordinators completed timely Level of Care redeterminations as described in Section 9.4 of this manual.
Section 17: Appendix
Adult Protective Services (APS), Hotline: 1-866-800-1409, 1-888-206-1327 (TTY)
Approved Representative Form [IL444-2998], pdf
Bed Hold Extension Request Form [IL462-2027], pdf
Bed Hold Request Process
Certificate of Understanding and Acknowledgment for the Critical Incident Reporting and Analysis System, pdf
Community Provider/External User I.D. And System Access Request [IL444-2022], pdf
Crisis Transition Plan and Funding Request form [IL462-0140], pdf
Critical Incident Reporting and Analysis System (CIRAS) Manual
DD Waiver Manual
DDD Medicaid Application Training Webinar, April 27, 2017, pdf
DDPAS Forms (see OBRA 1 for Initial Screen)
DDPAS-2: Intake, Assessment & Determination Summary [IL462-4435], pdf
DDPAS-3: Medication Review [IL462-4427], pdf
DDPAS-4: 24-Hour Nursing Care Determination [IL462-4434], pdf
DDPAS-5: Determination of Mental Retardation or Related Condition & Associated Treatment Needs form [IL462-4428], pdf
DDPAS-6: Identification of Service Needs [IL462-4429], pdf
DDPAS-7: Authorization for Release of Information [IL462-4430], pdf
DDPAS-8: Guardianship Screen [IL462-4431], pdf
DDPAS-9: Retirement from Active Treatment [IL462-4432], pdf
DDPAS-10: Determination Summary & Presentation and Selection of Service Options [IL462-1203], pdf
Department of Children and Family Services (DCFS) Hotline 800-252-2873, 1-800-358-5117 TTY
Developmental Disabilities Program Manual
Discovery Tool and Instructions for completing the Tool [IL462-4455], pdf
Documentation for Medicaid Waiver Appeals [IL444-0171], pdf
Employer of Record Implementation Strategy [IL462-1240], pdf
Health Care and Family Services (HFS), Illinois Department of
Illinois Administrative Code, Title 59, Chapter I:
Illinois PUNS Form - Enrollment Tool
Implementation Strategy Outline for DD Waiver Providers
Instructions for Completing the Referral for Monitoring and Technical Assistance Form
Independent Service Coordination Individual Monitoring and Interview Notes and Interpretive Guidelines [IL462-4465], pdf (for individuals enrolled in DD Waivers)
Individual Service and Support Advocacy (ISSA) Visiting Notes (doc) (Bogard)
Individual Service and Support Advocacy (ISSA) Visiting Notes Interpretive Guidelines (Bogard)
Notice of Individual's Right to Appeal Medicaid Waiver Determinations [IL462-1202] (pdf)
Notice of DHS Community-Based Services form [HFS 2653] (pdf), (also known as the Spenddown form)
OBRA 1: Initial Screen [IL462-4437], pdf
Office of the Inspector General (OIG)
Personal Plan and Instructions for completing the form [IL462-4457], pdf
Personal Plan and Instructions for completing the form, Spanish [IL462-4457 S], pdf
Public Health, Department of
Redetermination of Medicaid DD Waiver Eligibility form [IL462-0952], pdf
Referral for Monitoring and Technical Assistance Tool
Release of Information form [IL462-1214], pdf
Request for MIS Hardware, Software and Services [IL444-4144], pdf
Rights of Individuals form [IL462-1201], pdf
Rule 50, 115, 119, 120 -see Illinois Administrative Code
Service Termination Approval Request (STAR) form [IL462-2028], pdf
Service Termination Approval Request (STAR) Process and Information Bulletin