Responsibilities and Authority of ISSAs
Specific ISSA Tasks and General Areas of Responsibility-A minimum of 2 ISSA visits per year, will be conducted to each person in a waiver program and will consist of the following:
One annual visit for participation in the development of the Personal Centered Plan (PCP). The person's ISP will provide documentation for this visit.
One annual visit to assist the individual in completing the Consumer Satisfaction Survey, as required by DHS. The person's Consumer Satisfaction Survey will provide the documentation for this visit.
One annual visit to the individual's residence (whether or not it is a private home). The ISSA Visiting Notes will provide documentation for this visit.
Besides participating in the development of the annual service plan, ISSAs will review the service plan for adequacy in meeting the needs and preferences of the individual.
ISSAs will also assist the individual in self-advocacy with providers of waiver services and will assist with conflict resolution.
ISSAs will 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 preferences and unique perspectives.
Referrals will be made to DHS involving any recurring, unresolved issues or serious problems affecting the individual's health and welfare, so that DHS can monitor or provide technical assistance as needed.
ISSAs will report any allegations or observations of suspected abuse and neglect to the Office of the Inspector General (OIG).
At least annually, a redetermination will be made for each individual of eligibility for waiver services. The annual redetermination will usually be performed at the time of the ISP development; however, the redetermination may never be allowed to expire. If the redetermination and the ISP cannot be scheduled for the same day, the ISSA must perform the redetermination before it has expired, regardless of the timing of the ISP meeting.
ISSAs will maintain records including, but not limited to, an annual redetermination of waiver eligibility, an annual Consumer Satisfaction Survey results, documentation of ongoing visits to the individual and documentation to support ISSA billings.
Geographic Responsibility-Responsibility for ISSA visits will lie with the ISSA agency that serves the geographic area in which the individual's residence is located. If the individual receiving day program services and those day program services are delivered by a provider located outside the ISSA agency's service area, ISSSA services will still be provided by the ISSA agency serving the geographic area in which the individual's residence is located.
Annual Redetermination of Waiver Eligibility-The ISSA will make a redetermination of individual waiver eligibility on an annual basis, unless there is a change in circumstances affecting eligibility which necessitates a complete review earlier, e.g., change in income, assets or living arrangement. With the exception of developmental disability status, the redetermination must include a review of all eligibility factors. The purpose of the review is to verify eligibility for Medicaid claiming and to establish continuing need for an ICF/DD level of service.
Redetermination of Medicaid Eligibility-The DHS local office caseworker conducts an annual redetermination of eligibility for Medicaid. ISSAs and providers are responsible for ensuring that this occurs.
Providers are responsible for completing the DPA-26563 to document for the DHS local office caseworker that the individual continues to meet his/her Medicaid spenddown obligation, if necessary.
Redetermination of Waiver Programmatic Eligibility
Process and Requirements-The following assessments and programmatic information must be completed or reviewed in redetermining waiver eligibility:
Appeal Process-If the determination is made that the individual no longer meets the ICF/DD level of service criteria, the ISSA QIDP will provide the individual or guardian with a notice that includes the determination, whether or not services will continue, and copy of the Notice of Individual Right to Appeal (1202).
Qualifications of ISSAs
Accreditation-Agencies providing ISSA must be accredited according to accreditation requirements for Individual Service Coordination agencies, as administered through the Office of Accreditation, Licensure and Certification of the Department of Human Services.
Qualified Intellectual Disability Professionals-Persons employed to provide ISSA must be Qualified Intellectual Disability Professionals (QIDP) as defined in Rule 115.200, "Standards and Licensure Requirements for Community Integrated Living Arrangements." This requirement applies regardless of whether their work with ISSA is full-time or part-time. QIDP's working as ISSAs must update their job skills and knowledge annually, including earing 12 Continuing Education Units annually in job-related training. Skills necessary for the successful provision of ISSA include the following:
Recipients of ISSA-Persons who receive ISSA will be all persons enrolled in the Home and Community-Based Services Waiver. Among many other service profiles, this will include some individuals who:
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, individual who choose to participate in waiver residential support programs, including Intermittent CILA, Supported Living Services and host family settings, must provide access to their homes for on-site visits. Issues of personal preference should be respected, e.g., tidiness and clutter, but issues regarding health and safety must be addressed, e.g., decomposing food, roach infestation).
For individuals requesting waiver-funded services, PAS Agencies must inform families prior to enrollment that PAS/ISSA 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 visit by ISSA workers will be made to the individual's home.
Criteria for Determining Whether Additional Visits (More than the annual four visits) are Necessary
An additional visit may be needed if any of the following criteria is met. The ISSA will document the need for an additional visit in Section VI, Suggested Follow Up, on the Visiting Notes summary.
The guardian or individual has indicated valid and significant concerns about his/her services and has requested assistance from the ISSA.
The service provider has requested the further involvement of the ISSA, providing examples of ways that the ISSA can contribute significantly to enhanced services for the individual.
As the result of the current visit, the ISSA and his/her supervisor believe that major improvement in services is necessary and that additional visits will significantly contribute to a major improvement in services.
The Department of Human Services has requested that the ISSA make an additional visit. This assistance will be used in substantiated cases of abuse or neglect, among other instances.
The individual is experiencing significant disruptions in his/her status, e.g., potential termination from services, such as new health concerns, significant loss of supports within the community support team, increasing behavioral or emotional needs, legal difficulties, etc.
The individual is considered vulnerable due to severity of need, inability to communicate, inadequate services and supports, etc.; suitable services and supports are not in place to address all significant aspects of the individual's vulnerability; and, the ISSA is actively working to secure such services and supports.
The ISSA agency may determine the best way of documenting additional visits that occur over and basic four annual visits. The ISSA agency may wish to use the ISSA Visiting Notes, a shortened version thereof, a narrative case note, or some other means of written documentation. In every case, the reasons for the additional visit, the process of the visit (including persons involved and issues addressed), and the results of the visit must be thoroughly documented and shared with the individual, guardian and provider. Documentation must be retained in the ISSA's agency records, along with documentation of the annual four visits to the individual and other materials relevant to the individual's ISSA services. In every case, the purpose of the additional visit must be identified prior to the occurrence of the visit. The ISSA's role is not merely to observe, but to contribute to the resolution of problems.
QIDP Visiting Notes
ISSA Visiting Notes provide a format to assist the QIDP in accurately and consistently recording information gathered during ISSA visits to individuals receiving waiver services. The priority goal is that issues of health, safety and meaningful programming are receiving attention. ISSA workers should use their experience to guide them in ordering priorities.
Visiting Notes do not need to be sent to DHS on a routine basis; however, ISSA agencies will forward Visiting Notes when submitting the "Referral to Department of Human Services for Monitoring and/or Technical Assistance" form to the DDD Networks.
The necessary documentation of an ISSA worker's visits to an individual for participation in development of the Individual Service Plan (ISP) will be the ISP itself, which will include a signature page of those participation in the ISP development. The necessary documentation of an ISSA worker's visits to an individual in order to assist in completion of the Consumer Satisfaction Survey will be the completed satisfaction survey. Visiting Notes will be used to document the other two annual visits to the individual at the individual's residence and/or day program.
When completed, ISSA Visiting Notes must be shared with the individual and/or the guardian and the waiver service providers. Copies of the Visiting Notes must be provided on an average within seven working days following the completion of the visit. Documentation of follow up visits provided to the individual over and above the four annual visits will also be shared with the individual and/or guardian and providers on the same basis.
The Visiting Notes are generally appropriate for use in residential and day program settings. The following considerations will be applicable for visits to individuals at day programs and at residential settings that are private homes. Regardless of the location of a specific visit, however, the ISSA must review with the individual, guardian and staff, outcomes for the person's entire service package and the individual's level of satisfaction with all services.
For visits to individuals at day programs: Outcome #8 - The person appears to be able to access the community with support as desired: This may not be applicable to the day program itself, since day program activities are provided in specific settings and during specific times; however, the individual's willingness and interest in participation in the day program may be appropriately addressed in this outcome. The ISSA may also be able to gather information from interviews and record reviews that will be helpful in assessing the degree to which this outcome is present in the individual's residential setting.
For individuals receiving Support Employment: The ISSA should discuss ahead of time with the individual and/or guardian and staff of the Supported Employment provider (and business, where applicable), the need to provide ISSA services to the individual. This includes requirements by the State of Illinois as part of the individual's participation waiver-funded services, and observation of the individual's working conditions as part of the content of those services. As a team, persons involved should agree on the least intrusive means of obtaining the information necessary for completion of the ISSA responsibilities. It is not necessary that the individual or staff be interviewed at the work site, but some unobtrusive observations of the work site conditions must constitute part of the data that go into the ISSA's visiting notes for the day program visit.
For visits to individuals residing in private homes: The ISSA must take into consideration cultural and economic factors that may affect particular outcomes. Standards that apply in provider-supported residential settings may not be appropriate standards when visiting a person's own home. For example, in evaluating the presence of Outcome #2 ("The setting of the visit appears to be safe and clean"), the ISSA 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 ISSA has questions in this area, the ISSA should address whether the individual's health, safety and well-being are supported by the setting.
Another consideration relates to fairness. The ISSA 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 similar to the above should be utilized when reviewing Outcome #12 - "The individual appears to be well groomed and appropriately dressed."
Reporting Service Hours and Payment
ISSA services will be reimbursed at an hourly rate established by DHS. 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 service hours consist of time spent on behalf of the individual waiver recipient. Examples of billable hours could include the following:
Problem and Conflict Resolution Addressing Issues, Solving Problems, Troubleshooting
The problem resolution protocol is based on five foundational principles. These principles include:
ISSA Problem Resolution Protocol
Step 1 - Initial Level Resolution: Worker to Worker
Issues or concerns, identified during the course of any ISSA contact with community providers, should initially be addressed with the person responsible for oversight of daily program implementation (agency QIDP, house lead, ISSA worker, etc.). The ISSA and 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 ISSA. Likewise, problems that require reporting to OIG or some other regulatory body must first be handled per those requirements, and if appropriate, submitted to the dispute prevention/problem resolution process. If the identified issues or concerns are perceived to b significantly serious, then the ISSA will immediately utilize Step 2 or Step 3.
Step 2 - Second Level Resolution: Worker to Worker and Supervisor to Supervisor
If the matter is not resolved per the action plan, or if the parties fail to create a mutually acceptable action plan, the ISSA and/or the agency staff will immediately contact his/her supervisor to inform them of the unresolved issue or concern. Additional efforts at resolving the issue or concern will be promptly undertaken using the following guidelines:
Both the ISSA and the agency program level staff person must provide a written statement of the problem, 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 should include all four participants - ISSA, supervisor, agency program level staff person and agency program director.
Copies of resolution plans will be forwarded to the agency Executive Director and the PAS/ISC/ISSA Executive Director.
Step 3 - Third Level Resolution: Worker to Worker, Supervisor to Supervisor, and Executive Director to Executive Director
If the matter remains unresolved, the Executive Director of the PAS/ISC/ISSA agency and Executive Director of the agency will be brought into the problem-solving discussions. Discussions should now have six participants.
Step 4 - Fourth Level Resolution: Involvement of the DHS Network Facilitator
If the matter is not resolved within a reasonable period of time, the PAS/ISC/ISSA Executive Director will contact the responsible DHS Network Facilitator. The Network Facilitator will conduct a fact-finding session and work with the parties to bring about a final resolution to the problem. In the event that the parties, with the help of the Network Facilitator. are unable to reach agreement, then the Department will issue a final and binding decision.
Documentation-Documentation of the conflict resolution process will be maintained in the individual's ISSA record. The ISSA agency will document in the individual's ISSA record that it has provided the individual and/or guardian with the information regarding the progress of the conflict resolution process. The content of that information will be included in the documentation.
Note: This form is not used for suspected cases of abuse and neglect, which are reported immediately and directly to the Office of the Inspector General, which in turn notifies the Division of Developmental Disabilities for follow up on substantiated cases.
Abuse and Neglect - Observations and Reporting-Section 6.2 of the Abused and Neglected Long Term Care Facility Residents Reporting Act (210 ILCS 30) created the Office of the Inspector General (OIG) whose responsibility is to investigate reports of suspected abuse or neglect of individuals who are current enrollees of programs under its jurisdiction. OIG's area of authority includes any mental health or developmental disabilities facility or program that is licensed, certified or funded by DHS that is not under the jurisdiction of any other state agency. OIG is, therefore, responsible for such investigations in all waiver habilitation settings, except Community Living Facilities, which are licensed by the Department of Public Health.
The Illinois Administrative Code Title 59, Part 50 (Rule 50 or OIG Rule) establishes specific guidelines to follow from the initial reporting of abuse and neglect through final action which would result from any subsequent investigation. CILA Rule 115 and DT Rule 119 also contain amendments requiring reporting to OIG.
ISSA Workers are considered "required Reporters" under Rule 50 and must report all cases or suspected cases of abuse, neglect or other incidents specifically included in Rule 50. Reports may be made to an agency's authorized representative, who would follow up according to agency procedures and report to OIG, or the ISSA worker may directly contact OIG. If the ISSA worker notifies OIG, he/she would be considered the complainant in the case. In either scenario, the ISSA is responsible for ensuring that OIG is contacted. The ISSA worker should also inform the DDD Network to keep them apprised of the situation.
Rule 50 has three thresholds that, if met, would lead to report to OIG:
Key Definitions Contained in Rule 50-
Serious Injury (paraphrased):
Reporting Time Lines
How to Report
Monitoring of ISSA Agencies-ISSA agencies are monitored by both DHS and DPA. Specifically, annual reviews of the agencies' regulatory compliance are conducted by the Bureau of Accreditation, Licensure and Certification with DHS. In addition to this routine activity, ISSAs are subject to the sample monitoring conducted by DPA and DHS's quality assurance section. Based on the performance of each ISSA agency, DHS may terminate contracts, reduce the scope of contracts or impose administrative sanctions if an ISSA fails to comply with applicable regulations.
ISSA Monitoring by Bureau of Accreditation, Licensure and Certification (BALC)-Staff of BALC will conduct annual on-site surveys of all ISSA agencies. Accredited agencies are granted deemed status for some standards, because those standards are surveyed as part of the required national accreditation. ISSA providers will be n notified in writing of any deficiencies and are required to submit a plan of correction, including time frames for completion, if there are any deficiencies. BALC staff will review the plan of correction, and if acceptable, approve the participation of the provider. When violations occur, more frequent BALC site visits may be made. Staff of the Division of Developmental Disabilities, including the Bureau of Quality Assurance and System Improvement (BQASI) and Network staff may assist with site visits or provide additional monitoring or technical assistance.
Accreditation of ISSAs-DHS requires all programs funded by DHS and not licensed by another agency that receive more than $20,000 per year in funding for services for individuals with a developmental disability or mental illness to be accredited by a nationally recognized accreditation body (such as CARF or the Accreditation Council). BALC monitors ISSA agency compliance with this DHS requirement.
DPA Review Process-Each year, CPA will complete a record review of a random sample of 5% of participants. DPA will ensure that low utilization services are included in the random sample. In addition, DPA will randomly select one downstate provider and one provider in the Chicago Metro area per quarter for intensive on-site reviews. A ninth provider will be chosen annually for a targeted on-site review, based on concerns found while performing other DPA monitoring tasks. These record and intensive on-site reviews will include thorough review of the following, which involve ISSA agency activity:
The results of these reviews will be summarized with other DPA findings and will be forwarded to DHS for follow up action. The DHS BQASI will ensure appropriate corrective action plans are developed and implemented. This activity is subject to tracking and follow up monitoring by DPA.
DHS Random Monitoring Activities-DHS BQASI will conduct joint random on-site reviews of different individual cases and issue separate findings. Written plans of correction will also be required as a result of the DHS case reviews. The BQASI will track the plans of correction and will report to DPA on the status of these cased quarterly.
Maintenance of Records by ISSAs-The ISSA agencies are to maintain paper records for review by monitoring agencies of the following information:
When a person is awarded funding through the Illinois Department of Human Services (DHS) they begin participating in the Medicaid Waiver Program. The Medicaid Waiver Program is coordinated on a State level and the State contracts with Individual Service Coordination (ISC) agencies to monitor the services that an individual compliance. CISA is the ISC agency that monitors the services individuals receive. CISA represents DHS's interest in promoting independence and self-sufficiency for individuals participating in the Medicaid Waiver Program. CISA is designed to assist but not supplant the guardian or the individual themselves. An Individual Service Coordinator will be assigned to a person receiving services. The Individual Service Coordinator does a required minimum of 2 visits a year to see the person in their Residential and Day Program sites. The Individual Service Coordinator will Coordinate and Develop Personal Plan for individuals receiving services. With each visit the Individual Service Coordinator will contact the guardian to get their input regarding services that person is receiving.
Individual Service and Support Advocacy (ISSA)