Intermediate Care Facilities for Individuals with Intellectual Disabilities
The definition of "long-term care facility" as defined in 50-5-101(36) Montana Code Annotated (MCA), "means a facility or part of a facility that provides skilled nursing care, residential care, intermediate nursing care, or intermediate developmental disability care to a total of two or more individuals or that provides personal care."
"Intermediate Care Facilities for the developmentally disabled" (ICF/DD) "means a facility or part of a facility that provides intermediate developmental disability care for two or more persons." The term does not include licensed community homes for persons with developmental disabilities or licensed community homes for persons with severe disabilities as defined in 50-5-101(32), MCA. "Intermediate developmental disability care" as defined in 50-5-101 (33) MCA, "means the provision of intermediate nursing care services, health-related services, and social services for person with a developmental disability, as defined in 53-20-102 MCA, or for persons with related problems."
"Active treatment" means that "each client must receive a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services...that is directed toward- (I) The acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible; and (ii) The prevention or deceleration of regression or loss of current optimal functional status" (Code of Federal Regulations [CFR] 42§483.440).
The CFR also states that "an institution for the mentally retarded is not an institution for mental diseases." "Institution for the mentally retarded or persons with related conditions" means an institution (or distinct part of an institution) that - (a) is primarily for the diagnosis, treatment, or rehabilitation" of persons with mental retardation " or persons with related conditions; and (b) provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each individual function at his greatest ability" (CFR 42§435.1009).
"Developmental disability" means "a disability that (a) is attributed to intellectual disability, cerebral palsy, epilepsy, autism, or any other neurologically disabling condition closely related to intellectual disability; (b) requires treatment similar to that required by intellectually disabled individuals; (c) originated before the individual attained age 18; (d) has continued or can be expected to continue indefinitely; and (e) results in the person having a substantial disability."(MCA 53-20-102 and Administrative Rules of Montana [ARM] 37.34.102 (9). Current law allows only those individuals who have been found to have a serious developmental disability and to be 18 years of age or older to be admitted to a state-operated ICF/IID (53-20-125(1), MCA. After December 31, 2016, there will be no more admissions to the ICF/IID per 53-20-125 (12) MCA.
"Seriously developmentally disabled" means "a person who: a) has a developmental disability; b) is impaired in cognitive functioning; c) cannot be safely and effectively habilitated through voluntary use of community-based services because of behaviors that pose imminent risk of serious harm to self or others." (53-20-102(19), MCA).
"Community-based facilities or community-based services means those services and facilities which are available for the evaluation, treatment, and habilitation of persons with developmental disabilities in a community setting." (53-20-102(6), MCA, ARM 46.8.706(4)). A community home for individuals with developmental disabilities is defined as a "family-oriented residence or home designed to provide facilities for two to eight persons with developmental disabilities, established as an alternative to existing state institutions" (53-20-302, MCA).
The most common configuration of an ICF/ID includes at least two sites: the residential program site and the day training habilitation program site. ICF/ID must also provide primary medical services as part of the treatment model.
ICF/IID services should be regarded as an effective means of treatment for those individuals who have a serious developmental disability and who cannot be safely and effectively habilitated or served through less restrictive community-based services and facilities.
- To limit ICF/IID services to those persons who are determined to be seriously developmentally disabled by providing services funded through Medicaid's Home and Community-Based (HCB) Waiver program.
- To promote the accessibility and availability of appropriate community-based services throughout Montana to individuals with developmental disabilities as an alternative to ICF/ID.
- To coordinate any planning efforts towards the development and delivery of services for people with developmental disabilities with planning efforts of the Office of Public Instruction (OPI), and Department of Public Health and Human Services (DPHHS) divisions and programs, including the Developmental Services Division (DSD) and the Montana Council on Developmental Disabilities (MTCDD), as well as local agencies providing or affiliated with such services.
- To advocate for the expansion of community services funded through the HCB Waiver program to serve additional people with developmental disabilities who would otherwise require institutionalization or other ICF/IID services, and to deinstitutionalize those people who are inappropriately receiving care in an ICF/ID.
- To maintain or reduce the current number of licensed and certified ICF/ID beds
Certificate of Need Guidelines:
As outlined in 50-5-304, MCA, any applicant seeking to establish an ICF/IID should address the review criteria in its CON application, including an evaluation of the proposal with the guidelines established in this section. The review criteria consider consistency with this State Health Care Facilities Plan, but also allow consideration of additional data and information.
- No new ICF/ID will be approved, nor will any expansion of existing ICF/ID be approved. See Guideline #3.
- If a community home seeks to obtain a license to operate under the provisions of 53-20-205, MCA, it is not subject to Certificate of Need (CON) review. However, any HCB Waiver-funded community home under construction should meet the physical plant requirements for ICF/ID, or should be able to do so with only minor physical modifications.
- The establishment of any new ICF/ID should not be authorized unless the HCB Waiver program ceases to exist. Should this occur, the following CON guidelines will take effect.
- Applicants must have documentation from the DSD that there are individuals who need and want the services which would be provided by the proposed facility.
- An applicant must demonstrate that existing services are not meeting the demand for appropriate services to persons with developmental disabilities. Proposals for new ICF/ID will only be approved if there are specific local conditions which require such development.
- Proposals to add beds to existing ICF/ID shall be subject to the bed need methodology for long-term care beds contained in this plan (see the Nursing Home Services component). State-owned facilities are exempt from CON review (50-5-309, MCA).
- The maximum number of individuals to be served in a proposed new ICF/ID should be six. The facility should be located in a residential area and the structure should blend with other homes in the neighborhood. Programming should be directed toward maximum community involvement and participation of the individuals served.
- CON proposals for ICF/ID must demonstrate there is a qualified professional work force available to staff such a facility.
- Existing HCB Waiver-funded facilities should not be required to undergo CON review to convert to ICF/IID, in the event that HCB Waiver funding is terminated, but would be required to submit a letter of intent informing DPHHS of the conversion.
Need Methodology for ICF/ID:
See Nursing Home Services component (only applicable if HCB Waiver ceases to exist).
One of the most sensitive issues in determining service needs for Montana's citizens with developmental disabilities relates to the role of institutional care in an ICF/IID. As cited previously, Montana law limits placement in a state-operated ICF/ID or DD to those persons who are "seriously developmentally disabled." It is necessary to maintain institutional services in the form of ICF/IID since the resources currently available for community-based services may not be sufficient to serve an individual who is found to have serious developmental disabilities.
In Montana, the development of community-based services began around 1974 with a movement toward deinstitutionalization. This move has been mandated by legislative action and supported by federal monies, with the intention of providing improved services which are available in community settings where groups are smaller and services are more individualized than were previously available in large institutions. Montana law supports community-based services by mandating that services for persons with developmental disabilities be provided in the least restrictive environment according to their individual habilitation needs (53-20-148, MCA).
Community-based services, available through the HCB Waiver program are a cost-effective alternative for serving those individuals who would otherwise require institutionalization or other ICF/IID services. The needs of the great majority of Montana's residents with developmental disabilities can best be met in a community-based environment. Most community-based providers are qualified to participate in the waiver program.
The cost of serving people in the HCB Waiver program is less expensive than serving people in ICF/ID. Of even greater importance than the cost savings, however, the flexibility of the HCB Waiver program allows more personalized services and more accommodation to individual choices. The opportunity to use and take part in a variety of integrated activities and to become part of communities can reduce the isolation of individuals with developmental disabilities, and hopefully improve their quality of life.
There is presently one facility in Montana that is certified as ICF/ID and one certified as ICF/DD. The current bed capacity is believed to be sufficient to serve individuals who have serious developmental disabilities. There will be no new admissions to the ICF/ID after December 31, 2016. The ICF/ID is scheduled to close in June 2019.