DAR File No. 32633

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-504

Nursing Facility Payments

NOTICE OF PROPOSED RULE

DAR File No.: 32633
Filed: 04/30/2009, 05:10
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update the Quality Improvement Incentive programs.

Summary of the rule or change:

This amendment adds new state fiscal year 2010 Quality Incentive programs.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3

Anticipated cost or savings to:

the state budget:

There is no budget impact because the changes to this rule do not alter the overall amount of state and federal funds that regulated health care facilities may receive.

local governments:

There is no budget impact because the changes to this rule do not alter the overall amount of state and federal funds that local government operated health care facilities may receive.

small businesses and persons other than businesses:

The amendments impact small and large businesses equally. The aggregate paid to Medicaid certified nursing homes does not change because of the amendments. Nursing homes that take advantage of the incentives will receive more than nursing homes that do not. The total incentive amount available to nursing homes is $5,475,900, which is reserved from the base rate budget for nursing homes. The incentives positively impact the treatment that nursing home residents receive.

Compliance costs for affected persons:

There are no compliance costs because there are only increases in funds for a nursing facility that takes advantage of the quality improvement incentives that are available.

Comments by the department head on the fiscal impact the rule may have on businesses:

Applying for these programs is voluntary and should have a positive fiscal impact. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/15/2009

This rule may become effective on:

07/01/2009

Authorized by:

David N. Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-504. Nursing Facility Payments.

R414-504-2. Definitions.

The definitions in R414-1-2 and R414-501-2 apply to this rule. In addition:

(1) "Behaviorally complex resident" means a long-term care resident with a severe, medically based behavior disorder, including traumatic brain injury, dementia, Alzheimer's, Huntington's Chorea, which causes diminished capacity for judgment, retention of information or decision-making skills, or a resident, who meets the Medicaid criteria for nursing facility level of care and who has a medically-based mental health disorder or diagnosis and has a high level resource use in the nursing facility not currently recognized in the case mix.

(2) "Case Mix Index" means a score assigned to each facility based on the average of the Medicaid patients' RUGS scores for that facility.

(3) "Facility Case Mix Rate" means the rate the Department issues to a facility for a specified period of time. This rate utilizes the case mix index for a provider, labor wage index application and other case mix related costs.

(4) "FCP" means the Facility Cost Profile report filed by the provider on an annual basis.

(5) "Minimum Data Set" (MDS) means a set of screening, clinical and functional status elements, including common definitions and coding categories, that form the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicaid.

(6) "Nursing Costs" means the most current costs from the annual FCP report reported on lines 070-012 Nursing Admin Salaries and Wages; 070-013 Nursing Admin Tax and Benefits; 070-040 Nursing Direct Care Salaries and Wages; 070-041 Nursing Direct Care Tax and Benefits, and 070-050 Purchased Nursing Services.

(7) "Nursing facility" or "facility" means a Medicaid-participating NF, SNF, or a combination thereof, as defined in 42 USC 1396r (a) (1988), 42 CFR 440.150 and 442.12 (1993), and UCA 26-21-2(15).

(8) "Patient day" means the care of one patient during a day of service, excluding the day of discharge.

(9) "Property costs" means the fair rental value (FRV) established by this rule.

(10) "RUGS" means the 34 RUG identification system based on the Resource Utilization Group System established by Medicare to measure and ultimately pay for the labor, fixed costs and other resources necessary to provide care to Medicaid patients. Each "RUG" is assigned a weight based on an assessment of its relative value as measured by resource utilization.

(11) "RUGS score" means a total number based on the individual RUGS derived from a resident's physical, mental and clinical condition, which projects the amount of relative resources needed to provide care to the resident. RUGS is calculated from the information obtained through the submission of the MDS data.

(12) "Sole community provider" means a facility that is not an urban provider and is not within 30 paved road miles of another existing facility and is the only facility:

(a) within a city, if the facility is located within the incorporated boundaries of a city; or

(b) within the unincorporated area of the county if it is located in an unincorporated area.

(13)(a) "Urban provider" means a facility located in a county which has a population greater than 90,000 persons.

(b) "Rural provider" means a facility that is not an urban provider.

(14) "FRV Data Report" means a report that provides the Department with information relating to capital improvements to be included in the FRV calculation.

(15) "Banked beds" means beds that have been taken off-line by the provider, through the process defined by Utah Department of Health, Bureau of Facility Licensing, Certification, and Resident Assessment, to reduce the operational capacity of the facility, but does not reduce the licensed bed capacity.

(16) "Bed Addition" means, as used in the fair rental value calculation, a capitalized project that adds additional beds to the facility. This must be new and complete construction. An increase in total licensed beds and new construction costs support a claim of additional beds.

(17) "Bed Replacement" means, as used in the fair rental value calculation, a capitalized project that furnishes a bed in the place of another, previously existing, bed. Room remodeling is not a replacement of beds. This must be new and complete construction.

(18) "Major Renovation" means, as used in the fair rental value calculation, a capitalized project with a cost equal to or greater than $500 per licensed bed. A renovation extends the life, increases the productivity, or significantly improves the safety (such as by asbestos removal) of a facility as opposed to repairs and maintenance which either restore the facility to, or maintain it at, it's normal or expected service life. Vehicle costs are not a major renovation capital expenditure.

 

R414-504-4. Quality Improvement Incentive.

(1) The incentive period is from July 1, [2008,]2009 through [June 30, 2009]May 31, 2010.

(2) In order for a facility to qualify for any Quality Improvement Incentive or initiative in subsections (3) or (4):

(a) The [Department must receive the ]application form and all supporting documentation for that Incentive or Initiative must be faxed in or mailed with a postmark during[no later than June 8 in] the incentive period. Failure to include all required supporting documentation precludes a facility from qualification.[ Please note that a postmark is not sufficient, all documentation must be physically received in the Department by the June 8 deadline.]

(b) Facilities choosing to mail in applications and supporting documentation are responsible to ensure that documents are mailed to the correct address, as follows:

Via United States Postal Service

Utah Department of Health

DHCF, BCRP

Attn: Reimbursement Unit

P.O. Box 143102

Salt Lake City, UT 84114-3102

Via United Parcel Service or Federal Express

Utah Department of Health

DHCF, BCRP

Attn: Reimbursement Unit

288 North 1460 West

Salt Lake City, UT 84116-3231

(c) The facility must clearly mark and organize all supporting documentation to facilitate review by Department staff.

(3)(a) Upon federal approval of the Nursing Care Facilities State Plan Amendment for the quality program outlined in this subsection (3), funds in the amount of $1,000,000 shall be set aside from the base rate budget annually to reimburse non-ICF/MR facilities that have:

(i) a meaningful quality improvement plan which includes the involvement of residents and family;

(ii) a demonstrated process of assessing and measuring that plan;

(iii) customer satisfaction surveys conducted by an independent third-party in each quarter of the incentive period, along with an action plan addressing survey items rated below average for the year;

(iv) a plan for culture change along with an example of how the facility has implemented culture change;

(v) an employee satisfaction program;

(vi) no violations that are at an "immediate jeopardy" level, as determined by the Department, at the most recent re-certification survey and during the incentive period;

(vii) a facility that receives a substandard quality of care level F, H, I, J, K, or L during the incentive period is eligible for only 50% of the possible reimbursement. A facility receiving substandard quality of care level F, H, I, J, K, or L in more than one survey during the incentive period is ineligible for reimbursement under this incentive.

(b) The Department shall distribute incentive payments to qualifying facilities based on the proportionate share of the total Medicaid patient days in qualifying facilities.

(c) If a facility seeks administrative review of the determination of a survey violation, the incentive payment will be withheld pending the final administrative adjudication. If violations are found not to have occurred, the incentive payment will be paid to the facility. If the survey findings are upheld, the remaining incentive payments will be distributed to all qualifying facilities.

(4) Upon federal approval of the Nursing Care Facilities State Plan Amendment for the quality program outlined in this subsection (4) and in addition to the above incentive, funds in the amount of $4,275,900 shall be set aside from the base rate budget in state fiscal year [2009]2010 for use in state fiscal year [2009]2010.[ for the following quality improvement initiatives:]

(a) Qualifying Medicaid providers may receive up to $590.43 total, across all initiatives in Subsection R414-504-4(4), for each Medicaid certified bed. The Medicaid certified bed count used for each facility for this incentive and for each initiative in this incentive is the count in the facility as at the beginning of the incentive period.

(b) A facility may not receive more for any initiative than its documented costs for that initiative.

(c) In order to qualify for any of the quality improvement initiatives in Subsection R414-504-4(4)(d):

(i) Each item purchased under initiatives (i) through (iii) of Subsection R414-504-4(4)(d) must be purchased by the end of the incentive period, and installed during the incentive period. Each item purchased under initiatives (iv) to (ix) of Subsection R414-504-4(d) must be purchased by the end of the incentive period, and installed between July 1, 2008, and May 31, 2010.

(ii) A facility, with its application, must submit a detailed description of the functionality of each item purchased, attesting to its meeting all of the criteria for that initiative.

(iii) A facility, with its application, must submit detailed documentation supporting all purchase, installation and training costs for the initiative. This documentation must include invoices and proof of purchase (i.e. copies of cancelled checks, credit card slips, etc.).

(iv) A facility must clearly mark and organize all supporting documentation to facilitate review by Department staff.

(d) Each Medicaid provider may apply for the following quality improvement initiatives:

([a]i) Incentive for facilities to purchase or enhance nurse call systems. Qualifying Medicaid providers may receive up to [$390.51]$391 for each Medicaid certified bed.[ The Medicaid certified bed count used for each facility for this incentive is the count in the facility as of July 1, 2008.

(i)] Qualifying criteria include the following:

(A) The nurse call system[ that] is compliant with approved "Guidelines for Design and Construction of Health Care Facilities."

(B) The nurse call system does not primarily use overhead paging; rather a different type of paging system is used. The paging system could include pagers, cell phones, Personal Digital Assistant devices, hand-held radio, etc. If radio frequency systems are used, consideration should be given to electromagnetic compatibility between internal and external sources.

(C) The nurse call system shall be designed so that a call activated by a resident will initiate a signal distinct from the regular staff call system and that can be turned off only at the resident's location.

(D) The signal shall activate an annunciator panel or screen at the staff work area or other appropriate location, and either a visual signal in the corridor at the resident's door or other appropriate location, or staff pager indicating the calling resident's name and/or room location, and at other areas as defined by the functional program.

(E) The nurse call system must be capable of tracking and reporting response times, such as the length of time from the initiation of the call to the time a nurse enters the room and answers the call.

[(ii) A facility must purchase and implement the nurse call system on or after July 1, 2006, and no later than June 8, 2009.

(iii) A facility, with its application, must submit a detailed description of the functionality of the nurse call system, attesting to its meeting all of the above criteria.

(iv) A facility, with its application, must submit detailed supporting documentation of its nurse call system costs, installation and training costs.

(v) A facility, with its application, must submit proof of purchase that includes receipts and invoices.

(b)](ii) Incentive for facilities to purchase new patient lift systems capable of lifting patients weighing up to 400 pounds each. Qualifying Medicaid providers may receive up to $45 for each Medicaid certified bed per patient lift, with a maximum of $90 for each Medicaid certified bed.[ The Medicaid certified bed count used for each facility for this incentive is the count in the facility as of July 1, 2008.

(i) To qualify, a facility must, at a minimum, purchase one new normal duty patient lift capable of lifting patients weighing up to 450 pounds and one new heavy duty patient lift capable of lifting patients weighing up to 1,000 pounds; or, two new heavy duty patient lifts capable of lifting patients weighing up to 1,000 pounds.

(ii) A facility, with its application, must submit a detailed description of the lifts purchased.

(iii) The patient lifts must be purchased and installed on or after July 1, 2007, and no later than June 8, 2009.

(iv) A facility, with its application, must submit proof of purchase that includes receipts and invoices.]

[(c)](iii) Incentive for facilities to purchase new patient bathing systems. Qualifying Medicaid providers may receive up to $110 for each Medicaid certified bed.[ The Medicaid certified bed count used for each facility for this incentive is the count in the facility as of July 1, 2008.]

[(i)](A) To quality, a facility must, at a minimum, purchase one new side-entry bathing system that allows the resident to enter the bathing system without having to step over or be lifted into the bathing area.

(iv) Incentive for facilities to purchase or enhance patient life enhancing devices. Qualifying Medicaid providers may receive up to $495 for each Medicaid certified bed. Patient life enhancing devices must be one or more of the following:

(A) Telecommunication enhancements primarily for patient use. This may include land lines, wireless telephones, voice mail and push to talk devices. Overhead paging, if any, must be reduced.

(B) Wander management systems and patient security enhancement devices.

(C) Computers and game consoles for patient use.

(D) Garden enhancements.

(E) Furniture enhancements for patients.

(v) Incentive for facilities to educate staff on quality. Qualifying Medicaid providers may receive up to $110 for each Medicaid certified bed. The education or training must:

(A) Be by an industry recognized organization, and

(B) Have a patient centered perspective focused on improving quality of life or care for patients.

(vi) Incentive for facilities to purchase or make improvements to vans and van equipment for patient use. Qualifying Medicaid providers may receive up to $320 for each Medicaid certified bed.

(vii) Incentive for facilities to:

(A) Purchase or lease new or enhance existing clinical information systems software, which incorporates advanced technology into improved patient care including better integration, capture of more information at the point of care, more automated reminders etc. Qualifying Medicaid providers may receive up to $109 for each Medicaid certified bed. The following clinical tracking minimum requirements must all be included in the software:

(I) Care plans;

(II) Current conditions;

(III) Medical orders;

(IV) Activities of daily living;

(V) Medication administration records;

(VI) Timing of medications;

(VII) Medical notes; and

(VIII) Point of care data tracking.

(B) Purchase or lease new or enhance existing clinical information systems hardware. Qualifying Medicaid providers may receive up to $90 for each Medicaid certified bed. The hardware must facilitate the tracking of patient care and integrate the collection of data into clinical information systems software that meets all the tracking criteria in Subsection R414-504-4(4)(vii)(A).

(viii) Incentive for facilities to purchase a new or enhance its existing heating, ventilating, and air conditioning system (HVAC). Qualifying Medicaid providers may receive up to $162 for each Medicaid certified bed.

(ix) Incentive for facilities to use innovative means to improve the residents' dining experience. These changes may include meal ordering, dining times or hours, atmosphere, more food choices etc. Qualifying Medicaid providers may receive up to $111 for each Medicaid certified bed.

(A) A facility, with its application, must submit a detailed description of the changes along with supporting documentation and proof of costs incurred.

(B) Costs under this initiative are limited to incremental costs resulting from the dining program changes.[

(ii) A facility, with its application, must submit a detailed description of the bathing system purchased.

(iii) The bathing system must be purchased and installed on or after July 1, 2007, and no later than June 8, 2009.

(iv) A facility, with its application, must submit proof of purchase that includes receipts and invoices.

(d) A facility must clearly mark and organize all supporting documentation to facilitate review by Department staff.

(e) A facility may not receive more than its documented costs under these incentive programs.]

 

R414-504-5. Reimbursement for Intermediate Care Facilities for the Mentally Retarded.

The following principles apply to the payment of community-based intermediate care facilities for the mentally retarded (ICF/MRs) that are licensed under Utah Code 26-21-13.5:

(1) The Department pays approximately 93% of the aggregate payments to ICF/MRs based on a prospective flat rate established in Utah State Plan Attachment 4.19-D. The Department pays the balance as a property cost component calculated by the Fair Rental Value system pursuant to R414-504-3.

(2) The incentive period is from July 1, [2008]2009, through [June 30, 2009]May 31, 2010.

(3)(a) The Department shall set aside $200,000 annually from the base rate budget for incentives to facilities. In order for a facility to qualify for an incentive:

(i) The[ Department must receive the] application form and all supporting documentation for [that]this incentive must be faxed in or mailed with a postmark during[no later than June 8 in] the incentive period. Failure to include all required supporting documentation precludes a facility from qualification.[ Please note that a postmark is not sufficient, all documentation must be physically received by the June 8 deadline.]

(ii) Facilities choosing to mail in applications and supporting documentation are in addition responsible to ensure that documents are mailed to the correct address, as follows:

Via United States Postal Service

Utah Department of Health

DHCF, BCRP

Attn: Reimbursement Unit

P.O. Box 143102

Salt Lake City, UT 84114-3102

Via United Parcel Service or Federal Express

Utah Department of Health

DHCF, BCRP

Attn: Reimbursement Unit

288 North 1460 West

Salt Lake City, UT 84116-3231

(iii) The facility must clearly mark and organize all supporting documentation to facilitate review by Department staff.

(b) In order to qualify for an incentive, a facility must have:

(i) a meaningful quality improvement plan which includes the involvement of residents and family;

(ii) a demonstrated means to measure that plan;

(iii) customer satisfaction surveys conducted by an independent third-party in each quarter of the incentive period;

(iv) an employee satisfaction program; and

([iv]v) no violations, as determined by the Department, that are at an "immediate jeopardy" level at the most recent re-certification survey and during the incentive period.

(c) The Department shall distribute incentive payments to qualifying facilities based on the proportionate share of the total Medicaid patient days in qualifying facilities.

(d) If a facility seeks administrative review of a survey violation, the incentive payment will be withheld pending the final administrative determination. If violations are found not to have occurred at a severity level of "immediate jeopardy" or higher, the incentive payment will be paid to the facility. If the survey findings are upheld, the Department shall distribute the remaining incentive payments to all qualifying facilities.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [October 22, 2008]2009

Notice of Continuation: December 12, 2007

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-35a