Long Term Care Facilities may receive payment for the provision of nursing care under the Title XIX Medicaid Program only when they are properly licensed and certified by the Oklahoma Department of Health, meet Federal and State requirements and hold a valid written agreement with the Oklahoma Health Care Authority (Agreement to Provide Long Term Care Services under the Medicaid Act (Agreement). All long term care facility Agreements are time limited with specific effective and expiration dates and can be issued for no more than a twelve month period. Whenever possible, the agreement expiration date will correspond with the certification period by the State Survey Agency.
|317:30-5-121.||Coverage by category|
(a) Adults. Payment is made for compensable long term care for adults after the patient has been determined medically eligible to receive such care.
(b) Children. Coverage for children is the same as adults.
|317:30-5-122.||Levels of care|
(a) This rule sets forth the criteria used to determine whether an individual who is seeking SoonerCare payment for long term care services needs services at the level of Skilled Nursing Facility, or Intermediate Care Facility for People with Mental Retardation (ICF/MR). The criteria set forth in this Section must be used when determining level of care for individuals seeking SoonerCare coverage of either facility-based institutional long term care services or Home and Community Based Services (HCBS) Waivers.
(b) The level of care provided by a long term care facility or through a HCBS Waiver is based on the nature of the person's needs and the care, services, and treatment required from appropriately qualified personnel. The level of care review is a determination of an individual's physical, mental and social/emotional status to determine the appropriate level of care required. In addition to level of care requirements, other applicable eligibility criteria must be met.
(1) Skilled Nursing facility. Payment is made for the Part A coinsurance and deductible for Medicare covered skilled nursing facility care for dually eligible, categorically needy individuals.
(2) Nursing Facility. Care provided by a nursing facility to patients who require professional nursing supervision and a maximum amount of nonprofessional nursing care due to physical conditions or a combination of physical and mental conditions.
(3) Intermediate Care Facility for the Mentally Retarded. Care for persons with intellectual disabilities or related conditions to provide health and/or habilitative services in a protected residential setting. To qualify for ICF/MR level of care, persons must have substantial functional limitations in three or more of the following areas of major life activity:
(A) Self-care. The individual requires assistance, training or supervision to eat, dress, groom, bathe, or use the toilet.
(B) Understanding and use of language. The individual lacks functional communication skills, requires the use of assistive devices to communicate, does not demonstrate an understanding of request or is unable to follow two-step instructions.
(C) Learning. The individual has a valid diagnosis of intellectual disability as defined in the Diagnostic and Statistical Manual of Mental Disorders.
(D) Mobility. The individual requires the use of assistive devices to be mobile and cannot physically self-evacuate from a building during an emergency without assistive device.
(E) Self-direction. The individual is 7 years old or older and significantly at risk in making age appropriate decisions or an adult who is unable to provide informed consent for medical care, personal safety or for legal, financial, habilitative or residential issues and/or has been declared legally incompetent. The individual is a danger to himself or others without supervision.
(F) Capacity for independent living. The individual who is 7 years old or older and is unable to locate and use a telephone, cross the street safely or understand that it is unsafe to accept rides, food or money from strangers or an adult who lacks basic skills in the areas of shopping, preparing food, housekeeping or paying bills.
|317:30-5-123.||Patient certification for long term care|
(a) Medical eligibility. Initial approval of medical eligibility for long-term care is determined by the Oklahoma Department of Human Services (OKDHS) area nurse, or nurse designee. The certification is obtained by the facility at the time of admission.
(1) Pre-admission screening. Federal Regulations govern the State's responsibility for Preadmission Screening and Resident Review (PASRR) for individuals with mental illness and intellectual disability. PASRR applies to the screening or reviewing of all individuals for mental illness or intellectual disability or related conditions who apply to or reside in Title XIX certified nursing facilities regardless of the source of payment for the nursing facility services and regardless of the individual's or resident's known diagnoses. The nursing facility (NF) must independently evaluate the Level I PASRR Screen regardless of who completes the form and determine whether or not to admit an individual to the facility. Nursing facilities which inappropriately admit a person without a PASRR Screen are subject to recoupment of funds. PASRR is a requirement for nursing facilities with dually certified (both Medicare and Medicaid) beds. There are no PASRR requirements for Medicare skilled beds that are not dually certified, nor is PASRR required for individuals seeking residency in an intermediate care facility for the mentally retarded (ICF/MR).
(2) PASRR Level I screen.
(A) Form LTC-300, Nursing Facility Level of Care Assessment, must be completed by an authorized NF official or designee. An authorized NF official or designee must consist of one of the following:
(i) The nursing facility administrator or co-administrator;
(ii) A licensed nurse, social service director, or social worker from the nursing facility; or
(iii) A licensed nurse, social service director, or social worker from the hospital.
(B) Prior to admission, the authorized NF official must evaluate the properly completed OHCA Form LTC-300 and the Minimum Data Set (MDS), if available. Any other readily available medical and social information is also used to determine if there currently exists any indication of mental illness (MI), intellectual disability or other related condition, or if such condition existed in the applicant's past history. Form LTC-300 constitutes the Level I PASRR Screen and is utilized in determining whether or not a Level II Assessment is necessary prior to allowing the patient to be admitted. The NF is also responsible for consulting with the Level of Care Evaluation Unit (LOCEU) regarding any mental illness/intellectual disability related condition information that becomes known either from completion of the MDS or throughout the resident's stay.
(C) The nursing facility is responsible for determining from the evaluation whether or not the patient can be admitted to the facility. A "yes" response to any question from Form LTC-300, Section E, will require the nursing facility to contact the LOCEU for a consultation to determine if a Level II Assessment is needed. If there is any question as to whether or not there is evidence of mental illness, intellectual disability or related condition, LOCEU should be contacted prior to admission. The original Form LTC-300 must be submitted by mail to the LOCEU within 10 days of the resident admission. SoonerCare payment may not be made for a resident whose LTC-300 requirements have not been satisfied in a timely manner.
(D) Upon receipt and review of the Form LTC-300, the LOCEU may, in coordination with the OKDHS area nurse, re-evaluate whether a Level II PASRR assessment may be required. If a Level II Assessment is not required, the process of determining medical eligibility continues. If a Level II is required, a medical decision is not made until the results of the Level II Assessment are known.
(3) Level II Assessment for PASRR.
(A) Any one of the following three circumstances will allow a patient to enter the nursing facility without being subjected to a Level II PASRR Assessment.
(i) The patient has no current indication of mental illness or intellectual disability or other related condition and there is no history of such condition in the patient's past.
(ii) The patient does not have a diagnosis of intellectual disability or related condition.
(iii) An individual may be admitted to an NF if he/she has indications of mental illness or intellectual disability or other related condition, but is not a danger to self and/or others, and is being released from an acute care hospital as part of a medically prescribed period of recovery (Exempted Hospital Discharge). If an individual is admitted to an NF based on Exempted Hospital Discharge, it is the responsibility of the NF to ensure that the individual is either discharged by the 30th day or that a Level II has been requested and is in process. Exempted Hospital Discharge is allowed only if all three of the following conditions are met:
(I) The individual must be admitted to the NF directly from a hospital after receiving acute inpatient care at the hospital (not including psychiatric facilities);
(II) The individual must require NF services for the condition for which he/she received care in the hospital; and
(III) The attending physician must certify in writing before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. The NF will be required to furnish this documentation to OHCA upon request.
(B) If the patient has current indications of mental illness or intellectual disability or other related condition, or if there is a history of such condition in the patient's past, the patient cannot be admitted to the nursing facility until the LOCEU is contacted for consultation to determine if a Level II PASRR Assessment must be performed. Results of any Level II PASRR Assessment ordered must indicate that nursing facility care is appropriate prior to allowing the patient to be admitted.
(C) The OHCA, LOCEU, authorizes Advance Group Determinations for the mental illness and intellectual disability Authorities in the following categories listed in (i) through (iii) of this subparagraph. Preliminary screening by the LOCEU may indicate eligibility for nursing facility level of care prior to consideration of the provisional admission.
(i) Provisional admission in cases of delirium. Any person with mental illness, intellectual disability or related condition that is not a danger to self and or others, may be admitted to a Title XIX certified NF if the individual is experiencing a condition that precludes screening, i.e., effects of anesthesia, medication, unfamiliar environment, severity of illness, or electrolyte imbalance.
(I) A Level II evaluation is completed immediately after the delirium clears. The LOCEU must be provided with written documentation by a physician that supports the individual's condition which allows provisional admission as defined in (i) of this subparagraph.
(II) Payment for NF services will not be made after the provisional admission ending date. If an individual is determined to need a longer stay, the individual must receive a Level II evaluation before continuation of the stay may be permitted and payment made for days beyond the ending date.
(ii) Provisional admission in emergency situations. Any person with a mental illness, intellectual disability or related condition, who is not a danger to self and/or others, may be admitted to a Title XIX certified nursing facility for a period not to exceed seven days pending further assessment in emergency situations requiring protective services. The request for Level II evaluation must be made immediately upon admission to the NF if a longer stay is anticipated. The LOCEU must be provided with written documentation from OKDHS Adult Protective Services which supports the individual's emergency admission. Payment for NF services will not be made beyond the emergency admission ending date.
(iii) Respite care admission. Any person with mental illness, intellectual disability or related condition, who is not a danger to self and/or others, may be admitted to a Title XIX certified nursing facility to provide respite to in-home caregivers to whom the individual is expected to return following the brief NF stay. Respite care may be granted up to 15 consecutive days per stay, not to exceed 30 days per calendar year.
(I) In rare instances, such as illness of the caregiver, an exception may be granted to allow 30 consecutive days of respite care. However, in no instance can respite care exceed 30 days per calendar year.
(II) Respite care must be approved by LOCEU staff prior to the individual's admission to the NF. The NF provides the LOCEU with written documentation concerning circumstances surrounding the need for respite care, the date the individual wishes to be admitted to the facility, and the date the individual is expected to return to the caregiver. Payment for NF services will not be made after the respite care ending date.
(4) Resident Review.
(A) The nursing facility's routine resident assessment will identify those individuals previously undiagnosed as intellectally disaled or mentally ill. A new condition of intellectual disability or mental illness must be referred to LOCEU by the NF for determination of the need for the Level II Assessment. The facility's failure to refer such individuals for a Level II Assessment may result in recoupment of funds.
(B) A Level II Resident Review may be conducted the following year for each resident of a nursing facility who was found to experience a serious mental illness with no primary diagnosis of dementia on his or her pre-admission Level II, to determine whether, because of the resident's physical and mental condition, the resident requires the level of services provided by a nursing facility and whether the resident requires specialized services.
(C) A significant change in a resident's mental condition could trigger a Level II Resident Review. If such a change should occur in a resident's condition, it is the responsibility of the nursing facility to notify the LOCEU of the need to conduct a resident review.
(5) Results of Level II Pre-Admission Assessment and Resident Review. Through contractual arrangements between the OHCA and the mental illness/intellectual disability authorities, individualized assessments are conducted and findings presented in written evaluations. The evaluations determine if nursing facility services are needed, if specialized services or less than specialized services are needed, and if the individual meets the federal PASRR definition of mental illness or intellectual disability or related conditions. Evaluations are delivered to the LOCEU to process formal, written notification to patient, guardian, NF and interested parties.
(6) Readmissions, and interfacility transfers. The Preadmission Screening process does not apply to readmission of an individual to an NF after transfer for a continuous hospital stay, and then back to the NF. There is no specific time limit on the length of absence from the nursing facility for the hospitalization. Inter-facility transfers are also subject to preadmission screening. In the case of transfer of a resident from an NF to a hospital or to another NF, the transferring NF is responsible for ensuring that copies of the resident's most recent LTC-300 and any PASRR evaluations accompany the transferring resident. The receiving NF must submit an updated LTC-300 that reflects the resident's current status to LOCEU within 10 days of the transfer. Failure to do so could result in possible recoupment of funds. LOCEU should also be contacted prior to admitting out-of-state NF applicants with mental illness or intellectual disability or related condition, so that PASRR needs can be ascertained. Any PASRR evaluations previously completed by the referring state should be forwarded to LOCEU as part of this PASRR consultation.
(7) PASRR appeals process.
(A) Any individual who has been adversely affected by any PASRR determination made by the State in the context of either a preadmission screening or an annual resident review may appeal that determination by requesting a fair hearing. If the individual does not consider the PASRR decision a proper one, the individual or their authorized representative must contact the local county OKDHS office to discuss a hearing. Forms for requesting a fair hearing (OKDHS Form 13MP001E, Request for a Fair Hearing), as well as assistance in completing the forms, can be obtained at the local county OKDHS office. Any request for a hearing must be made no later than 20 days following the date of written notice. Appeals of these decisions are available under OAC 317:2-1-2. All individuals seeking an appeal have the same rights, regardless of source of payment. Level I determinations are not subject to appeal.
(B) When the individual is found to experience mental illness, intellectual disability or related condition through the Level II Assessment, the PASRR determination made by the intellectual disability/mental illness authorities cannot be countermanded by the Oklahoma Health Care Authority, either in the claims process or through other utilization control/review processes, or by the Oklahoma State Department of Health. Only appeals determinations made through the fair hearing process may overturn a PASRR determination made by the intellectual disability /mental illness authorities.
(b) Determination of Title XIX medical eligibility for long term care. The determination of medical eligibility for care in a nursing facility is made by the OKDHS area nurse, or nurse designee. The procedures for determining Nursing Facility (NF) program medical eligibility are found in OAC 317:35-19. Determination of ICF/MR medical eligibility is made by LOCEU. The procedures for obtaining and submitting information required for a decision are outlined below.
(1) Pre-approval of medical eligibility. Pre-approval of medical eligibility for private ICF/MR care is based on results of a current comprehensive psychological evaluation by a licensed psychologist or state staff psychologist, documentation of intellectual disability or related condition prior to age 22, and the need for active treatment according to federal standards. Pre-approval is made by LOCEU analysts.
(2) Medical eligibility for ICF/MR services. Within 30 calendar days after services begin, the facility must submit the original of the Nursing Facility Level of Care Assessment (Form LTC-300) to LOCEU. Required attachments include current (within 90 days of requested approval date) medical information signed by a physician, a current (within 12 months of requested approval date) psychological evaluation, a copy of the pertinent section of the Individual Developmental Plan or other appropriate documentation relative to discharge planning and the need for ICF/MR level of care, and a statement that the member is not an imminent threat of harm to self or others (i.e., suicidal or homicidal). If pre-approval was determined by LOCEU and the above information is received, medical approval will be entered on MEDATS.
(3) Categorical relationship. Categorical relationship must be established for determination of eligibility for long-term medical care. If categorical relationship to disability has not already been established, the proper forms and medical information are submitted to LOCEU. (Refer to OAC 317:35-5-4). In such instances, LOCEU will render a decision on categorical relationship using the same definition as used by the Social Security Administration (SSA). A follow-up is required by the OKDHS worker with SSA to be sure that their disability decision agrees with the decision of LOCEU.
(a) Nursing home license required. A nursing facility must meet state nursing home licensing standards to provide, on a regular basis, health related care and services to individuals who do not require hospital care.
(1) In order for long term care facilities to receive payment from the Authority for the provision of nursing care, they must be currently licensed under provisions of Title 63 O.S., Nursing Home Care Act, 1995, Section 1-1901, et seq.
(2) The State Department of Health is responsible for the issuance, renewal, suspension and revocation of a facility's license in addition to the enforcement of the standards. The denial, suspension or revocation of a facility's license is subject to appeal to the State Department of Health. All questions regarding a facility's license should be directed to the State Department of Health.
(b) Certification survey. The Oklahoma State Department of Health is designated as the State Survey Agency and is responsible for determining a long term care facility's compliance with Title XIX requirements. The results of the survey are forwarded to the OHCA by the State Survey Agency.
(c) Certification period. The certification period of a long term care facility is determined by the State Survey Agency. In the event the facility's deficiencies are found to be of such serious nature as to jeopardize the health and safety of the patient, the State Survey Agency may terminate (de-certify) the facility's certification period and notify the Authority. Upon notification by the State Survey Agency, the Authority will notify the facility by certified letter that the Agreement is being terminated. The letter will indicate the effective date and specify the time period that payment may continue in order to allow orderly relocation of recipient/patients. The decision to terminate a facility's certification by the State Survey Agency is subject to appeal to the State Department of Health. The decision to terminate a facility's Agreement by the Authority (for a reason other than the facility decertification or suspension/revocation of the facility license) is subject to appeal to the Oklahoma Health Care Authority (see OAC 317:2-1-8 for grievance procedures and process).
(d) Certification with deficiencies.
(1) When an ICF/MR facility is certified to be in compliance with the Title XIX requirements but has deficiencies which must be corrected, an Agreement may be executed, subject to the facility's resolution of deficiencies according to the approved plan of correction. Following the visit by the State Survey Agency, one of two actions may occur:
(A) The State Survey Agency will notify the Authority that all deficiencies have been corrected or acceptable progress has been made toward correction. The Authority, by letter, will notify the facility of the action and the Agreement may run to the expiration date; or
(B) The State Survey Agency will notify the Authority that some or all of the deficiencies have not been corrected and circumstances require that the automatic cancellation date be invoked. The Authority, by certified letter, will notify the facility, owners of the facility and regulatory agencies when the automatic cancellation date is invoked.
(2) The Agreement will terminate as a result of the automatic cancellation date being invoked. In accordance with federal regulations, payment for current residents of the facility can continue for no more than thirty (30) days from the date the automatic cancellation date is invoked, to permit an orderly relocation of patients. Payment cannot be made for patients admitted after the automatic cancellation date is invoked. The decision to invoke a facility's automatic cancellation date is subject to appeal to the State Department of Health.
(e) Agreement procedures.
(1) A facility participating in the Medicaid program will be notified by letter from the Authority 60 days prior to the expiration of the existing Agreement. New Agreement forms will be sent to be completed if the facility wishes to continue participation in the Medicaid Program.
(2) Two copies of the Agreement to Provide Long Term Care Services under the Medicaid Act (Agreement) will be sent to the facility for completion. Both signed copies of the Agreement (signed with original signature only of owner, operator or administrator and properly notarized) must be returned to the OHCA.
(3) When the Agreement is received, approved by the Authority, and the HCFA-1539 has been received from the State Department of Health indicating the facility's certification period, the Agreement will be completed. A copy of the executed Agreement will be returned to the facility where it must be maintained for a period of six years for inspection purposes.
(4) Intermediate care facilities for the mentally retarded wishing to participate in the ICF/MR program must be approved and certified by the State Survey Agency as being in compliance with the ICF/MR regulations (42 CFR 442 Subpart C). It is the responsibility of a facility to request the State Survey Agency perform a survey of compliance with ICF/MR regulations.
(A) When the Authority has received notification of a facility's approval as an ICF/MR and the Title XIX survey of compliance has begun, the Agreement will be sent to the facility for completion.
(B) A facility which has been certified as an ICF/MR and has an Agreement with the Authority will be paid only for recipient/patients who have been approved for ICF/MR level of care. When the facility is originally certified to provide ICF/MR services, payment for recipient/patients currently residing in the facility who are approved for a NF level of care will be made if such care is appropriate to the recipient/patient's needs.
(f) New facilities. Any new facility in Oklahoma must receive, from the State Department of Health, a Certificate of Need. When construction of a new facility is completed and licensure and certification is imminent, facilities wishing to participate in the Title XIX Medicaid Program should request, by letter, an Agreement form. When the Authority has received notification from the State Department of Health of the new facility's licensure, the Agreement will be sent to the facility for completion, if not previously sent.
(1) It is the responsibility of the new facility to request the State Survey Agency to perform a survey for Title XIX compliance.
(2) The effective date of the provider Agreement will be subsequent to completion of all requirements for participation in the Medicaid Program. In no case can payment be made for any period prior to the effective date of the facility's certification.
(g) Change of ownership. The acquisition of a facility operation, either whole or in part, by lease or purchase, or if a new FEIN is required, constitutes a change of ownership. When such change occurs, it is necessary that a new Agreement be completed between the new owner and the Authority in order that payment can continue for the provision of nursing care. If there is any doubt about whether a change of ownership has occurred, the facility owner should contact the State Department of Health for a final determination.
(1) License changes due to change of ownership. State Law prescribes specific requirements regarding the transfer of ownership of a nursing facility from one person to another. When a transfer of ownership is contemplated, the buyer/seller or lessee/lessor must notify the State Department of Health, in writing, of the forthcoming transfer at least thirty (30) days prior to the final transfer and apply for a new facility license.
(2) Certificate of Need. A change of ownership is subject to review by the Oklahoma State Department of Health. Any person contemplating the acquisition of a nursing facility should contact Certificate of Need Division of the State Department of Health for further information regarding Certificate of Need requirements.
(A) When a long term care facility changes ownership, federal regulations require automatic assignment of the Agreement to the new owner. An assigned Agreement is subject to all applicable statutes and regulations under which it was originally issued. This includes but is not limited to:
(i) any existing plan of correction,
(ii) any expiration date,
(iii) compliance with applicable health and safety regulations, and
(iv) compliance with any additional requirements imposed by the Medicaid agency.
(B) The new owner must obtain a Certificate of Need as well as a new facility license from the State Department of Health. Pending notification of licensure of the new owner, no changes are made to the Authority's' facility records (i.e., provider number) with the exception of change in administrator or change in name, if applicable.
(C) When notification and licensure from the State Department of Health is received, procedures for transmitting forms to the facility and completing the Agreement, as described in Agreement Procedures for New Facilities, will be followed.
(D) The effective date of a facility's change of ownership is the date specified on the new license issued by the State Department of Health to the new owner or lessee.
When a new recipient is admitted to a nursing facility, the administrator will complete and send to the county office the Management of Recipient's Funds form to indicate whether or not the recipient has requested the administrator to handle personal funds. If the administrator agrees to handle the recipient's funds, the Management of Recipient's Funds form will be completed each time funds or other items of value, other than monthly income, are received.
(1) By using the Management of Recipient's Funds form as a source document, the facility personnel will prepare a Ledger Sheet for Recipient's Account in a form acceptable to the Authority, for each recipient for whom they are holding funds or other items of value. This form is used to keep an accurate accounting of all receipts and expenditures and the amount of money on hand at all times. This form is to be available in the facility for inspection and audit. The facility must have written policies that ensure complete accounting of the recipient's personal funds. All recipient's funds which are handled by the facility must be clearly identified and maintained separately from funds belonging to the facility or to private patients. When the total sum of all funds for all recipients is $250.00 or more, they must be deposited by the facility in a local bank account designated as "Recipient's Trust Funds." The funds are not to be commingled with the operating funds of the facility. Each resident in an ICF/MR facility must be allowed to possess and use money in normal ways or be learning to do so.
(2) The facility is responsible for notifying the county office at any time a recipient's account reaches or exceeds the maximum reserve by use of the Accounting-Recipient's Personal Funds and Property form. This form is also prepared by the facility when the recipient dies or is transferred or discharged, and at the time of the county eligibility review of the recipient.
(3) The Management of Recipient's Funds form, the Accounting-Recipient's Personal Funds and Property form and Ledger Sheets for Recipient's Account can be obtained from the local county DHS office.
(4) When the ownership or operation of the facility is discontinued or where the facility is sold and the recipients' trust funds are to be transferred to a successor facility, the status of all recipient's trust funds must be verified by the Authority and/or the buyer must be provided with written verification by an independent public accountant of all residents' monies and properties being transferred, and a signed receipt obtained from the owner. All transfers of recipient's trust funds must be acknowledged, in writing, by the transferring facility and proper receipts given by the receiving facility.
(5) Unclaimed funds or other property of deceased recipients, with no known heirs, must be reported to the Oklahoma Tax Commission. If it remains unclaimed for a certain period, the money or property escheats to the State.
(6) It is permissible to use an individual trust fund account to defray the cost of last illness, outstanding personal debts and burial expenses of a deceased recipient of this Authority; however, any remaining balance of unclaimed funds must be reported to the Oklahoma Tax Commission. The Unclaimed Property Division, Oklahoma Tax Commission, State Capitol Complex, Oklahoma City, Oklahoma, is to be notified for disposition instructions on any unclaimed funds or property. No money is to be sent to the Oklahoma Tax Commission until so instructed by the Unclaimed Property Division.
(7) Books, records, ledgers, charge slips and receipts must be on file in the facility for a period of six (6) years and available at all times in the facility for inspection and audit purposes.
|317:30-5-126.||Therapeutic leave and Hospital leave|
Therapeutic leave is any planned leave other than hospitalization that is for the benefit of the patient. Hospital leave is planned or unplanned leave when the patient is admitted to a licensed hospital. Therapeutic leave must be clearly documented in the patient's plan of care before payment for a reserved bed can be made.
(1) Effective July 1, 1994, the nursing facility may receive payment for a maximum of seven (7) days of therapeutic leave per calendar year for each recipient to reserve the bed.
(2) No payment shall be made to a nursing facility for hospital leave.
(3) The Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) may receive payment for a maximum of 60 days of therapeutic leave per calendar year for each recipient to reserve a bed. No more than 14 consecutive days of therapeutic leave may be claimed per absence. Recipients approved for ICF/IID on or after July 1 of the year will only be eligible for 30 days of therapeutic leave during the remainder of that year. No payment shall be made for hospital leave.
(4) Midnight is the time used to determine whether a patient is present or absent from the facility. The day of discharge for therapeutic leave is counted as the first day of leave, but the day of return from such leave is not counted.
(5) Therapeutic leave balances are recorded on the Medicaid Management Information System (MMIS). When a patient moves to another facility, it is the responsibility of the transferring facility to forward the patient's leave records to the receiving facility.
|317:30-5-127.||Notification of nursing facility changes|
It is important that the nursing facility keep the Authority's Service Contracts Operations Unit informed of any change in administrator, operator, mailing address, or telephone number of the facility. Inaccurate information can cause a delay in receipt of payments or correspondence. The facility should also report all changes to the Oklahoma State Department of Health and the Oklahoma State Board of Nursing Homes.
A private room may be provided for a recipient only on the written order of the patient's attending physician and only if the long term care facility agrees to collect any additional cost from someone other than the patient or spouse. The determination by the attending physician that a private room is needed will be on an individual patient basis and be for a period of not more than thirty (30) days. The physician's signed written order, must give full medical reasons for the need of this special service and the order must be included as a part of the individual patient's record in the facility. A redetermination in writing, by the patient's attending physician must be made for this special service each subsequent thirty (30) days to support a charge for a private room.
|317:30-5-129.||Required monthly notifications|
(a) The Notification Regarding Patient in a Nursing Facility or ICF/MR form is completed and forwarded to the local DHS office by the facility each time a recipient is admitted to or discharged from the facility except for therapeutic leave or hospital leave.
(b) A Computer Generated Notice or the Notice to Client Regarding Long-Term Medical Care form is used by the county office to notify the recipient and the facility of the amount of money, if any, the recipient is responsible for paying to the facility and the action taken with respect to the patient's eligibility for nursing facility care. This form reflects dates of transfer between facilities and termination of eligibility for any reason.
|317:30-5-130.||Inspections of care in Intermediate Care Facilities for the Mentally Retarded (ICF/MR)|
The Oklahoma Health Care Authority (OHCA) is responsible for periodic inspections of care and services in each ICF/MR providing services for Title XIX applicants and recipients. The inspection of care reviews are made by the OHCA or its designated agent. The frequency of inspections is based on the quality of care and service being provided in a facility and the condition of recipients in the facility. However, the care and services provided to each recipient in the facility must be inspected at least annually. No notification of the time of the inspection will be given to the facility prior to the inspections.
(1) The purpose of periodic inspections is to determine:
(A) The level of care required by each patient for whom Title XIX benefits have been requested or approved.
(B) The adequacy of the services available in the particular facility to meet the current health, rehabilitative and social needs of each recipient in an ICF/MR and promote the maximum physical, mental, and psychosocial functioning of the recipient receiving care in such facility.
(C) The necessity and desirability of the continued placement of each patient in such facility.
(D) The feasibility of meeting the health care needs and the recipient's rehabilitative needs through alternative institutional or noninstitutional services.
(E) If each recipient in an institution for the mentally retarded or persons with related conditions is receiving active treatment.
(2) Each applicant and recipient record will be reviewed for the purpose of determining adequacy of services, unmet needs and appropriateness of placement. Personal contact with and observation of each recipient will occur during the visit. This may necessitate observing recipients at sites outside of the facility.
(A) Record reviews will include confirmation of whether:
(i) All required evaluations including medical, social and psychological are complete and current.
(ii) The habilitation plan is complete and current.
(iii) All ordered services are provided and properly recorded.
(iv) The attending physician reviews prescribed medications at least quarterly.
(v) Tests or observations of each recipient indicated by his medication regimen are made at appropriate times and properly recorded.
(vi) Physicians, nurse, and other professional progress notes are made as required and appear consistent with the observed condition of the recipient.
(vii) There is a habilitation plan to prevent regression and reflects progress toward meeting objectives of the plan.
(viii) All recipient needs are met by the facility or through arrangements with others.
(ix) The recipient needs continued placement in the facility or there is an appropriate plan to transfer the recipient to an alternate method of care.
(B) Observations and personal contact with recipients will include confirmation of whether:
(i) The habilitation plans are followed.
(ii) All ordered services are provided.
(iii) The condition of the recipient is consistent with progress notes.
(iv) The recipient is clean and is receiving adequate hygiene services.
(v) The recipient is free of signs of malnutrition, dehydration and preventable injuries.
(vi) The recipient is receiving services to maintain maximum physical, mental, and psychosocial functioning.
(vii) The recipient needs any service that is not furnished by the facility or through arrangements with others.
(3) A full and complete report of observations, conclusions and recommendations are required concerning:
(A) The adequacy, appropriateness, and quality of all services provided in the facility or through other arrangements, including physician services to recipients; and
(B) Specific findings about individual recipients in the facility.
(4) The inspection report must include the dates of the inspection and the names and qualifications of the individuals conducting the inspection. A copy of each inspection report will be sent to:
(A) The facility inspected;
(B) The facility's utilization review committee;
(C) The agency responsible for licensing, certification, or approval of the facility for purposes of Medicare and Medicaid; and
(D) Other state agencies that use the information in the reports to perform their official function, including if inspection reports concern Institutions for Mental Diseases (IMDs), the appropriate State mental health authorities.
(5) The Oklahoma Health Care Authority will take corrective action as needed based on required reports and recommendations.
|317:30-5-131.||Rates of payments|
(a) Rates of payments shown on the Fee Schedule for Nursing Facilities and ICF/MR's are based on the cost of the nursing facility level of care provided and the nursing care staffing pattern. The rate of payment to a nursing facility is also determined by the type of facility and quality of care rating.
(b) A rate of payment established by the facility for private patients is not under the jurisdiction of OHCA. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State Plan for all individuals regardless of source of payment. The facility may charge any amount for services furnished to non-Medicaid residents consistent with the written notice requirements describing the charges found at 42 CFR 483.10.
(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise:
(1) "Employee Benefits" means the benefits an employer provides to an employee which include:
(A) FICA taxes,
(B) Unemployment Compensation Tax,
(C) Worker's Compensation Insurance,
(D) Group health and dental insurance,
(E) Retirement and pensions, and
(F) Other employee benefits (any other benefit that is provided by a majority of the industry).
(2) "Enhanced" means the upward adjusted rate as required by Title 63, Section 5022 of Oklahoma Statutes.
(3) "Enhancement" means the upward adjusted rate as required by Title 63, Section 5022 of Oklahoma Statute.
(4) "Regular employee" means an employee that is paid an hourly/salaried amount for services rendered, however, the facility is not excluded from paying employee benefits.
(5) "Specified staff" means the employee positions listed in the Oklahoma Statutes under Section 5022, Title 63 that meet the requirements listed in 42 CFR Section 483.75(e)(1)-(8).
(b) Enhancement. Effective May 1, 1997, the OHCA provides a wage and salary enhancement to nursing facilities serving adults and Intermediate Care Facilities for Individuals with Intellectual Disabilities required by Title 63, Section 5022 of Oklahoma Statutes. The purpose of the wage and salary enhancement is to provide an adjustment to the facility payment rate in order for facilities to reduce turnover and be able to attract and retain qualified personnel. The maximum wage enhancement rates that may be reimbursed to the facilities per diem include:
(1) Three dollars and fifteen cents ($3.15) per patient day for NFs,
(2) Four dollars and twenty cents ($4.20) per patient day for standard private ICFs/IID, and
(3) Five dollars and fifteen cents ($5.15) per patient day for specialized private ICFs/IID.
(c) Reporting requirements. Each NF and ICF/IID is required to submit a Nursing and Intermediate Care Facilities Quarterly Wage Enhancement Report (QER) which captures and calculates specified facility expenses. The report must be completed quarterly and returned to OHCA no later than 45 days following the end of each quarter. QERs must be filed for the State Fiscal Year (SFY) which runs from July 1 to June 30. The Oklahoma Health Care Authority reserves the right to recoup all dollars that cannot be accounted for in the absence of a report. The QER is designed to capture and calculate specified facility expenses for quarterly auditing by the OHCA. The report is used to determine whether wage enhancement payments are being distributed among salaries/wages, employee benefits, or both for the employee positions listed in (1) through (8) of this subsection. Furthermore, the OHCA reserves the right to recoup all dollars not spent on salaries, wages, employee benefits, or both for the employee positions. The specified employee positions included on the QER are:
(1) Licensed Practical Nurse (LPN),
(2) Nurse Aide (NA),
(3) Certified Medication Aide (CMA),
(4) Social Service Director (SSD),
(5) Other Social Service Staff (OSSS),
(6) Activities Director (AD),
(7) Other Activities Staff (OAS), and
(8) Therapy Aide Assistant (TAA).
(d) Timely filing and extension of time.
(1) Quarterly reports. Quarterly reports are required to be filed within 45 days following the end of each quarter. This requirement is rigidly enforced unless approved extensions of time for the filing of the quarterly report is granted by OHCA. Filing extensions not to exceed 15 calendar days may be granted for extraordinary cause only. A failure to present any of the items listed in (A)-(D) of this paragraph will result in a denial of the request for an extension. The extension request will be attached to the filing of the report after the request has been granted. For an extension to be granted, the following must occur.
(A) An extension request must be received at the Oklahoma Health Care Authority on or before the 30th day after the end of the quarter.
(B) The extension must be addressed on a form supplied by the Health Care Authority.
(C) The facility must demonstrate there is an extraordinary reason for the need to have an extension. An extraordinary reason is defined in the plain meaning of the word. Therefore, it does not include reasons such as the employee who normally makes these requests was absent, someone at the facility made a mistake and forgot to send the form, the facility failed to get documents to some third party to evaluate the expenditures. An unusual and unforeseen event must be the reason for the extension request.
(D) The facility must not have any extension request granted for a period of two years prior to the current request.
(2) Failure to file a quarterly report. If the facility fails to file the quarterly report within the required (or extended) time, the facility is treated as out of compliance and payments made for the quarter in which no report was filed will be subject to a 100% recoupment. The overpayment is recouped in future payments to the facility immediately following the filing deadline for the reporting period. The full overpayment is recovered within a three month period. The Oklahoma Health Care Authority reserves the right to discontinue wage enhancement payments until an acceptable QER (quarterly enhancement report) is received. In addition to the recoupment of payments, the matter of noncompliance is referred to the Legal Division of the OHCA to be considered in connection with the renewal of the facility's contract.
(3) Ownership changes and fractional quarter report. Where the ownership or operation of a facility changes hands during the quarter, or where a new operation is commenced, a fractional quarter report is required, covering each period of time the facility was in operation during the quarter.
(A) Fractional quarter reports are linked to the legal requirement that all facility reports be properly filed in order that the overall cost of operation of the facility may be determined.
(B) Upon notice of any change in ownership or management, the OHCA withholds payments from the facility until a fractional quarter report is received and evaluation of payment for the wage enhancement is conducted. In this case the QER is due within 15 days of the ownership or management change.
(4) Pay periods and employee benefits reflected in the QER. Salaries and wages are determined by accruing the payroll to reflect the number of days reported for the month. Unpaid salaries and wages are accrued through the quarter. Any salaries and wages accrued in the previous quarter and paid in the current quarter are excluded. Employee benefits are determined by accruing any benefits paid to coincide with the reporting month. Unpaid employee benefits are accrued through the quarter. Any employee benefits accrued in the previous quarter and paid in the current quarter are excluded. To be included as an allowable wage enhancement expenditure, accrued salaries, wages and benefits must be paid within forty-five (45) days from the end of the reporting quarter.
(5) Report accuracy. Errors and/or omissions discovered by the provider after the initial filing/approved extension are not considered grounds for re-opening/revisions of previously filed reports. Furthermore, errors and/or omission discovered by the provider after the initial filing/approved extension can not be carried forward and claimed for future quarterly reporting periods.
(6) False statements or misrepresentations. Penalties for false statements or misrepresentations made by or on behalf of the provider are provided at 42 U.S.C. Section 1320a-7b which states, in part, "(a) Whoever...(2) at any time knowingly and willfully makes or cause to be made any false statement of a material fact for use in determining rights to such benefit or payment... shall (i) in the case of such a statement, representation, concealment, failure, or conversion by any person in connection with furnishing (by that person) of items or services for which payment is or may be made under this title (42 U.S.C.
1320 et. seq.), be guilty of a felony and upon conviction thereof fined not more than $25,000 or imprisoned for not more than five years or both, or (ii) in the case of such a statement, representation, concealment, failure, or conversion by any other person, be guilty of a misdemeanor and upon conviction thereof fined not more than $10,000 or imprisoned for not more than one year, or both."
(7) Audits, desk and site reviews.
(A) Upon receipt of each quarterly report a desk review is performed. During this process, the report is examined to insure it is complete. If any required information is deemed to have been omitted, the report may be returned for completion. Delays that are due to incomplete reports are counted toward the 45 day deadline outlined in (c) of this Section. At that time the mathematical accuracy of all totals and extensions is verified. Census information may be independently verified through other sources. After completion of the desk review, each report is entered into the OHCA's computerized data base. This facilitates the overall evaluation of the industry's costs.
(B) Announced and/or unannounced site reviews are conducted at a time designated by the OHCA. The purpose of site reviews is to verify the information reported on the QER(s) submitted by the facility to the OHCA. Errors and/or omissions discovered by the OHCA upon the completion of a site review is immediately reflected in future payment(s) to the facility. The OHCA makes deficiencies known to the facility within 30 calendar days. A deficiency notice in no way prevents the OHCA from additionally finding any overpayment and adjusting future payments to reflect these findings.
(8) Appeals process.
(A) If the desk or site review indicates that a facility has been improperly paid, the OHCA will notify the facility that the OHCA will rectify the improper payment in future payments to the facility. Improper payments consist of an overpayment to a facility. The facility may appeal the determination to recoup an alleged overpayment and/or the size of the alleged overpayment, within 20 days of receipt of notice of the improper payment from the OHCA. Such appeals will be Level I proceedings heard pursuant to OAC 317:2-1-2(c)(2). The issues on appeals will be limited to whether an improper payment occurred and the size of the alleged improper payment. The methodology for determining base period computations will not be an issue considered by the administrative law judge.
(B) Certain exceptional circumstances, such as material expenses due to the use of contract employees, overtime expenses paid to direct care staff, or changes within classes of staff may have an effect on the wage enhancement payment and expense results. Facilities may demonstrate and present documentation of the affects of such circumstances before the administrative law judge.
(e) Methodology for the distribution of payments/adjustments. The OHCA initiates a two-part process for the distribution and/or recoupment of the wage enhancement.
(1) Distribution of wage enhancement revenue. All wage enhancement rates are added to the current facility per diem rate. Facilities receive the maximum wage enhancement rate applicable to each facility type.
(2) Payment/recoupment of adjustment process. Initially, all overpayments resulting from the Fourth Quarter of SFY-1997 and the First Quarter of SFY-1998 audits will be deducted from the first month's payment of the Third Quarter of SFY-1998 (January-1998). The Fourth and First Quarter of SFY-1997 and SFY 1998 audit results will be averaged to determine the adjustment. All overpayments as a result of the Second Quarter of SFY-1998 audit will be deducted from the first month's payment of the Fourth Quarter of SFY-1998 (April-1998). Audit results will determine whether or not a facility is utilizing wage enhancement payments that are being added to the facility's per diem rate. When audit results for a given quarter after the Second Quarter of SFY-1998 (October, November, and December 1997) reflect an adjustment, recoupments will be deducted from the facility. Any adjustments calculated will not be recouped during the quarter in which the calculation is made, rather, they will be recouped during the following quarter. The recoupments, as a result of an adjustment, will not exceed the wage enhancement revenue received for the quarter in which the audit is conducted. Recoupments will be included in the facility's monthly payment and will not exceed the three month period of the quarter in which it is being recouped.
(f) Methodology for determining base year cost. The information used to calculate Base Year Cost is taken from actual SFY-1995 cost reports submitted, to the OHCA, by the NFs and ICFs/MR that will be receiving a wage enhancement. A Statewide Average Base Cost is calculated for facilities that did not submit a cost report for SFY-1995. Newly constructed facilities that submit a partial year report are assigned the lower of the Statewide Average Base Cost or actual cost. The process for calculating the Base Year Cost, the Statewide Average Base Cost, and the process for newly constructed facilities is determined as follows.
(1) Methodology used for determining base year cost. The methodology for determining the Base Year Cost is determined by the steps listed in (A) through (E) of this paragraph.
(A) Regular employee salaries are determined by adding the salaries of LPNs, NAs, CMAs, SSDs, OSSS, ADs, OAS, and TAAs.
(B) Percentage of benefits allowed are determined by dividing total facility benefits by total facility salaries and wages.
(C) Total expenditures are determined by multiplying the sum of regular employee salaries by a factor of one plus the percentage of benefits allowed in (B) of this subparagraph.
(D) Base Year PPD Costs are determined by dividing total expenditures, in (3) of this subparagraph by total facility patient days. This information is used to determine statewide average base year cost.
(E) Inflated Base Year Costs are determined by multiplying Base Year Cost, in (C) of this subparagraph by the appropriate inflation factors. Base Year Expenditures were adjusted from the midpoint of the base year to the midpoint of the rate year using the moving rate of change forecast in the Data Resources, Inc., (DRI) "HCFA Nursing Home without Capital Market Basket" Index as published for the fourth quarter of calendar year 1995. The OHCA uses this same index (DRI) for subsequent years as it becomes available and is appropriate.
(2) Methodology used for determining Statewide Average Base Cost. A Statewide Average Base Cost is calculated for all facilities that did not submit a cost report, to the OHCA, for SFY-1995. The steps listed in (A) through (C) of this paragraph are applied to determine the Base Cost in the absence of actual SFY-1995 cost report information.
(A) Statewide Average Base Year PPD Costs are determined by adding Base Year PPD Cost, calculated in (1)(D) of this subsection, for all facilities that submitted SFY-1995 cost reports, the sum of this calculation is then divided by the number of facilities that submitted cost reports.
(B) Inflated Base Year PPD Costs are determined by multiplying Statewide Base Year PPD Cost by the appropriate inflation factors. Statewide Base Year PPD Cost was adjusted from the midpoint of the base year to the midpoint of the rate year using the moving rate of change forecast in the Data Resources, Inc., (DRI) "HCFA Nursing Home without Capital Market Basket" Index as published for the fourth quarter of calendar year 1995. The OHCA uses this same index (DRI) for subsequent years as it becomes available and is appropriate.
(C) The facilities base cost is determined by multiplying the facilities' current quarter census by the inflated statewide average PPD costs calculated in (B) of this unit.
(g) Methodology for determining wage enhancement revenue and expenditure results. The methodology for determining the facilities' wage enhancement revenue and expenditures results are calculated in (1) through (3) of this paragraph.
(1) Wage enhancement revenue. Total wage enhancement revenue received by the facility for the current quarter is calculated by multiplying the facilities total paid Medicaid days for the current quarter by the facilities wage enhancement rate. The Oklahoma Health Care Authority adjusts the computations and results when actual paid Medicaid data for the reporting quarter becomes available.
(2) Wage enhancement expenditures. Total wage enhancement expenditures are determined in a four step process as described in (A) through (D) of this paragraph.
(A) Total current quarter allowable expenses are calculated. Salaries and wages of specified staff are totaled and added to the applicable percent of customary employee benefits and 100% of the new employee benefits.
(B) Base period expenditures are calculated. An occupancy adjustment factor is applied to the quarterly average base period cost to account for changes in census.
(C) Current quarter wage enhancement expenditures are calculated by subtracting allowable base period expenditures (see (B) of this subparagraph) from total current quarter allowable expenses (see (A) of this subparagraph).
(D) Total wage enhancement expenditures are calculated by adding current quarter wage enhancement expenditures (see (C) of this subparagraph) to prior period wage enhancement expenditures carried forward.
(3) Wage enhancement revenue and expenditure results. Wage enhancement revenue and expenditure results are determined by comparing total wage enhancement revenue (see (1) of this paragraph) to total wage enhancement expenditures (see (2)(D) of this paragraph). Revenue exceeding expenses is subject to recoupment. Expenses exceeding revenue are carried forward to the next reporting period as a prior period wage enhancement expenditure carry over.
(4) Due to rate increases and increases in the federal minimum wage, wage enhancements to nursing facilities and ICFs/MR are no longer paid.
|317:30-5-131.2.||Quality of care fund requirements and report|
(a) Definitions. The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise:
(1) "Nursing Facility and Intermediate Care Facility for Individuals with Intellectual Disabilities" means any home, establishment, or institution or any portion thereof, licensed by the State Department of Health as defined in Section 1-1902 of Title 63 of the Oklahoma Statutes.
(2) "Quality of Care Fee" means the fee assessment created for the purpose of quality care enhancements pursuant to Section 2002 of Title 56 of the Oklahoma Statutes upon each nursing facility and intermediate care facility for individuals with intellectual disabilities licensed in this State.
(3) "Quality of Care Fund" means a revolving fund established in the State Treasury pursuant to Section 2002 of Title 56 of the Oklahoma Statutes.
(4) "Quality of Care Report" means the monthly report developed by the Oklahoma Health Care Authority to document the staffing ratios, total patient gross receipts, total patient days, and minimum wage compliance for specified staff for each nursing facility and intermediate care facility for individuals with intellectual disabilities licensed in the State.
(5) "Staffing ratios" means the minimum direct-care-staff-to-resident ratios pursuant to Section 1-1925.2 of Title 63 of the Oklahoma Statutes and pursuant to OAC 310:675-1 et seq.
(6) "Peak In-House Resident Count" means the maximum number of in-house residents at any point in time during the applicable shift.
(7) "Staff Hours worked by Shift" means the number of hours worked during the applicable shift by direct-care staff.
(8) "Direct-Care Staff" means any nursing or therapy staff who provides direct, hands-on care to residents in a nursing facility and intermediate care facility for individuals with intellectual disabilities pursuant to Section 1-1925.2 of Title 63 of the Oklahoma Statues, pursuant to OAC 310:675-1 et seq., and as defined in subsection (c) of this Section.
(9) "Major Fraction Thereof" is defined as an additional threshold for direct-care-staff-to-resident ratios at which another direct-care staff person(s) is required due to the peak in-house resident count exceeding one-half of the minimum direct-care-staff-to-resident ratio pursuant to Section 1-1925.2 of Title 63 of the Oklahoma Statutes.
(10) "Minimum wage" means the amount paid per hour to specified staff pursuant to Section 5022.1 of Title 63 of the Oklahoma Statutes.
(11) "Specified staff" means the employee positions listed in the Oklahoma Statutes under Section 5022.1 of Title 63 and as defined in subsection (d) of this Section.
(12) "Total Patient Days" means the monthly patient days that are compensable for the current monthly Quality of Care Report.
(13) "Total Gross Receipts" means all cash received in the current Quality of Care Report month for services rendered to all residents in the facility. Receipts should include all Medicaid, Medicare, Private Pay and Insurance including receipts for items not in the normal per diem rate. Charitable contributions received by the nursing facility are not included.
(14) "Service rate" means the minimum direct-care-staff-to-resident rate pursuant to Section 1-1925.2 of Title 63 of Oklahoma Statutes and pursuant to OAC 310:675-1 et seq.
(b) Quality of care fund assessments.
(1) The Oklahoma Health Care Authority (OHCA) was mandated by the Oklahoma Legislature to assess a monthly service fee to each Licensed Nursing Facility in the State. The fee is assessed on a per patient day basis. The amount of the fee is uniform for each facility type. The fee is determined as six percent (6%) of the average total gross receipts divided by the total days for each facility type.
(2) In determination of the fee for the time period beginning October 1, 2000, a survey was mailed to each licensed nursing facility requesting calendar year 1999 Total Patient Days, Gross Revenues and Contractual Allowances and Discounts. This data is used to determine the amount of the fee to be assessed for the period of 10-01-00 through 06-30-01. The fee is determined by totaling the "annualized" gross revenue and dividing by the "annualized" total days of service. "Annualized" means that the surveys received that do not cover the whole year of 1999 are divided by the total number of days that are covered and multiplied by 365.
(3) The fee for subsequent State Fiscal Years is determined by using the monthly gross receipts and census reports for the six month period October 1 through March 31 of the prior fiscal year, annualizing those figures, and then determining the fee as defined above. As per 56 O.S. Section 2002, as amended, the fees are frozen at the amount in effect at July 1, 2004. Also, the fee will be monitored to never surpass the federal maximum.
(4) The fee is authorized through the Medicaid State Plan and by the Centers for Medicare and Medicaid Services (CMS) regarding waiver of uniformity requirements related to the fee.
(5) Monthly reports of Gross Receipts and Census are included in the monthly Quality of Care Report. The data required includes, but is not limited to, the Total Gross Receipts and Total Patient Days for the current monthly report.
(6) The method of collection is as follows:
(A) The Oklahoma Health Care Authority assesses each facility monthly based on the reported patient days from the Quality of Care Report filed two months prior to the month of the fee assessment billing. As defined in this subsection, the total assessment is the fee times the total days of service. The Oklahoma Health Care Authority notifies the facility of its assessment by the end of the month of the Quality of Care Report submission date.
(B) Payment is due to the Oklahoma Health Care Authority by the 15th of the following month. Failure to pay the amount by the 15th or failure to have the payment mailing postmarked by the 13th will result in a debt to the State of Oklahoma and is subject to penalties of 10% of the amount and interest of 1.25% per month. The Quality of Care Fee must be submitted no later than the 15th of the month. If the 15th falls upon a holiday or weekend (Saturday-Sunday), the fee is due by 5 p.m. (Central Standard Time) of the following business day (Monday-Friday).
(C) The monthly assessment including applicable penalties and interest must be paid regardless of any appeals action requested by the facility. If a provider fails to pay the Authority the assessment within the time frames noted on the second invoice to the provider, the assessment, applicable penalty, and interest will be deducted from the facility's payment. Any change in payment amount resulting from an appeals decision will be adjusted in future payments. Adjustments to prior months' reported amounts for gross receipts or patient days may be made by filing an amended part C of the Quality of Care Report.
(D) The Quality of Care fee assessments excluding penalties and interest are an allowable cost for Oklahoma Health Care Authority Cost Reporting purposes.
(E) The Quality of Care fund which contains assessments collected excluding penalties and interest as described in this subsection and any interest attributable to investment of any money in the fund must be deposited in a revolving fund established in the State Treasury. The funds will be used pursuant to Section 2002 of Title 56 of the Oklahoma Statutes.
(c) Quality of care direct-care-staff-to resident-ratios.
(1) Effective September 1, 2000, all nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) subject to the Nursing Home Care Act, in addition to other state and federal staffing requirements, must maintain the minimum direct-care-staff-to-resident ratios or direct-care service rates as cited in Section 1-1925.2 of Title 63 of the Oklahoma Statutes and pursuant to OAC 310:675-1 et seq.
(2) For purposes of staff-to-resident ratios, direct-care staff are limited to the following employee positions:
(A) Registered Nurse
(B) Licensed Practical Nurse
(C) Nurse Aide
(D) Certified Medication Aide
(E) Qualified Intellectual Disability Professional (ICFs/IID only)
(F) Physical Therapist
(G) Occupational Therapist
(H) Respiratory Therapist
(I) Speech Therapist
(J) Therapy Aide/Assistant
(3) The hours of direct care rendered by persons filling non-direct care positions may be used when those persons are certified and rendering direct care in the positions listed in OAC 317:30-5-131.2(c)(2) when documented in the records and time sheets of the facility.
(4) In any shift when the direct-care-staff-to-resident ratio computation results in a major fraction thereof, direct-care staff is rounded to the next higher whole number.
(5) To document and report compliance with the provisions of this subsection, nursing facilities and intermediate care facilities for individuals with intellectual disabilities must submit the monthly Quality of Care Report pursuant to subsection (e) of this Section.
(d) Quality of care minimum wage for specified staff. Effective November 1, 2000, all nursing facilities and private intermediate care facilities for individuals with intellectual disabilities receiving Medicaid payments, in addition to other federal and state regulations, must pay specified staff not less than in the amount of $6.65 per hour. Employee positions included for purposes of minimum wage for specified staff are as follows:
(1) Registered Nurse
(2) Licensed Practical Nurse
(3) Nurse Aide
(4) Certified Medication Aide
(5) Other Social Service Staff
(6) Other Activities Staff
(7) Combined Social Services/Activities
(8) Other Dietary Staff
(9) Housekeeping Supervisor and Staff
(10) Maintenance Supervisor and Staff
(11) Laundry Supervisor and Staff
(e) Quality of care reports. Effective September 1, 2000, all nursing facilities and intermediate care facilities for individuals with intellectual disabilities must submit a monthly report developed by the Oklahoma Health Care Authority, the Quality of Care Report, for the purposes of documenting the extent to which such facilities are compliant with the minimum direct-care-staff-to-resident ratios or direct-care service rates.
(1) The monthly report must be signed by the preparer and by the Owner, authorized Corporate Officer or Administrator of the facility for verification and attestation that the reports were compiled in accordance with this section.
(2) The Owner or authorized Corporate Officer of the facility must retain full accountability for the report's accuracy and completeness regardless of report submission method.
(3) Penalties for false statements or misrepresentation made by or on behalf of the provider are provided at 42 U.S.C. Section 1320a-7b which states, in part, "Whoever...(2) at any time knowingly and willfully makes or causes to be made any false statement of a material fact for use in determining rights to such benefit or payment...shall (i) in the case of such statement, representation, concealment, failure, or conversion by any person in connection with furnishing (by that person) of items or services for which payment is or may be made under this title (42 U.S.C. '1320 et seq.), be guilty of a felony and upon conviction thereof fined not more than $25,000 or imprisoned for not more than five years or both, or (ii) in the case of such a statement, representation, concealment, failure or conversion by any other person, be guilty of a misdemeanor and upon conviction thereof fined not more than $10,000 or imprisoned for not more than one year, or both."
(4) The Quality of Care Report must be submitted by 5 p.m. (CST) on the 15th of the following month. If the 15th falls upon a holiday or a weekend (Saturday-Sunday), the report is due by 5 p.m. (CST) of the following business day (Monday - Friday).
(5) The Quality of Care Report will be made available in an electronic version for uniform submission of the required data elements.
(6) Facilities must submit the monthly report through the OHCA Provider Portal.
(7) Should a facility discover an error in its submitted report for the previous month only, the facility must provide to the Long Term Care Financial Management Unit written notification with adequate, objective and substantive documentation within five business days following the submission deadline. Any documentation received after the five business day period will not be considered in determining compliance and for reporting purposes by the Oklahoma Health Care Authority.
(8) An initial administrative penalty of $150.00 is imposed upon the facility for incomplete, unauthorized, or non-timely filing of the Quality of Care Report. Additionally, a daily administrative penalty will begin upon the Authority notifying the facility in writing that the report was not complete or not timely submitted as required. The $150.00 daily administrative penalty accrues for each calendar day after the date the notification is received. The penalties are deducted from the Medicaid facility's payment. For 100% private pay facilities, the penalty amount(s) is included and collected in the fee assessment billings process. Imposed penalties for incomplete reports or non-timely filing are not considered for Oklahoma Health Care Authority Cost Reporting purposes.
(9) The Quality of Care Report includes, but is not limited to, information pertaining to the necessary reporting requirements in order to determine the facility's compliance with subsections (b) and (c) of this Section. Such reported information includes, but is not limited to: total gross receipts, patient days, available bed days, direct care hours, Medicare days, Medicaid days, number of employees, monthly resident census, and tenure of Certified Nursing Assistants, nurses, directors of nursing, and administrators
(10) Audits may be performed to determine compliance pursuant to subsections (b), (c) and (d) of this Section. Announced/unannounced on-site audits of reported information may also be performed.
(11) Direct-care-staff-to-resident information and on-site audit findings pursuant to subsection (c), will be reported to the Oklahoma State Department of Health for their review in order to determine "willful" non-compliance and assess penalties accordingly pursuant to Title 63 Section 1-1912 through Section 1-1917 of the Oklahoma Statutes. The Oklahoma State Department of Health informs the Oklahoma Health Care Authority of all final penalties as required in order to deduct from the Medicaid facility's payment. Imposed penalties are not considered for Oklahoma Health Care Authority Cost Reporting purposes.
(12) If a Medicaid provider is found non-compliant pursuant to subsection (d) based upon a desk audit and/or an on-site audit, for each hour paid to specified staff that does not meet the regulatory minimum wage of $6.65, the facility must reimburse the employee(s) retroactively to meet the regulatory wage for hours worked. Additionally, an administrative penalty of $25.00 is imposed for each non-compliant staff hour worked. For Medicaid facilities, a deduction is made to their payment. Imposed penalties for non-compliance with minimum wage requirements are not considered for Oklahoma Health Care Authority Cost Reporting purposes.
(13) Under OAC 317:2-1-2, Long Term Care facility providers may appeal the administrative penalty described in (b)(5)(B) and (e)(8) and (e)(12) of this section.
(14) Facilities that have been authorized by the Oklahoma State Department of Health (OSDH) to implement flexible staff scheduling must comply with OAC 310:675-1 et seq. The authorized facility is required to complete the flexible staff scheduling section of Part A of the Quality of Care Report. The Owner, authorized Corporate Officer or Administrator of the facility must complete the flexible staff scheduling signature block, acknowledging their OSDH authorization for Flexible Staff Scheduling.
Each Medicaid-participating long term care facility is required to submit an annual uniform cost report, designed by OHCA, for the state fiscal year just completed. The state fiscal year is July 1 through June 30. The reports must be submitted to the OHCA on or before the last day of October of the subsequent year.
(1) The report must be prepared on the basis of generally accepted accounting principles and the accrual basis of accounting, except as otherwise specified in the cost report instructions.
(2) The cost report must be filed using the Secure Website. The instructions and data entry screen simulations will be made available on the OHCA public website under the Provider/Long Term Care Facility/Cost Reporting options.
(3) When there is a change of operation or ownership, the selling or closing ownership is required to file a cost report for that portion of the fiscal year it was in operation. The successor ownership is correspondingly required to file a cost report for that portion of the fiscal year it was in operation. These "Partial Year Reports" must be filed on paper or electronically by e-mail (not on the secure website system) to the Finance Division of the OHCA on the forms and by the instructions found on the OHCA public website (see directions as noted above).
(4) Cost report instructions are available on the public website at OKHCA.org/Provider/Opportunitiesforliving life/longtermcarefacilities.
(5) Normally, all ordinary and necessary expenses net of any offsets of credits incurred in the conduct of an economical and efficiently operated business are recognized as allowable. Allowable costs include all items of Medicaid-covered expense which nursing facilities incur in the provision of routine services. "Routine services" include, but are not limited to, regular room, dietary and nursing services, minor medical and surgical supplies, over-the-counter medications, transportation, dental examinations, dentures and related services, eye glasses, routine eye examinations, and the use and maintenance of equipment and facilities essential to the provision of routine care. Allowable costs must be considered reasonable, necessary and proper, and shall include only those costs that are considered allowable for Medicare purposes and that are consistent with federal Medicaid requirements. (The guidelines for allowable costs in the Medicare program are set forth in the Medicare Provider Reimbursement Manual ("PRM"), HCFA-Pub. 15.) Ancillary items reimbursed outside the nursing facility rate are not included in the cost report and are not allowable costs.
(6) All reports are subject to on-site audits and are deemed public records.
(a) Private Nursing Facilities.
(1) Facilities. Private Nursing Facilities include:
(A) Nursing Facilities serving adults (NF),
(B) Nursing Facilities serving Aids Patients (NF-Aids),
(C) Nursing Facilities serving Ventilator Patients (NF-Vents),
(D) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID),
(E) Intermediate Care Facilities with 16 beds or less serving Severely or Profoundly intellectually disabled Patients (Acute ICF/IID), and
(F) Payment will be made for non-routine nursing facility services identified in an individual treatment plan prepared by the State MR Authority. Services are limited to individuals approved for NF and specialized services as the result of a PASRR/MR Level II screen. The per diem add-on is calculated as the difference in the statewide standard private MR base rate and the statewide NF facility base rate.
(2) Reimbursement calculations. Rates for Private Nursing Facilities will be reviewed periodically and adjusted as necessary through a public process. Payment will be made to Private Nursing Facilities pursuant to the methodology described in the Oklahoma Title XIX State Plan.
(b) Public Nursing Facilities. Reimbursement for public Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) shall be based on each facility's reasonable cost and shall be paid on an interim basis with an annual retroactive adjustment. Reasonable costs shall be based on Medicare principles of cost reimbursement as set forth in the provider reimbursement manual.
(a) Nursing facility care includes routine items and services that must be provided directly or through appropriate arrangement by the facility when required by SoonerCare residents. Charges for routine services may not be made to resident's personal funds or to resident family members, guardians or other parties who have responsibility for the resident. If reimbursement is available from Medicare or another public or private insurance or benefit program, those programs are billed by the facility. In the absence of other available reimbursement, the facility must provide routine services from the funds received from the regular SoonerCare vendor payment and SoonerCare resident's applied income, or spend down amount.
(b) The Oklahoma Health Care Authority will review the listing periodically for additions or deletions, as indicated. Routine services are patient specific and in accordance with standard medical care. Routine Services include, but are not limited to:
(l) Regular room;
(2) Dietary Services:
(A) regular diets,
(B) special diets,
(C) salt and sugar substitutes,
(D) supplemental feedings,
(E) special dietary preparations,
(F) equipment required for preparing and dispensing tube and oral feedings, and
(G) special feeding devices (furnished or arranged for);
(3) Medically related social services to attain or maintain the highest practicable physical, mental and psycho social well-being of each resident, nursing care, and activities programs (costs for a private duty nurse or sitter are not allowed);
(4) Personal services - personal laundry services for residents (does not include dry cleaning);
(5) Personal hygiene items (personal care items required to be provided does not include electrical appliances such as shavers and hair dryers, or individual personal batteries) include:
(A) shampoo, comb and brush;
(B) bath soap;
(C) disinfecting soaps or specialized cleansing agents when indicated to treat or prevent special skin problems or to fight infection;
(D) razor and/or shaving cream;
(E) nail hygiene services; and
(F) sanitary napkins, douche supplies, perineal irrigation equipment, solutions and disposable douches;
(6) Routine oral hygiene items including:
(C) dental floss;
(D) lemon glycerin swabs or equivalent products; and
(E) denture cleaners, denture adhesives, and containers for dental prosthetic appliances such as dentures and partial dentures.
(7) Necessary items furnished routinely as needed to all patients, e.g., water pitcher, cup and tray, towels, wash cloths, hospital gowns, emesis basin, bedpan, and urinal.
(8) The facility will furnish as needed items such as alcohol, applicators, cotton balls, tongue depressors. Also, first aid supplies including small bandages, ointments and preparations for minor cuts and abrasions, enema supplies, including disposable enemas, gauze, 4 x 4's ABD pads, surgical and micropore tape, telfa gauze, ace bandages, etc.
(9) Over the counter drugs (non-legend) not covered by the prescription drug program (PRN or routine). In general, nursing facilities are not required to provide any particular brand of non-legend drugs, only those items necessary to ensure appropriate care.
(A) If the physician orders a brand specific non-legend drug with no generic equivalent, the facility must provide the drug at no cost to the patient. If the physician orders a brand specific non-legend drug that has a generic equivalent, the facility may choose a generic equivalent, upon approval of the ordering physician;
(B) If the physician does not order a specific type or brand of non-legend drug, the facility may choose the type or brand;
(C) If the member, family, or other responsible party (excluding nursing facility) prefers a specific type or brand of non-legend drug rather than the ones furnished by the facility, the member, family or responsible party may be charged the difference between the cost of the brand the resident requests and the cost of the brand generally provided by the facility. (Facilities are not required to provide an unlimited variety of brands of these items and services. It is the required assessment of resident needs, not resident preferences, that will dictate the variety of products facilities need to provide);
(D) Before purchasing or charging for the preferred items, the facility must secure written authorization from the member, family member, or responsible party indicating his or her desired preference, the date and signature of the person requesting the preferred item. The signature may not be that of an employee of the facility. The authorization is valid until rescinded by the maker of the instrument;
(10) The facility will furnish or obtain any necessary equipment to meet the needs of the patient upon physician order. Examples include: trapeze bars and overhead frames, foot and arm boards, bed rails, cradles, wheelchairs and/or geriatric chairs, foot stools, adjustable crutches, canes, walkers, bedside commode chairs, hot water bottles or heating pad, ice bags, sand bags, traction equipment, IV stands, etc.;
(11) Physician prescribed lotions, ointments, powders, medications and special dressings for the prevention and treatment of decubitus ulcers, skin tears and related conditions, when medications are not covered under the Vendor Drug Program or other third party payer;
(12) Supplies required for dispensing medications, including needles, syringes including insulin syringes, tubing for IVs, paper cups, medicine containers, etc.;
(13) Equipment and supplies required for simple tests and examinations, including scales, sphygmomanometers, stethoscopes, clinitest, acetest, dextrostix, pulse oximeters, blood glucose meters and test strips, etc.;
(14) Underpads and diapers, waterproof sheeting and pants, etc., as required for incontinence or other care.
(A) If the assessment and care planning process determines that it is medically necessary for the resident to use diapers as part of a plan to achieve proper management of incontinence, and if the resident has a current physician order for adult diapers, then the facility must provide the diapers without charge;
(B) If the resident or the family requests the use of disposable diapers and they are not prescribed or consistent with the facility's methods for incontinent care, the resident/family would be responsible for the expense;
(15) Oxygen for emergency use, or intermittent use as prescribed by the physician for medical necessity;
(16) Other physician ordered equipment to adequately care for the patient and in accordance with standard patient care, including infusion pumps and supplies, and nebulizers and supplies, etc.
(17) Dentures and Related Services. Payment for the cost of dentures and related services is included in the daily rate for routine services. The projected schedule for routine denture services must be documented on the Admission Plan of Care and on the Annual Plan of Care. The medical records must also contain documentation of steps taken to obtain the service. When the provision of denture services is medically appropriate, the nursing facility must make timely arrangements for the provision of these services by licensed dentists. In the event dentures services are not medically appropriate, the treatment plan must reflect the reason the service is not considered appropriate, i.e., the patient is unable to ingest solid nutrition, comatose, etc. When the need for dentures is identified, one set of complete dentures or partial dentures and one dental examination is considered medically appropriate every three years. One rebase and/or one reline is considered appropriate each three years. It is the responsibility of the nursing facility to ensure that the member has adequate assistance in the proper care, maintenance, identification and replacement of these items. The nursing facility cannot set up payment limits which result in barriers to obtaining denture services. However, the nursing facility may restrict the providers of denture services to providers who have entered into payment arrangements with the facility. The facility may also choose to purchase a private insurance dental coverage product for each SoonerCare member. The policy must cover at a minimum all denture services included in routine services. The member cannot be expected to pay any co-payments and/or deductibles. If a difference of opinion occurs between the nursing facility, member, and/or family regarding the provision of dentures services, the OHCA will be the final authority. All members and/or families must be informed of their right to appeal at the time of admission and yearly thereafter. The member cannot be denied admission to a facility because of the need for denture services.
(18) Vision Services. Routine eye examinations for the purpose of medical screening or prescribing or changing glasses and the cost of glasses are included in the daily rate for routine services. This does not include follow-up or treatment of known eye disease such as diabetic retinopathy, glaucoma, conjunctivitis, corneal ulcers, iritis, etc. Treatment of known eye disease is a benefit of the patient's medical plan. The projected schedule for routine vision care must be documented on the Admission Plan of Care and on the Annual Plan of Care. The medical record must contain documentation of the steps that have been taken to access the service. When vision services are not appropriate, documentation of why vision services are not medically appropriate must be included in the treatment plan. For example, patient is comatose, unresponsive, blind, etc. Nursing Home providers may contract with individual eye care providers, providers groups or a vision plan to provide routine vision services to their members. The member cannot be expected to pay any co-payments and/or deductibles.
(A) The following minimum level of services must be included:
(i) Individuals 21 to 40 years of age are eligible for one routine eye examination and one pair of glasses every 36 months (three years).
(ii) Individuals 41 to 64 years of age are eligible for one routine eye examination and one pair of glasses every 24 months (2 years).
(iii)Individuals 65 years of age or older are eligible for one routine eye examination and one pair of glasses each 12 months (yearly).
(B) It is the responsibility of the nursing facility to ensure that the member has adequate assistance in the proper care, maintenance, identification and replacement of these items. When vision services have been identified as a needed service, nursing facility staff will make timely arrangements for provision of these services by licensed ophthalmologists or optometrists. If a difference of opinion occurs between the nursing facility, member, and/or family regarding the provision of vision services, the OHCA will be the final authority. All members and/or families must be informed of their right to appeal at admission and yearly thereafter. The member cannot be denied admission to the facility because of the need for vision services.
(19) An attendant to accompany SoonerCare eligible members during SoonerRide Non-Emergency Transportation (NET). Please refer to OAC 317:30-5-326 through OAC 317:30-5-327.9 for SoonerRide rules regarding members residing in a nursing facility.
(a) Ancillary services are those items which are not considered routine services. Ancillary services may be billed separately to the SoonerCare program, unless reimbursement is available from Medicare or other insurance or benefit programs. Coverage criteria, utilization controls and program limitations are specified in Part 17 of OAC 317:30-5. Ancillary services are limited to the following services:
(1) Services requiring prior authorization:
(A) External breast prosthesis and support accessories.
(B) Ventilators and supplies.
(C) Total Parenteral Nutrition (TPN), and supplies.
(D) Custom seating for wheelchairs.
(2) Services not requiring prior authorization:
(A) Permanent indwelling or male external catheters and catheter accessories.
(B) Colostomy and urostomy supplies.
(C) Tracheostomy supplies.
(D) Catheters and catheter accessories.
(E) Oxygen and oxygen concentrators.
(i) PRN Oxygen. Members in nursing facilities requiring oxygen PRN will be serviced by oxygen kept on hand as part of the per diem rate.
(ii) Billing for Medicare eligible members. Oxygen supplied to Medicare eligible nursing home members may be billed directly to OHCA. It is not necessary to obtain a denial from Medicare prior to filing the claim with OHCA.
(b) Items not considered ancillary, but considered routine and covered as part of the routine rate include but are not limited to:
(3) Medicine cups.
(4) Eating utensils.
(5) Personal comfort items.
|317:30-5-133.3.||Nursing home ventilator-dependent and tracheostomy care services|
(a) Admission is limited to ventilator-dependent and/or qualified tracheostomy residents.
(b) The ventilator-dependent resident and/or qualified tracheostomy resident must meet the current nursing facility level of care criteria. (Refer to OAC 317:30-5-123.)
(c) All criteria must be present in order for a resident to be considered ventilator-dependent:
(1) The resident is not able to breathe without a volume with a backup.
(2) The resident must be medically dependent on a ventilator for life support 6 hours per day, seven days per week.
(3) The resident has a tracheostomy.
(4) The resident requires daily respiratory therapy intervention (i.e., oxygen therapy, tracheostomy care, physiotherapy or deep suctioning). These services must be available 24 hours a day.
(5) The resident must be medically stable and not require acute care services. A Registered Nurse or Licensed Practical Nurse must be readily available and have primary responsibility of the unit at all times.
(d) The resident will also be considered ventilator-dependent if all of the above requirements were met at admission but the resident is in the process of being weaned from the ventilator. This excludes residents who are on C-PAP or Bi-PAP devices only.
(e) All criteria must be present in order for a resident to be considered as tracheostomy care qualified:
(1) The resident is not able to breathe without the use of a tracheostomy.
(2) The resident requires daily respiratory therapy intervention (i.e., oxygen therapy, tracheostomy care, chest physiotherapy, or deep suctioning). These services must be available 24 hours a day.
(3) A Registered Nurse or Licensed Practical Nurse must be readily available and have primary responsibility of the unit.
(f) Not withstanding the foregoing, a ventilator-dependent or qualified tracheostomy resident who is in the process of being weaned from ventilator dependence or requiring qualified tracheostomy treatment shall continue to be considered a qualified resident until the weaning process is completed.
|317:30-5-134.||Nurse Aide Training Reimbursement|
(a) Nurse Aide training programs and competency evaluation programs occur in two settings, a nursing facility setting and private training courses. Private training includes, but is not limited to, certified training offered at vocational technical institutions. This rule outlines payment to qualified nurse aides trained in either setting.
(b) In the case a nursing facility provides training and competency evaluation in a program that is not properly certified under federal law, the Oklahoma Health Care Authority may offset the nursing facility's payment for monies paid to the facility for these programs. Such action shall occur after notification to the facility of the period of non-certification and the amount of the payment by the Oklahoma Health Care Authority.
(c) In the case of nurse aide training provided in private training courses, reimbursement is made to nurse aides who have paid a reasonable fee for training in a certified training program at the time training was received. The federal regulations prescribe applicable rules regarding certification of the program and certification occurs as a result of certification by the State Survey Agency. For nurse aides to receive reimbursement for private training courses, all of the following requirements must be met:
(1) the training and competency evaluation program must be certified at the time the training occurred;
(2) the nurse aide has paid for training;
(3) a reasonable fee was paid for training (however, reimbursement will not exceed the maximum amount set by the Oklahoma Health Care Authority of 800 dollars);
(4) the Oklahoma Health Care Authority is billed by the nurse aide receiving the training within 12 months of the completion of the training. Reimbursement requests outside the first 12 months are not compensable;
(5) the nurse aide has passed her or his competency evaluation; and
(6) the nurse aide is employed at a SoonerCare contracted nursing facility as a nurse aide during all or part of the year after completion of the training and competency evaluation.
(d) If all the conditions in subsection (c) are met, then the Authority will compensate the nurse aide on a quarterly basis. For every qualifying month employed in a nursing facility during a quarter, OHCA will pay the previous quarter's sum of eligible expenses incurred by the nurse aide. The term "qualifying month" is defined as a period of 16 days or more within one calendar month. The terms "quarter" and "quarterly basis" are defined as three qualifying months.
|317:30-5-135.||Intermediate care facility for the mentally retarded (ICF/MR) service fee [REVOKED]|
|317:30-5-136.||Nursing Facility Supplemental Payment Program|
(a) Purpose. The nursing facility supplemental payment program is a supplemental payment, up to the Medicare upper payment limit, made to a non-state government owned entity that owns and as applicable has operating responsibility for a nursing facility(ies).
(b) Definitions. The following words and terms, when used in this Section have the following meaning, unless the context clearly indicates otherwise:
(1) "Funds" means a sum of money or other resources, as outlined in 42 Code of Federal Regulations 433.51, appropriated directly to the State or local Medicaid agency, or funds that are transferred from other public agencies (including Indian tribes) to the State or local agency and under its administrative control, or funds certified by the contributing public agency as representing expenditures eligible for Federal Financial Participation (FFP).
(2) "Intergovernmental transfer (IGT)" means a transfer of state share funds from a non-state government owned entity to the Oklahoma Health Care Authority.
(3) "Non-state government-owned (NSGO)" means an entity owned and as applicable operated by a unit of government other than the state and approved by OHCA as a qualified NSGO. Pursuant to federal and OHCA approval an NSGO may include public trusts pursuant to the Trust Authorities established under Oklahoma Statute Title 60.
(4) "Resource Utilization Groups (RUGs)" means the system used to set Medicare per diem payments for skilled nursing facilities, as the basis to demonstrate a Medicare payment estimate for use in the upper payment limit calculation.
(5) "Supplemental payment calculation period" means the calendar quarter for which supplemental payment amounts are calculated based on adjudicated claims for days of service provided in the qualifying quarter. Note, in the event there are no paid days in the quarter as a result of the time in which the claims are adjudicated, the supplemental payment will be calculated on days billed in a subsequent quarter.
(6) "Upper payment limit (UPL)" refers to a reasonable estimate of the amount that would be paid for the services furnished by a facility under Medicare payment principles.
(c) Eligible nursing facilities. A nursing facility that is owned and as applicable under the operational responsibility of an NSGO is eligible for participation when the following conditions are met:
(1) the nursing facility is licensed and certified by the Oklahoma State Department of Health;
(2) the participating NSGO has provided proof that it holds the facility's license and has complete operational responsibility for the facility;
(3) the participating NSGO has filed the certification of eligibility application for the UPL program participation and received approval from OHCA for participation;
(4) the NSGO has signed an attestation that a plan towards the reduction and mitigation of unnecessary Return to Acute Admissions (RTA) will be implemented within six months of program participation;
(5) the facility is an active participant in the Focus on Excellence program; and
(6) the facility and NSGO comply with Care Criteria requirements.
(d) NSGO participation requirements. The following conditions are required of the NSGO:
(1) must execute a nursing facility provider contract as well as an agreement of participation with the OHCA;
(2) must provide and identify the state share dollars' source of the IGT;
(3) must pay the calculated IGT to OHCA by the required deadline;
(4) must provide proof of ownership, if applicable (i.e. Change of Ownership) as Licensed Operator of the nursing facility;
(5) must provide OHCA with an executed Management Agreement between the NSGO and the facility Manager;
(6) must provide proof of district authority for nursing facility participants which include proximity requirements of no greater than 150 miles of NSGO. Exceptions may be made at the sole discretion of OHCA; and
(7) must provide per facility, the per patient per Medicaid day (PPMD) IGT within specified timeframe of receipt of the Notice of Program Reimbursement (NPR) as indicated below:
(A) For the first year-$6.50 PPMD.
(B) For the second year-$7.50 PPMD.
(C) For the third year-$8.50 PPMD, or the equivalent of 10% of nursing facility budget of the current fiscal year, whichever is less. This amount excludes any IGT for actual administration cost associated with the nursing home UPL supplemental program. Any remaining IGT after administration cost will be distributed through the rate setting methodology process. Distribution will occur once escrowed funds reach an amount sufficient to distribute as determined by OHCA.
(e) Care Criteria. Each facility must comply with the below care criteria quality metric:
(1) Facilities must adhere to performance measures outlined in the Focus on Excellence program. The resulting outcome is to improve the quality of care being delivered to members. A written action plan must be developed and must include the following:
(A) the satisfaction survey results;
(B) analysis of satisfaction survey with identification of areas for improvement; and
(C) plan of action towards identified areas of improvement.
(2) Facilities must develop and implement a written plan for the mitigation of unnecessary Return to Acute Admissions (RTA) within six (6) months of participation. The resulting outcome is to improve the efficiency and care avoidance cost to the overall SoonerCare program. A written plan must be developed and must include the following:
(A) the RTA management tool which identifies those residents at high risk for the potential return to acute;
(B) the RTA management tools to support effective communications;
(C) advance directive planning and implementation; and
(D) application of Quality Assurance/Program Integrity (QA/PI) methodology in review of RTAs for the root cause analysis and teaching needs.
(3) Facilities are required to implement a pro-active Pneumonia/Flu Vaccination program which will result in improved vaccination scores above the facility specific baseline at or above the national average, as measured using the CMS Quality Metrics. The resulting outcome is to improve efficiency and care avoidance costs to the overall SoonerCare program. A written plan must be developed and must include the following:
(A) the latest available three quarter average of CMS measure code 411 (% of long-stay residents assessed and appropriately given the seasonal influenza vaccine) and 415 (% of long-stay residents assessed and appropriately given the pneumococcal vaccine) to establish baseline;
(B) the current measure code 411 and 415 score; and
(C) the written plan for flu and pneumonia vaccination program to address new admissions and current residents.
(4) Facilities are required to participate in the Oklahoma Healthy Aging Initiative. The resulting outcome is to improve the quality of care and health of members. Facilities must attest to elevate healthy aging in Oklahoma by implementing a plan that accomplishes at least one of the following strategies:
(A) preventing and reducing of falls;
(B) improving of nutrition;
(C) increasing physical activity; or
(D) reducing depression.
(5) Facilities are required to demonstrate improvement above the facility specific baseline in the 5-Star Quality Measures Composite scoring. Metrics will be determined based upon CMS Nursing Home Compare composite score over the trailing 12-month period. Facilities with Quality Measures star rating of three (3) or better for the most recent quarter or showing improvement in composite scoring with no two (2) quarters consistently below three (3), will be recognized as meeting the care criteria. The resulting outcome is to improve the quality of care being provided.
(A) Facilities must provide the most recent three (3) quarter average of the CMS quality measure star rating to establish baseline.
(B) Facilities are required to have a star rating of (3) or better or must demonstrate improvement over previous quarter with no two (2) quarters below three (3) stars.
(6) The care criteria measures may be evaluated at the discretion of OHCA on an annual basis after each fiscal year, following implementation of the program. However, OHCA reserves the right to conduct intermittent evaluations within any given year based on the quality, care and safety of SoonerCare members. The evaluation may be conducted by an independent evaluator. In addition, care criteria metrics may be internally evaluated after each fiscal year at the discretion of OHCA, in collaboration with an advisory committee composed of OHCA agency staff and provider representatives. The OHCA may make adjustments to the care criteria measures based on findings and recommendations as a result of the independent or internal evaluation.
(f) Supplemental Payments.
(1) The nursing facility supplemental payments to a NSGO under this program shall not exceed Medicare payment principles pursuant to 42 CFR 447.272. Payments are made in accordance with the following criteria:
(A) The methodology utilized to calculate the upper payment limit is the RUGs.
(B) The eligible supplemental amount is the difference/gap between the SoonerCare payment and the Medicare upper payment limit as determined based on compliance with the Care Criteria metrics.
(2) The amount of the eligible supplemental payment is associated with improvement of care of SoonerCare nursing facility residents as demonstrated through the care criteria. NSGO participants receive payment under the program based on earned percentages related to the care criteria. The NSGO must meet or exceed at least two (2) of the five (5) established care criteria metrics to be eligible for UPL payment for each quarter. After at least two (2) of the five (5) metrics have been met, the NSGO is eligible for eighty-five percent (85%) of the total eligible UPL amount for participating nursing facilities. The NSGO may qualify for the remaining fifteen percent (15%) of the total UPL by attribution in five percent (5%) increments for each additional care criterion that is met resulting in the full one hundred percent (100%) of the eligible UPL amount.
(g) Change in ownership.
(1)A nursing facility participating in the supplemental payment program must notify the OHCA of changes in ownership (CHOW) that may affect the nursing facility's continued eligibility within thirty (30) days after such change.
(2) For a nursing facility that changes ownership on or after the first day of the SoonerCare supplemental payment limit calculation period, the data used for the calculations will include data from the facility for the entire upper payment limit calculation period relating to payments for days of service provided under the prior owner, pro-rated to reflect only the number of calendar days during the calculation period that the facility is owned by the new owner.
(h) Disbursement of payment to facilities. Facilities must secure allowable Intergovernmental Transfer funds (IGT) from a NSGO to fund the non-federal share amount. The method is as follows:
(1) The OHCA or its designee will notify the NSGO of the non-federal share amount to be transferred by an IGT, via a designated portal and NPR, for purposes of seeking federal financial participation (FFP) for the UPL supplemental payment, within twenty-five (25) business days after the end of the quarter. This amount will take into account the percentage of metrics achieved under the care criteria requirement. The NSGO will have five (5) business days to sign the participant agreement and make payment of the state share in the form of an IGT either in person or via mail. In addition, the NSGO will be responsible to also remit, upon receipt of the NPR, the applicable PPMD IGT in full, pursuant to (d)(7) above.
(2) If the total transfer and PPMD IGT are received within five (5) business days, the UPL payment will then be disbursed to the NSGO by OHCA within ten (10) business days in accordance with established payment cycles. An IGT that is not received by the date specified by OHCA, or that is not the total indicated on the NPR shall be subject to penalty and suspension from the program.
(i) Penalties/Adjustments. Failure by an NSGO to remit the full IGT indicated on the NPR by OHCA or its designee within the defined timeframes below indicates the NSGO has voluntarily elected to withdraw participation for that current quarter and may reapply for participation in the program in subsequent quarter(s).
(1) The total IGT must be received within five (5) business days from receipt of the NPR uploaded by OHCA or its designee in the program portal.
(A) Receipt of the total IGT within five (5) business days is not subject to penalty.
(B) The date the NPR is uploaded to the portal is the official date the clock starts to measure the five (5) business days.
(2) Any IGT received after the fifth business day but with an OHCA date stamp or mailing postal mark on or prior to five (5) business days from the official date of the uploaded NPR in the portal will not be subject to penalty; however, payment will be disbursed during the next available OHCA payment cycle.
(3) Any IGT with an OHCA date stamp or mailing postal mark received with a date after five (5) business days of receipt of the NPR, but not exceeding eight (8) business days of receipt of the NPR will be deemed late and subject to a penalty in accordance with (3)(B) below.
(A) Any NSGO that remits payment of the total IGT under the above circumstances will receive payment during the next available OHCA payment cycle including an assessed penalty as described below.
(B) A five percent (5%) penalty will be assessed for total IGT payments received after five (5) business days but within eight business days of receipt of the NPR of assessed amount. The five percent (5%) penalty will be assessed on the total eligible supplemental payment for the quarter in which the IGT is late and assessed to the specific NSGO as applicable.
(C) The OHCA will notify the NSGO of the assessed penalty via invoice. If the provider fails to pay the OHCA the assessed penalty within the time frame noted on the invoice to the NSGO, the assessed penalty will be deducted from the nursing facility's Medicaid payment. The penalty must be paid regardless of any appeals action requested by the NSGO. Should an appeals decision result in a disallowance of a portion or the entire assessed penalty, reimbursement to the NSGO will be made to future nursing facility Medicaid payments.
(4) If a nursing facility fails to achieve at a minimum, two (2) of the care criteria metrics for two (2) consecutive quarters, the facility will be suspended for two (2) subsequent quarters and will not be eligible to participate in the program during suspended quarters. A facility that has been suspended for a total of four (4) quarters within a two (2) year period due to non-compliance with the Care Criteria will be terminated from the program, and if the facility wishes to participate again, it will be required to reapply. Reentry into the program is at the sole discretion of the OHCA, taking into consideration input from the advisory committee and/or stakeholders. If the facility is readmitted to the program, terms of participation may include a probationary period with defined requirements as it relates to care.
Appeals. Applicant and participant appeals may be filed in accordance with grievance procedures found at OAC 317:2-1-2(b) and 317:2-1-16.