C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-67, subsec. 144-101-III-67-16

Current through 2024-46, November 13, 2024

Subsection 144-101-III-67-16 - DIRECT CARE COST COMPONENT

16.1Direct care costs include salary, wages, and benefits for:

16.1.1 registered nurses salaries/wages (excluding Director of Nursing),

16.1.2 licensed practical nurses salaries/wages,

16.1.3 nurse aides salaries/wages,

16.1.4 patient activities personnel salaries/wages,

16.1.5 ward clerks' salaries/wages,

16.1.6 contractual labor costs,

16.1.7 fringe benefits for the positions in Principles 16.1.1 through 16.1.5 include:

(1) payroll taxes,

(2) qualified retirement plan contributions,

(3) group health, dental, and life insurance,

(4) cafeteria plans,

(5)* health savings accounts (if cost-effective), and

(6)* flexible spending accounts (if cost-effective).

*The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions.

16.1.8Cost of Educational Activities

(1)Principle. An appropriate part of the net cost of educational activities is an allowable cost. Appropriate means the net cost of the activity apportioned in accordance with the methods set forth in these Principles. Expenses for education activities may be evaluated as to appropriateness; quality and cost may not be included as an allowable cost based on findings.

(2)Orientation, On-the-Job Training, In-Service Education and Similar Work Learning. Orientation, on-the-job training, in-service education and similar work learning programs are not within the scope of this principle, but, if provided by a staff person, are recognized as normal operating costs for routine services in accordance with the Principles relating thereto.

(3)Basic Education. Educational training programs, which a staff member must successfully complete in order to qualify for a position or a job, shall be considered basic education. Cost related to this education are not within the scope of reimbursement.

(4)Educational Activities. Educational activities mean formally organized or planned workshops, seminars, or programs of study usually engaged in by the staff members of a facility in order to enhance the quality of resident care within the facility. These continuing education activities are distinguished from and do not include orientation, basic education programs, on-the-job training, in-service education and similar learning programs.

16.1.9 Medical supplies, medicine and drugs that are supplied as part of the regular rate of reimbursement. See MaineCare Benefits Manual, Section 60. Excluded are costs that are an integral part of another cost center.

16.2Resident Assessments

The Resident Assessment Instrument (RAI) is the assessment tool approved by the Department to provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. It is comprised of the Minimum Data Set (MDS) currently specified for use by Centers for Medicare and Medicaid (CMS) and the Resident Assessment Protocols (RAPs).

The MDS provides the basis for resident classification into one (1) of forty-four (44) case mix classification groups. An additional unclassified group is assigned when assessment data are determined to be incomplete or in error. Resident assessment protocols (RAPs) are structured frameworks for organizing MDS elements and gathering additional clinically relevant information about a resident that contributes to care planning.

Per CMS guidelines, all residents admitted to a Nursing Facility (NF), regardless of payment source, shall be assessed using the MDS.

16.2.1Schedule for MDS submissions

(1) An Admission Assessment (Comprehensive) must be completed and submitted (VB2) by the fourteenth (14^th) day of the resident's stay.

(2) An Annual Reassessment (Comprehensive) must be completed and submitted (VB2) within three hundred-sixty-six (366) days of the most recent comprehensive assessment.

(3) A Significant Change in Status Reassessment (Comprehensive) must be completed and submitted (VB2) by the end of the fourteenth (14^th) calendar day following determination that a significant change has occurred.

(4) A Quarterly Assessment must be completed and submitted every ninety-two (92) days.

16.2.2Electronic Submission of the MDS Information

(1)Encoding Data: A facility must encode the data on every assessment as listed in Sec 16.2.1 within seven (7) days after a facility completes a resident's assessment.

(2)Transmitting data: A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries within seven (7) days after a facility completes a resident's assessment.

Should extraordinary conditions arise whereby the nursing facility is unable to submit electronically, a request to submit MDS information via diskette shall be submitted to the Office of MaineCare Services. This request must be made a minimum of five (5) days prior to the required date of submission of the MDS assessment data. Transmission of MDS information will be in accordance with standards and specifications established under CMS guidelines.

16.2.3Quality review of the MDS process

16.2.3.1Definitions

(1)MDS Correction Form. The MDS correction form is a form specified by CMS that allows for the correction of MDS assessment information previously submitted and accepted into the MDS central data repository.

Facility staff identifies and determines the need for data correction. The MDS clinical process must be maintained under CMS requirements. Corrections take two (2) forms:

(a)Modification: Information contained in the MDS central repository is inaccurate for an assessment and requires correction.

(b)Deletion: The facility determines the MDS was submitted in error and is wrong. The facility submits an MDS Correction Form requesting the inaccurate record be deleted from the database.

(2)"MDS assessment review" is a review conducted at nursing facilities (NFs) by the Maine Department of Health and Human Services, for review of assessments submitted in accordance with Principle 16.2 to ensure that assessments accurately reflect the resident's clinical condition.

(3)"Effective date of the Rate" is established by the date on the rate letter. A rate letter will be generated at least annually.

(4)"Assessment review error rate" is the percentage of unverified Case Mix Group Record in the drawn sample. Samples shall be drawn from Case Mix Group Record completed for residents who have MaineCare reimbursement. MDS Correction Forms received in the central repository or included in the clinical record will be the basis for review when completed before the day of the review and included as part of the resident's clinical record.

(5)"Verified Case Mix Group Record" is a NF's completed MDS assessment form, which has been determined to accurately represent the resident's clinical condition, during the MDS assessment review process. Verification activities include reviewing resident assessment forms and supporting documentation, conducting interviews, and observing residents.

(6)"Unverified Case Mix Group Record" is one which, for reimbursement purposes, the Department has determined does not accurately represent the resident's condition, and therefore results in the resident's inaccurate classification into a case mix group that increases the case mix weight assigned to the resident. Records so identified will require facilities to submit the appropriate MDS correction form and follow CMS clinical guidelines for MDS completion. Correction forms received prior to calculating the rate setting quarterly index will be used in the calculation of that index.

(7)"Unverified MDS Record" is one, which, for clinical purposes, does not accurately reflect the resident's condition. Records so identified will require facilities to submit the appropriate MDS correction form and follow the CMS clinical guidelines for MDS completion.

16.2.3.2Criteria for Assessment Review

NFs may be selected for a MDS assessment review by the Department based upon but not limited to any of the following:

(1) The findings of a licensing and certification survey conducted by the Department indicate that the facility is not accurately assessing residents.

(2) An analysis of the case mix profile of NFs included but not limited to changes in the frequency distribution of their residents in the major categories or a change in the facility Average case mix score.

(3) Prior resident assessment performance of the provider, including, but not limited to, ongoing problems with assessments submission deadlines, error rates, high percentages of MDS corrections or deletions, and incorrect assessment dates.

16.2.3.3Assessment Review Process

(1) Assessment reviews shall be conducted by staff or designated agents of the Department.

(2) Facilities selected for assessment reviews must provide reviewers with reasonable access to residents, professional and non-licensed direct care staff, the facility assessors, clinical records, and completed resident assessment instruments as well as other documentation regarding the residents' care needs and treatments.

(3) Samples shall be drawn from MDS assessments completed for residents who have MaineCare reimbursement. The sample size is determined following the CMS State Operations Manual (SOM) Transmittal 274, Table 1 "Resident Sample Selection".

(4) At the conclusion of the on-site portion of the review process, the Department's reviewers shall hold an exit conference with facility representatives. Reviewers will share written findings for reviewed records.

16.2.3.4Sanctions

The following sanctions shall be applied to the total allowable inflated direct care cost per day for a three month period subsequent to the quality review date. The sanction will apply to all MaineCare resident days billed by the facility during the three month sanction period. Such sanctions shall be a percentage of the total allowable inflated direct care rate per day after the application of the wage index and upper limit. Upon notification of the error rates as determined by the reviewers (in 16.2.3.3.), the staff of the rate setting unit of the Department will implement the appropriate sanction by issuing a rate letter with the start and end dates of the three month sanction period. At the completion of the three month sanction period, the staff of rate setting unit will issue a rate letter reinstating the total allowable inflated direct care cost per day.

(1) A two percent (2%) decrease in the total allowable inflated direct care rate per day after the application of the wage index and upper limit will be imposed when the NF assessment review results in an error rate of thirty-four percent (34%) or greater, but is less than thirty-seven percent (37%).

(2) A five percent (5%) decrease in the total allowable inflated direct care rate per day after the application of the wage index and upper limit will be imposed when the NF assessment review results in an error rate of thirty-seven percent (37%) or greater, but is less than forty-one percent (41%).

(3) A seven percent (7%) decrease in the total allowable inflated direct care rate per day after the application of the wage index and upper limit will be imposed when NF assessment review results in an error rate of forty-one percent (41%) or greater, but is less than forty-five percent (45%).

(4) A ten percent (10%) decrease in the total allowable inflated direct care rate per day after the application of the wage index and upper limit will be imposed when the NF assessment review results in an error rate of forty-five percent (45%) or greater.

16.2.3.5 Failure to complete MDS corrections by the nursing facility staff within fourteen (14) days of a written request by staff of the Office of MaineCare Services may result in the imposition of the deficiency per diem as specified in Principle 37 of these Principles of Reimbursement. Completed MDS corrections and assessments, as defined in Principle 16.2, shall be submitted to the Department or its designee according to CMS guidelines.

16.2.3.6Appeal Procedures: A facility may administratively appeal an Office of MaineCare Services rate determination for the direct care cost component. An administrative appeal will proceed in the following manner:

(1) Within thirty (30) days of receipt of rate determination, the facility must request, in writing, an informal review before the Director of the Office of MaineCare Services or his/her designee. The facility must forward, with the request, any and all specific information it has relative to the issues in dispute. Only issues presented in this manner and time frame will be considered at an informal review or at a subsequent administrative hearing.

(2) The Director or his/her designee shall notify the facility in writing of the decision made as a result of the informal review. If the facility disagrees with the results of the informal review, the facility may request an administrative hearing before the Commissioner or a presiding officer designated by the Commissioner. Only issues presented in the informal review will be considered at the administrative hearing. A request for an administrative hearing must be made, in writing, within thirty (30) days of receipt of the decision made as a result of the informal review.

(3) To the extent the Department rules in favor of the facility, the rate will be corrected.

(4) To the extent the Department upholds the original determination of the Office of MaineCare Services, review of the results of the administrative hearing is available in conformity with the Administrative Procedure Act, 5 M.R.S.A. §11001et seq.

16.3Allowable costs for the Direct Care component of the rate shall include:

16.3.1Direct Care Cost. The base year costs for direct care shall be the base year cost as defined in Principle 1.4 for those costs listed in Principle 16.1, except for facilities whose MaineCare rates are based on pro forma cost reports in accordance with Principles 22.5 and 22.6. The direct care cost component is determined by adjusting direct care costs pursuant to Principle 22.3.3.

16.3.2Continuing Education for Direct Care Staff. The cost of employee education, as defined in 16.1.8 for direct care staff is included as a direct care component rather than a routine cost component.

C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-67, subsec. 144-101-III-67-16