Minn. R. agency 144, ch. 4656, CASE MIX REIMBURSEMENT CLASSIFICATIONS, pt. 4656.0080

Current through Register Vol. 49, No. 29, 2025

Part 4656.0080 - AUDITS OF ASSESSMENTS OF NURSING HOME RESIDENTS

Subpart 1.Audit types.

The department shall audit the accuracy of resident assessments performed under parts 9549.0050 to 9549.0059 through desk audits and on-site review of residents and their records. The department shall reclassify a resident it determines to have been incorrectly classified.

Subp. 2.Unannounced audits.

The department is authorized to conduct on-site audits on an unannounced basis.

Subp. 3.Access to records.

Facilities shall grant the department access during regular business hours, to examine the medical records relating to the resident assessments selected for audit under this part. For the purpose of clarifying or substantiating these records, the department may also speak to facility staff and physically observe the resident.

Subp. 4.Documentation time frame.

The department shall consider the following documentation, as relevant to the audit process:

A. documentation recorded in the resident record up to four days after the date the resident returns from the hospital, but only as the documentation relates to the resident's condition at the time the resident is assessed under part 9549.0059, subpart 4, item A;

B. documentation recorded in the resident record up to nine days after the date the resident is admitted to the nursing home, but only as the documentation relates to the resident's condition at the time the resident is assessed under part 9549.0059, subpart 1; and

C. documentation recorded in the resident record up to the time the resident is assessed under parts 9549.0059, subpart 2 or subpart 4, item B and 4656.0030.

Subp. 5.Routine audits procedures.

Facilities will be routinely audited at least once per calendar year in accordance with the following procedures:

A. The department shall select for audit either ten percent or ten, whichever is greater, of the assessments submitted in accordance with part 9549.0059, subpart 2, or ten percent or ten, whichever is greater, of the assessments submitted during the previous four months in accordance with part 9549.0059, subparts 1 and 4.

B. If more than 20 percent of the assessments audited under item A contain errors that could result in a change of classification, the auditors shall remain on-site and audit a second sample equal in size and selected from the same types of assessments as in item A.

C. If more than 35 percent of the assessments audited under items A and B contain errors that could result in a change of classification, the facility may be subject to an additional audit of up to 100 percent of the assessments. The decision of whether or not to schedule a 100 percent audit shall be made by the program manager of the Quality Assurance and Review Section and based upon a review of the case mix index, the remaining classifications not audited, a determination of the effect of the unaudited classifications on the case mix index, and staff availability.

Subp. 6.Special audits.

The department may conduct special audits if it determines that circumstances exist that could alter or affect the validity of case mix classifications of residents. Examples of circumstances include the following: frequent changes in the administration or management of the facility; an unusually high percentage of residents in a specific case mix classification; a high frequency in the number of reconsideration requests received from a facility; frequent adjustments of case mix classifications as the result of reconsiderations or audits; a criminal indictment alleging provider fraud; or other similar factors that relate to a facility's ability to conduct accurate assessments.

Subp. 7.Notice to facility.

No exit interview will be conducted at the facility to discuss the preliminary findings of the department. Within 15 working days of completing the audit process, the department shall mail the written results of the audit to the facility, along with a written notice to the resident and to the facility which contains the resident's classification and a statement informing the resident, the resident's authorized representative, and the facility of their right to review the department's documents supporting the classification and to request a reconsideration of the classification. This notice must also include the address and telephone number of the area nursing home ombudsman.

Minn. R. agency 144, ch. 4656, CASE MIX REIMBURSEMENT CLASSIFICATIONS, pt. 4656.0080

12 SR 239; 18 SR 2584

Statutory Authority: MS s 144.072; 256B.502