Section 1200-13-02-.11 - QUALITY-BASED COMPONENT OF THE REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES(1) In addition to Quality Informed aspects of the NF reimbursement methodology, a specified amount of the funding for NF services shall be set aside during each fiscal year for purposes of calculating a quality-based component of each NF provider's per diem payment (i.e., a quality incentive component). At implementation of this Chapter, the amount of funding set aside for the quality-based component of the reimbursement methodology for NFs shall be no less than forty million dollars ($40 million) or four percent (4.00%) of the total projected fiscal year expenditures for NF services, whichever is greater. In each subsequent year, the amount of funding set aside for the quality-based component of the reimbursement methodology for NFs shall increase at two (2) times the rate of inflation of the index factor. Index factor inflation shall be calculated from the midpoint of the prior state fiscal year to the midpoint of the new state fiscal year. This annual quality-based component index factor adjustment shall continue until such time that the quality-based component of the reimbursement methodology for NFs constitutes ten percent (10%) of the total projected fiscal year expenditures for NF services. Once the quality-based component of the reimbursement methodology constitutes ten percent (10%) of the total projected fiscal year expenditures for NF services, it shall then increase or decrease at a rate necessary to ensure that the quality-based component of the reimbursement methodology remains at ten percent (10%). All noted minimum quality-based component thresholds and index factor inflationary adjustments are made prior to consideration of the BAF.(2) The quality-based component of each NF provider's per diem payment shall be calculated based on the facility's volume of Medicaid resident days and the percentage of total quality points earned for the measurement period.(3) The initial quality outcome measures and point values established for the NF reimbursement system implemented on July 1, 2018, shall be based upon the structure of the QuILTSS Nursing Facility Value-Based Purchasing Quality Framework as described in the memorandum of August 5, 2014, to Medicaid NF Providers and described in this rule. Quality outcome measures and point values for each measure shall not be modified for the first three (3) fiscal years of reimbursement following implementation of the reimbursement system. Performance benchmarks shall be established as described in this rule. After the initial three (3) year period, quality outcome measures, performance benchmarks for each measure, and point values shall be reviewed and may be modified as appropriate in consultation with THCA and other NF stakeholders. Any modifications to such criteria shall be established through rulemaking and shall not be changed for another three-year period.(4) Quality outcome measures shall reflect those aspects of the delivery of NF services determined based on input from individuals receiving services, their family members and representatives, and other NF stakeholders, and in consultation with THCA and the QuILTSS Stakeholder Advisory Group, to most impact the day-to-day experience of care for NF residents, as follows: (a) Satisfaction shall be valued at thirty-five (35) of the one hundred (100) possible quality performance points. 1. Satisfaction shall include three separate measures: (i) Resident satisfaction shall be valued at fifteen (15) of the one hundred (100) possible quality performance points.(ii) Family satisfaction shall be valued at ten (10) of the one hundred (100) possible quality performance points.(iii) Staff satisfaction shall be valued at ten (10) of the one hundred (100) possible quality performance points.2. In order to measure Satisfaction on the basis of outcomes and to establish performance benchmarks for each of the three (3) Satisfaction measures, NFs shall be required to use a standardized survey instrument and methodology that provides for anonymous submission to a neutral third party, which shall be responsible for submission of required data to TennCare.3. The survey instrument(s) and methodology for conducting each survey shall be selected or designed with input from NF stakeholders, and subject to mutual agreement between TennCare and THCA. Providers shall be notified of the acceptable survey instrument(s) and methodology no later than two (2) months prior to their implementation.4. For purposes of the NF reimbursement rates effective on July 1, 2018, the methodology used for calculating a facility's Satisfaction score shall be based upon the criteria established by TennCare in the QuILTSS #10 memorandum of March 20, 2017.5. For purposes of the NF reimbursement rates effective on July 1, 2019, the methodology used for calculating a facility's Satisfaction score shall be based on the facility's adoption and implementation of the survey instrument(s) according to with the methodology described in this subparagraph. Data collected during the baseline year of the Satisfaction survey instrument(s) described in this subparagraph shall be used to establish a performance benchmark for each of the three (3) Satisfaction measures, in consultation with THCA and other NF Stakeholders.6. For purposes of the NF reimbursement rates effective on July 1, 2020, the methodology used for calculating a facility's Satisfaction score shall be based in part on whether the facility achieves the performance benchmark for each of the three (3) Satisfaction measures described in this subparagraph, and for facilities who do not achieve the performance benchmarks, a lesser score based on the percentage of improvement over the baseline year. Providers shall be notified of the performance benchmark for each of the three (3) Satisfaction measures and the specific methodology for calculating a facility's Satisfaction score no later than July 1, 2019.7. TennCare shall provide (or arrange for the provision of) training regarding each survey instrument, the survey methodology, and the methodology that will be used to calculate a facility's score for each of the three (3) Satisfaction measures.8. Upon the collection and analysis of two (2) years of data pertaining to each of the survey instruments, this Chapter shall be modified to include performance benchmarks for each of the three (3) Satisfaction measures that will be applied for the next three-year period.9. Results of each NF's surveys (excluding any information that could be used to identify respondents) shall be made available to the NF for purposes of quality improvement activities.(b) Culture Change and Quality of Life shall be valued at thirty (30) of the one hundred (100) possible quality performance points.1. Culture Change and Quality of Life shall encompass four (4) different aspects of the degree to which a NF's environment, programs, policies, and practices are individualized and person-directed; reflect the core values of self-determination, choice, dignity, and respect; and support meaningful roles and relationships for residents and staff. Culture Change and Quality of Life shall include four (4) separate measures:(i) Respectful Treatment shall be valued at ten (10) out of the one hundred (100) possible quality performance points. (ii) Resident Choice shall be valued at ten (10) out of the one hundred (100) possible quality performance points.(iii) Resident and Family Input shall be valued at five (5) out of the one hundred (100) possible quality performance points.(iv) Meaningful Activities shall be valued at five (5) out of the one hundred (100) possible quality performance points.2. In order to measure Culture Change and Quality of Life on the basis of outcomes and to establish performance benchmarks for each of the four (4) Culture Change and Quality of Life measures, NFs shall be required to use a standardized survey instrument and methodology that provides for anonymous submission to a neutral third party, which shall be responsible for submission of required data to TennCare. The survey questions for measuring Culture Change and Quality of Life may be incorporated into the Resident satisfaction survey described in Subparagraph (a) above to ease survey fatigue.3. The survey questions and/or instrument and methodology for conducting the survey shall be selected or designed with input from NF stakeholders, and subject to mutual agreement between TennCare and THCA. Providers shall be notified of the acceptable survey instrument(s) and methodology no later than two (2) months prior to their implementation.4. For purposes of the NF reimbursement rates effective on July 1, 2018, the methodology used for calculating a facility's score encompassing each of the four (4) aspects of Culture Change and Quality of Life shall be developed in consultation with THCA and with input from the NF stakeholders, including individuals receiving services and their family members and representatives. These criteria shall be provided to NFs and posted on the TennCare website no later than two (2) months prior to the implementation of the reimbursement system.5. For purposes of the NF reimbursement rates effective on July 1, 2019, the methodology used for calculating a facility's Culture Change and Quality of Life score shall be based on the facility's adoption and implementation of the survey questions and/or instrument(s) in accordance with the methodology described in this subparagraph. Data collected during the baseline year of the Culture Change and Quality of Life survey instrument(s) described in this section shall be used to establish a performance benchmark for each of the four (4) Culture Change and Quality of Life measures, in consultation with THCA and other NF Stakeholders.6. For purposes of the NF reimbursement rates effective on July 1, 2020, the methodology used for calculating a facility's Culture Change and Quality of Life score shall be based in part on whether the facility achieves the performance benchmark for each of the four (4) Culture Change and Quality of Life measures described in this subparagraph, and for facilities who do not achieve the performance benchmarks, a lesser score based on the percentage of improvement over the baseline year. Providers shall be notified of the performance benchmark for each of the four (4) Culture Change and Quality of Life measures and the specific methodology for calculating a facility's Satisfaction score no later than July 1, 2019.7. TennCare shall provide (or arrange for the provision of) training regarding the methodology that will be used to calculate a facility's score encompassing each of the four (4) aspects of Culture Change and Quality of Life.8. Upon the collection and analysis of two (2) years of data pertaining to the survey questions and/or survey instrument, this Chapter shall be modified to include performance benchmarks for each of the four (4) Culture Change and Quality of Life measures that will be applied for the next three-year period.9. Results of each NF's performance on each of the four (4) aspects of Culture Change and Quality of Life (excluding any information that could be used to identify respondents) shall be made available to the NF for purposes of quality improvement activities.(c) Staffing and Staff Competency shall be valued at twenty-five (25) of the one hundred (100) possible quality performance points.1. Staffing and Staff Competency shall include five (5) separate measures, with each measure valued at five (5) of the one hundred (100) possible quality performance points, as follows:(i) Registered Nurse (RN) hours per resident day.(ii) Nurse Aide (NA) hours per resident day.(iii) RN, LPN, and CNA Staff Retention.(iv) Consistent Staff Assignment.(v) Staff Training (Onboarding and Continuing).2. NA resident hours per resident day shall be calculated consistent with the methodology described in the CMS Five Star Nursing Home Quality Rating System.(i) The source document for the reported NA hours is the CMS form CMS-671 (Long Term Care Facility Application for Medicare and Medicaid) obtained from CASPER, Certification And Survey Provider Enhanced Reports, the CMS system which NFs must use to report data pertaining to survey and certification processes.(ii) The resident census is based on the count of total residents from the CMS form CMS-672 (Resident Census and Conditions of Residents).(iii) NA hours include certified nurse aides, aides in training, and medication aides/technicians.(iv) Staffing data include both NF employees (full-time and part-time) and individuals under an organization (agency) or individual contract.(v) Staffing data do not include staff reimbursed by a resident or his/her family, hospice staff, or feeding assistants.(vi) Staffing hours reported are for the residents in Medicare- and/or Medicaid-certified beds only.(vii) Performance benchmarks for RN and NA hours per resident day measures shall be established in consultation with THCA, and with input from other NF stakeholders, including individuals receiving services and their family members and representatives. These criteria shall be provided to NFs and posted on the TennCare website no later than two (2) months prior to the implementation of the reimbursement system.3. Consistent Staff Assignment shall be defined and calculated consistent with the methodology described in the National Nursing Home Quality Improvement Campaign. (i) Consistent Staff Assignment shall include two measurements:(I) The percentage of long-stay residents who have no more than twelve (12) caregivers within a one (1) month measurement period; and(II) The percentage of short-stay residents who have no more than twelve (12) caregivers within a two-week measurement period.(ii) Long-stay residents shall be defined as residents who have been in the facility for greater than one hundred (100) days.(iii) Short-stay-residents shall be defined as residents who have been in the facility for no more than one hundred (100) days.(iv) A caregiver shall be defined as any staff assigned to provide and delivering direct NA-type care to the resident during the measurement period. (I) For purposes of measuring Consistent Staff, licensed staff shall not be counted as caregivers unless they are working in the capacity of a CNA. For example, if a nurse is in a resident's room administering medications or performing other skilled tasks, and stops to take the resident to the bathroom, that nurse shall not be counted as a caregiver. However, if a nurse (or other staff) is working as a CNA because the home is short staffed or because nurses (or other staff) routinely provide direct care to residents, that person shall be included in the caregiver count.(II) Staff assigned to assist one or more residents only with mealtime and/or bathing shall be counted as a caregiver for all residents for whom such assistance is provided, even if the staff functions as a float or as part of a care team dedicated to such functions on behalf of multiple residents.(v) NAs shall include certified nurse aides, aides in training, and medication aides/technicians.(vi) Caregivers shall include both NF employees (full-time and part-time) and individuals under an organization (agency) or individual contract that provide care to the resident during the measurement period.(vii) To be eligible for Consistent Staff Assignment points, a NF must track its performance using the tools created by the National Nursing Home Quality Improvement Campaign (NNHQIC), and report data to it in a manner consistent with the NNHQIC. A NF must also provide permission to the NNHQIC for it to share the facility's performance data with TennCare.(viii) The performance benchmark for the Consistent Staff Assignment measure shall be established in consultation with THCA, and with input from other NF stakeholders, including individuals receiving services and their family members and representatives. The performance benchmark for rates effective on July 1, 2018, shall be provided to NFs and posted on the TennCare website no later than two (2) months prior to the implementation of the reimbursement system. The performance benchmark for rates effective on July 1, 2019, and July 1, 2020, shall be provided to NFs and posted on the TennCare website by May 1 of each year.4. Staff Retention shall be defined as the percentage of specified staff that have been employed (or contracted) by the NF for at least one (1) year.(i) Specified staff shall include only RNs, LPNs, and NAs.(ii) RNs shall include registered nurses, RN directors of nursing, and nurses with administrative duties.(iii) LPNs shall include licensed practical/licensed vocational nurses.(iv) NAs shall include certified nurse aides, aides in training, and medication aides/technicians.(v) Specified staff shall include both NF employees (full-time and part-time) and individuals under an organization (agency) or individual contract. Retention of contracted staff shall be reported and measured based on the length of service of each staff person, and not the length of the contract. For example, if a staffing agency is used, a person shall be considered "continuously" contracted only if that staff person has been assigned to and working at the facility throughout the course of the twelve (12) month measurement period, even if the contract with that organization (agency) has been in place for a longer period.(vi) Specified staff shall not include staff reimbursed by a resident or his/her family, hospice staff, or feeding assistants.(vii) Specified staff information at the beginning and end of the measurement period shall be provided to TennCare in the required form and format.(viii) A NF's performance on the Staff Retention measure shall be calculated by dividing the number of specified staff continuously employed (or contracted) by the facility for the twelve (12) month measurement period divided by the total number of specified facility staff employed at the outset of the twelve (12) month measurement period.(ix) The performance benchmark for the Staff Retention measure shall be established in consultation with THCA, and with input from other NF stakeholders, including individuals receiving services and their family members and representatives. The performance benchmark for rates effective on July 1, 2018, shall be provided to NFs and posted on the TennCare website no later than two (2) months prior to the implementation of the reimbursement system. The performance benchmark for rates effective on July 1, 2019, and July 1, 2020, shall be provided to NFs and posted on the TennCare website by May 1 of each year.5. Staff Training shall be defined as the percentage of specified staff who complete specified training activities. (i) For purposes of the NF reimbursement rates effective on July 1, 2018, July 1, 2019, and July 1, 2020, the methodology used for calculating a facility's score for the Staff Training measure and the performance benchmark for the Staff Training measure shall be developed in consultation with THCA, and with input from other NF stakeholders including individuals receiving services and their family members and representatives. These criteria shall be provided to NFs and posted on the TennCare website no later than May 1 of each year.(ii) Upon implementation of the QuILTSS comprehensive competency-based workforce development training program, specified training activities shall be completion of badges based on the CMS-funded core competencies for direct support workforce.(d) Clinical Performance shall be valued at ten (10) of the one hundred (100) possible quality performance points.1. Clinical Performance shall include two (2) separate measures, with each measure valued at five (5) of the one hundred (100) possible quality performance points, as follows: (i) Antipsychotic Medications shall include two measurements:(I) The percentage of long-stay residents who receive an antipsychotic medication during the measurement period.(II) The percentage of short-stay residents who receive an antipsychotic medication during the measurement period but not on their initial assessment.(III) Long-stay and short-stay residents shall be as defined in Subparagraph (c).(IV) Antipsychotic Medications measures shall be calculated consistent with the methodology described in the CMS Five Star Nursing Home Quality Rating System.(ii) Infection Prevention measures shall be calculated based on the rate of urinary tract infections among patients consistent with the methodology described in the CMS Five Star Nursing Home Quality Rating System.2. Performance benchmarks for each of the Clinical Performance measures shall be established in consultation with THCA, and with input from other NF stakeholders, including individuals receiving services and their family members and representatives. These criteria shall be provided to NFs and posted on the TennCare website no later than two (2) months prior to implementation of the reimbursement system.(e) In addition to the one hundred (100) possible quality performance points that a NF may score in the areas described in Subparagraphs (a), (b), (c) and (d) above, a NF may also earn ten (10) bonus points for qualifying awards and/or accreditations that evidence the facility's commitment to quality improvement processes. Qualifying awards or accreditations must be current in the review period and are restricted to the following:1. Full participation in the National Nursing Home Quality Improvement Campaign, which must be active during the period in which bonus points are sought.2. Membership in Eden Registry, which must be active during the period in which bonus points are sought.3. Achievement of the Malcolm Baldrige Quality Award. This includes AHCA Award (Bronze, Silver, or Gold) and the TN Center for Performance Excellence Award (Level 2, 3, or 4, which correspond with the Commitment Award, Achievement Award, and Excellence Award; the Level 1 Interest Award is specifically excluded from points). Any such award must have been achieved within the three (3) years prior to the end of the period in which bonus points are sought.4. Accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARE).5. Accreditation by the Joint Commission. (5) A NF shall be eligible to receive the quality-based component of the per diem payment for NF services only if it has fully satisfied the following threshold measures: (a) The facility must be current on its payment of the NF Assessment Fee. Anytime a facility is more than thirty (30) days delinquent on its NF Assessment Fee, the qualitybased component of the per-diem payment for NF services shall be suspended, and the facility shall forfeit any quality-based component of its per diem reimbursement rate until such time that the NF is current on its Assessment Fee payments. This shall be operationalized as an MCO rate withhold, pursuant to T.C.A. § 71-5-1006.(b) The facility has submitted complete, accurate and timely quality measurement data as required by TennCare in order to determine the NF's quality performance. 1. Except as otherwise specified by TennCare, quality measurement data shall be submitted by the NF on an annual basis. Where possible and appropriate, TennCare will utilize existing data sources to minimize administrative burden.2. The data measurement period shall be January 1 through December 31 of each year, which shall be used to inform the quality-based component of the per diem payment for the fiscal year beginning July 1 immediately after.3. A NF shall not be entitled to a quality-based component of the per diem payment for any NF services provided if the facility has not complied with quality performance reporting requirements, or if the facility knowingly submits, or causes or allows to be submitted any such data used for purposes of setting quality-based rate components that is determined (including upon post-payment audit or review) to be inaccurate or incomplete.4. Any facility knowingly submitting false (including inaccurate or incomplete) quality performance data for purposes of calculating its Medicaid payment shall be subject to all applicable federal and state laws pertaining to the submission of false claims.5. For purposes of this subparagraph, the term "knowingly" shall mean that a NF, or any person acting on its behalf: (a) has or should have, upon exercise of due diligence, actual knowledge of the information;(b) acts in deliberate ignorance of the truth or falsity of the information; or (c) acts in reckless disregard of the truth or falsity of the information. No proof of specific intent is required.(6) Based on quality incentive program scoring a NF will be placed into one of three quality tiers. The quality tier cut points may only be updated for the July 1 rate setting of a rebase period. For the July 1, 2018, rate effective date, the quality tier cut points will be as follows: Quality Tier | Cut Point Range |
Quality Tier 1 | 75- 100 |
Quality Tier 2 | 50- 74.99 |
Quality Tier 3 | 0- 49.99 |
(7) A NF's quality tier and quality incentive program score will be established for each July 1 rate setting. The quality tier and quality incentive program score will be based on the quality incentive program measurement period for the calendar year period immediately preceding the applicable July 1 rate setting. (8) A NFs quality incentive program score is based on the point structure previously described in this rule. As quality data is collected throughout the quality incentive program measurement period, the following score weighting will be applied to the varying metric collection intervals:(a) Quality incentive program scoring metrics that are annual in nature will not be weighted.(b) Quality incentive program scoring metrics that are semi-annual in nature will be weighted as follows:1. 2/3rds weight for the most recent six month period.2. 1/3rd weight for the first six month period.(c) Quality incentive program scoring metrics that are quarterly in nature will be weighted as follows: 1. 50% weight for the fourth quarter of the calendar year.2. 25% weight for the third quarter of the calendar year.3. 15% weight for the second quarter of the calendar year.4. 10% weight for the first quarter of the calendar year.(d) For any metric collection period, regardless of collection interval, in which the final period is not the highest scoring period, the NF provider's quality incentive program scoring metrics will use the metric weighting method below that results in the greatest overall quality incentive program score:1. The quality incentive program scoring metric weighting methods previously described in this paragraph.2. A Quality incentive program scoring metric weighting method that equally weights all metric collection periods, regardless of collection interval.(9) Confidentiality of Submitted Quality Information. Any submissions by any facility relating to documentation of and participation in the Quality-based Component of the Reimbursement Methodology for Nursing Facilities pursuant to Rule .11 shall be confidential and privileged and shall be protected from direct or indirect means of discovery, subpoena or admission into evidence in any judicial or administrative proceeding. However, nothing in this rule shall not be construed to make immune from discovery or use in any judicial or administrative proceeding information, record, or documents that are otherwise available from original sources kept in the facility, and would otherwise be available to a litigant through discovered requested from the Facility. The confidentiality provisions of this paragraph shall also not apply to any judicial or administrative proceeding contesting the determination of TennCare regarding the Facility's quality component reimbursement.Tenn. Comp. R. & Regs. 1200-13-02-.11
Original rules filed May 1, 2018; effective July 30, 2018. Amendments filed January 28, 2021; effective 4/28/2021.Authority: T.C.A. §§ 4-5-202, 71-5-105, 71-5-109, and 71-5-1413.