Section 1603-T - Resident care and related costs.(a) County and nonpublic nursing facility.--The following applies to a county and nonpublic nursing facility enrolled in the medical assistance program: (1) The county or nonpublic nursing facility shall demonstrate on its submitted MA-11 that 70% of its total costs, as reported by the facility, are resident care costs or other resident-related costs under 55 Pa. Code § 1187.51(e)(1) and (2) (relating to scope).(2) Except as provided under paragraph (3), the Department of Human Services shall use the following methodology to determine the facility's compliance with paragraph (1): (i) Add the facility's unallocated total net operating costs reported as total expenses on the facility's Schedule C of the MA-11, plus the following capital costs reported by the facility on its Schedule C, to determine the facility's total costs: (B) Nursing facility assessment/hai assessment.(D) Interest on capital indebtedness.(F) Amortization capital costs.(ii) Add the facility's unallocated total resident care costs reported as total expenses on the facility's Schedule C and the unallocated total other resident related costs reported as total expenses on the facility's Schedule C to determine the facility's total resident cost of care.(iii) Divide the facility's total resident cost of care under subparagraph (ii) by the facility's total costs under subparagraph (i) to determine the percentage of total costs related to resident care costs and other resident-related costs.(3) When a county or nonpublic nursing facility is affiliated with a continuing care retirement community, the following shall apply:(i) The facility shall submit a supplemental cost report form apportioning the capital costs related to the nursing facility, in a form and manner as prescribed by the Department of Human Services.(ii) The Department of Human Services shall use the following methodology to determine the facility's compliance with paragraph (1):(A) Add the facility's unallocated total net operating costs reported as total expenses on the facility's Schedule C of the MA-11, plus the following capital costs, reported by the facility on its supplemental cost report form under subparagraph (i), to determine the facility's total costs:(II) Nursing facility assessment/hai assessment.(IV) Interest on capital indebtedness.(VI) Amortization capital costs.(B) Add the facility's unallocated total resident care costs reported as total expenses on the facility's Schedule C and the unallocated total other resident related costs reported as total expenses on the facility's Schedule C to determine the facility's total resident cost of care.(C) Divide the facility's total resident cost of care under clause (B) by the facility's total costs under clause (A) to determine the percentage of total costs related to resident care and other resident-related costs.(b) Penalty.-- (1) If in any 12-month cost-reporting period a county or nonpublic nursing facility enrolled in the medical assistance program fails to meet the resident care percentage under subsection (a)(1), the Department of Human Services may impose a penalty on the facility up to the difference between the 70% of total costs requirement under paragraph (2) and the percentage spent by the facility on resident care costs or other resident-related costs, but no more than 5%.(2) The formula for determining the maximum penalty amount is as follows:(i) Determine the percentage difference from the 70% resident care requirement by subtracting the percentage of total costs related to resident care and other resident-related costs under subsection (a)(2)(iii) or (3)(ii)(c) from 70%.(ii) Determine the penalty amount as follows: (A) Use the lesser of the following: (II) The difference under subparagraph (i).(B) Multiply the lowest numeral under clause (A) by one hundredth (.01).(C) Multiply the product under clause (B) by the county or nonpublic nursing facility's fee-for-service per diem payment rate as of June 30, 2022.(D) Multiply the product under clause (C) by the total MA resident days of care on the facility's MA-11.(3) A penalty imposed under this section shall be transmitted by the facility to the Department of Human Services for deposit into the Nursing Facility Quality Improvement Fund.(4) The Department of Human Services shall enforce the penalty provisions under this subsection against full 12-month cost reports with reporting periods that begin on or after January 1, 2023, after making the first payment of the increased county and nonpublic nursing facility rates, under both the fee-for-service program and the Community HealthChoices Program, beginning January 1, 2023. If the first payment of the increased county and nonpublic nursing facility rates, including payments under both the fee-for-service program and the Community HealthChoices Program, is after June 30, 2023, the enforcement of the penalty provisions of this subsection shall commence with the first full 12-month cost report after payment of the increased county and nonpublic nursing facility rates.(5) Paragraph (4) shall expire December 31, 2025. (c)Nursing facility quality improvement fund.-- (1) The Nursing Facility Quality Improvement Fund is established as a separate fund in the State Treasury and shall be administered by the Department of Human Services.(2) All interest earned from the investment or deposit of money accumulated in the fund shall be deposited into the fund for the same use.(3) Money in the fund shall be expended by the Department of Human Services for the following purposes: (i) To administer and enforce this section.(ii) To provide funding for nursing facility quality improvement.(d)Guidelines.--The Department of Human Services may promulgate guidelines, as necessary, to implement this section. The guidelines shall be transmitted to the Legislative Reference Bureau for publication in the Pennsylvania Bulletin. Prior to publication of the guidelines, the Department of Human Services shall consult interested parties. The guidelines under this section shall not be subject to: (1) Sections 201, 202, 203, 204 and 205 of the act of July 31, 1968 (P.L. 769, No. 240), referred to as the Commonwealth Documents Law.(2) Sections 204(b)and 301(10) of the act of October 15, 1980 (P.L. 950, No. 164), known as the Commonwealth Attorneys Act.(3) The act of June 25, 1982 (P.L. 633, No. 181), known as the Regulatory Review Act.(e)Definitions.--As used in this section, the following words and phrases shall have the meanings given to them in this subsection unless the context clearly indicates otherwise: "HAI." Hospital acquired infection.
"MA-11." The medical assistance financial and statistical report for nursing facilities and services submitted to the Department of Human Services by either a county nursing facility or a nonpublic nursing facility for a 12-month cost report period.
"Nonpublic nursing facility." A nursing facility other than a county nursing facility or a facility owned or operated by the Federal or State government.
"Schedule C". The computation and allocation of allowable costs schedule.
"Total MA resident days of care." THe nursing facility MA fee-for-service days of care and the Nursing Facility MA Community HealthChoices days of care, as reported on the MA-11.
Added by P.L. TBD 2022 No. 54, § 16, eff. 7/11/2022.