Iowa Admin. Code r. 441-81.6
Current through Register Vol. 47, No. 11, December 11, 2024
With the exception of hospital-based nursing facilities that are Medicare-certified and provide only the skilled level of care, herein referred to as Medicare-certified hospital-based nursing facilities, all facilities in Iowa wishing to participate in the program shall submit a Financial and Statistical Report, Form 470-0030, to the Iowa Medicaid enterprise provider cost audit and rate setting unit. All Medicare-certified hospital-based nursing facilities shall submit a copy of their Medicare cost report. These reports shall be based on the following rules.
On an annual basis, the maximum allowed compensation amounts for these administrators shall be increased or decreased by an annual inflation factor as specified by subrule 81.6(18).
The per diem normalized direct care cost for each facility is arrayed from low to high to determine the direct care component patient-day-weighted median cost based on the number of patient days provided by facilities. The per diem non-direct care cost for each facility is also arrayed from low to high to determine the non-direct care component patient-day-weighted median cost based on the number of patient days provided by facilities. An array and patient-day-weighted median for each cost component is determined separately for both non-state government owned nursing facilities and the Medicare-certified hospital-based nursing facilities.
The wage index factor applied July 1, 2001, through June 30, 2002, shall be 11.46 percent. Beginning July 1, 2002, and thereafter, the wage index factor shall be determined annually by calculating the average difference between the Iowa hospital-based rural wage index and all Iowa hospital-based Metropolitan Statistical Area wage indices as published by the Centers for Medicare and Medicaid Services (CMS) each July. The geographic wage index adjustment shall not exceed $8 per patient day.
A nursing facility may request an exception to application of the geographic wage index based upon a reasonable demonstration of wages, locations, and total cost. The nursing facility shall request the exception within 30 days of receipt of notification to the nursing facility of the new reimbursement rate using the department's procedures for requesting exceptions at rule 441-1.8 (17A,217).
Standard | Measurement Period | Value | Source |
Subcategory: Person-Directed Care | |||
Enhanced Dining A: The facility makes available menu options and alternative selections for all meals. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 1 point | Self-certification |
Enhanced Dining B: The facility provides residents with access to food and beverages 24 hours per day and 7 days per week and empowers staff to honor resident choices. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 1 point | Self-certification |
Enhanced Dining C: The facility offers at least one meal per day for an extended period to give residents the choice of what time to eat. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 2 points | Self-certification |
Resident Activities A: The facility employs a certified activity coordinator for at least 38 minutes per week per licensed bed. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 1 point | Self-certification |
Resident Activities B: The facility either has activity staff that exceed the required minimum set by law or has direct care staff who are trained to plan and conduct activities and carry out both planned and spontaneous activities on a daily basis. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 1 point | Self-certification |
Resident Activities C: The facility's residents report that activities meet their social, emotional and spiritual needs. | For SFY 2010, 10/1/09 to 3/31/10; thereafter, July through March of payment period | 2 points | Self-certification |
Resident Choice A: The facility allows residents to set their own schedules, including what time to get up and what time to go to bed. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 1 point | Self-certification |
Resident Choice B: The facility allows residents to have a choice of whether to take a bath or shower and on which days and at what time the bath or shower will be taken. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 1 point | Self-certification |
Consistent Staffing: The facility has all direct care staff members caring for the same residents at least 70% of their shifts. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 3 points | Self-certification |
National Accreditation: The facility has CARF or another nationally recognized accreditation for the provision of person-directed care. | For SFY 2010, 10/1/09 to 6/30/10; thereafter, payment period | 13 points NOTE: A facility that receives points for this measure does not receive points for any other measures in this subcategory. | Self-certification |
Subcategory: Resident Satisfaction | |||
Resident/Family Satisfaction Survey: The facility administers an anonymous resident/family satisfaction survey annually. The survey tool must be developed, recognized, and standardized by an entity external to the facility. Results must be tabulated by an entity external to the facility. To qualify for the measure, the facility must have a response rate of at least 35%. A summary report of the aggregate results and point scale must be made publicly available and be posted prominently along with the facility's state survey results until the next satisfaction survey is completed. | For SFY 2010, survey completed between 9/1/08 and 3/31/10; thereafter, survey completed between October 1 and March 31 of the payment period | 5 points | Form 470-3891, Nursing Facility Opinion Survey Transmittal, submitted by independent entity that compiled results |
Long-Term Care Ombudsman: The facility has resolved 70% or more of complaints received and investigated by the local or state ombudsman. | Calendar year ending December 31 of the payment period | 5 points if resolution 70% to 74% 7 points if resolution 75% or greater | LTC ombudsman's list of facilities meeting the standard |
Standard | Measurement Period | Value | Source |
Subcategory: Survey | |||
Deficiency-Free Survey: The facility is deficiency-free on the latest annual state and federal licensing and certification survey and any subsequent surveys, complaint investigations, or revisit investigations. If a facility's only scope and severity deficiencies are an A level pursuant to 42 CFR Part 483 , Subparts B and C, as amended to July 30, 1999, the facility shall be deemed to have a deficiency-free survey for purposes of this measure. Surveys are considered complete when all appeal rights have been exhausted. | Calendar year ending December 31 of the payment period, including any subsequent surveys, revisit, or complaint investigations | 10 points | DIA list of facilities meeting the standard |
Regulatory Compliance with Survey: No on-site revisit to the facility is required for recertification surveys or for any substantiated complaint investigations during the measurement period. | Calendar year ending December 31 of the payment period, including any subsequent surveys, revisits, or complaint investigations | 5 points NOTE: A facility that receives points for a deficiency-free survey does not receive points for this measure. | DIA list of facilities meeting the standard |
Subcategory: Staffing | |||
Nursing Hours Provided: The facility's per-resident-day nursing hours are at or above one-half standard deviation above the mean of per-resident-day nursing hours for all facilities. Nursing hours include those of RNs, LPNs, CNAs, rehabilitation nurses, and other contracted nursing services. Nursing hours shall be normalized to remove variations in staff hours associated with different levels of resident case mix. | Facility fiscal year ending on or before December 31 of the payment period | 5 points if case-mix adjusted nursing hours are above mean plus one-half standard deviation 10 points if case-mix adjusted nursing hours are greater than mean plus one standard deviation | Form 470-0030, Financial and Statistical Report, as analyzed by IME provider cost audit and rate setting unit. The facility cost report period case-mix index shall be used to normalize nursing hours. |
Employee Turnover: The facility has overall employee turnover of 50% or less and CNA turnover of 55% or less. | Facility fiscal year ending on or before December 31 of the payment period | 5 points if overall turnover is between 40% and 50% and CNA turnover is between 45% and 55% 10 points if overall turnover is less than or equal to 40% and CNA turnover is less than or equal to 45% | Form 470-0030, Financial and Statistical Report, as analyzed by IME provider cost audit and rate setting unit |
Staff Education, Training and Development: The facility provides staff education, training, and development at 25% above the basic requirements for each position that requires continuing education. The number of hours for these programs must apply to at least 75% of all staff of the facility, based upon administrator or officer certification. | Calendar year ending December 31 of the payment period | 5 points | Self-certification |
Staff Satisfaction Survey: The facility annually administers an anonymous staff satisfaction survey. The survey tool must be developed, recognized, and standardized by an entity external to the facility and must identify worker job classification. Results must be tabulated by an entity external to the facility. To qualify for this measure, the facility must have a response rate of at least 35%. A summary report of the aggregate results and point scale must be made publicly available and be posted prominently along with the facility's state survey results until the next satisfaction survey is completed. | For SFY 2010, survey completed between 9/1/08 and 3/31/10; thereafter, survey completed between October 1 and March 31 of the payment period | 5 points | Form 470-3891, Nursing Facility Opinion Survey Transmittal, submitted by independent entity that compiled results |
Subcategory: Nationally Reported Quality Measures | |||
High-Risk Pressure Ulcer: The facility has occurrences of high-risk pressure ulcers at rates one-half standard deviation or more below the mean percentage of occurrences for all facilities, based on MDS data as applied to the nationally reported quality measures. | 12-month period ending September 30 of the payment period | 3 points if one-half to one standard deviation below the mean percentage of occurrences 5 points if one standard deviation or more below the mean percentage of occurrences | IME medical services unit report based on MDS data as reported by CMS |
Physical Restraints: The facility has a physical restraint rate of 0% based on MDS data as applied to the nationally reported quality measures. | 12-month period ending September 30 of the payment period | 5 points | IME medical services unit report based on MDS data as reported by CMS |
Chronic Care Pain: The facility has occurrences of chronic care pain at rates one-half standard deviation or more below the mean rate of occurrences for all facilities based on MDS data as applied to the nationally reported quality measures. | 12-month period ending September 30 of the payment period | 3 points if one-half to one standard deviation below the mean rate of occurrences 5 points if one standard deviation or more below the mean rate of occurrences | IME medical services unit report based on MDS data as reported by CMS |
High Achievement of Nationally Reported Quality Measures: The facility received at least 9 points from a combination of the measures listed in this subcategory. | 12-month period ending September 30 of the payment period | 2 points if the facility receives 9 to 12 points in the subcategory of nationally reported quality measures 4 points if the facility receives 13 to 15 points in this subcategory | IME medical services unit report based on MDS data as reported by CMS |
Standard | Measurement Period | Value | Source |
Special Licensure Classification: The facility has a unit licensed for the care of residents with chronic confusion or a dementing illness (CCDI unit). | Status on December 31 of the payment period | 4 points | DIA list of facilities meeting the standard |
High Medicaid Utilization: The facility has Medicaid utilization at or above the statewide median plus 10%. Medicaid utilization is determined by dividing total nursing facility Medicaid days by total nursing facility patient days. | Facility fiscal year ending on or before December 31 of the payment period | 3 points if Medicaid utilization is more than the median plus 10% 4 points if Medicaid utilization is more than the median plus 20% | Form 470-0030, Financial and Statistical Report, as analyzed by IME provider cost audit and rate setting unit |
Standard | Measurement Period | Value | Source |
High Occupancy Rate: The facility has an occupancy rate at or above 95%. "Occupancy rate" is defined as the percentage derived when dividing total patient days based on census logs by total bed days available based on the number of authorized licensed beds within the facility. | Facility fiscal year ending on or before December 31 of the payment period | 4 points | Form 470-0030, Financial and Statistical Report, as analyzed by IME provider cost audit and rate setting unit |
Low Administrative Costs: The facility's percentage of administrative costs to total allowable costs is one-half standard deviation or more below the mean percentage of administrative costs for all Iowa facilities. | Facility fiscal year ending on or before December 31 of the payment period | 3 points if administrative costs percentage is less than the mean less one-half standard deviation 4 points if administrative costs percentage is less than the mean less one standard deviation | Form 470-0030, Financial and Statistical Report, as analyzed by IME provider cost audit and rate setting unit |
Score | Amount of Add-on Payment |
0-50 points | No additional reimbursement |
51-60 points | 1 percent of the direct care plus nondirect care cost component patient-day-weighted medians, subject to reduction as provided in subparagraph (13) |
61-70 points | 2 percent of the direct care plus nondirect care cost component patient-day-weighted medians, subject to reduction as provided in subparagraph (13) |
71-80 points | 3 percent of the direct care plus nondirect care cost component patient-day-weighted medians, subject to reduction as provided in subparagraph (13) |
81-90 points | 4 percent of the direct care plus nondirect care cost component patient-day-weighted medians, subject to reduction as provided in subparagraph (13) |
91-100 points | 5 percent of the direct care plus nondirect care cost component patient-day-weighted medians, subject to reduction as provided in subparagraph (13) |
* The estimated date the assets will be placed into service;
* The total estimated depreciable value of the assets;
* The estimated useful life of the assets based upon existing Medicaid and Medicare provisions; and
* The estimated annual depreciation expense of the assets using the straight-line method in accordance with generally accepted accounting principles.
Quality Measures | Metrics | Tracking/Scoring | Data Resource |
Staffing | Metric 1: Nursing facility maintains an additional four or more hours of registered nurse (RN) coverage per day beyond the CMS minimum standard (8 hrs/day). Does not include managerial hours. Metric 2: Nursing facility's per-resident day certified nursing assistants (CNAs), rehabilitation aid, and other contracted aid services are at or above one-half standard deviation above the statewide mean of per-resident-day CNA hours. CNA hours include those of CNAs, rehabilitation aid, and other contracted aide services. CNA hours shall be normalized to remove variations in staff hours associated with different levels of resident case mix. Metric 3: Nursing facility's per-resident day total nursing hours are at or above one-half standard deviation above the statewide mean of per-resident-day total nursing hours. Nursing hours include those of RNs and licensed practical nurses (LPNs) including restorative nurses. Nursing hours shall be normalized to remove variations in staff hours associated with different levels of resident case mix. | Staffing metrics 1, 2, and 3 must be met for facility to be eligible for per diem rate add-on payment. | Payroll-based journal (PBJ) or cost reports |
Infection Control | Metric 1: Nursing facility has an infection control program that includes antibiotic stewardship. The program incorporates policies and training as well as monitoring, documenting, and providing staff with feedback. Metric 2: Percentage of residents with urinary tract infections (UTIs) at rates one-half standard deviation or more below the mean percentage of occurrences for all facilities, based on minimum data set (MDS) data as applied to the nationally reported quality measures. Metric 3: Percentage of residents with up-to-date pneumonia vaccine measured against a fixed benchmark that is set as the most recently published national average for the related MDS quality metric. | Infection control metrics 1, 2, and 3 must be met for facility to be eligible for per diem rate add-on payment. | Nursing facility will be required to provide its infection control policy and procedure. In addition, facilities will need to provide information regarding training, monitoring, documentation and monitoring of required elements to meet this metric on a periodic basis CASPER Report MDS Assessment Care Compare |
Quality Measures | Metric 1: Percentage of high-risk residents with pressure ulcers (for longer-term stay residents) are at rates one-half standard deviation or more below the mean percentage of occurrences for all facilities, based on MDS data as applied to the nationally reported quality measures. Metric 2: Percentage of residents who had a fall with major injury (for longer-term stay residents) are at rates one-half standard deviation or more below the mean percentage of occurrences for all facilities, based on MDS data as applied to the nationally reported quality measures. Metric 3: Percentage of residents who received antipsychotic medications are at rates one-half standard deviation or more below the mean percentage of occurrences for all facilities, based on MDS data as applied to the nationally reported quality measures. Metric 4: Percentage of residents who required increased activities of daily living (ADL) assistance (for longer-term stay residents) are at rates one-half standard deviation or more below the mean percentage of occurrences for all facilities, based on MDS data as applied to the nationally reported quality measures. | Quality measures metrics 1, 2, 3, and 4 must be met for the facility to be eligible for per diem rate add-on payment. | CASPER Report MDS Assessment Care Compare |
State Survey Results | Number of deficiencies is at or below the state of Iowa average number of nursing facility deficiencies AND the facility has no deficiencies with a scope of F, H, I, J, K, or L. | State survey results must be met for the facility to be eligible for per diem rate add-on payment. | Department of inspections and appeals (DIA) surveys |
Quality Assurance Performance Improvement (QAPI) Report | Nursing facility must submit QAPI reports on quarterly basis. | QAPI results must be submitted for the facility to be eligible for per diem rate add-on payment. | QAPI reports |
The facilitywide average case-mix index is the simple average, carried to four decimal places, of all resident case-mix indices. The Medicaid average case-mix index is the simple average, carried to four decimal places, of all indices for residents where Medicaid is known to be the per diem payor source on the last day of the calendar quarter. Assessments that cannot be classified to a RUG-III group due to errors shall be excluded from both average case-mix index calculations.
"Crossover claim" means a claim for Medicaid payment for Medicare-covered nursing facility services rendered to a Medicare beneficiary who is also eligible for Medicaid. Crossover claims include claims for services rendered to beneficiaries who are eligible for Medicaid in any category including, but not limited to, qualified Medicare beneficiaries and beneficiaries who are eligible for full Medicaid coverage.
"Medicaid-allowed amount" means the Medicaid reimbursement rate for the services rendered (including any portion to be paid by the Medicaid beneficiary as client participation) multiplied by the number of Medicaid units of service included in a crossover claim, as determined under state and federal law and policies.
"Medicaid reimbursement" includes any amount to be paid by the Medicaid beneficiary as Medicaid client participation and any amount to be paid by the department after application of any applicable Medicaid client participation.
"Medicare payment amount" means the Medicare reimbursement rate for the services rendered multiplied by the number of Medicare units of service included in a crossover claim, excluding any Medicare coinsurance or deductible amounts to be paid by the Medicare beneficiary.
This rule is intended to implement Iowa Code sections 249A.4 and 249A.16 and chapters 249K and 249L.
Iowa Admin. Code r. 441-81.6