Ill. Admin. Code tit. 89, § 147.340 - Minimum Data Set On-Site Reviews
a)
The Department shall conduct reviews to determine the accuracy of the resident
assessment information transmitted in the Minimum Data Set (MDS) that are
relevant to the determination of reimbursement rates. The MDS data used by the
Department to set the reimbursement rate will be used to conduct the validation
reviews. Such reviews may, at the discretion of the Department, be conducted
electronically or onsite in the facility.
b) The Department may select, at random, a
number of facilities in which to conduct quarterly on-site reviews.
c) The Department may also select facilities
for on-site review based upon facility characteristics, atypical patterns of
scoring MDS items, non-submission or late submission of assessments, high
percentage of significant corrections, previous history of review changes, or
the Department's experience. The Department may also use the findings of the
licensing and certification survey conducted by the Department of Public Health
(DPH) indicating the facility is not accurately assessing residents.
d) In addition, the Department may conduct
reviews if the Department determines that circumstances exist that could alter
or affect the validity of case mix classifications of residents. These
circumstances include, but are not limited to, the following:
1) Frequent changes in administration or
management of the facility;
2) An
unusually high percentage of residents in a specific case mix classification or
high percentage of change in the number of residents in a specific case mix
classification;
3) Frequent
adjustments of case mix classification as result of reconsiderations, reviews,
or significant corrections submitted;
4) A criminal indictment alleging fraud;
and
5) Other similar factors that
relate to a facility's ability to conduct accurate assessments.
e) The Department shall provide
for a program of delegated utilization review and quality assurance. The
Department may contract with medical peer review organizations to provide
utilization review and quality assurance.
f) Electronic review. The Department shall
conduct quarterly an electronic review of MDS data for eligible individuals to
identify facilities for on-site review.
g) On-site review. The Department shall
conduct an on-site review of MDS data for eligible individuals. The Department
is authorized to conduct unannounced on-site reviews. On-site reviews may
include, but shall not be limited to, the following:
1) Review of the resident records and
supporting documentation.
2)
Observation and interviews of residents, families and/or staff, to determine
the accuracy of data relevant to the determination of reimbursement
rates.
3) Review and collection of
information necessary to assess the resident's need for a specific service or
care area.
h) The
Department shall select at least 20 percent, with a minimum of 10 assessments,
of the assessments submitted. The number of residents in any selected facility
for whom information is reviewed may, at the sole discretion of the Department,
be limited or expanded.
i) If more
than 25 percent of the RUG-IV classifications are changed as a result of the
initial review, the review may be expanded to a second 25 percent, with a
minimum of 10 assessments. If the total changes between the first and second
sample exceed 40 percent, the Department may expand the review to all the
remaining assessments.
j) If the
facility qualifies for an expanded review, the Department may review the
facility again within 6 months. If a facility has 2 expanded reviews within a
24-month period, that facility may be subject to reviews every 6 months for the
next 18 months and a penalty may be applied as defined in subsection (s) of
this Section.
k) Pursuant to 89
Ill. Adm. Code
140.12(f),
the facility shall provide Department staff with access to residents,
professional and non-licensed direct care staff, facility assessors, clinical
records and completed resident assessment instruments, as well as other
documentation regarding the residents' care needs and treatments. Failure to
provide timely access to records may result in suspension or termination of a
facility's provider agreement in accordance with 89 Ill. Adm. Code
140.l16(a)(4).
l) Department staff
shall request in writing the current charts of individual residents needed to
begin the review process. Current charts and completed MDS for the previous 15
months shall be provided to review team within an hour after the request.
Additional documentation regarding reimbursement areas for the identified
Assessment Reference Date (ARD) timeframe shall be provided to the review team
within 4 hours after the initial request. The team will request no more than 2
records per reviewer to begin the review process. If the facility chooses to
have HFS staff review the electronic health record, at least 2 computer
terminals with read-only access will be made available to the review team
within one hour. Within 4 hours after the team's arrival and for the remainder
of the review, the facility shall provide a computer terminal for each reviewer
or hard copies shall be provided.
m) When further documentation is needed by
the review team to validate an area, the team shall identify the MDS item
requiring additional documentation and provide the facility with the
opportunity to produce that information. The facility shall provide the team
with additional documentation within 24 hours after the initial
request.
n) Facilities shall ensure
that clinical records, regardless of form, are easily and readily accessible to
Department staff.
o) Throughout the
review, the Department shall identify to the facility any preliminary
conclusions regarding the MDS items/areas that could not be validated. If the
facility disagrees with those preliminary conclusions they shall present the
Department with any and all documentation to support their position. It is up
to the facility to determine what documentation is needed to support both the
Resident Assessment Instrument (RAI) Manual and rule requirements regarding the
MDS items identified.
p) All
documentation that is to be considered for validation must be provided to the
team prior to exit. All RAI Manual requirements and requirements identified in
this subsection shall be presented to validate the identified area.
q) Corrective Action. Upon conclusion of the
review and the consideration of any subsequent supporting documentation
provided by the facility, the Department shall notify the facility of its final
conclusions, both with respect to accuracy of data and recalculation of the
facility's reimbursement rate. The Department shall reclassify a resident if
the Department determines that the resident was incorrectly
classified.
r) Data Accuracy. Final
conclusions with respect to inaccurate data may be referred to the appropriate
agencies, including, but not limited to, the Department's Office of Inspector
General, Illinois State Police or Department of Public Health.
s) Recalculation of Reimbursement Rate. The
Department shall determine if the reported MDS data that was subsequently
determined to be unverifiable would cause the direct care component of the
facility's rate to be calculated differently when using the accurate
data.
t) A facility's rate shall be
subject to change if the recalculation of the direct care component rate, as a
result of using RUGs-IV data that is verifiable:
1) Decreases the rate by more than one
percent. The rate is to be changed, retroactive to the beginning of the rate
period, to the recalculated rate.
2) Decreases the rate by more than 10 percent
in addition to the rate change specified in this subsection (t). The direct
care component of the rate may be reduced, retroactive to the beginning of the
rate period, by $1.00 for each whole percentage decrease in excess of 2
percent.
u) Based on the
areas identified as reclassified, the nursing facility may request that the
Department reconsider the assigned classification. The request for
reconsideration shall be submitted in writing to the Department within 30 days
after the date of the Department's notice to the facility. The request for
reconsideration shall include the name and address of the facility, the name of
each resident in which reconsideration is requested, the reasons for the
reconsideration for each resident, and the requested classification changes for
each resident based on the MDS items coded. In addition, a facility may offer
explanations as to how they feel the documentation presented during the review
supports their request for reconsideration. However, all documentation used to
validate an area shall be submitted to the Department prior to exit.
Documentation presented after exit will not be considered when determining a
recalculation request. If the facility fails to provide the required
information with the reconsideration request, or the request is not timely, the
request shall be denied.
v)
Reconsideration by the Department shall be made by individuals not directly
involved in that facility review. The reconsideration shall be based upon the
initial assessment documentation and the reconsideration information sent to
the Department by the facility. The Department shall have 120 days after the
date of the request for reconsideration to make a determination and notify the
facility in writing of the final decision.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.