Ohio Admin. Code 5123-7-33 - Intermediate care facilities for individuals with intellectual disabilities - resident assessment classification system based on administration of the Ohio developmental disabilities profile

(A) Purpose

This rule sets forth a method and process for determining the per resident/per day rate paid to an intermediate care facility for individuals with intellectual disabilities (ICFIID) for direct care costs using the Ohio developmental disabilities profile pursuant to sections 5124.19 to 5124.193 of the Revised Code.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Annual facility average case mix score" means the ICFIID's average case mix score of all qualifying quarters in a calendar year.

(2) "Case mix score" means the measure of the relative direct care resources needed to provide care and rehabilitation to a resident of an ICFIID using the Ohio developmental disabilities profile.

(3) "Correction submission due date" means the deadline for an ICFIID to submit corrected Ohio developmental disabilities profile data to the department. The correction submission due date applies to corrections submitted in electronic format for facility level errors and resident record changes.

(4) "Cost per case mix unit" is calculated by dividing an ICFIID's desk-reviewed, actual, allowable, per diem direct care costs for the calendar year preceding the fiscal year in which the rate will be paid by the annual facility average case mix score for the calendar year preceding the fiscal year in which the rate will be paid.

(5) "Facility level errors" means errors which must be corrected before a facility average case mix score can be calculated and include:

(a) Failure to electronically submit the certification of Ohio developmental disabilities profile data by the filing date; and

(b) Incomplete or inaccurate changes to a resident's assessment data are submitted to the department.

(6) "Filing date" means the deadline for initial quarterly electronic submission and certification of an ICFIID's Ohio developmental disabilities profile data, which is the fifteenth calendar day following the reporting period end date.

(7) "Individual assessment form" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities for the purpose of calculating an ICFIID's direct care costs pursuant to sections 5124.195 to 5124.198 of the Revised Code.

(8)(7) "Ohio developmental disabilities profile" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities for the purpose of calculating an ICFIID's direct care component rate pursuant to sections 5124.19 to 5124.193 of the Revised Code.

(9)(8) "Peer group" means one of the following groups of ICFIID:

(a) "Peer group 1-A 1" includes each ICFIID with a medicaid-certified capacity exceeding sixteen.

(b) "Peer group 2-A 2" includes each ICFIID with a medicaid-certified capacity exceeding eight but not exceeding sixteen.

(c) "Peer group 3-A 3" includes each ICFIID with a medicaid-certified capacity of seven or eight.

(d) "Peer group 4-A 4" includes each ICFIID with a medicaid-certified capacity not exceeding six, other than an ICFIID that is in peer group 5-A 5.

(e) "Peer group 5-A 5" includes each ICFIID to which all of the following apply:

(i) The ICFIID is first certified as an ICFIID after July 1, 2014;

(ii) The ICFIID has a medicaid-certified capacity not exceeding six;

(iii) The ICFIID has a contract with the department that is for fifteen years and includes a provision for the department to approve all admissions to, and discharges from, the ICFIID; and

(iv) The ICFIID's residents are admitted to the ICFIID directly from a department-operated ICFIID or have been determined by the department to be at risk of admission to a department-operated ICFIID.

(f) "Peer group 6" includes each ICFIID to which all of the following apply:

(i) The ICFIID has submitted a best practices protocol for providing services to youth up to twenty-one years of age in need of intensive behavioral support services that has been approved by the department;

(ii) The ICFIID, or a distinct unit of the ICFIID, has a medicaid-certified capacity not exceeding six;

(iii) The ICFIID has a contract with the department that includes a provision for the department to approve all admissions to the ICFIID; and

(iv) The ICFIID has agreed to be reimbursed in accordance with the reimbursement methodology established under the rules authorized by section 5124.03 of the Revised Code.

(10)(9) "Processing quarter" means the quarter that follows the reporting quarter and is the quarter in which the department receives the Ohio developmental disabilities profile data for the reporting quarter.

(11)(10) "Quarterly facility average case mix score" means the facility average case mix score based on Ohio developmental disabilities profile data submitted for one reporting quarter.

(12)(11) "Record" means a resident's Ohio developmental disabilities profile data processed by the department.

(13)(12) "Relative resource weight" means the measure of the relative costliness of caring for residents in one case mix classification versus another, indicating the relative amount and cost of staff time required on average for defined job types to care for residents in a single case mix classification.

(14)(13) "Reporting period end date" means the last day of each calendar quarter.

(15)(14) "Reporting quarter" means the quarter which precedes the processing quarter.

(16)(15) "Resident assessment classification system" means the system for classifying residents of an ICFIID into case mix classifications that reflect clusters of residents, defined by resident characteristics, determined using data from the Ohio developmental disabilities profile, that explain resource use.

(17)(16) "Resident case mix score" means the relative resource weight for the classification to which a resident is assigned based on data elements from the resident's Ohio developmental disabilities profile.

(C) Calculating direct care costs

For a period of three years commencing on the effective date of this rule, the department shall calculate for each eligible ICFIID, two separate per resident/per day rates for direct care costs using data from:

(1) Administration of the individual assessment form to residents of the ICFIID in accordance with rule 5123-7-20 of the Administrative Code; and

(2) Administration of the Ohio developmental disabilities profile to residents of the ICFIID in accordance with this rule and rule 5123:2-7-32 of the Administrative Code.

(D)(C) Resident assessment classification system

(1) The department shall will use the resident assessment classification system to classify residents of an ICFIID based on the data from the Ohio developmental disabilities profile. Using point values assigned to responses to questions on the Ohio developmental disabilities profile as set forth in the appendix to this rule, the Ohio developmental disabilities profile for each resident will be scored in three distinct domains:

(a) Medical;

(b) Behavioral; and

(c) Adaptive skills.

(2) The department shall will calculate a resident's assessment score for each of the medical, behavioral, and adaptive skills domains and assign points:

(a) If the resident's assessment score for the domain is more than one standard deviation above the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, one point;

(b) If the resident's assessment score for the domain is more than one-half standard deviation above the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one standard deviation above that mean, two points;

(c) If the resident's assessment score for the domain is more than the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one-half standard deviation above that mean, three points;

(d) If the resident's assessment score for the domain is not more than the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one-half standard deviation below that mean, four points;

(e) If the resident's assessment score for the domain is more than one-half standard deviation below the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one standard deviation below that mean, five points; and

(f) If the resident's assessment score for the domain is more than one standard deviation below the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, six points.

(3) The department shall will determine the weighted sum of the points assigned in accordance with paragraph (D)(2) (C)(2) of this rule to each of the resident's domain assessment scores and round the weighted sum to the nearest whole number:

(a) Points assigned to the resident's assessment score for the medical domain shall will be weighted at thirty-five per cent;

(b) Points assigned to the resident's assessment score for the behavioral domain shall will be weighted at thirty per cent; and

(c) Points assigned to the resident's assessment score for the adaptive skills domain shall will be weighted at thirty-five per cent.

(4) The department shall will place the resident into an acuity group:

(a) If the resident's weighted sum of points is five or lower, group one;

(b) If the resident's weighted sum of points is at least six and not more than eight, group two;

(c) If the resident's weighted sum of points is nine or ten, group three;

(d) If the resident's weighted sum of points is eleven or twelve, group four;

(e) If the resident's weighted sum of points is at least thirteen and not more than fifteen, group five; and

(f) If the resident's weighted sum of points is sixteen or higher, group six.

(E)(D) Relative resource weights

(1) Analysis of staff time and resident assessment data, collected in a work measurement study of Ohio medicaid-certified ICFIID for the purpose of establishing common staff times associated with all resident classifications that are standard across residents, staff, facilities, and units, determined that the job classifications listed in paragraphs (E)(1)(a) to (E)(1)(h) (D)(1)(a) to (D)(1)(h) of this rule are job types that perform activities that vary by case mix classification established using the Ohio developmental disabilities profile. Job types determined not to be positions participating in activities that vary by case mix classification are not used to calculate the relative resource weights described in paragraph (E)(2) (D)(2) of this rule.

(a) Habilitation specialists consisting of nurse aides and habilitation staff;

(b) Licensed practical nurses;

(c) Occupational therapists;

(d) Program specialists;

(e) Qualified intellectual disability professionals;

(f) Registered nurses;

(g) Social workers/counselors; and

(h) Speech therapists.

(2) Each of the six resident acuity groups is assigned a relative resource weight. The relative resource weight indicates the relative amount and cost of staff time required on average for the job types listed in paragraphs (E)(1)(a) to (E)(1)(h) (D)(1)(a) to (D)(1)(h) of this rule to deliver care to residents in that classification. The relative resource weight was calculated using the average minutes of care per job type per classification as determined during the work measurement study, and the averages of the wages by job type as reported on the cost report. By setting the wage weight at one for the job type receiving the lowest hourly wage, wage weights for the other job types are calculated by dividing the lowest wage into the wage of each of the other job types. To calculate the total weighted minutes for each classification, the wage weight for each job type is multiplied by the average number of minutes staff of that job type spend caring for a resident in that classification, and the products are summed. The classification with the lowest total weighted minutes receives a relative resource weight of one. Relative resource weights are calculated by dividing the total weighted minutes of the lowest classification into the total weighted minutes of each classification. Weight calculations are rounded to the second decimal place. Relative resource weights for the resident acuity groups are:

(a) Resident acuity group one = 2.75.

(b) Resident acuity group two = 1.86.

(c) Resident acuity group three = 1.43.

(d) Resident acuity group four = 1.31.

(e) Resident acuity group five = 1.12.

(f) Resident acuity group six = 1.00.

(3) Except as provided in paragraph (E)(3)(a) (D)(3)(a) of this rule, relative resource weights may be recalibrated using wage weights based on three-year statewide averages of wages of the job types listed in this rule as reported on the cost report, and minutes of care per job type per resident assessment classification.

(a) The department may recalibrate the relative resource weights no more often than every three years, using the minutes of care per job type per classification from the most current work measurement study and the wages per job type per hour, to be effective at the beginning of the next state fiscal year. When recalibrating the relative resource weights, the department shall will use cost report wage data from the most recent three calendar years available ninety calendar days prior to the start of the fiscal year.

(b) The department may recalibrate relative resource weights more frequently if significant variances in wage ratios between job types occur.

(c) The department may rebase the relative resource weights through the deletion or addition of job types or with revised minutes of care per job type by conducting a new work measurement study, if significant changes in the job types or work roles of the job types occur, or following a change in state policy which would significantly affect statewide case mix of the ICFIID population.

(d) After recalibrating or rebasing relative resource weights in accordance with paragraph (E)(3)(a), (E)(3)(b), or (E)(3)(c) (D)(3)(a), (D)(3)(b), or (D)(3)(c) of this rule, the department shall will use the recalibrated or rebased relative resource weights to recalculate the annual facility average case mix score for the calendar year preceding the fiscal year.

(4) The annual facility average case mix score is used in conjunction with the lesser of the ICFIID's cost per case mix unit or the maximum allowable cost per case mix unit, adjusted by the inflation rate, to establish the direct care rate, as outlined in sections 5124.19 to 5124.193 of the Revised Code. The ICFIID's cost per case mix unit is calculated using the annual facility average case mix score. The method for determining the annual facility average case mix score is described in paragraph (G) (F) of this rule.

(F)(E) Quarterly facility average case mix score

(1) The department shall will establish each ICFIID's rate for direct care costs annually pursuant to sections 5124.19 to 5124.193 of the Revised Code. To set the rate, the department shall will:

(a) Calculate the ICFIID's cost per case mix unit;

(b) Multiply the lesser of the ICFIID's cost per case mix unit or the maximum cost per case mix unit for the ICFIID's peer group determined pursuant to division (C) of section 5124.19 of the Revised Code by the ICFIID's case mix score for the calendar quarter ending March thirty-first of the calendar year in which the fiscal year for which the rate is set begins, except that for fiscal year 2019, the department shall use the ICFIID's case mix score for the quarter that ends December 31, 2017; and

(c) Multiply the amount determined in accordance with paragraph (F)(1)(b) (E)(1)(b) of this rule by the inflation factor specified in division (D) of section 5124.19 of the Revised Code.

(2) The quarterly facility average case mix score for an ICFIID that submitted Ohio developmental disabilities profile data and modifications timely, and has no facility level errors is calculated by:

(a) Adding together all residents' relative resource weights for the quarter; and

(b) Dividing the sum of relative resource weights by the total number of residents.

(3) The department shall will assign a quarterly facility average case mix score or cost per case mix unit used to establish an ICFIID's rate for direct care costs if the ICFIID fails to correct facility level errors. Before taking such action, the department shall will permit the ICFIID a reasonable period of time to correct the information, in accordance with rule 5123:2-7-32 5123-7-32 of the Administrative Code.

(a) The department may assign a quarterly facility average case mix score that is five per cent less than the ICFIID's quarterly facility average case mix score for the preceding calendar quarter instead of using the quarterly facility average case mix score calculated based on the ICFIID's submitted information as described in paragraph (F)(2) (E)(2) of this rule. If the ICFIID was assigned a quarterly facility average case mix score for the preceding calendar quarter, the assigned quarterly facility average case mix score shall will be the score that is five per cent less than that score assigned for the preceding quarter.

(b) The department may assign a cost per case mix unit that is five per cent less than the ICFIID's calculated or assigned cost per case mix unit for the preceding calendar year if the ICFIID has fewer than two acceptable quarterly facility average case mix scores as described in paragraph (G)(1)(b) (F)(1)(b) of this rule.

(G)(F) Annual facility average case mix score

(1) The annual facility average case mix score is used pursuant to section 5124.19 of the Revised Code to compute the cost per case mix unit for the ICFIID and the peer group maximum cost per case mix unit. Ohio developmental disabilities profile data for all four quarters of the calendar year shall will be used to calculate the annual facility average case mix score:

(a) The department-assigned facility average case mix scores shall will be omitted from the ICFIID's annual average case mix score calculation.

(b) The annual facility average case mix score shall will be calculated from no fewer than two acceptable quarterly facility average case mix scores. Acceptable quarterly facility average case mix scores shall will be summed and divided by the total number of quarters of acceptable scores. Acceptable quarterly facility average case mix scores for the purposes of calculating the annual facility average case mix score and for paragraph (F)(3) (E)(3) of this rule include quarterly facility average case mix scores calculated based on the ICFIID's submitted information as described in paragraph (F)(2) (E)(2) of this rule.

(2) If at least two acceptable quarterly facility average case mix scores are not available, the department shall will assign the cost per case mix unit in accordance with paragraph (F)(3)(b) (E)(3)(b) of this rule.

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Notes

Ohio Admin. Code 5123-7-33

Effective: 7/1/2024
Five Year Review (FYR) Dates: 4/12/2024 and 07/01/2029
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03, 5124.192, 5124.193
Rule Amplifies: 5123.04, 5124.03, 5124.19 to 5124.193
Prior Effective Dates: 07/08/2018, 12/16/2019