(A) As used in this rule:
(1) "Annual facility average case mix score"
is the score used to calculate the facility's cost per case-mix unit.
(2) "Assessment reference date (ARD)" is the
last day of the observation (or "look back") period that the MDS 3.0 assessment
covers for the resident.
(3) "Care area assessment (CAA)
process" is the mechanism to facilitate care planning decisions and includes
care area triggers (CATs), assessment of a triggered care area to facilitate
care planning decision making and completion of the CAA summary (on the MDS 3.0
, section V, item V0200) titled CAAs and care planning.
(4)(3) "Case mix report"
is a report generated by the Ohio department of
job
and family services (ODJFS)
medicaid
(ODM) and distributed to the provider on the status of all MDS 3.0
assessment data that pertains to the calculation of a quarterly, semiannual
, or annual facility average case mix score.
(5)(4)
"Comprehensive assessment" means an assessment that includes completion of
not only the appropriate MDS 3.0 assessment
type listed in paragraph (B)(2) of this rule and
designated for use in Ohio but also completion of the CAA
process.
(6)(5) "Critical elements"
are data items from a resident's MDS 3.0 that
ODJFS
ODM verifies prior to determining a
resident's resource utilization group
, version
III (
RUG III)
class
classification.
(7)(6)
"Critical errors" are errors in the MDS 3.0 critical elements that prevent
ODJFS
ODM
from determining the resident's
RUG III
classification.
(8)(7) "Default group" is
RUG III group forty-five, the case mix
group assigned to residents with MDS 3.0 records with inconsistent date fields,
missing, incomplete, out of range
, or inaccurate
data, including inaccurate resident identifiers
,
any of which precludes grouping the record into
non-default RUG III groups
one through
forty-four.
(9)(8) "Encoded," when
used with reference to a record, means that the record has been recorded in
electronic format. The record must be encoded in accordance with
the United States centers for medicare and medicaid
services (CMS) uniform data submission document and state
specifications
MDS 3.0 data submission
specifications version 1.15.0.
(10)(9) "Filing date" is
the deadline for submission of the NF's MDS 3.0 assessment data that will be
used to calculate the preliminary facility quarterly average case mix score.
The filing date is the fifteenth calendar day following the reporting period
end date (RPED).
(10)
"MDS 3.0 " is the uniform resident assessment
instrument specified for use in Ohio pursuant to
42 C.F.R.
483.20 (October 1, 2014) for implementing
standardized resident assessments and for facilitating care management in
nursing facilities. The MDS 3.0 provides the core data elements used to group
residents into case mix categories. It also includes Ohio-specific data
elements, designated as section S. A copy of the section S requirements is
available at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities.aspx
.
(11)
"Medicare required assessment" means the MDS 3.0
specified for use in Ohio that is required only for
facilities participating in the medicare prospective payment system
but does not include the CAA process.
(12) "Omnibus Budget Reconciliation
Act of 1987 (OBRA 1987)" is the statutory authority for the RAI which specifies
the minimum data set (MDS) of core elements for use in conducting assessments
of nursing home residents. Assessments are federally mandated and must be
performed for all residents of medicare and/or medicaid certified nursing
homes.
(13)(12) "Other medicare
required assessment (OMRA)" is an unscheduled MDS 3.0
prospective payment system (PPS)
PPS assessment required to be completed
during a resident's medicare "Part A" SNF covered stay based on the start or
cessation of rehabilitation services.
(14)(13) "PPS assessment"
is the
tool
MDS
3.0 that skilled nursing facilities (SNFs) use to assess the clinical
condition for each medicare resident receiving "Part A" SNF level care for
reimbursement under the SNF PPS.
(15)(14) "Quarterly
facility average total case mix score" is the facility average case mix score
based on both medicaid and non-medicaid resident data submitted for one
reporting quarter and calculated pursuant to paragraph (B)(1) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(16)(15)
"Quarterly facility average medicaid case mix score" is the facility average
case mix score based on only medicaid resident data submitted for one reporting
quarter and calculated pursuant to paragraph (B)(2) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(17)(16)
"Quarterly review assessment" means an assessment that is normally conducted no
less than once every three months using the MDS 3.0designated for use in Ohio that does not include the CAA
process.
(18)(17) "Record" means a
resident's encoded MDS 3.0 assessment as described in paragraphs (B)(1) to
(B)(4) of this rule.
(19)(18) "Relative
resource weight" is the measure of the relative costliness of caring for
residents in one case mix group versus another, indicating the relative amount
and cost of staff time required on average for defined worker classifications
to care for residents in a single case mix group. The methodology for
calculating relative resource weights is described in paragraph
(H)
(E) of
rule
5101:3-3- 43.2
5160-3- 43.2 of the Administrative Code.
(20)(19)
"Reporting period end date" (RPED) is the last day of each calendar
quarter.
(21)(20) "Reporting
quarter" is the calendar quarter in which the MDS 3.0 is completed, as
indicated by the assessment reference date in MDS 3.0 section A, item A2300,
except as specified in paragraphs (C)(7) and (C)(8) of this rule.
(22)(21)
"Resident Assessment Instrument (RAI)" is the
instrument
MDS 3.0
used by NFs in Ohio to comply with
regulations in
42 C.F.R.
483.20
(effective
8/11/09 http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?
sid=2e0cc442b567f836691e8d460522a8a3 &
c=ecfr&tpl0=/ecfrbrowse/Title42/42tab_02.tpl) and provides a comprehensive,
accurate, standardized, reproducible assessment of each long term care facility
resident's functional capabilities and identifies medical problems. The Ohio
specified and federally approved instrument is composed of the MDS 3.0 , and
CAA process.
(23)(22) "Resident case
mix score" is the relative resource weight for the RUG
III group to which the resident is assigned
based on data elements from the resident's MDS 3.0 assessment.
(24)(23)
"Resident identifier code" is an alternative resident identifier if the
resident does not have a social security number. The resident identifier code
shall be reported in MDS 3.0
section S, item
S0150. The following method must be used to construct the identifier
code
.
:
In the first three boxes, enter the first three
letters of the resident's last name. In the next six boxes, enter the six
digits of the resident's date of birth. Omit the century in the birth
date.
(a)
In the first three boxes, enter the first three letters of the resident's last
name.
(b)
In the next six boxes, enter the six digits of the
resident's date of birth.
(c)
Omit the century in the birth date.
(25)(24) "
RUG
III" is the resource utilization
groups
, version III system of classifying
NF residents
into case mix groups described
in paragraph (B) of rule
5101:3-3- 43.2
5160-3- 43.2 of the Administrative Code. Resource
utilization groups are clusters of NF residents
, defined by resident characteristics
, that correlate with resource use.
(a)
For rates paid
for services provided before July 1, 2016, the RUG version used in Ohio is
version III (RUG III).
(b)
For rates paid for services provided July 1, 2016 and
thereafter, the RUG version used in Ohio shall be version IV (RUG
IV).
(26)(25) "Semiannual
facility average medicaid case mix score" is the average of a facility's two
quarterly facility average medicaid case mix scores. It is used to establish
the direct care rate and is calculated pursuant to paragraph (E) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(B) For the purpose of assigning a
RUG III classification
for determining medicaid payment rates for NFs,
ODJFS
ODM
shall utilize the data from the MDS 3.0
as specified
by the state and approved by CMS. Each NF shall assess all residents
of medicaid-certified beds using the appropriate MDS 3.0
for assessment reference dates (ARDs) on or after October 1,
2010 as set forth in appendix A to this rule for a comprehensive assessment, or
appendix D to this rule for a quarterly assessment, or appendix E to this rule
for a PPS assessment. When the
Omnibus
Budget Reconciliation Act of 1987 (OBRA 1987) assessment
(admission assessment, annual assessment, quarterly
assessment, or significant change in status or a significant correction to a
prior assessment) and
coincides with
medicare assessment time frames
coincide,
one assessment shall be used to satisfy both assessments. Admission assessments
must be combined with either the medicare five day or medicare fourteen day
assessment. For a resident who is not a
new admission to the facility, the
quarterly,
the annual, and significant
change in status assessments must be combined with any medicare assessment if
the assessment reference date (ARD) is within the assigned medicare observation
period. When combining the
OBRA and
medicare assessments, the most stringent requirement for MDS
completion must be met.
ODJFS
ODM may not utilize the data in the other
medicare required assessments (OMRAs) for calculating case mix scores or
determining medicaid payment rates.
(1)
Comprehensive assessments, medicare-required assessments, quarterly review
assessments
, and significant corrections of
quarterly assessments must be conducted in accordance with the requirements and
frequency schedule found at
42 C.F.R.
483.20.
(2) For a comprehensive assessment, NFs must
use the
Ohio specified MDS 3.0, including
section S. The comprehensive assessment
, as set
forth in appendix A to this rule is completed
upon admission, annually, and when a significant
change in the resident's status has occurred or a significant correction to a
prior comprehensive assessment is required
as
specified in the MDS 3.0 RAI manual. NFs must use the
Ohio specified nursing home quarterly MDS
3.0
,
as set forth in
appendix D to this rule including section S
, for the quarterly review assessment or a significant
correction to a prior quarterly assessment. The nursing home PPS assessment
(set forth in appendix E to this rule) must
be used for all medicare required assessments.
(3) NFs must use the MDS 3.0 discharge item
set
as set forth in appendix B to this rule
for any residents who
transfer
, or are
discharged
, and the MDS 3.0 tracking record
as set forth in appendix C to this rule for
any residents entering or reentering or who died in the facility in accordance
with
42 C.F.R.
483.20.
(4) NFs must use the MDS correction request
in section X of the MDS 3.0 for modification or inactivation of MDS records
that have been accepted into the
national
MDS
CMS database.
(C) All NFs must submit to the
national
CMS
database encoded, accurate, and complete MDS 3.0 data for all residents of
medicaid certified NF beds, regardless of pay source or anticipated length of
stay.
(1) MDS 3.0 data completed in
accordance with paragraphs (B)(1) to (B)(4) of this rule must be encoded in
accordance with
42 C.F.R. 483.20, CMS' uniform data
submission document, and state record layout specifications
MDS 3.0 data submission specifications version
1.15.0.
(2) MDS 3.0 data must
be
submitted in an electronic format
encoded
and in accordance
with the frequency schedule found in 42 C.F.R. 483.20. The data may be
submitted at any time during the reporting quarter that is permitted by
instructions
issued by the state
in the MDS 3.0 RAI manual. Except as provided in
paragraph (D) of this rule, all records used in determining the quarterly
facility average total case mix score and quarterly facility average medicaid
case mix score must be submitted by the filing date.
(3) If a NF submits MDS 3.0 data needed for
determining the quarterly facility average total case mix score and quarterly
facility average medicaid case mix score after the forty-fifth day after the
RPED,
ODJFS
ODM may assign a quarterly facility average total case
mix score as set forth in paragraph (C)(3) of rule
5101:3-3- 43.3
5160-3-
43.3 of the Administrative Code and a quarterly facility average medicaid
case mix score as set forth in paragraph (D)(4) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(4) MDS 3.0 data submitted by a provider that
can not be timely extracted by
ODJFS
ODM from the CMS data server may result in
assignment of a quarterly facility average total case mix score as set forth in
paragraph (C)(3) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code and a
quarterly facility average medicaid case mix score as set forth in paragraph
(D)(4) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(5) The annual
facility average case mix score,
semiannual, and quarterly facility average
total case mix score
, and quarterly
and semiannual facility average medicaid case mix
score
scores
will be calculated using the MDS 3.0 record in effect on the RPED for:
(a) Residents who were admitted to the
medicaid certified NF prior to the RPED and continue to be physically present
in the NF on the RPED; and
(b)
Residents who were admitted to the medicaid certified NF on the RPED; and
(c) Residents who were temporarily
absent on the RPED but are considered residents and for whom a return is
anticipated from hospital stays, visits with friends or relatives, or
participation in therapeutic programs outside the facility.
(6) Records for residents who were
permanently discharged from the NF, transferred to another NF, or expired prior
to or on the RPED will not be used for determining the quarterly facility
average total case mix score and quarterly facility average medicaid case mix
score.
(7) For a resident admitted
within fourteen days prior to the RPED, and whose initial assessment is not due
until after the RPED, both of the following shall apply:
(a) The NF shall submit the appropriate
initial assessment as specified in
the "Long-Term
Care Facility Resident Assessment Instrument User's Manual version 3.0 " issued
by CMS (May 2010 http://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp)
and in
42 C.F.R.
483.20
and in the MDS
3.0 RAI manual.
(b) The
initial assessment, if completed and submitted timely in accordance with
paragraphs (C)(1) and (C)(2) of this rule, shall be used for determining the
quarterly facility average total case mix score and may be used for determining
the quarterly facility average medicaid case mix score in the quarter the
resident entered the facility even if the assessment reference date is after
the RPED provided the record is identified as a medicaid record pursuant to the
calculation methodology in rule
5101:3-3-
43.3
5160-3- 43.3 of the Administrative
Code.
(8) For a resident
who had at least one MDS 3.0 assessment completed before being transferred to a
hospital,
who then reenters the NF within
fourteen days prior to the RPED, and has experienced a significant change in
status that requires a comprehensive assessment upon reentry, the following
shall apply:
(a) The NF shall submit a
significant change assessment within fourteen days of reentry, as indicated by
the MDS 3.0 assessment reference date (MDS 3.0, item A2300).
(b) The significant change assessment shall
be used for determining the quarterly facility average total case mix score and
may be used for determining the quarterly facility average medicaid case mix
score for the quarter in which the resident reentered the facility even if the
assessment reference date is after the RPED provided the record is identified
as a medicaid record pursuant to the calculation methodology in rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(D)
Corrections to MDS 2.0 data with an ARD on or before
September 30, 2010 must be made in accordance with the requirements in the "CMS
Revised Long Term Care Resident Assessment Instrument User's Manual version 2.0
", and the "State Operations Manual" issued by CMS
(http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&=1sortByDID=ascending&itemID=CMS1201984
&intNumPerPage=10). Corrections to MDS 3.0 data
with an ARD on or after October 1, 2010
must be made in accordance with the requirements in the
"Long-Term Care Facility Resident Assessment
Instrument User's Manual version 3.0 "
MDS 3.0
RAI manual
, and the "State Operations Manual"
issued by CMS (Rev.1, May 21, 2004
http://www.cms.gov/Manuals/IOM/).
(1) For use in determining the quarterly
facility average total case mix score and quarterly facility average medicaid
case mix score, the facility must transmit the corrections to the
national
CMS
database no later than forty-five days after the RPED.
(2) For use in determining the quarterly
facility average total case mix score and quarterly facility average medicaid
case mix score, all significant correction assessments must contain an
assessment reference date within the reporting quarter.
(3) The provider shall submit an accurate,
encoded
MDS 2.0 record for an ARD on or before
September 30, 2010, or an accurate, encoded MDS 3.0 record
for an ARD on or after October 1, 2010 for
each resident in a medicaid certified bed on the RPED.
(a) The provider shall transmit MDS
assessments that were completed timely but omitted from the previous
transmissions and
ODJFS
ODM shall use the resident case mix scores from
the assessments for determining the quarterly facility average total case mix
score
, and may
be
used
use them for determining the
quarterly facility average medicaid case mix score
, if the assessments are transmitted no later than
forty-five days after the RPED provided the record is identified as a medicaid
record pursuant to the calculation methodology in rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code. If the
assessments are not transmitted within forty-five days after the RPED,
ODJFS
ODM may
assign a default group for those records.
(b) The provider shall notify
ODJFS
ODM
within forty-five days of the RPED of any records for residents in medicaid
certified beds on the RPED that were not completed timely and were not
transmitted to the
national
CMS database.
ODJFS
ODM may
assign default scores to those records
as described
in paragraph (F) of rule 5101:3-3-43.2 of the Administrative Code.
(c) The provider has forty-five
days after the RPED to transmit the appropriate discharge assessment to the
national
CMS
database
, if more residents are determined
as being
to be
in the facility on the RPED than the number of
its medicaid certified beds
in the facility on that same date. If the facility
does not correct the error within forty-five days after the RPED,
ODJFS
ODM may
assign a quarterly facility average total case mix score as specified in
paragraph (C)(3) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code and a
quarterly facility average medicaid case mix score as specified in paragraph
(D)(4) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(d) The provider shall notify
ODJFS
ODM
within forty-five days of the RPED of any residents who were reported to be
residents of the facility on the RPED, but who had actually been discharged
prior to the RPED. If the provider fails to correct the error within forty-five
days after the RPED,
ODJFS
ODM may assign a quarterly facility average total
case mix score as specified in paragraph (C)(3) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code and a
quarterly facility average medicaid case mix score as specified in paragraph
(D)(4) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(e) The provider has forty-five days after
the RPED to submit appropriate modifications or discharge assessments to
rectify any discrepancy between the records selected for determining the
quarterly facility average total case mix score and the facility census on the
RPED. If the facility does not correct the error(s) within forty-five days
after the RPED,
ODJFS
ODM may assign a quarterly facility average total
case mix score as specified in paragraph (C)(3) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code and a
quarterly facility average medicaid case mix score as specified in paragraph
(D)(4) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
(4) If the provider's number of
records assigned to the default group in accordance with paragraphs (D)(3)(a)
and (D)(3)(b) of this rule is greater than ten per cent,
ODJFS
ODM may
assign a quarterly facility average total case mix score as specified in
paragraph (C)(3) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code and a
quarterly facility average medicaid case mix score as specified in paragraph
(D)(4) of rule
5101:3-3- 43.3
5160-3- 43.3 of the Administrative Code.
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