Or. Admin. R. 411-070-0005 - Definitions
Unless the context indicates otherwise, the following definitions and the definitions in OAR 411-085-0005 apply to the rules in OAR chapter 411, division 070:
(1)
"Accrual Method of Accounting" means a method of accounting where revenues are
reported in the period they are earned, regardless of when they are collected,
and expenses are reported in the period they are incurred, regardless of when
they are paid.
(2) "Active
Treatment" means the implementation of an individualized care plan developed
under and supervised by a physician and other qualified mental health
professionals that prescribes specific therapies and activities.
(3) "Activities of Daily Living" means
activities usually performed in the course of a normal day in an individual's
life such as eating, dressing, grooming, bathing, personal hygiene, mobility
(ambulation and transfer), elimination (toileting, bowel, and bladder
management), and cognition and behavior.
(4) "Aging and People with Disabilities
(APD)" means the program area of Aging and People with Disabilities, within the
Department of Human Services.
(5)
"Alternative Services" mean individuals or organizations offering services to
persons living in a community other than a nursing facility or
hospital.
(6) "Area Agency on Aging
(AAA)" means the Department of Human Services designated agency charged with
the responsibility to provide a comprehensive and coordinated system of
services to seniors and individuals with disabilities in a planning and service
area. For the purpose of these rules, the term Area Agency on Aging is
inclusive of both Type A and Type B Area Agencies on Aging as defined in ORS
410.040
and described in ORS
410.210
to
410.300.
(7) "Augmented Rate" means the additional
compensation to a nursing facility who qualifies for the Quality and Efficiency
Incentive Program described in OAR 411-070-0437. The augmented rate is a daily
rate of $9.75 and is in addition to the rate a nursing facility would otherwise
receive. The Department may pay the augmented rate to a qualifying facility for
a period not to exceed four years from the date the facility purchases bed
capacity under the Quality and Efficiency Incentive Program.
(8) "Bariatric rate" means a rate paid for a
Medicaid resident of a nursing facility if the resident meets the criteria
described in OAR 411-070-0087.
(9)
"Basic Flat Rate Payment" and "Basic Rate" means the statewide standard payment
rate for all long-term services provided to a Medicaid resident of a nursing
facility, except for services reimbursed through another Medicaid payment
source. The "Basic Rate" is the bundled payment rate, unless the resident
qualifies for the complex medical rate, the ventilator assisted program rate,
the bundled pediatric rate or the bariatric rate (instead of the basic
rate).
(10) "Bi-PAP" means bi-level
positive airway pressure/spontaneous timed.
(11) "Behavioral Health" means the program
within the Health Systems Division (HSD) within the Oregon Health Authority
(OHA), responsible for addictions and mental health services.
(12) "Capacity" means licensed nursing beds
multiplied by number of days in operation.
(13) "Case Manager" means a Department of
Human Services or Area Agency on Aging employee who assesses the service needs
of an applicant, determines eligibility, and offers service choices to the
eligible individual. The case manager authorizes and implements the service
plan and monitors the services delivered.
(14) "Cash Method of Accounting" means a
method of accounting where revenues are recognized only when cash is received,
and expenditures for expense and asset items are not recorded until cash is
disbursed for them.
(15)
"Categorical Determinations" mean the provisions in the Code of Federal
Regulations (42 CFR
483.130) for creating categories that
describe certain diagnoses, severity of illness, or the need for a particular
service that clearly indicates that admission to a nursing facility is normally
needed or that the provision of specialized services is not normally needed.
(a) Membership in a category may be made by
the evaluator only if existing data on the individual is current, accurate, and
of sufficient scope.
(b) An
individual with mental illness or developmental disabilities may enter a
nursing facility without a PASRR Level II evaluation if criteria of a
categorical determination are met as described in OAR 411-070-0043(2)(a) -
(2)(c).
(16)
"Certification" and "Certification for the Categorical Determination of
Exempted Hospital Discharge" means the attending physician has written orders
for the individual to receive skilled services at the nursing
facility.
(17) "Certified Program"
means a hospital, private agency, or an Area Agency on Aging certified by the
Department of Human Services to conduct private admission assessments in
accordance with ORS
410.505
through
410.530.
(18) "Change of Ownership" means a change in
the individual or legal organization that is responsible for the operation of a
nursing facility. Change of ownership does not include changes in personnel,
e.g., a change of administrators. Events that change ownership include, but are
not limited to, the following:
(a) The form of
legal organization of the owner is changed (e.g., a sole proprietor forms a
partnership or corporation);
(b)
The title to the nursing facility enterprise is transferred to another
party;
(c) The nursing facility
enterprise is leased or an existing lease is terminated;
(d) Where the owner is a partnership, any
event occurs which dissolves the partnership;
(e) Where the owner is a corporation, it is
dissolved, merges with another corporation that is the survivor, or
consolidates with one or more other corporations to form a new corporation;
or
(f) The facility changes
management via a management contract.
(19) "Compensation" means the total of all
benefits and remuneration, exclusive of payroll taxes and regardless of the
form, provided to or claimed by an owner, administrator, or other employee.
Compensation includes, but is not limited to:
(a) Salaries paid or accrued;
(b) Supplies and services provided for
personal use;
(c) Compensation paid
by the facility to employees for the sole benefit of the owner;
(d) Fees for consultants, directors, or any
other fees paid regardless of the label;
(e) Key man life insurance;
(f) Living expenses, including those paid for
related persons; or
(g) Gifts for
employees in excess of federal Internal Revenue Service reporting
guidelines.
(20) "Complex
Medical Payment" and "Complex Medical" means the statewide standard
supplemental payment rate for a Medicaid resident of a nursing facility whose
service is reimbursed at the basic rate if the resident needs one or more of
the medication procedures, treatment procedures, or rehabilitation services
listed in OAR 411-070-0091, for the additional licensed nursing services needed
to meet the resident's increased needs.
(21) "Continuous" means more than once per
day, seven days per week. Exception: If only skilled rehabilitative services
and no skilled nursing services are required, "continuous" means at least once
per day, five days per week.
(22)
"Costs Not Related to Resident Services" means costs that are not appropriate
or necessary and proper in developing and maintaining the operation of a
nursing facility. Such costs are not allowable in computing reimbursable costs.
Costs not related to resident services include, for example, cost of meals sold
to visitors, cost of drugs sold to individuals who are not residents, cost of
operation of a gift shop, and similar items.
(23) "Costs Related to Resident Services"
mean all necessary costs incurred in furnishing nursing facility services,
subject to the specific provisions and limitations set out in these rules.
Examples of costs related to resident services include nursing costs,
administrative costs, costs of employee pension plans, and interest
expenses.
(24) "COVID-19 Pandemic"
is an ongoing pandemic of coronavirus disease 2019 (COVID-19), caused by severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
(25) "CPAP" means continuous positive airway
pressure.
(26) "CPI" means the
consumer price index for all items and all urban consumers.
(27) "Day of Admission" means an individual
being admitted, determined as of 12:01 a.m. of each day, for all days in the
calendar period for which an assessment is being reported and paid. If an
individual is admitted and discharged on the same day, the individual is deemed
present on 12:01 a.m. of that day.
(28) "Department" means the Department of
Human Services (DHS).
(29)
"Developmental Disability" means "developmental disability" as defined in OAR
411-320-0020 and described in OAR 411-320-0080.
(30) "Direct Costs" mean costs incurred to
provide services required to directly meet all the resident nursing and
activity of daily living service needs. Direct costs are further defined in OAR
411-070-0359 and OAR 411-070-0465. Examples: The person who feeds food to the
resident is directly meeting the resident's needs, but the person who cooks the
food is not. The person who is trained to meet the resident's needs incurs
direct costs whereas the person providing the training is not. Costs for items
that are capitalized or depreciated are excluded from this
definition.
(31) "DRI Index" means
the "HCFA or CMS Nursing Home Without Capital Market Basket" index, which is
published quarterly by DRI/McGraw - Hill in the publication, "Global Insight
Health Care Cost Review".
(32)
"Emergency Health Care Center (EHCC)" is a designated existing licensed nursing
facility, in response to the COVID-19 pandemic, designed to provide long term
care services to individuals that have tested positive for COVID-19. The
purpose of the stay is to allow an individual to recover in an environment
meeting their needs.
(33) "Employee
Retention Payment Reimbursement Program" means the program described in OAR
411-070-0436 designed to support nursing facilities with employee retention by
providing reimbursement to facilities who meet criteria.
(34) "Enhanced Wage Add-on Program" means the
program described in OAR 411-070-0438 designed to provide additional
compensation to facilities who meet the criteria.
(35) "Essential Nursing Facility" means a
nursing facility that serves predominantly rural and frontier communities as
designated by the Office of Rural Health that is located more than 32 miles
from another nursing facility or from a hospital that has received a formal
notice of Critical Access Hospital (CAH) designation from the Centers for
Medicare and Medicaid Services and that is currently contracted to provide
swing bed services for Medicaid-eligible individuals.
(36) "Exempted Hospital Discharge" for PASRR
means an individual seeking temporary admission to a nursing facility from a
hospital as described in OAR 411-070-0043(2)(a).
(37) "Facility" or "Nursing Facility" means
an establishment that is licensed and certified by the Department of Human
Services as a nursing facility. A nursing facility also means a Medicaid
certified nursing facility only if identified as such.
(38) "Fair Market Value" means the price for
which an asset would have been purchased on the date of acquisition in an
arms-length transaction between a well-informed buyer and seller, neither being
under any compulsion to buy or sell.
(39) "Generally Accepted Accounting
Principles" mean the accounting principles approved by the American Institute
of Certified Public Accountants.
(40) "Goodwill" means the excess of the price
paid for a business over the fair market value of all other identifiable,
tangible, and intangible assets acquired, or the excess of the price paid for
an asset over its fair market value.
(41) "Health Systems Division (HSD)" means a
Division, within the Oregon Health Authority, responsible for coordinating the
medical assistance programs within the State of Oregon including, but not
limited to the Oregon Health Plan Medicaid demonstration and the State
Children's Health Insurance Program.
(42) "Historical Cost" means the actual cost
incurred in acquiring and preparing a fixed asset for use. Historical cost
includes such planning costs as feasibility studies, architects' fees, and
engineering studies. Historical cost does not include "start-up costs" as
defined in this rule.
(43)
"Hospital-Based Facility" means a nursing facility that is physically connected
and operated by a licensed general hospital.
(44) "Indirect Costs" mean the costs
associated with property, administration, and other operating support (real
property taxes, insurance, utilities, maintenance, dietary (excluding food),
laundry, and housekeeping). Indirect costs are further described in OAR
411-070-0359 and OAR 411-070-0465.
(45) "Individual" means a person who
receives, or is expected to receive, nursing facility services.
(46) "Intellectual Disability" means
"intellectual disability" as defined in OAR 411-320-0020 and described in OAR
411-320-0080.
(47)
"Interrupted-Service Facility" means an established facility recertified by DHS
following decertification.
(48)
"Level I" means a component of the federal PASRR requirement. Level I refers to
the identification of individuals who are potential nursing facility admissions
who have indicators of mental illness or developmental disabilities
(42 CFR
483.128(a)).
(49) "Level II" means a component of the
federal PASRR requirement. Level II refers to the evaluation and determination
of whether nursing facility services and specialized services are needed for
individuals with mental illness or developmental disability who are potential
nursing facility admissions, regardless of the source of payment for the
nursing facility service (42 CFR
483.128(a)). Level II
evaluations include assessment of the individual's physical, mental, and
functional status (42
CFR 483.132).
(50) "Level of Care Determination" means an
evaluation of the intensity of a person's health service needs. The level of
care determination may not be used to require that the person receive services
in a nursing facility.
(51)
"Medicaid Occupancy Percentage" means the total Medicaid bed days divided by
total resident days.
(52) "Mental
Illness" means a major mental disorder as defined in the Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition (DSM IV-TR) limited to
schizophrenic, paranoid and schizoaffective disorders, bipolar
(manic-depressive), and atypical psychosis. "Mental Illness" for pre-admission
screening means having both a primary diagnosis of a major mental disorder
(schizophrenic, paranoid, major affective and schizoaffective disorders, or
atypical psychosis) and treatment related to the diagnosis in the past two
years. Diagnoses of dementia or Alzheimer's are excluded.
(53) "Necessary Costs" mean costs that are
appropriate and helpful in developing and maintaining the operation of resident
facilities and activities. Necessary costs are usually costs that are common
and accepted occurrences in the field of long term nursing services.
(54) "New Admission" for PASRR purposes means
an individual admitted to any nursing facility for the first time. It does not
include individuals moving within a nursing facility, transferring to a
different nursing facility, or individuals who have returned to a hospital for
treatment and are being admitted back to the nursing facility. New admissions
are subject to the PASRR process (42 CFR
483.106(b)(1), (3),
(4)).
(55) "New Facility" means a nursing facility
commencing to provide services to individuals.
(56) "Nursing Aide Training and Competency
Evaluation Program (NATCEP)" means a nursing assistant training and competency
evaluation program approved by the Oregon State Board of Nursing pursuant to
ORS chapter 678 and the rules adopted pursuant thereto.
(57) "Nursing Facility Financial Statement
(NFFS)" means Form DHS 35, or Form DHS 35A (for hospital-based facilities), and
includes an account number listing of all costs to be used by all nursing
facility providers in reporting to the Department of Human Services for
reimbursement.
(58) "Occupancy
Rate" means total resident days divided by capacity.
(59) "Official Bed Count Measurement" means
the number of licensed nursing facility beds as of October 7, 2013 and the beds
being developed by facilities that either applied to the Oregon Health
Authority for a certificate of need between August 1, 2011 and December 1, 2012
or submitted a letter of intent under ORS
442.315(7)
between January 15, 2013 and January 31, 2013.
(60) "Ordinary Costs" mean costs incurred
that are customary for the normal operation.
(61) "Oregon Medical Professional Review
Organization (OMPRO)" means the organization that determines level of services,
need for services, and quality of services.
(62) "Pediatric Rate" means the statewide
standard payment rate for all long term services provided to a Medicaid
resident under the age of 21 who is served in a pediatric nursing facility or a
self-contained pediatric unit.
(63)
"Perquisites" mean privileges incidental to regular wages.
(64) "Personal Incidental Funds" mean
resident funds held or managed by the licensee or other person designated by
the resident on behalf of a resident.
(65) "Placement" means the location of a
specific place where health services can be adequately provided to meet the
service needs.
(66) "Pre-Admission
Screening (PAS)" means the assessment and determination of a potential
Medicaid-eligible individual's need for nursing facility services, including
the identification of individuals who can transition to community-based service
settings and the provision of information about community-based alternatives.
This assessment and determination is required when potentially
Medicaid-eligible individuals are at risk for admission to nursing facility
services. PAS may include the completion of the federal PASRR Level I
requirement (42 CFR, Part 483, (C)-(E)), to identify individuals with mental
illness or intellectual or developmental disabilities.
(67) "Pre-Admission Screening and Resident
Review (PASRR)" means the federal requirement, (42 CFR, Part 483, (C)-(E)), to
identify individuals who have mental illness or developmental disabilities and
determine if nursing facility service is required and if specialized services
are required. PASRR includes Level I and Level II functions.
(68) "Prior Authorization" means the local
Aging and People with Disabilities or Area Agency on Aging office participates
in the development of proposed nursing facility care plans to assure the
facility is the most suitable service setting for the individual. Nursing
facility reimbursement is contingent upon prior authorization.
(69) "Private Admission Assessment (PAA)"
means the assessment that is conducted for non-Medicaid residents as
established by ORS
410.505
to
410.545
and OAR chapter 411, division 071, who are potential admissions to a
Medicaid-certified nursing facility. Service needs are evaluated, and
information is provided about long-term service choices. A component of private
admission assessment is the federal PASRR Level I requirement, (42 CFR, Part
483.128(a)), to identify individuals with mental illness or developmental
disabilities.
(70) "Provider" means
an entity, licensed by Aging and People with Disabilities, responsible for the
direct delivery of nursing facility services.
(71) "Provider Preventable Condition (PPC)"
means a condition listed below caused by the provider:
(a) Foreign object retained after
treatment;
(b) Stage III and IV
pressure ulcers;
(c) Falls and
trauma;
(d) Manifestations of poor
glycemic control;
(e)
Catheter-associated urinary tract infection;
(f) Medication error; or
(g) Surgical site or wound site
infection.
(72) "Quality
and Efficiency Incentive Program" means the program described in OAR
411-070-0437 designed to reimburse quality nursing facilities that voluntarily
reduce bed capacity that increases occupancy levels and enhances efficiency
with the goal of slowing the growth of system-wide costs.
(73) "Reasonable Consideration" means an
inducement that is equivalent to the amount that would ordinarily be paid for
comparable goods and services in an arms-length transaction.
(74) "Related Organization" means an entity
that is under common ownership or control with, or has control of, or is
controlled by the contractor. An entity is deemed to be related if it has 5
percent or more ownership interest in the other. An entity is deemed to be
related if it has capacity derived from any financial or other relationship,
whether or not exercised, to influence directly or indirectly the activities of
the other.
(75) "Resident" means a
person who receives nursing facility services.
(76) "Resident Days" mean the number of
occupied bed days.
(77) "Resident
Review" means a review conducted by the Addictions and Mental Health Division
for individuals with mental illness or by the Aging and People with
Disabilities Division for individuals with developmental disabilities who are
residents of nursing facilities. The findings of the resident review may result
in referral to PASRR Level II (42 CFR
483.114).
(78) "Restricted Fund" means a fund in which
the use of the principal or principal and income is restricted by agreement
with, or direction by, the donor to a specific purpose. Restricted fund does
not include a fund over which the owner has complete control. The owner is
deemed to have complete control over a fund that is to be used for general
operating or building purposes.
(79) "Specialized Services for Mental
Illness" means mental health services delivered by an interdisciplinary team in
an inpatient psychiatric hospital for treatment of acute mental
illness.
(80) "Specialized Services
for Intellectual or Developmental Disabilities" means:
(a) For individuals with intellectual or
developmental disabilities under age 21, specialized services are equal to
school services; and
(b) For
individuals with t intellectual or developmental disabilities over age 21,
specialized services mean:
(A) A consistent
and ongoing program that includes participation by the individual in
continuous, aggressive training and support to prevent loss of current optimal
function;
(B) Promotes the
acquisition of function, skills, and behaviors necessary to increase
independence and productivity; and
(C) Is delivered in community-based or
vocational settings at a minimum of 25 hours a week.
(81) "Start-Up Costs" mean
one-time costs incurred prior to the first resident being admitted. Start-up
costs include, but are not limited to, administrative and nursing salaries,
utility costs, taxes, insurance, mortgage and other interest, repairs and
maintenance, training costs. Start-up costs do not include such costs as
feasibility studies, engineering studies, architect's fees, or other fees that
are part of the historical cost of the facility.
(82) "Supervision" means initial direction
and periodic monitoring of performance. Supervision does not mean the
supervisor is physically present when the work is performed.
(83) "These Rules" mean the rules in OAR
chapter 411, division 070.
(84)
"Title XVIII" and "Medicare" means Title XVIII of the Social Security
Act.
(85) "Title XIX," "Medicaid,"
and "Medical Assistance" means Title XIX of the Social Security Act.
(86) "Uniform Chart of Accounts (Form DHS
35)" means a list of account titles identified by code numbers established by
the Department of Human Services for providers to use in reporting their
costs.
(87) "Ventilator" means a
device to provide breathing assistance to individuals. This includes both
positive and negative pressure devices.
(88) "Ventilator Assisted Program" means a
program that provides services to residents who are dependent on an invasive
mechanical ventilation as means of life support as defined in OAR
411-090-0110.
(89) "Ventilator
Assisted Program Unit" means a unit that meets the Ventilator Assisted Program
criteria.
Notes
Forms referenced are available from the agency.Publications: Publications referenced are available from the agency.
Statutory/Other Authority: ORS 410.070
Statutes/Other Implemented: ORS 410.070 & 414.065
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.
Current through Register Vol. 61, No. 4, April 1, 2022
Unless the context indicates otherwise, the following definitions and the definitions in OAR 411-085-0005 apply to the rules in OAR chapter 411, division 070:
(1) "Accrual Method of Accounting" means a method of accounting where revenues are reported in the period they are earned, regardless of when they are collected, and expenses are reported in the period they are incurred, regardless of when they are paid.
(2) "Active Treatment" means the implementation of an individualized care plan developed under and supervised by a physician and other qualified mental health professionals that prescribes specific therapies and activities.
(3) "Activities of Daily Living" means activities usually performed in the course of a normal day in an individual's life such as eating, dressing, grooming, bathing, personal hygiene, mobility (ambulation and transfer), elimination (toileting, bowel, and bladder management), and cognition and behavior.
(4) "Aging and People with Disabilities (APD)" means the program area of Aging and People with Disabilities, within the Department of Human Services.
(5) "Alternative Services" mean individuals or organizations offering services to persons living in a community other than a nursing facility or hospital.
(6) "Area Agency on Aging (AAA)" means the Department of Human Services designated agency charged with the responsibility to provide a comprehensive and coordinated system of services to seniors and individuals with disabilities in a planning and service area. For the purpose of these rules, the term Area Agency on Aging is inclusive of both Type A and Type B Area Agencies on Aging as defined in ORS 410.040 and described in ORS 410.210 to 410.300.
(7) "Augmented Rate" means the additional compensation to a nursing facility who qualifies for the Quality and Efficiency Incentive Program described in OAR 411-070-0437. The augmented rate is a daily rate of $9.75 and is in addition to the rate a nursing facility would otherwise receive. The Department may pay the augmented rate to a qualifying facility for a period not to exceed four years from the date the facility purchases bed capacity under the Quality and Efficiency Incentive Program.
(8) "Bariatric rate" means a rate paid for a Medicaid resident of a nursing facility if the resident meets the criteria described in OAR 411-070-0087.
(9) "Basic Flat Rate Payment" and "Basic Rate" means the statewide standard payment rate for all long-term services provided to a Medicaid resident of a nursing facility, except for services reimbursed through another Medicaid payment source. The "Basic Rate" is the bundled payment rate, unless the resident qualifies for the complex medical rate, the ventilator assisted program rate, the bundled pediatric rate or the bariatric rate (instead of the basic rate).
(10) "Bi-PAP" means bi-level positive airway pressure/spontaneous timed.
(11) "Behavioral Health" means the program within the Health Systems Division (HSD) within the Oregon Health Authority (OHA), responsible for addictions and mental health services.
(12) "Capacity" means licensed nursing beds multiplied by number of days in operation.
(13) "Case Manager" means a Department of Human Services or Area Agency on Aging employee who assesses the service needs of an applicant, determines eligibility, and offers service choices to the eligible individual. The case manager authorizes and implements the service plan and monitors the services delivered.
(14) "Cash Method of Accounting" means a method of accounting where revenues are recognized only when cash is received, and expenditures for expense and asset items are not recorded until cash is disbursed for them.
(15) "Categorical Determinations" mean the provisions in the Code of Federal Regulations (42 CFR 483.130) for creating categories that describe certain diagnoses, severity of illness, or the need for a particular service that clearly indicates that admission to a nursing facility is normally needed or that the provision of specialized services is not normally needed.
(a) Membership in a category may be made by the evaluator only if existing data on the individual is current, accurate, and of sufficient scope.
(b) An individual with mental illness or developmental disabilities may enter a nursing facility without a PASRR Level II evaluation if criteria of a categorical determination are met as described in OAR 411-070-0043(2)(a) - (2)(c).
(16) "Certification" and "Certification for the Categorical Determination of Exempted Hospital Discharge" means the attending physician has written orders for the individual to receive skilled services at the nursing facility.
(17) "Certified Program" means a hospital, private agency, or an Area Agency on Aging certified by the Department of Human Services to conduct private admission assessments in accordance with ORS 410.505 through 410.530.
(18) "Change of Ownership" means a change in the individual or legal organization that is responsible for the operation of a nursing facility. Change of ownership does not include changes in personnel, e.g., a change of administrators. Events that change ownership include, but are not limited to, the following:
(a) The form of legal organization of the owner is changed (e.g., a sole proprietor forms a partnership or corporation);
(b) The title to the nursing facility enterprise is transferred to another party;
(c) The nursing facility enterprise is leased or an existing lease is terminated;
(d) Where the owner is a partnership, any event occurs which dissolves the partnership;
(e) Where the owner is a corporation, it is dissolved, merges with another corporation that is the survivor, or consolidates with one or more other corporations to form a new corporation; or
(f) The facility changes management via a management contract.
(19) "Compensation" means the total of all benefits and remuneration, exclusive of payroll taxes and regardless of the form, provided to or claimed by an owner, administrator, or other employee. Compensation includes, but is not limited to:
(a) Salaries paid or accrued;
(b) Supplies and services provided for personal use;
(c) Compensation paid by the facility to employees for the sole benefit of the owner;
(d) Fees for consultants, directors, or any other fees paid regardless of the label;
(e) Key man life insurance;
(f) Living expenses, including those paid for related persons; or
(g) Gifts for employees in excess of federal Internal Revenue Service reporting guidelines.
(20) "Complex Medical Payment" and "Complex Medical" means the statewide standard supplemental payment rate for a Medicaid resident of a nursing facility whose service is reimbursed at the basic rate if the resident needs one or more of the medication procedures, treatment procedures, or rehabilitation services listed in OAR 411-070-0091, for the additional licensed nursing services needed to meet the resident's increased needs.
(21) "Continuous" means more than once per day, seven days per week. Exception: If only skilled rehabilitative services and no skilled nursing services are required, "continuous" means at least once per day, five days per week.
(22) "Costs Not Related to Resident Services" means costs that are not appropriate or necessary and proper in developing and maintaining the operation of a nursing facility. Such costs are not allowable in computing reimbursable costs. Costs not related to resident services include, for example, cost of meals sold to visitors, cost of drugs sold to individuals who are not residents, cost of operation of a gift shop, and similar items.
(23) "Costs Related to Resident Services" mean all necessary costs incurred in furnishing nursing facility services, subject to the specific provisions and limitations set out in these rules. Examples of costs related to resident services include nursing costs, administrative costs, costs of employee pension plans, and interest expenses.
(24) "COVID-19 Pandemic" is an ongoing pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
(25) "CPAP" means continuous positive airway pressure.
(26) "CPI" means the consumer price index for all items and all urban consumers.
(27) "Day of Admission" means an individual being admitted, determined as of 12:01 a.m. of each day, for all days in the calendar period for which an assessment is being reported and paid. If an individual is admitted and discharged on the same day, the individual is deemed present on 12:01 a.m. of that day.
(28) "Department" means the Department of Human Services (DHS).
(29) "Developmental Disability" means "developmental disability" as defined in OAR 411-320-0020 and described in OAR 411-320-0080.
(30) "Direct Costs" mean costs incurred to provide services required to directly meet all the resident nursing and activity of daily living service needs. Direct costs are further defined in OAR 411-070-0359 and OAR 411-070-0465. Examples: The person who feeds food to the resident is directly meeting the resident's needs, but the person who cooks the food is not. The person who is trained to meet the resident's needs incurs direct costs whereas the person providing the training is not. Costs for items that are capitalized or depreciated are excluded from this definition.
(31) "DRI Index" means the "HCFA or CMS Nursing Home Without Capital Market Basket" index, which is published quarterly by DRI/McGraw - Hill in the publication, "Global Insight Health Care Cost Review".
(32) "Emergency Health Care Center (EHCC)" is a designated existing licensed nursing facility, in response to the COVID-19 pandemic, designed to provide long term care services to individuals that have tested positive for COVID-19. The purpose of the stay is to allow an individual to recover in an environment meeting their needs.
(33) "Employee Retention Payment Reimbursement Program" means the program described in OAR 411-070-0436 designed to support nursing facilities with employee retention by providing reimbursement to facilities who meet criteria.
(34) "Enhanced Wage Add-on Program" means the program described in OAR 411-070-0438 designed to provide additional compensation to facilities who meet the criteria.
(35) "Essential Nursing Facility" means a nursing facility that serves predominantly rural and frontier communities as designated by the Office of Rural Health that is located more than 32 miles from another nursing facility or from a hospital that has received a formal notice of Critical Access Hospital (CAH) designation from the Centers for Medicare and Medicaid Services and that is currently contracted to provide swing bed services for Medicaid-eligible individuals.
(36) "Exempted Hospital Discharge" for PASRR means an individual seeking temporary admission to a nursing facility from a hospital as described in OAR 411-070-0043(2)(a).
(37) "Facility" or "Nursing Facility" means an establishment that is licensed and certified by the Department of Human Services as a nursing facility. A nursing facility also means a Medicaid certified nursing facility only if identified as such.
(38) "Fair Market Value" means the price for which an asset would have been purchased on the date of acquisition in an arms-length transaction between a well-informed buyer and seller, neither being under any compulsion to buy or sell.
(39) "Generally Accepted Accounting Principles" mean the accounting principles approved by the American Institute of Certified Public Accountants.
(40) "Goodwill" means the excess of the price paid for a business over the fair market value of all other identifiable, tangible, and intangible assets acquired, or the excess of the price paid for an asset over its fair market value.
(41) "Health Systems Division (HSD)" means a Division, within the Oregon Health Authority, responsible for coordinating the medical assistance programs within the State of Oregon including, but not limited to the Oregon Health Plan Medicaid demonstration and the State Children's Health Insurance Program.
(42) "Historical Cost" means the actual cost incurred in acquiring and preparing a fixed asset for use. Historical cost includes such planning costs as feasibility studies, architects' fees, and engineering studies. Historical cost does not include "start-up costs" as defined in this rule.
(43) "Hospital-Based Facility" means a nursing facility that is physically connected and operated by a licensed general hospital.
(44) "Indirect Costs" mean the costs associated with property, administration, and other operating support (real property taxes, insurance, utilities, maintenance, dietary (excluding food), laundry, and housekeeping). Indirect costs are further described in OAR 411-070-0359 and OAR 411-070-0465.
(45) "Individual" means a person who receives, or is expected to receive, nursing facility services.
(46) "Intellectual Disability" means "intellectual disability" as defined in OAR 411-320-0020 and described in OAR 411-320-0080.
(47) "Interrupted-Service Facility" means an established facility recertified by DHS following decertification.
(48) "Level I" means a component of the federal PASRR requirement. Level I refers to the identification of individuals who are potential nursing facility admissions who have indicators of mental illness or developmental disabilities (42 CFR 483.128(a)).
(49) "Level II" means a component of the federal PASRR requirement. Level II refers to the evaluation and determination of whether nursing facility services and specialized services are needed for individuals with mental illness or developmental disability who are potential nursing facility admissions, regardless of the source of payment for the nursing facility service (42 CFR 483.128(a)). Level II evaluations include assessment of the individual's physical, mental, and functional status (42 CFR 483.132).
(50) "Level of Care Determination" means an evaluation of the intensity of a person's health service needs. The level of care determination may not be used to require that the person receive services in a nursing facility.
(51) "Medicaid Occupancy Percentage" means the total Medicaid bed days divided by total resident days.
(52) "Mental Illness" means a major mental disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM IV-TR) limited to schizophrenic, paranoid and schizoaffective disorders, bipolar (manic-depressive), and atypical psychosis. "Mental Illness" for pre-admission screening means having both a primary diagnosis of a major mental disorder (schizophrenic, paranoid, major affective and schizoaffective disorders, or atypical psychosis) and treatment related to the diagnosis in the past two years. Diagnoses of dementia or Alzheimer's are excluded.
(53) "Necessary Costs" mean costs that are appropriate and helpful in developing and maintaining the operation of resident facilities and activities. Necessary costs are usually costs that are common and accepted occurrences in the field of long term nursing services.
(54) "New Admission" for PASRR purposes means an individual admitted to any nursing facility for the first time. It does not include individuals moving within a nursing facility, transferring to a different nursing facility, or individuals who have returned to a hospital for treatment and are being admitted back to the nursing facility. New admissions are subject to the PASRR process (42 CFR 483.106(b)(1), (3), (4)).
(55) "New Facility" means a nursing facility commencing to provide services to individuals.
(56) "Nursing Aide Training and Competency Evaluation Program (NATCEP)" means a nursing assistant training and competency evaluation program approved by the Oregon State Board of Nursing pursuant to ORS chapter 678 and the rules adopted pursuant thereto.
(57) "Nursing Facility Financial Statement (NFFS)" means Form DHS 35, or Form DHS 35A (for hospital-based facilities), and includes an account number listing of all costs to be used by all nursing facility providers in reporting to the Department of Human Services for reimbursement.
(58) "Occupancy Rate" means total resident days divided by capacity.
(59) "Official Bed Count Measurement" means the number of licensed nursing facility beds as of October 7, 2013 and the beds being developed by facilities that either applied to the Oregon Health Authority for a certificate of need between August 1, 2011 and December 1, 2012 or submitted a letter of intent under ORS 442.315(7) between January 15, 2013 and January 31, 2013.
(60) "Ordinary Costs" mean costs incurred that are customary for the normal operation.
(61) "Oregon Medical Professional Review Organization (OMPRO)" means the organization that determines level of services, need for services, and quality of services.
(62) "Pediatric Rate" means the statewide standard payment rate for all long term services provided to a Medicaid resident under the age of 21 who is served in a pediatric nursing facility or a self-contained pediatric unit.
(63) "Perquisites" mean privileges incidental to regular wages.
(64) "Personal Incidental Funds" mean resident funds held or managed by the licensee or other person designated by the resident on behalf of a resident.
(65) "Placement" means the location of a specific place where health services can be adequately provided to meet the service needs.
(66) "Pre-Admission Screening (PAS)" means the assessment and determination of a potential Medicaid-eligible individual's need for nursing facility services, including the identification of individuals who can transition to community-based service settings and the provision of information about community-based alternatives. This assessment and determination is required when potentially Medicaid-eligible individuals are at risk for admission to nursing facility services. PAS may include the completion of the federal PASRR Level I requirement (42 CFR, Part 483, (C)-(E)), to identify individuals with mental illness or intellectual or developmental disabilities.
(67) "Pre-Admission Screening and Resident Review (PASRR)" means the federal requirement, (42 CFR, Part 483, (C)-(E)), to identify individuals who have mental illness or developmental disabilities and determine if nursing facility service is required and if specialized services are required. PASRR includes Level I and Level II functions.
(68) "Prior Authorization" means the local Aging and People with Disabilities or Area Agency on Aging office participates in the development of proposed nursing facility care plans to assure the facility is the most suitable service setting for the individual. Nursing facility reimbursement is contingent upon prior authorization.
(69) "Private Admission Assessment (PAA)" means the assessment that is conducted for non-Medicaid residents as established by ORS 410.505 to 410.545 and OAR chapter 411, division 071, who are potential admissions to a Medicaid-certified nursing facility. Service needs are evaluated, and information is provided about long-term service choices. A component of private admission assessment is the federal PASRR Level I requirement, (42 CFR, Part 483.128(a)), to identify individuals with mental illness or developmental disabilities.
(70) "Provider" means an entity, licensed by Aging and People with Disabilities, responsible for the direct delivery of nursing facility services.
(71) "Provider Preventable Condition (PPC)" means a condition listed below caused by the provider:
(a) Foreign object retained after treatment;
(b) Stage III and IV pressure ulcers;
(c) Falls and trauma;
(d) Manifestations of poor glycemic control;
(e) Catheter-associated urinary tract infection;
(f) Medication error; or
(g) Surgical site or wound site infection.
(72) "Quality and Efficiency Incentive Program" means the program described in OAR 411-070-0437 designed to reimburse quality nursing facilities that voluntarily reduce bed capacity that increases occupancy levels and enhances efficiency with the goal of slowing the growth of system-wide costs.
(73) "Reasonable Consideration" means an inducement that is equivalent to the amount that would ordinarily be paid for comparable goods and services in an arms-length transaction.
(74) "Related Organization" means an entity that is under common ownership or control with, or has control of, or is controlled by the contractor. An entity is deemed to be related if it has 5 percent or more ownership interest in the other. An entity is deemed to be related if it has capacity derived from any financial or other relationship, whether or not exercised, to influence directly or indirectly the activities of the other.
(75) "Resident" means a person who receives nursing facility services.
(76) "Resident Days" mean the number of occupied bed days.
(77) "Resident Review" means a review conducted by the Addictions and Mental Health Division for individuals with mental illness or by the Aging and People with Disabilities Division for individuals with developmental disabilities who are residents of nursing facilities. The findings of the resident review may result in referral to PASRR Level II (42 CFR 483.114).
(78) "Restricted Fund" means a fund in which the use of the principal or principal and income is restricted by agreement with, or direction by, the donor to a specific purpose. Restricted fund does not include a fund over which the owner has complete control. The owner is deemed to have complete control over a fund that is to be used for general operating or building purposes.
(79) "Specialized Services for Mental Illness" means mental health services delivered by an interdisciplinary team in an inpatient psychiatric hospital for treatment of acute mental illness.
(80) "Specialized Services for Intellectual or Developmental Disabilities" means:
(a) For individuals with intellectual or developmental disabilities under age 21, specialized services are equal to school services; and
(b) For individuals with t intellectual or developmental disabilities over age 21, specialized services mean:
(A) A consistent and ongoing program that includes participation by the individual in continuous, aggressive training and support to prevent loss of current optimal function;
(B) Promotes the acquisition of function, skills, and behaviors necessary to increase independence and productivity; and
(C) Is delivered in community-based or vocational settings at a minimum of 25 hours a week.
(81) "Start-Up Costs" mean one-time costs incurred prior to the first resident being admitted. Start-up costs include, but are not limited to, administrative and nursing salaries, utility costs, taxes, insurance, mortgage and other interest, repairs and maintenance, training costs. Start-up costs do not include such costs as feasibility studies, engineering studies, architect's fees, or other fees that are part of the historical cost of the facility.
(82) "Supervision" means initial direction and periodic monitoring of performance. Supervision does not mean the supervisor is physically present when the work is performed.
(83) "These Rules" mean the rules in OAR chapter 411, division 070.
(84) "Title XVIII" and "Medicare" means Title XVIII of the Social Security Act.
(85) "Title XIX," "Medicaid," and "Medical Assistance" means Title XIX of the Social Security Act.
(86) "Uniform Chart of Accounts (Form DHS 35)" means a list of account titles identified by code numbers established by the Department of Human Services for providers to use in reporting their costs.
(87) "Ventilator" means a device to provide breathing assistance to individuals. This includes both positive and negative pressure devices.
(88) "Ventilator Assisted Program" means a program that provides services to residents who are dependent on an invasive mechanical ventilation as means of life support as defined in OAR 411-090-0110.
(89) "Ventilator Assisted Program Unit" means a unit that meets the Ventilator Assisted Program criteria.
Notes
Forms referenced are available from the agency.Publications: Publications referenced are available from the agency.
Statutory/Other Authority: ORS 410.070
Statutes/Other Implemented: ORS 410.070 & 414.065