Tenn. Comp. R. & Regs. 1200-13-02-.11 - QUALITY-BASED COMPONENT OF THE REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES
(1) In addition to
Quality Informed aspects of the NF reimbursement methodology, a specified
amount of the funding for NF services shall be set aside during each fiscal
year for purposes of calculating a quality-based component of each NF
provider's per diem payment (i.e., a quality incentive component). At
implementation of this Chapter, the amount of funding set aside for the
quality-based component of the reimbursement methodology for NFs shall be no
less than forty million dollars ($40 million) or four percent (4.00%) of the
total projected fiscal year expenditures for NF services, whichever is greater.
In each subsequent year, the amount of funding set aside for the quality-based
component of the reimbursement methodology for NFs shall increase at two (2)
times the rate of inflation of the index factor. Index factor inflation shall
be calculated from the midpoint of the prior state fiscal year to the midpoint
of the new state fiscal year. This annual quality-based component index factor
adjustment shall continue until such time that the quality-based component of
the reimbursement methodology for NFs constitutes ten percent (10%) of the
total projected fiscal year expenditures for NF services. Once the
quality-based component of the reimbursement methodology constitutes ten
percent (10%) of the total projected fiscal year expenditures for NF services,
it shall then increase or decrease at a rate necessary to ensure that the
quality-based component of the reimbursement methodology remains at ten percent
(10%). All noted minimum quality-based component thresholds and index factor
inflationary adjustments are made prior to consideration of the BAF.
(2) The quality-based component of each NF
provider's per diem payment shall be calculated based on the facility's volume
of Medicaid resident days and the percentage of total quality points earned for
the measurement period.
(3) The
initial quality outcome measures and point values established for the NF
reimbursement system implemented on July 1, 2018, shall be based upon the
structure of the QuILTSS Nursing Facility Value-Based Purchasing Quality
Framework as described in the memorandum of August 5, 2014, to Medicaid NF
Providers and described in this rule. Quality outcome measures and point values
for each measure shall not be modified for the first three (3) fiscal years of
reimbursement following implementation of the reimbursement system. Performance
benchmarks shall be established as described in this rule. After the initial
three (3) year period, quality outcome measures, performance benchmarks for
each measure, and point values shall be reviewed and may be modified as
appropriate in consultation with THCA and other NF stakeholders. Any
modifications to such criteria shall be established through rulemaking and
shall not be changed for another three-year period.
(4) Quality outcome measures shall reflect
those aspects of the delivery of NF services determined based on input from
individuals receiving services, their family members and representatives, and
other NF stakeholders, and in consultation with THCA and the QuILTSS
Stakeholder Advisory Group, to most impact the day-to-day experience of care
for NF residents, as follows:
(a)
Satisfaction shall be valued at thirty-five (35) of the one hundred (100)
possible quality performance points.
1.
Satisfaction shall include three separate measures:
(i) Resident satisfaction shall be valued at
fifteen (15) of the one hundred (100) possible quality performance
points.
(ii) Family satisfaction
shall be valued at ten (10) of the one hundred (100) possible quality
performance points.
(iii) Staff
satisfaction shall be valued at ten (10) of the one hundred (100) possible
quality performance points.
2. In order to measure Satisfaction on the
basis of outcomes and to establish performance benchmarks for each of the three
(3) Satisfaction measures, NFs shall be required to use a standardized survey
instrument and methodology that provides for anonymous submission to a neutral
third party, which shall be responsible for submission of required data to
TennCare.
3. The survey
instrument(s) and methodology for conducting each survey shall be selected or
designed with input from NF stakeholders, and subject to mutual agreement
between TennCare and THCA. Providers shall be notified of the acceptable survey
instrument(s) and methodology no later than two (2) months prior to their
implementation.
4. For purposes of
the NF reimbursement rates effective on July 1, 2018, the methodology used for
calculating a facility's Satisfaction score shall be based upon the criteria
established by TennCare in the QuILTSS #10 memorandum of March 20,
2017.
5. For purposes of the NF
reimbursement rates effective on July 1, 2019, the methodology used for
calculating a facility's Satisfaction score shall be based on the facility's
adoption and implementation of the survey instrument(s) according to with the
methodology described in this subparagraph. Data collected during the baseline
year of the Satisfaction survey instrument(s) described in this subparagraph
shall be used to establish a performance benchmark for each of the three (3)
Satisfaction measures, in consultation with THCA and other NF
Stakeholders.
6. For purposes of
the NF reimbursement rates effective on July 1, 2020, the methodology used for
calculating a facility's Satisfaction score shall be based in part on whether
the facility achieves the performance benchmark for each of the three (3)
Satisfaction measures described in this subparagraph, and for facilities who do
not achieve the performance benchmarks, a lesser score based on the percentage
of improvement over the baseline year. Providers shall be notified of the
performance benchmark for each of the three (3) Satisfaction measures and the
specific methodology for calculating a facility's Satisfaction score no later
than July 1, 2019.
7. TennCare
shall provide (or arrange for the provision of) training regarding each survey
instrument, the survey methodology, and the methodology that will be used to
calculate a facility's score for each of the three (3) Satisfaction
measures.
8. Upon the collection
and analysis of two (2) years of data pertaining to each of the survey
instruments, this Chapter shall be modified to include performance benchmarks
for each of the three (3) Satisfaction measures that will be applied for the
next three-year period.
9. Results
of each NF's surveys (excluding any information that could be used to identify
respondents) shall be made available to the NF for purposes of quality
improvement activities.
(b) Culture Change and Quality of Life shall
be valued at thirty (30) of the one hundred (100) possible quality performance
points.
1. Culture Change and Quality of Life
shall encompass four (4) different aspects of the degree to which a NF's
environment, programs, policies, and practices are individualized and
person-directed; reflect the core values of self-determination, choice,
dignity, and respect; and support meaningful roles and relationships for
residents and staff. Culture Change and Quality of Life shall include four (4)
separate measures:
(i) Respectful Treatment
shall be valued at ten (10) out of the one hundred (100) possible quality
performance points.
(ii) Resident
Choice shall be valued at ten (10) out of the one hundred (100) possible
quality performance points.
(iii)
Resident and Family Input shall be valued at five (5) out of the one hundred
(100) possible quality performance points.
(iv) Meaningful Activities shall be valued at
five (5) out of the one hundred (100) possible quality performance
points.
2. In order to
measure Culture Change and Quality of Life on the basis of outcomes and to
establish performance benchmarks for each of the four (4) Culture Change and
Quality of Life measures, NFs shall be required to use a standardized survey
instrument and methodology that provides for anonymous submission to a neutral
third party, which shall be responsible for submission of required data to
TennCare. The survey questions for measuring Culture Change and Quality of Life
may be incorporated into the Resident satisfaction survey described in
Subparagraph (a) above to ease survey fatigue.
3. The survey questions and/or instrument and
methodology for conducting the survey shall be selected or designed with input
from NF stakeholders, and subject to mutual agreement between TennCare and
THCA. Providers shall be notified of the acceptable survey instrument(s) and
methodology no later than two (2) months prior to their
implementation.
4. For purposes of
the NF reimbursement rates effective on July 1, 2018, the methodology used for
calculating a facility's score encompassing each of the four (4) aspects of
Culture Change and Quality of Life shall be developed in consultation with THCA
and with input from the NF stakeholders, including individuals receiving
services and their family members and representatives. These criteria shall be
provided to NFs and posted on the TennCare website no later than two (2) months
prior to the implementation of the reimbursement system.
5. For purposes of the NF reimbursement rates
effective on July 1, 2019, the methodology used for calculating a facility's
Culture Change and Quality of Life score shall be based on the facility's
adoption and implementation of the survey questions and/or instrument(s) in
accordance with the methodology described in this subparagraph. Data collected
during the baseline year of the Culture Change and Quality of Life survey
instrument(s) described in this section shall be used to establish a
performance benchmark for each of the four (4) Culture Change and Quality of
Life measures, in consultation with THCA and other NF Stakeholders.
6. For purposes of the NF reimbursement rates
effective on July 1, 2020, the methodology used for calculating a facility's
Culture Change and Quality of Life score shall be based in part on whether the
facility achieves the performance benchmark for each of the four (4) Culture
Change and Quality of Life measures described in this subparagraph, and for
facilities who do not achieve the performance benchmarks, a lesser score based
on the percentage of improvement over the baseline year. Providers shall be
notified of the performance benchmark for each of the four (4) Culture Change
and Quality of Life measures and the specific methodology for calculating a
facility's Satisfaction score no later than July 1, 2019.
7. TennCare shall provide (or arrange for the
provision of) training regarding the methodology that will be used to calculate
a facility's score encompassing each of the four (4) aspects of Culture Change
and Quality of Life.
8. Upon the
collection and analysis of two (2) years of data pertaining to the survey
questions and/or survey instrument, this Chapter shall be modified to include
performance benchmarks for each of the four (4) Culture Change and Quality of
Life measures that will be applied for the next three-year period.
9. Results of each NF's performance on each
of the four (4) aspects of Culture Change and Quality of Life (excluding any
information that could be used to identify respondents) shall be made available
to the NF for purposes of quality improvement activities.
(c) Staffing and Staff Competency shall be
valued at twenty-five (25) of the one hundred (100) possible quality
performance points.
1. Staffing and Staff
Competency shall include five (5) separate measures, with each measure valued
at five (5) of the one hundred (100) possible quality performance points, as
follows:
(i) Registered Nurse (RN) hours per
resident day.
(ii) Nurse Aide (NA)
hours per resident day.
(iii) RN,
LPN, and CNA Staff Retention.
(iv)
Consistent Staff Assignment.
(v)
Staff Training (Onboarding and Continuing).
2. NA resident hours per resident day shall
be calculated consistent with the methodology described in the CMS Five Star
Nursing Home Quality Rating System.
(i) The
source document for the reported NA hours is the CMS form CMS-671 (Long Term
Care Facility Application for Medicare and Medicaid) obtained from CASPER,
Certification And Survey Provider Enhanced Reports, the CMS system which NFs
must use to report data pertaining to survey and certification
processes.
(ii) The resident census
is based on the count of total residents from the CMS form CMS-672 (Resident
Census and Conditions of Residents).
(iii) NA hours include certified nurse aides,
aides in training, and medication aides/technicians.
(iv) Staffing data include both NF employees
(full-time and part-time) and individuals under an organization (agency) or
individual contract.
(v) Staffing
data do not include staff reimbursed by a resident or his/her family, hospice
staff, or feeding assistants.
(vi)
Staffing hours reported are for the residents in Medicare- and/or
Medicaid-certified beds only.
(vii)
Performance benchmarks for RN and NA hours per resident day measures shall be
established in consultation with THCA, and with input from other NF
stakeholders, including individuals receiving services and their family members
and representatives. These criteria shall be provided to NFs and posted on the
TennCare website no later than two (2) months prior to the implementation of
the reimbursement system.
3. Consistent Staff Assignment shall be
defined and calculated consistent with the methodology described in the
National Nursing Home Quality Improvement Campaign.
(i) Consistent Staff Assignment shall include
two measurements:
(I) The percentage of
long-stay residents who have no more than twelve (12) caregivers within a one
(1) month measurement period; and
(II) The percentage of short-stay residents
who have no more than twelve (12) caregivers within a two-week measurement
period.
(ii) Long-stay
residents shall be defined as residents who have been in the facility for
greater than one hundred (100) days.
(iii) Short-stay-residents shall be defined
as residents who have been in the facility for no more than one hundred (100)
days.
(iv) A caregiver shall be
defined as any staff assigned to provide and delivering direct NA-type care to
the resident during the measurement period.
(I) For purposes of measuring Consistent
Staff, licensed staff shall not be counted as caregivers unless they are
working in the capacity of a CNA. For example, if a nurse is in a resident's
room administering medications or performing other skilled tasks, and stops to
take the resident to the bathroom, that nurse shall not be counted as a
caregiver. However, if a nurse (or other staff) is working as a CNA because the
home is short staffed or because nurses (or other staff) routinely provide
direct care to residents, that person shall be included in the caregiver
count.
(II) Staff assigned to
assist one or more residents only with mealtime and/or bathing shall be counted
as a caregiver for all residents for whom such assistance is provided, even if
the staff functions as a float or as part of a care team dedicated to such
functions on behalf of multiple residents.
(v) NAs shall include certified nurse aides,
aides in training, and medication aides/technicians.
(vi) Caregivers shall include both NF
employees (full-time and part-time) and individuals under an organization
(agency) or individual contract that provide care to the resident during the
measurement period.
(vii) To be
eligible for Consistent Staff Assignment points, a NF must track its
performance using the tools created by the National Nursing Home Quality
Improvement Campaign (NNHQIC), and report data to it in a manner consistent
with the NNHQIC. A NF must also provide permission to the NNHQIC for it to
share the facility's performance data with TennCare.
(viii) The performance benchmark for the
Consistent Staff Assignment measure shall be established in consultation with
THCA, and with input from other NF stakeholders, including individuals
receiving services and their family members and representatives. The
performance benchmark for rates effective on July 1, 2018, shall be provided to
NFs and posted on the TennCare website no later than two (2) months prior to
the implementation of the reimbursement system. The performance benchmark for
rates effective on July 1, 2019, and July 1, 2020, shall be provided to NFs and
posted on the TennCare website by May 1 of each year.
4. Staff Retention shall be defined as the
percentage of specified staff that have been employed (or contracted) by the NF
for at least one (1) year.
(i) Specified staff
shall include only RNs, LPNs, and NAs.
(ii) RNs shall include registered nurses, RN
directors of nursing, and nurses with administrative duties.
(iii) LPNs shall include licensed
practical/licensed vocational nurses.
(iv) NAs shall include certified nurse aides,
aides in training, and medication aides/technicians.
(v) Specified staff shall include both NF
employees (full-time and part-time) and individuals under an organization
(agency) or individual contract. Retention of contracted staff shall be
reported and measured based on the length of service of each staff person, and
not the length of the contract. For example, if a staffing agency is used, a
person shall be considered "continuously" contracted only if that staff person
has been assigned to and working at the facility throughout the course of the
twelve (12) month measurement period, even if the contract with that
organization (agency) has been in place for a longer period.
(vi) Specified staff shall not include staff
reimbursed by a resident or his/her family, hospice staff, or feeding
assistants.
(vii) Specified staff
information at the beginning and end of the measurement period shall be
provided to TennCare in the required form and format.
(viii) A NF's performance on the Staff
Retention measure shall be calculated by dividing the number of specified staff
continuously employed (or contracted) by the facility for the twelve (12) month
measurement period divided by the total number of specified facility staff
employed at the outset of the twelve (12) month measurement period.
(ix) The performance benchmark for the Staff
Retention measure shall be established in consultation with THCA, and with
input from other NF stakeholders, including individuals receiving services and
their family members and representatives. The performance benchmark for rates
effective on July 1, 2018, shall be provided to NFs and posted on the TennCare
website no later than two (2) months prior to the implementation of the
reimbursement system. The performance benchmark for rates effective on July 1,
2019, and July 1, 2020, shall be provided to NFs and posted on the TennCare
website by May 1 of each year.
5. Staff Training shall be defined as the
percentage of specified staff who complete specified training activities.
(i) For purposes of the NF reimbursement
rates effective on July 1, 2018, July 1, 2019, and July 1, 2020, the
methodology used for calculating a facility's score for the Staff Training
measure and the performance benchmark for the Staff Training measure shall be
developed in consultation with THCA, and with input from other NF stakeholders
including individuals receiving services and their family members and
representatives. These criteria shall be provided to NFs and posted on the
TennCare website no later than May 1 of each year.
(ii) Upon implementation of the QuILTSS
comprehensive competency-based workforce development training program,
specified training activities shall be completion of badges based on the
CMS-funded core competencies for direct support workforce.
(d) Clinical Performance shall be
valued at ten (10) of the one hundred (100) possible quality performance
points.
1. Clinical Performance shall include
two (2) separate measures, with each measure valued at five (5) of the one
hundred (100) possible quality performance points, as follows:
(i) Antipsychotic Medications shall include
two measurements:
(I) The percentage of
long-stay residents who receive an antipsychotic medication during the
measurement period.
(II) The
percentage of short-stay residents who receive an antipsychotic medication
during the measurement period but not on their initial assessment.
(III) Long-stay and short-stay residents
shall be as defined in Subparagraph (c).
(IV) Antipsychotic Medications measures shall
be calculated consistent with the methodology described in the CMS Five Star
Nursing Home Quality Rating System.
(ii) Infection Prevention measures shall be
calculated based on the rate of urinary tract infections among patients
consistent with the methodology described in the CMS Five Star Nursing Home
Quality Rating System.
2. Performance benchmarks for each of the
Clinical Performance measures shall be established in consultation with THCA,
and with input from other NF stakeholders, including individuals receiving
services and their family members and representatives. These criteria shall be
provided to NFs and posted on the TennCare website no later than two (2) months
prior to implementation of the reimbursement system.
(e) In addition to the one hundred (100)
possible quality performance points that a NF may score in the areas described
in Subparagraphs (a), (b), (c) and (d) above, a NF may also earn ten (10) bonus
points for qualifying awards and/or accreditations that evidence the facility's
commitment to quality improvement processes. Qualifying awards or
accreditations must be current in the review period and are restricted to the
following:
1. Full participation in the
National Nursing Home Quality Improvement Campaign, which must be active during
the period in which bonus points are sought.
2. Membership in Eden Registry, which must be
active during the period in which bonus points are sought.
3. Achievement of the Malcolm Baldrige
Quality Award. This includes AHCA Award (Bronze, Silver, or Gold) and the TN
Center for Performance Excellence Award (Level 2, 3, or 4, which correspond
with the Commitment Award, Achievement Award, and Excellence Award; the Level 1
Interest Award is specifically excluded from points). Any such award must have
been achieved within the three (3) years prior to the end of the period in
which bonus points are sought.
4.
Accreditation by the Commission on Accreditation of Rehabilitation Facilities
(CARE).
5. Accreditation by the
Joint Commission.
(5) A NF shall be eligible to receive the
quality-based component of the per diem payment for NF services only if it has
fully satisfied the following threshold measures:
(a) The facility must be current on its
payment of the NF Assessment Fee. Anytime a facility is more than thirty (30)
days delinquent on its NF Assessment Fee, the qualitybased component of the
per-diem payment for NF services shall be suspended, and the facility shall
forfeit any quality-based component of its per diem reimbursement rate until
such time that the NF is current on its Assessment Fee payments. This shall be
operationalized as an MCO rate withhold, pursuant to T.C.A. §
71-5-1006.
(b) The facility has submitted complete,
accurate and timely quality measurement data as required by TennCare in order
to determine the NF's quality performance.
1.
Except as otherwise specified by TennCare, quality measurement data shall be
submitted by the NF on an annual basis. Where possible and appropriate,
TennCare will utilize existing data sources to minimize administrative
burden.
2. The data measurement
period shall be January 1 through December 31 of each year, which shall be used
to inform the quality-based component of the per diem payment for the fiscal
year beginning July 1 immediately after.
3. A NF shall not be entitled to a
quality-based component of the per diem payment for any NF services provided if
the facility has not complied with quality performance reporting requirements,
or if the facility knowingly submits, or causes or allows to be submitted any
such data used for purposes of setting quality-based rate components that is
determined (including upon post-payment audit or review) to be inaccurate or
incomplete.
4. Any facility
knowingly submitting false (including inaccurate or incomplete) quality
performance data for purposes of calculating its Medicaid payment shall be
subject to all applicable federal and state laws pertaining to the submission
of false claims.
5. For purposes of
this subparagraph, the term "knowingly" shall mean that a NF, or any person
acting on its behalf:
(a) has or should have,
upon exercise of due diligence, actual knowledge of the information;
(b) acts in deliberate ignorance of the truth
or falsity of the information; or
(c) acts in reckless disregard of the truth
or falsity of the information. No proof of specific intent is
required.
(6) Based on quality incentive program
scoring a NF will be placed into one of three quality tiers. The quality tier
cut points may only be updated for the July 1 rate setting of a rebase period.
For the July 1, 2018, rate effective date, the quality tier cut points will be
as follows:
Quality Tier |
Cut Point Range |
Quality Tier 1 |
75- 100 |
Quality Tier 2 |
50- 74.99 |
Quality Tier 3 |
0- 49.99 |
(7)
A NF's quality tier and quality incentive program score will be established for
each July 1 rate setting. The quality tier and quality incentive program score
will be based on the quality incentive program measurement period for the
calendar year period immediately preceding the applicable July 1 rate setting.
(8) A NFs quality incentive
program score is based on the point structure previously described in this
rule. As quality data is collected throughout the quality incentive program
measurement period, the following score weighting will be applied to the
varying metric collection intervals:
(a)
Quality incentive program scoring metrics that are annual in nature will not be
weighted.
(b) Quality incentive
program scoring metrics that are semi-annual in nature will be weighted as
follows:
1. 2/3rds
weight for the most recent six month period.
2. 1/3rd weight
for the first six month period.
(c) Quality incentive program scoring metrics
that are quarterly in nature will be weighted as follows:
1. 50% weight for the fourth quarter of the
calendar year.
2. 25% weight for
the third quarter of the calendar year.
3. 15% weight for the second quarter of the
calendar year.
4. 10% weight for
the first quarter of the calendar year.
(d) For any metric collection period,
regardless of collection interval, in which the final period is not the highest
scoring period, the NF provider's quality incentive program scoring metrics
will use the metric weighting method below that results in the greatest overall
quality incentive program score:
1. The
quality incentive program scoring metric weighting methods previously described
in this paragraph.
2. A Quality
incentive program scoring metric weighting method that equally weights all
metric collection periods, regardless of collection interval.
(9) Confidentiality of
Submitted Quality Information. Any submissions by any facility relating to
documentation of and participation in the Quality-based Component of the
Reimbursement Methodology for Nursing Facilities pursuant to Rule .11 shall be
confidential and privileged and shall be protected from direct or indirect
means of discovery, subpoena or admission into evidence in any judicial or
administrative proceeding. However, nothing in this rule shall not be construed
to make immune from discovery or use in any judicial or administrative
proceeding information, record, or documents that are otherwise available from
original sources kept in the facility, and would otherwise be available to a
litigant through discovered requested from the Facility. The confidentiality
provisions of this paragraph shall also not apply to any judicial or
administrative proceeding contesting the determination of TennCare regarding
the Facility's quality component reimbursement.
Notes
Authority: T.C.A. §§ 4-5-202, 71-5-105, 71-5-109, and 71-5-1413.
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