5160-3-43.1 Nursing facility (NF) case mix assessment instrument: minimum data set version 3.0 (MDS 3.0).
5160-3-43.1 Nursing
facility (NF)facilities (NFs): case mix assessment instrument: - minimum data set version 3.0 (MDS 3.0).(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 careplanning decisions and includes care area triggers (CATs), assessment of atriggered care area to facilitate care planning decision making and completionof the CAA summary (on the MDS 3.0, section V, item V0200) titled CAAsand care planning.(4)(3) "Case mix report" is a report generated by the Ohio department ofjob andfamily 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 ofnot onlythe appropriate MDS 3.0 assessment type listed in paragraph (B)(2) of this ruleand designated for use in Ohio but also completion of theCAA process.(6)(5) "Critical elements" are data items from a resident's MDS 3.0 thatODJFSODM verifies prior to determining a resident's resource utilization group,version III(RUGIII)classclassification.(7)(6) "Critical errors" are errors in the MDS 3.0 critical elements that preventODJFSODM from determining the resident's RUGIIIclassification.(8)(7) "Default group" isRUG 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 RUGIIIgroupsone 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 withthe United States centers for medicare and medicaid services(CMS) uniform data submission document and state specificationsMDS 3.0data 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/LongTerm CareFacilities.aspx.
(11) "Medicare required assessment" means the MDS 3.0
specified for use in Ohiothat is required only for facilities participating in the medicare prospective payment systembut does not include the CAA process.(12)
"Omnibus Budget Reconciliation Act of 1987 (OBRA 1987)" is the statutoryauthority for the RAI which specifies the minimum data set (MDS) of coreelements for use in conducting assessments of nursing home residents.Assessments are federally mandated and must be performed for all residentsof medicare and/or medicaid certified nursing homes.(13)(12) "Other medicare required assessment (OMRA)" is an unscheduled MDS3.0 Prospective Payment System (PPS)
PPSassessment 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 thetoolMDS 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 rule5101:3-3-43.35160-3-43.3 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 rule5101:3-3-43.35160-3-43.3 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 rule5101:3-3-43.25160-3-43.2 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 theinstrumentMDS 3.0 used by NFs in Ohio to comply with regulations in 42 C.F.R. 483.20(effective8/11/09 http://ecfr.gpoaccess.gov/cgi/t/text/text-idx? sid=2e0cc442b567f836691e8d460522a8a3 &c=ecfr&tpl=/ecfrbrowse/Title42/42tab_02.tpl) and provides a comprehensive,accurate, standardized, reproducible assessment of each long term carefacility resident's functional capabilities and identifies medical problems. TheOhio specified and federally approved instrument is composed of the MDS3.0, and CAA process.(23)(22) "Resident case mix score" is the relative resource weight for the RUGIIIgroup 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 beused to construct the identifier code.:
In the first three boxes, enter the firstthree letters of the resident's last name. In the next six boxes, enter the sixdigits 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) "RUGIII" is the resource utilization groups, version IIIsystem of classifying NF residentsinto case mix groupsdescribed in paragraph (B) of rule5101:3-3-43.25160-3-43.2 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 rule5101:3-3-43.35160-3-43.3 of the Administrative Code.(B) For the purpose of assigning a RUG
IIIclassification for determining medicaid payment rates for NFs,ODJFSODM shall utilize the data from the MDS 3.0asspecified by the state and approved by CMS. Each NF shall assess all residents of medicaid-certified beds using the appropriate MDS 3.0for assessment referencedates (ARDs) on or after October 1, 2010 as set forth in appendix A to this rule fora comprehensive assessment, or appendix D to this rule for a quarterly assessment,or appendix E to this rule for a PPS assessment. When theOmnibus BudgetReconciliation Act of 1987 (OBRA 1987)assessment(admission assessment,annual assessment, quarterly assessment, or significant change in status or asignificant correction to a prior assessment) andcoincides with medicare assessment time framescoincide, 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,theannual, 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 theOBRA and medicareassessments, the most stringent requirement forMDS completion must be met.
ODJFSODM 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 specifiedMDS 3.0, including section S. The comprehensive assessment, as set forth in appendixA to this ruleis completedupon admission, annually, and when a significantchange in the resident's status has occurred or a significant correction to aprior comprehensive assessment is requiredas specified in the MDS 3.0 RAI manual. NFs must use theOhio specified nursing homequarterly MDS 3.0,as set forth in appendix D to this ruleincluding 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 thisrulefor any residents who transfer, or are discharged, and the MDS 3.0 tracking recordas set forth in appendix C to this rulefor 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 MDSCMS database.(C) All NFs must submit to the
nationalCMS 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' uniformdata submission document, and state record layout specificationsMDS 3.0 data submission specifications version 1.15.0.(2) MDS 3.0 data must be
submitted in an electronic formatencodedand inaccordance 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 instructionsissued by the statein the MDS 3.0 RAI manual. Except asprovided 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,
ODJFSODM may assign a quarterly facility average total case mix score as set forth in paragraph (C)(3) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as set forth in paragraph (D)(4) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code.(4) MDS 3.0 data submitted by a provider that can not be timely extracted by
ODJFSODM 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 rule5101:3-3-43.35160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as set forth in paragraph (D)(4) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code.(5) The annual facility average case mix score,
semiannual, andquarterly facility average total case mix score, and quarterly and semiannual facility average medicaid case mixscorescores 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'sManual version 3.0" issued by CMS (May 2010http://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp)and in42 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
5101:3-3-43.35160-3-43.3 of the Administrative Code.(8) For a resident who had at least one MDS 3.0 assessment completed before being transferred to a hospital,
whothen 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
5101:3-3-43.35160-3-43.3 of the Administrative Code.(D)
Corrections to MDS 2.0 data with an ARD on or before September 30, 2010 must bemade in accordance with the requirements in the "CMS Revised Long Term CareResident Assessment Instrument User's Manual version 2.0", and the "StateOperations Manual" issued by CMS(http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS1201984&intNumPerPage=10).Corrections to MDS 3.0 datawith an ARD on or afterOctober 1, 2010must be made in accordance with the requirements in the"Long-Term Care Facility Resident Assessment Instrument User's Manual version3.0"MDS 3.0 RAI manual, and the "State Operations Manual" issued by CMS(Rev.1, May 21, 2004http://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
nationalCMS 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 onor before September 30, 2010, or an accurate, encodedMDS 3.0 recordfor anARD on or after October 1, 2010for 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
ODJFSODM shall use the resident case mix scores from the assessments for determining the quarterly facility average total case mix score, and maybe useduse 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 rule5101:3-3-43.35160-3-43.3 of the Administrative Code. If the assessments are not transmitted within forty-five days after the RPED,ODJFSODM may assign a default group for those records.(b) The provider shall notify
ODJFSODM 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 thenationalCMS database.ODJFSODM may assign default scores to those recordsas described in paragraph (F) of rule 5101:3-3-43.2 of theAdministrative Code.(c) The provider has forty-five days after the RPED to transmit the appropriate discharge assessment to the
nationalCMS database, if more residents are determinedas beingto be in the facility on the RPED than the number ofitsmedicaid certified beds in the facility on that same date. If the facility does not correct the error within forty-five days afterthe RPED,
ODJFSODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code.(d) The provider shall notify
ODJFSODM 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,ODJFSODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule5101:3-3-43.35160-3-43.3 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,
ODJFSODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule5101:3-3-43.35160-3-43.3 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,
ODJFSODM may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule5101:3-3-43.35160-3-43.3 of the Administrative Code.Effective: 03/01/2016
Five Year Review (FYR) Dates: 11/27/2015 and 03/01/2021
CERTIFIED ELECTRONICALLY
Certification
02/19/2016
Date
Promulgated Under: 119.03
Statutory Authority: 5165.02, 5165.192
Rule Amplifies: 5165.191, 5165.192
Prior Effective Dates: 10/1/92 (Emer.), 12/31/92, 4/15/93 (Emer.), 7/1/93,
12/1/93 (Emer.), 3/17/94, 7/1/94 (Emer.), 9/30/94,
7/1/98, 10/1/00, 1/8/04, 7/1/05, 2/2/06, 7/1/06,
10/1/06, 4/3/10, 10/1/10
Document Information
- Effective Date:
- 3/1/2016
- File Date:
- 2016-02-19
- Last Day in Effect:
- 2016-03-01
- Five Year Review:
- Yes
- Rule File:
- 5160-3-43$1_PH_FF_A_RU_20160219_1055.pdf
- Related Chapter/Rule NO.: (1)
- Ill. Adm. Code 5160-3-43.1. Nursing facility (NF) case mix assessment instrument: minimum data set version 3.0 (MDS 3.0)