Chapter 5123-7 Personnel

5123-7-01 Intermediate care facilities for individuals with intellectual disabilities - definitions.

For the purposes of rules in Chapters 5123-7 and 5123:2-7 of the Administrative Code, the following definitions shall apply unless otherwise provided:

(A) "Allowable costs" are those costs incurred for certified beds in an ICFIID as determined by the department to be reasonable, as defined in paragraph (K) of this rule, and do not include recoupments, fines, penalties, or interest paid in accordance with sections 5124.39, 5124.41, 5124.42, 5124.523, and 5124.99 of the Revised Code. Unless otherwise enumerated in Chapter 5123-7 or 5123:2-7 of the Administrative Code, allowable costs are also determined in accordance with the following reference material, in the following priority:

(1) 42 C.F.R. Chapter IV, as in effect on the effective date of this rule;

(2) The centers for medicare and medicaid services provider reimbursement manual (publications 15-1 and 15-2, available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals.html); and

(3) Generally accepted accounting principles in accordance with standards prescribed by the "American Institute of Certified Public Accountants" (available at https://www.aicpa.org).

(B) "Date of licensure," for an ICFIID originally licensed as a nursing home under Chapter 3721. of the Revised Code, means the date specific beds were originally licensed as nursing home beds under that chapter, regardless of whether they were subsequently licensed as residential facility beds. For a facility originally licensed as a residential facility, "date of licensure" means the date specific beds were originally licensed as residential facility beds under that section.

(1) If nursing home beds licensed under Chapter 3721. of the Revised Code or residential facility beds licensed under section 5123.19 of the Revised Code were not required by law to be licensed when they were originally used to provide nursing home or residential facility services, "date of licensure" means the date the beds first were used to provide nursing home or residential facility services, regardless of the date the present provider obtained licensure.

(2) If a facility adds nursing home or residential facility beds or in the case of an ICFIID with more than eight beds or a nursing facility, it extensively renovates the facility after its original date of licensure, it will have a different date of licensure for the additional beds or for the extensively renovated facility, unless, in the case of the addition of beds, the beds are added in a space that was constructed at the same time as the previously licensed beds but was not licensed under Chapter 3721. or section 5123.19 of the Revised Code at that time. The licensure date for additional beds or facilities which extensively renovate shall be the date the beds are placed into service.

(C) "Department" means the Ohio department of developmental disabilities.

(D) "Fiscal year" means the fiscal year of this state, as specified in section 9.34 of the Revised Code.

(E) "Inpatient days" means all days during which a resident, regardless of payment source, occupies a bed in an ICFIID that is included in the ICFIID's certified capacity under Title XIX of the Social Security Act, 49 stat. 620 , 42 U.S.C.A. 301, as in effect on the effective date of this rule. Bed-hold days determined in accordance with rule 5123:2-7-08 of the Administrative Code are considered inpatient days proportionate to the percentage of the ICFIID's per resident per day rate paid for those days.

(F) "Intermediate care facility for individuals with intellectual disabilities" (or "ICFIID") has the same meaning as in section 5124.01 of the Revised Code.

(G) "Owner" means any person or government entity that has at least five per cent ownership or interest, either directly, indirectly, or in any combination, in an ICFIID.

(H) "Provider" means a person or government entity that operates an ICFIID under a provider agreement.

(I) "Provider agreement" means a contract between the Ohio department of medicaid and an operator of an ICFIID for the provision of ICFIID services under the medicaid program. The signature of the operator or the operator's authorized agent binds the operator to the terms of the agreement.

(J) "Qualified intellectual disability professional" has the same meaning as in 42 C.F.R. 483.430, as in effect on the effective date of this rule.

(K) "Reasonable" means that a cost is an actual cost that is appropriate and helpful to develop and maintain the operation of an ICFIID and resident activities, including normal standby costs, and that does not exceed what a prudent buyer pays for a given item or service. Reasonable costs may vary from provider to provider and from time to time for the same provider.

(L) "Related party" means an individual or organization that, to a significant extent, has common ownership with, is associated or affiliated with, has control of, or is controlled by, the provider.

(1) An individual who is a relative of an owner is a related party.

(2) Common ownership exists when an individual or individuals possess significant ownership or equity in both the provider and the other organization. Significant ownership or equity exists when an individual or individuals possess five per cent ownership or equity in both the provider and a supplier. Significant ownership or equity is presumed to exist when an individual or individuals possess ten per cent ownership or equity in both the provider and another organization from which the provider purchases or leases real property.

(3) Control exists when an individual or organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization.

(4) An individual or organization that supplies goods or services to a provider shall not be considered a related party if all of the following conditions are met:

(a) The supplier is a separate bona fide organization;

(b) A substantial part of the supplier's business activity of the type carried on with the provider is transacted with others than the provider and there is an open, competitive market for the types of goods or services the supplier furnishes;

(c) The types of goods or services are commonly obtained by other ICFIID from outside organizations and are not a basic element of resident care ordinarily furnished directly to residents by the ICFIID; and

(d) The charge to the provider is in line with the charge for the goods or services in the open market and no more than the charge made under comparable circumstances to others by the supplier.

(M) "Relative of an owner" means a person who is related to an owner of an ICFIID by one of the following relationships:

(1) Spouse;

(2) Natural parent, child, or sibling;

(3) Adopted parent, child, or sibling;

(4) Stepparent, stepchild, stepbrother, or stepsister;

(5) Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law;

(6) Grandparent or grandchild; or

(7) Foster parent, foster child, foster brother, or foster sister.

(N) "Representative" means a person acting on behalf of an individual who is applying for or receiving medicaid. A representative may be a family member, guardian, attorney, hospital social worker, ICFIID social worker, or any other person chosen to act on the individual's behalf.

(O) "State survey agency" means the agency that inspects long-term care facilities for the purposes of survey and certification. The state survey agency in Ohio is the Ohio department of health.

Replaces: 5123:2-7-01

Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.01, 5124.03
Prior Effective Dates: 01/10/2013

5123-7-11 [Rescinded] Unclassified service.

Effective: 03/24/2012
Promulgated Under: 111.15
Statutory Authority: 124.34, 5123.04
Rule Amplifies: 124.34, 5123.04
Prior Effective Dates: 11/26/1979, 07/01/1980, 07/24/1982, 09/16/1984, 08/07/1995, 02/18/2002

5123-7-12 Intermediate care facilities for individuals with intellectual disabilities - cost report and chart of accounts.

(A) Purpose

This rule sets forth standards and requirements for an intermediate care facility for individuals with intellectual disabilities (ICFIID), other than a department-operated ICFIID, to submit cost reports to the department and maintain supporting documents and records.

(B) Submission of cost reports

(1) An ICFIID shall utilize the medicaid information technology system maintained by the Ohio department of medicaid to submit a cost report to the department in accordance with sections 5124.10, 5124.101, and 5124.522 of the Revised Code.

(2) For good cause, an ICFIID may request and the department may grant an extension of fourteen calendar days for submitting a cost report. An ICFIID requesting an extension shall do so in writing via email to cr-icf@dodd.ohio.gov and explain the circumstances resulting in the need for an extension. The request shall be submitted no later than ninety calendar days after the end of the reporting period.

(C) Classifying costs

(1) For purposes of the cost report, an ICFIID shall use the chart of accounts in the appendix to this rule and classify costs in accordance with applicable guidance and directives issued by the centers for medicare and medicaid services.

(a) When an account has sub-accounts, the sub-accounts shall be used to capture the information for cost reporting purposes. For example:

(i) When revenue accounts appear by payor type, charges shall be reported by payor type as applicable; and

(ii) When salary accounts differentiate between "supervisory" and "other," this level of detail shall be reported as applicable.

(b) While the chart of accounts facilitates the level of detail necessary for cost reporting purposes, an ICFIID may maintain records in a manner that allows for greater detail.

(c) The chart of accounts allows for a range of account numbers for a specified account. For example, account 1001 is for petty cash, with the next account, cash in bank, beginning at account 1010. An ICFIID may delineate sub-accounts 1010.1 to 1010.7 as separate cash accounts. An ICFIID need only use the applicable sub-accounts.

(d) Within the expense section (i.e., tables 5, 6, and 7), accounts identified as "salary" accounts are only to be used to report wages for employees of the ICFIID. Wages are to include wages for sick pay, vacation pay, and other paid time off, as well as any other compensation to be paid to an employee.

(e) Expense accounts identified as "contract" accounts are only to be used to report costs incurred for services performed by contracted personnel engaged by the ICFIID to perform a service that would otherwise be performed by personnel on the ICFIID's payroll.

(f) Expense accounts identified as "purchased nursing services" are only to be used to report costs incurred for personnel acquired through a nursing pool agency.

(g) Expense accounts designated as "other" may be used to report any appropriate non-wage expenses, including contract services and supplies.

(h) Completion of the cost report requires that the number of hours paid be reported (depending on ICFIID type of control, on an accrual or cash basis) for all salary expense accounts. An ICFIID's record keeping shall include accumulating hours paid consistent with the salary accounts included within the chart of accounts.

(2) Cost reports submitted by a county-operated ICFIID may be completed on accrual basis accounting and generally accepted accounting principles unless otherwise specified in Chapter 5123-7, 5123:2-7, or 5160-3 of the Administrative Code.

(3) All depreciable equipment valued at five hundred dollars or more per item with a useful life of at least two years, is to be reported in the capital cost component set forth in rule 5123:2-7-18 of the Administrative Code. The costs of equipment (including vehicles) acquired by an operating lease executed before December 1, 1992, may be reported in the indirect care cost component if the costs were reported as administrative and general costs on the ICFIID's cost report for the reporting period ending December 31, 1992, until the current lease term expires. The costs of any equipment leases executed before December 1, 1992 and reported as capital costs, shall continue to be reported under the capital cost component. The costs of any new leases for equipment executed on or after December 1, 1992, shall be reported under the capital cost component. Operating lease costs for equipment, which result from extended leases under the provision of a lease option negotiated on or after December 1, 1992, shall be reported under the capital cost component.

(4) Costs of ownership

(a) The desk-reviewed, actual, allowable, per diem costs of ownership are based upon certified beds for property costs and equipment for the calendar year preceding the fiscal year in which the rate will be paid and include:

(i) The costs of ownership directly related to purchasing or acquiring capital assets including:

(a) Except as otherwise required by paragraph (C)(4)(e) of this rule, depreciation expense for the cost of buildings equal to the actual cost depreciated in accordance with rule 5123:2-7-18 of the Administrative Code. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(b) Except as otherwise required by paragraph (C)(4)(e) of this rule, depreciation expense for major components of property and fixed equipment equal to the actual cost depreciated in accordance with rule 5123:2-7-18 of the Administrative Code. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(c) Except as otherwise required by paragraph (C)(4)(e) of this rule, depreciation expense for major movable equipment equal to the actual cost depreciated in accordance with rule 5123:2-7-18 of the Administrative Code. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(d) Interest expense incurred on money borrowed for construction or the purchase of real property, major components of that property, and equipment.

(e) Depreciation expense for costs paid or reimbursed by any government agency, if that part of the prospective per diem rate is used to reimburse the government agency and a loan provides for repayment over a time-limited period.

(f) Amortization expense of financing costs.

(ii) The costs of ownership directly related to renting or leasing capital assets.

(iii) The costs of ownership directly related to the amortization of leasehold improvements. These costs shall be expensed over the lesser of the remaining life of the lease, but not less than five years, or the useful life of the improvement as specified in rule 5123:2-7-18 of the Administrative Code. If the useful life of the improvement is less than five years, it may be amortized over its useful life. Options on leases shall not be considered. Lessees who report leasehold improvements and who leave the program before the minimum amortization period is complete shall not receive reimbursement for the balance of unamortized costs.

(b) The costs of ownership directly attributable to the purchase, rent, or lease of property and equipment costs from one related party to another through common ownership or control shall be based upon the lesser of the actual purchase, rent, or lease of property and equipment costs or the actual costs of the related party.

(i) If a provider leases or transfers an interest in an ICFIID to another provider who is a related party, the related party's allowable costs of ownership shall include the lesser of:

(a) The annual lease expense or actual costs of ownership, whichever is applicable; or

(b) The reasonable cost to the lessor or provider making the transfer.

(ii) If a provider leases or transfers an interest in an ICFIID to another provider who is a related party, regardless of the date of the lease or transfer, the related party's allowable costs of ownership shall include the annual lease expense or actual costs of ownership, whichever is applicable, if all of the following conditions are met:

(a) The related party is a relative of the owner.

(b) In the case of a lease, if the lessor retains any ownership interest, it is, except as provided in paragraph (C)(4)(b)(ii)(d)(i)(B) of this rule, in only the real property and any improvements to the real property.

(c) In the case of a transfer, the provider making the transfer retains, except as provided in paragraph (C)(4)(b)(ii)(d)(ii)(B) of this rule, no ownership interest in the ICFIID.

(d) The department determines that the lease or transfer is an arm's length transaction when:

(i) In the case of a lease:

(A) Once the lease goes into effect, the lessor has no direct or indirect interest in the lessee or, except as provided in paragraph (C)(4)(b)(ii)(b) of this rule, the ICFIID itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a lessor.

(B) The lessor does not reacquire an interest in the ICFIID except through the exercise of a lessor's rights in the event of a default. If the lessor reacquires an interest in the ICFIID in this manner, the department shall treat the ICFIID as if the lease never occurred when the department calculates its reimbursement rates for capital costs.

(ii) In the case of a transfer:

(A) Once the transfer goes into effect, the provider that made the transfer has no direct or indirect interest in the provider that acquires the ICFIID or in the ICFIID itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a creditor. If the provider making the transfer maintains an interest as a creditor, the interest rate of the creditor shall not exceed the lessor of:

(1) The prime rate, as published by the "Wall Street Journal" on the first business day of the calendar year plus four per cent; or

(2) Fifteen per cent.

(B) The provider that made the transfer does not reacquire an interest in the ICFIID except through the exercise of a creditor's rights in the event of a default. If the provider reacquires an interest in the ICFIID in this manner, the department shall treat the ICFIID as if the transfer never occurred when the department calculates its reimbursement rates for capital costs.

(e) Except in the case of hardship caused by a catastrophic event, as determined by the department, or in the case of a lessor or provider making the transfer who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same ICFIID, allowable costs of ownership was determined most recently.

(c) A provider proposing to lease or transfer an interest in an ICFIID to a related party shall provide the department with a certified appraisal for each ICFIID to be leased or transferred at least ninety calendar days prior to the actual change of the provider agreement. The certified appraisal shall be conducted no earlier than one hundred eighty calendar days prior to the actual change of the provider agreement for each ICFIID leased or transferred to a related party.

(d) A provider proposing to lease or transfer an interest in an ICFIID to a related party shall notify the department in writing and shall supply sufficient documentation demonstrating compliance with the provisions of this rule at least ninety calendar days prior to the anticipated date of completion of the transfer or lease. A provider that fails to supply the required documentation shall not qualify for a rate adjustment. The department shall issue a written decision determining whether the lease or transfer meets the requirements of this rule within sixty calendar days after receiving complete information as determined by the department.

(e) Reporting of accumulated depreciation

(i) Upon the sale of an ICFIID, the allowable capital asset cost basis, depreciation expense, and interest expense for the new provider/ buyer of the ICFIID shall be the new provider's/buyer's actual depreciation and interest expense subject to the ceilings set forth in section 5124.171 of the Revised Code. If the operating rights are separately identified and valued in a sale that includes both the building and the operating rights, the operating rights shall be considered to be a part of the building for purposes of determining the allowable capital asset cost basis under this paragraph. If a new provider/buyer purchases only the operating rights to the ICFIID and uses the operating rights to create a new ICFIID or add beds to an existing ICFIID, the purchase price of the operating rights shall be added to the capital asset cost basis of the new ICFIID building or the additional beds.

(ii) Upon the sale of an ICFIID, the initial accumulated depreciation for the new provider/buyer of the ICFIID shall be recalculated starting at zero.

(5) Except for the employer's share of payroll taxes, workers' compensation, employee benefits, and home office costs, allocation of commonly shared expenses across cost centers shall not be allowed. Wages and benefits for staff, including related parties who perform duties directly related to functions performed in more than one cost center which would be expended under separate cost centers if performed by separate staff, may be expended to separate cost centers based upon documented hours worked, provided the ICFIID maintains adequate documentation of hours worked in each cost center. For example, the salary of an aide who is assigned to bathing and dressing chores in the early hours but works in the kitchen as a dietary aide for the remainder of the shift may be expended to separate cost centers provided the ICFIID maintains adequate documentation of hours worked in each cost center.

(6) The cost of purchasing resident transport vehicles is reported under the capital cost component. The cost of maintaining and repairing these vehicles is reported under the indirect care cost component.

(7) As part of its cost report, an ICFIID may complete the addendum for disputed costs to defend costs the ICFIID believes may be disputed by the department. The costs stated on the addendum are to have been applied to the other schedules and attachments for the reporting period in question (either in the reimbursable or the nonreimbursable cost centers). Any costs reported on the addendum may be considered by the department in establishing the ICFIID's prospective rate.

(8) The following costs are not reimbursable to an ICFIID through the prospective reimbursement cost reporting mechanism, except as otherwise specified in Chapter 5123-7 or 5123:2-7 of the Administrative Code:

(a) Recoupments, fines, penalties, or interest paid in accordance with sections 5124.39, 5124.41, 5124.42, 5124.523, and 5124.99 of the Revised Code.

(b) Disallowances made during an audit of the ICFIID's cost report which are sanctioned through adjudication in accordance with Chapter 119. of the Revised Code.

(c) Costs which are determined not to be reasonable and allowable costs during an audit of the ICFIID's cost report.

(d) Cost of ancillary services (e.g., physicians, legend drugs, radiology, laboratory, oxygen, or resident-specific medical equipment) rendered to residents of the ICFIID by providers who bill medicaid directly.

(e) Cost per case mix units in excess of the applicable peer group ceiling for direct care cost.

(f) Expenses in excess of the applicable peer group ceiling for indirect care cost.

(g) Expenses in excess of the capital costs limitations.

(h) Expenses associated with lawsuits filed against the department or the Ohio department of medicaid which are not upheld by the courts.

(i) Cost of meals sold to visitors or the public (e.g., meals on wheels).

(j) Cost of supplies or services sold to persons who do not reside at the ICFIID.

(k) Cost of operating a gift shop.

(D) Required disclosures As a component of the cost report, providers shall identify:

(1) Each known related party.

(2) Each known individual, group of individuals, or organization not otherwise publicly disclosed that owns or has common ownership in whole or in part, in any mortgage, deed of trust, property, or asset of the ICFIID. When the ICFIID or the common owner is a publicly owned and traded corporation, this information beyond basic identifying criteria is not required as part of the cost report but must be available within two weeks when requested. Publicly disclosed information must be available at the time of an audit.

(3) Each corporate officer or director, if the provider is a corporation.

(4) Each partner, if the provider is a partnership.

(5) Each provider, whether participating in the medicare or medicaid program or not, which is part of an organization which is owned, or through any other device controlled, by the organization of which the provider is a part.

(6) Any director, officer, manager, employee, individual, or organization having direct or indirect ownership or control of five per cent or more, or who has been convicted of or pleaded guilty to a civil or criminal offense related to his or her involvement in programs established by Title XVIII, Title XIX, or Title XX of the Social Security Act, as in effect on the effective date of this rule. The amount of indirect ownership is determined by multiplying the percentage of ownership interest at each level (e.g., forty per cent interest in corporation "A" which owns fifty per cent of corporation "B" results in a twenty per cent indirect interest in corporation "B").

(7) Any individual currently employed by or under contract with the provider, or a related party in a managerial, accounting, auditing, legal, or similar capacity who was employed by the department, the Ohio department of medicaid, the Ohio department of health, the Ohio attorney general, the Ohio department of aging, the Ohio department of commerce, or the industrial commission of Ohio within the previous twelve months.

(E) Contracts for service

A provider shall provide upon request, each contract for service in effect during the reporting period for which the cost of the service from any subcontractor, individual, or organization is ten thousand dollars or more in a twelve-month period or for the services of a sole proprietor or partnership where there is no cost incurred and the imputed value of the service is ten thousand dollars or more in a twelve-month period. For the purposes of this paragraph:

(1) "Contract for service" is defined as the component of a contract that details services provided exclusive of supplies and equipment. It includes any contract which details services, supplies, and equipment to the extent the value of the service component is ten thousand dollars or more within a twelve-month period.

(2) "Subcontractor" is defined as any entity, including an individual or individuals, who contract with a provider to supply a service, either to the provider or directly to the beneficiary, where medicaid reimburses the provider for the cost of the service. This includes organizations related to the subcontractor that have a contract with the subcontractor for which the cost or value is ten thousand dollars or more in a twelve-month period.

(F) Preliminary determination by the department

(1) The department shall conduct a desk review of each cost report it receives. The desk review is an analysis of the cost report to determine its adequacy, completeness, and accuracy and reasonableness of the data contained therein. It is a process of reviewing information pertaining to the cost report without detailed verification and is designed to identify problems warranting additional review.

(2) Based on the desk review, the department shall make a preliminary determination of whether the reported costs are reasonable and allowable costs. "Reasonable and allowable costs" means costs established in accordance with the centers for medicare and medicaid services provider reimbursement manual (publications 15-1 and 15-2, available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals.html). Before issuing the preliminary determination, the department shall notify the provider of any information in the cost report that requires additional support. The provider shall provide any documentation or other information requested by the department and may submit any information that it believes supports the reported costs. The department shall notify each provider of any costs preliminarily determined not to be reasonable and allowable costs and provide the reasons for the determination.

(3) A provider may revise the cost report within sixty calendar days after the original due date without the revised information being considered an amended cost report.

(4) The cost report is considered accepted after the department has completed the desk review process.

(5) After final rates have been issued, a provider who disagrees with a preliminary determination based on the desk review may request a rate reconsideration in accordance with rule 5123-7-27 of the Administrative Code.

(G) Amending a cost report

(1) Except as provided in paragraph (G)(2) of this rule and not later than three years after a provider files a cost report with the department, the provider may amend the cost report if the provider discovers a material error in the cost report or additional information to be included in the cost report. The department shall review the amended cost report for accuracy and notify the provider of its determination.

(2) A provider may not amend a cost report if the Ohio department of medicaid has notified the provider that an audit of the cost report or a cost report of the provider for a subsequent cost reporting period is to be conducted under section 5124.109 of the Revised Code. The provider may, however, provide the Ohio department of medicaid information that affects the costs included in the cost report. Such information may not be provided after the adjudication of the final settlement of the cost report.

(3) The department shall not charge interest under division (B) of section 5124.41 of the Revised Code based on any error or additional information that is not required to be reported under this rule. The department shall review the amended cost report for accuracy and notify the provider of its determination in accordance with section 5124.107 of the Revised Code.

(H) Retention of records

(1) Financial, statistical, and medical records (which shall be available to the department, the Ohio department of medicaid, and to the United States department of health and human services and other federal agencies) supporting the cost reports or claims for services rendered to residents shall be retained for the greater of seven years after the cost report is filed if the Ohio department of medicaid issues an audit report, or six years after all appeal rights relating to the audit report are exhausted.

(2) Failure to retain the required financial, statistical, or medical records to the extent that filed cost reports are unauditable renders the provider liable for monetary damages of the greater amount:

(a) One thousand dollars per audit; or

(b) Twenty-five per cent of the amount by which the undocumented cost increased the medicaid payments to the provider during the fiscal year.

(3) Providers whose records have been found to be unauditable will be allowed sixty calendar days to provide the necessary documentation. If, at the end of the sixty calendar days, the required records have been provided and are determined auditable, the proposed penalty will be withdrawn. If the Ohio department of medicaid, after review of the documentation submitted during the sixty-day period, determines that the records are still unauditable, the department shall impose the penalty as specified in paragraph (H)(2) of this rule.

(4) Refusing access to financial, statistical, or medical records shall result in a penalty as specified in paragraph (H)(2) of this rule for outstanding medicaid services until such time as the requested information is made available to the department or the Ohio department of medicaid.

(5) All requested financial, statistical, and medical records supporting the cost reports or claims for services rendered to residents shall be available at a location in the state of Ohio for an ICFIID certified for participation in the medicaid program by this state within at least sixty calendar days after request by the state or its subcontractors. The preferred Ohio location is the ICFIID itself, but may be a corporate office, an accountant's office, or an attorney's office elsewhere in Ohio. This requirement, however, does not preclude the state or its subcontractors from the option of conducting the audit and/or a review at the site of such records if outside of Ohio.

Replaces: 5123:2-7-12

Click to view Appendix

Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5124.03, 5123.04
Rule Amplifies: 5123.04 , 5124.522, 5124.10 to 5124.109, 5124.03
Prior Effective Dates: 01/10/2013, 01/01/2017, 02/15/2018

5123-7-20 Intermediate care facilities for individuals with intellectual disabilities - resident assessment classification system based on administration of the individual assessment form.

(A) Purpose

This rule sets forth a method and process for determining the per resident/per day rate paid to an intermediate care facility for individuals with intellectual disabilities (ICFIID) for direct care costs using the individual assessment form pursuant to sections 5124.195 to 5124.198 of the Revised Code.

(B) Definitions

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

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

(2) "Case mix score" means the measure of the relative direct care resources needed to provide care and rehabilitation to a resident of an ICFIID using the individual assessment form.

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

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

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

(a) Failure to electronically submit the certification of individual assessment form data by the correction submission due date.

(b) Incomplete or inaccurate data are submitted to the department.

(c) The number of individual assessment form records processed is more than the reported number of residents in medicaid-certified beds on the reporting period end date.

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

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

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

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

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

(b) "Peer group 2-B" includes each ICFIID with a medicaid-certified capacity not exceeding eight, other than an ICFIID that is in peer group 3-B.

(c) "Peer group 3-B" includes each ICFIID to which all of the following apply:

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

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

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

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

(10) "Processing quarter" means the quarter that follows the reporting quarter and is the quarter in which the department receives the individual assessment form data for the reporting quarter.

(11) "Quarterly facility average case mix score" means the facility average case mix score based on individual assessment form data submitted for one reporting quarter.

(12) "Record" means a resident's individual assessment form data processed by the department.

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

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

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

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

(17) "Resident case mix score" means the relative resource weight for the classification to which a resident is assigned based on data elements from the resident's individual assessment form.

(C) Calculating direct care costs

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

(1) Administration of the individual assessment form to residents of the ICFIID in accordance with this rule; and

(2) Administration of the Ohio developmental disabilities profile to residents of the ICFIID in accordance with rules 5123-7-33 and 5123:2-7-32 of the Administrative Code.

(D) Resident assessment classification system

(1) The department shall use the resident assessment classification system to classify residents of an ICFIID based on data from the individual assessment form. Residents in each classification utilize similar quantities and patterns of resources. Based upon the data collected in the individual assessment form, a resident that meets the criteria for placement in more than one classification shall be placed in the highest classification according to the hierarchy. Residents without characteristics resulting in assignment to the higher classifications shall be placed in the sixth classification.

(2) The resident assessment classification system defines criteria used to assign residents to one of six mutually exclusive classifications listed in descending order of the hierarchy:

(a) The chronic medical classification includes residents receiving one or more of the following types of special care:

(i) Parenteral therapy on all shifts (on the individual assessment form at the medical domain section, item 24 is scored "4"),

(ii) Tracheostomy care/suctioning on all shifts (on the individual assessment form at the medical domain section, item 25 is scored "4"),

(iii) Oxygen and respiratory therapy on all shifts (on the individual assessment form at the medical domain section, item 27 is scored "4"),

(iv) Oral medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item 29a is scored "3"),

(v) Topical medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item 29b is scored "3"),

(vi) Injections of medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item 29c is scored "3"),

(vii) Medication administered more than eight times in a twenty-four-hour day using a method other than oral, topical, or injection (on the individual assessment form at the medical domain section, item 29d is scored "3"), and/or

(viii) Utilization of out-of-home health care requiring over thirty days of staff time on average per year (on the individual assessment form at the medical domain section, item 31 is scored "3").

(b) The overriding behaviors classification includes residents exhibiting one or more of the following specific behaviors that require continual staff intervention as defined in the individual assessment form instructions:

(i) Aggressive behavior (on the individual assessment form at the behavior domain section, item 14 is scored "3"),

(ii) Self-injurious behavior (on the individual assessment form at the behavior domain section, item 17 is scored "3"), and/or

(iii) Acute suicidal behavior (on the individual assessment form at the behavior domain section, item 21 is scored "3").

(c) The high adaptive needs and chronic behaviors classification includes residents requiring a specific level of staff assistance/supervision for one or more personal care and safety needs described in paragraphs (D)(2)(c) (i) to (D)(2)(c)(vi) of this rule and exhibiting one or more of the behaviors described in paragraphs (D)(2)(c)(vii) to (D)(2)(c)(x) of this rule that require frequent or continual staff intervention as defined in the individual assessment form instructions:

(i) Eating (on the individual assessment form at the adaptive skills domain section, item 1 is scored "2" for needing hands-on assistance),

(ii) Toileting (on the individual assessment form at the adaptive skills domain section, item 2 is scored either "3" for as a rule does not indicate the need to toilet and requires assistance with wiping, or "4" for requires colostomy, ileostomy, or urinary catheter),

(iii) Dressing (on the individual assessment form at the adaptive skills domain section, item 5 is scored "3" for requiring hands-on assistance and/or constant supervision to complete the tasks, or tasks must be done completely by staff for the resident),

(iv) Turning and positioning more than twelve times in a twenty-four-hour period (on the individual assessment form at the adaptive skills domain section, item 6 is scored "4"),

(v) Mobility requiring the help of one or more persons (on the individual assessment form at the adaptive skills domain section, item 7 is scored "3"),

(vi) Transfer requiring direction and/or physical help from one or more persons (on the individual assessment form at the adaptive skills domain section, item 8 is scored "2"),

(vii) Aggressive behavior requiring frequent staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item 14 is scored "2"),

(viii) Self-injurious behavior requiring frequent staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item 17 is scored "2"),

(ix) Disruptive behavior requiring continual staff intervention as defined in the individual assessment form (on the individual assessment form at the behavior domain section, item 19 is scored "4"), and/or

(x) Withdrawn behavior requiring continual staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item 20 is scored "3").

(d) The high adaptive needs and non-significant behaviors classification includes residents requiring a specific level of staff assistance/supervision for one or more personal care and safety needs described in paragraphs (D)(2)(c)(i) to (D)(2)(c)(vi) of this rule.

(e) The chronic behaviors and typical adaptive needs classification includes residents exhibiting one or more of the behaviors described in paragraphs (D)(2)(c)(vii) to (D)(2)(c)(x) of this rule that require frequent or continual staff intervention as defined in the individual assessment form instructions.

(f) The typical adaptive needs and non-significant behaviors classification includes residents not meeting the criteria of the other five classifications.

(E) Relative resource weights

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

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

(b) Licensed practical nurses;

(c) Occupational therapists;

(d) Program specialists;

(e) Qualified intellectual disability professionals;

(f) Registered nurses;

(g) Social workers/counselors; and

(h) Speech therapists.

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

(a) Chronic medical = 2.0888.

(b) Overriding behaviors = 1.9206.

(c) High adaptive needs and chronic behaviors = 1.8935.

(d) High adaptive needs and non-significant behaviors = 1.7434.

(e) Chronic behaviors and typical adaptive needs = 1.3593.

(f) Typical adaptive needs and non-significant behaviors = 1.000.

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

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

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

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

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

(F) Collection and submission of individual assessment form data

(1) The department shall process individual assessment form data submitted by an ICFIID and classify residents using the resident assessment classification system to determine resident case mix scores. These resident case mix scores, based on relative resource weights as set forth in paragraph (E) of this rule, are used to establish the quarterly facility average case mix score. The method for determining the quarterly facility average case mix score is described in paragraph (G)(4) of this rule.

(2) The individual assessment form shall be administered by ICFIID staff authorized by the department. In order to become authorized, ICFIID staff shall attend and successfully complete a training session conducted or approved by the department that includes a demonstration.

(3) Each ICFIID shall use the individual assessment form software provided by the department at no cost to complete and electronically submit to the department through the department's website (http://dodd.ohio.gov) a quarterly case mix assessment for each resident of the ICFIID, regardless of payment source or anticipated length of stay, to reflect the resident's condition on the reporting period end date, which is the last day of the calendar quarter. The electronic data shall be submitted in the exact layout provided in the individual assessment form software.

(4) The following shall be considered residents of the ICFIID on the reporting period end date:

(a) Residents admitted or transferred to the ICFIID prior to or on the reporting period end date and physically residing in the ICFIID on the reporting period end date; and

(b) Residents temporarily absent on the reporting period end date but for whom the ICFIID is receiving payment from any source to hold a bed for the resident during a hospital stay, visit with friends or relatives, or participation in therapeutic programs outside the facility in accordance with rule 5123:2-7-08 of the Administrative Code.

(5) The following shall not be considered residents of the ICFIID on the reporting period end date:

(a) Residents discharged from the ICFIID prior to or on the reporting period end date; and

(b) Residents transferred to another ICFIID prior to or on the reporting period end date; and

(c) Residents who die prior to or on the reporting period end date.

(6) An ICFIID shall complete and electronically submit a certification of individual assessment form data with the quarterly submission of individual assessment form data identifying the name of the ICFIID, its provider number, the total number of beds the ICFIID has certified by the Ohio department of health for medicaid, total number of residents in the ICFIID as of the reporting period end date for whom the ICFIID must submit an individual assessment form, and the name of the authorized staff member who administered the individual assessment form for each resident. The certification of individual assessment form data shall be electronically submitted to the department no later than the fifteenth day of the month following the reporting period end date.

(7) The annual facility average case mix score calculated in accordance with this rule is used in conjunction with the lesser of the ICFIID's cost per case mix unit or the maximum allowable cost per case mix unit, adjusted by the inflation rate, to establish the direct care rate, as outlined in sections 5124.195 to 5124.198 of the Revised Code. The ICFIID's cost per case mix unit is calculated using the annual facility average case mix score. The method for determining the annual facility average case mix score is described in paragraph (H) of this rule.

(G) Quarterly facility average case mix score

(1) The department shall establish each ICFIID's rate for direct care costs using data from the individual assessment form, annually pursuant to sections 5124.195 to 5124.198 of the Revised Code. The department shall assign a quarterly facility average case mix score or cost per case mix unit used to establish an ICFIID's rate for direct care costs if the ICFIID fails to certify individual assessment form data in accordance with this rule or fails to correct facility level errors. Before taking such action, the department shall permit the ICFIID a reasonable period of time to correct the information, as described in paragraph (G)(3)(c) of this rule. To set the rate, the department shall:

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

(b) Multiply the lesser of the ICFIID's cost per case mix unit or the maximum cost per case mix unit for the ICFIID's peer group determined pursuant to division (C) of section 5124.195 of the Revised Code by the ICFIID's annual average case mix score for the calendar year preceding the fiscal year for which the rate is set begins; and

(c) Multiply the amount determined in accordance with paragraph (G)(1)(b) of this rule by the inflation factor specified in division (D) of section 5124.195 of the Revised Code.

(2) The department shall calculate and use the actual quarterly facility average case mix score described in paragraph (G)(4) of this rule for determining the direct care rate if:

(a) The ICFIID submits individual assessment form data by the filing date and includes assessments for all residents of the ICFIID as of the reporting period end date;

(b) In accordance with the procedures outlined in paragraph (G)(3) of this rule for correcting inaccurate information, the ICFIID timely submits and timely corrects individual assessment form data for that reporting quarter; and

(c) The ICFIID's submission and certification of individual assessment form data does not contain facility level errors or such errors have been timely corrected.

(3) After the department has processed the ICFIID's individual assessment form data for a reporting quarter, the department shall make available the "Case Mix Provider Summary Report" to the ICFIID. The ICFIID may correct errors or omissions identified by either the department or the ICFIID by sending in a modification submission and submitting corrections to the department along with an amended certification of individual assessment form data.

(a) The department shall notify an ICFIID of a missing or incomplete certification of individual assessment form data.

(b) The department may notify an ICFIID of its initial quarterly submission through two documents:

(i) The "Submission Tracking Summary" report which shows the status of the individual assessment form data after initial processing by the department.

(ii) The "Detailed Listing of Successfully Grouped Assessments" report which is a list of individual assessment form records that were grouped into resident assessment classification system groups one through six.

(c) The department shall allow forty-five calendar days after the reporting period end date for an ICFIID to make corrections and return them to the department. Timeliness of the submission to the department shall be determined by the electronic submission date.

(d) Corrections received by the department shall be used in computing the quarterly facility average case mix score, in accordance with the conditions outlined in paragraph (G)(2) of this rule.

(e) The department shall process corrections submitted in electronic format if the file format is the same as used by the department.

(f) Changes made on the individual assessment form modification submission data element entries must be consistent with changes made to the original individual assessment form maintained at the ICFIID.

(4) The quarterly facility average case mix score for an ICFIID that submitted individual assessment form data and modifications timely, and has no facility level errors is calculated by:

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

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

(5) The department may assign a quarterly facility average case mix score that is five per cent less than the ICFIID's quarterly facility average case mix score for the preceding calendar quarter instead of using the quarterly facility average case mix score calculated based on the ICFIID's submitted information as described in paragraph (G)(4) of this rule.

(a) If the ICFIID was subject to an exception review conducted pursuant to rule 5123-7-30 of the Administrative Code for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the ICFIID was assigned a quarterly facility average case mix score for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than that score assigned for the preceding quarter.

(6) The department may assign a cost per case mix unit that is five per cent less than the ICFIID's calculated or assigned cost per case mix unit for the preceding calendar year if the ICFIID has fewer than two acceptable quarterly facility average case mix scores.

(H) Annual facility average case mix score

(1) The annual facility average case mix score is used to compute the cost per case mix unit for the ICFIID and the peer group maximum cost per case mix unit for the purpose of calculating direct care rates pursuant to sections 5124.195 to 5124.198 of the Revised Code. Individual assessment form data for all four quarters of the calendar year shall be used to calculate the annual facility average case mix score.

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

(b) The annual facility average case mix score shall be calculated from no fewer than two acceptable quarterly facility average case mix scores. Acceptable quarterly facility average case mix scores shall be summed and divided by the total number of quarters of acceptable scores. Acceptable quarterly facility average case mix scores for the purposes of calculating the annual facility average case mix score include, in order of hierarchy:

(i) Adjusted quarterly facility average case mix scores as a result of exception review findings, or

(ii) Quarterly facility average case mix scores calculated based on the ICFIID's submitted information as described in paragraph (G)(4) of this rule.

(2) If at least two acceptable quarterly facility average case mix scores are not available, the department shall assign the cost per case mix unit in accordance with paragraph (G)(6) of this rule.

Replaces: 5123:2-7-20

Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.03 , 5124.195 to 5124.198
Prior Effective Dates: 01/10/2013, 10/01/2013, 06/26/2014, 10/01/2014

5123-7-24 Intermediate care facilities for individuals with intellectual disabilities - costs of ownership payment.

(A) Purpose

This rule sets forth conditions necessary for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to receive a costs of ownership payment. This rule applies only to the capital rate calculation prescribed in section 5124.171 of the Revised Code.

(B) Definitions

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

(1) "Costs of ownership" means the actual expense incurred for:

(a) Depreciation and interest on any items capitalized including:

(i) Buildings;

(ii) Building improvements;

(iii) Equipment;

(iv) Extensive renovation;

(v) Transportation equipment; and

(vi) Replacement beds.

(b) Amortization and interest on land improvements and leasehold improvements.

(c) Amortization of financing costs.

(d) Lease and rent of land, building, and equipment.

(2) "Extensive renovation" means a renovation that costs more than sixty-five per cent and no more than eighty-five per cent of the cost of constructing a new bed and that extends the useful life of the assets for at least ten years. To calculate the per-bed cost of a renovation project for purposes of determining whether it is an extensive renovation, the allowable cost of the project shall be divided by the number of beds in the facility certified for participation in the medicaid program, even if the project does not affect all medicaid-certified beds. Allowable extensive renovations are considered an integral part of costs of ownership.

(a) The cost of constructing a new bed shall be considered to be forty thousand dollars, adjusted for inflation from January 1, 1993 to the end of the calendar year during which the renovation is completed using the consumer price index for shelter costs for all urban consumers for the midwest region, as published by the United States bureau of labor statistics.

(b) The department may treat a renovation that costs more than eighty-five per cent of the cost of constructing new beds as an extensive renovation if the department determines that the renovation is more prudent than construction of new beds.

(3) "Nonextensive renovation" has the same meaning as in rule 5123-7-25 of the Administrative Code.

(4) "Replacement beds" are beds which are relocated to a new building or portion of a building attached to and/or constructed outside of the original licensed structure of an ICFIID. Replacement beds may originate from within the licensed structure of an ICFIID or from another ICFIID. Replacement beds are eligible for the costs of ownership efficiency incentive ceiling which corresponds to the period in which the beds were replaced.

(C) Costs of ownership payment

(1) For an ICFIID that has dates of licensure or that has been granted project authorization by the department on or after July 1, 1993, for which substantial commitments of funds were not made before July 1, 1993, costs of ownership payments shall not exceed the ceilings established in section 5124.171 of the Revised Code, if the department gives prior approval for construction of the ICFIID.

(a) Prior to commencement of construction, the provider must submit a request in writing to the department. The request shall include:

(i) The projected completion date for the new ICFIID.

(ii) A projected budget for the new ICFIID that includes a projected three-month cost report that contains all cost centers and inpatient days so that an overall rate can be calculated. For beds relocated from an existing ICFIID, the same information must be received for the existing ICFIID and the ICFIID to which the beds are to be relocated.

(b) The department shall review the request and the projected budget, comparing the projected cost per diem to the rate currently associated with the beds for cost neutrality to the Ohio medicaid program. Cost neutrality shall be evaluated across beds transferred to the new ICFIID and the beds remaining in the existing ICFIID.

(c) Approval for the increased costs of ownership payments shall be granted contingent upon the receipt by the department of the provider's filed actual cost report for the first three months of operation confirming cost neutrality to the Ohio medicaid program. Until a final determination is made by the department with regard to the request for increased costs of ownership payments, the lower costs of ownership ceiling shall be effective.

(d) Written approval or denial of the preliminary request shall be made by the department within sixty calendar days of the date the initial request was made and the required documentation was received. Written documentation of the final determination shall be provided by the department within sixty calendar days from the date the new ICFIID's actual three-month cost report is received.

(e) If the project continues to satisfy the cost neutrality standard, the higher costs of ownership ceiling shall be implemented retroactively to the first day the new ICFIID's provider agreement was effective. If the request is denied, the provider shall continue to receive the lower costs of ownership ceiling.

(2) An ICFIID that completes extensive renovations shall receive a per diem for costs of ownership based upon the costs as specified in paragraph (C)(1) of this rule.

(a) The date of licensure for an extensively renovated ICFIID shall be considered to be the date of completion of the extensive renovation.

(b) The current limits as calculated in accordance with section 5124.171 of the Revised Code shall be assigned to the extensively renovated ICFIID using the date of licensure.

(c) An extensively renovated ICFIID that obtains new ceilings in accordance with this rule, shall not be permitted any reimbursement for nonextensive renovation under rule 5123-7-25 of the Administrative Code made prior to the extensive renovation project which resulted in the new ceilings. Thereafter, the cost and accumulated depreciation of the nonextensive renovation shall be included in costs of ownership.

(d) An extensively renovated ICFIID shall not be permitted to receive any reimbursement for nonextensive renovation under rule 5123-7-25 of the Administrative Code for a period of five years after the completion of the extensive renovations, with the exception of those nonextensive renovation projects necessary to meet the requirements of federal, state, or local statutes, ordinances, rules, or policies.

Replaces: 5123:2-7-24

Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5124.03, 5123.04
Rule Amplifies: 5123.04 , 5124.171, 5124.03
Prior Effective Dates: 01/10/2013

5123-7-25 Intermediate care facilities for individuals with intellectual disabilities - nonextensive renovation.

(A) Purpose

This rule defines nonextensive renovation and sets forth the process for calculating the per-bed cost of a nonextensive renovation project at an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(B) Definitions

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

(1) "Extensive renovation" has the same meaning as in rule 5123-7-24 of the Administrative Code.

(2) "Nonextensive renovation" means a project, approved by the department prior to the effective date of this rule in accordance with rule 5123:2-7-25 of the Administrative Code as it existed on the day immediately prior to the effective date of this rule, for the betterment, improvement, or restoration of an ICFIID beyond its current functional capacity through a structural change that costs at least five hundred dollars per bed. To calculate the per-bed cost of a renovation project for purposes of determining whether it is a nonextensive renovation, the allowable cost of the project shall be divided by the number of beds in the ICFIID certified for participation in the medicaid program, even if the project does not affect all medicaid-certified beds. "Nonextensive renovation" may include betterment, improvement, restoration, or replacement of assets that are affixed to the building and have a useful life of at least five years. "Nonextensive renovation" may include costs that otherwise would be considered maintenance and repair expenses if they are included as part of the nonextensive renovation project and are an integral part of the structural change that makes up the nonextensive renovation project. "Nonextensive renovation" does not mean construction of additional space for beds that will be added to an ICFIID's licensed or certified capacity. Allowable nonextensive renovation projects are not considered costs of ownership.

(C) Determining the cost of nonextensive renovation

(1) The desk-reviewed actual, allowable, per diem cost of nonextensive renovation is based upon certified beds for property costs and assets affixed to the building for the calendar year preceding the fiscal year in which the rate will be paid. The desk-reviewed actual, allowable, per diem cost of nonextensive renovation includes:

(a) The cost of purchasing or acquiring capital assets that meet the requirements of nonextensive renovation in accordance with this rule which includes:

(i) Depreciation expense for the cost of buildings equal to the actual cost depreciated in accordance with rule 5123:2-7-18 of the Administrative Code for nonextensive renovation. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(ii) Depreciation expense for major components of property and fixed equipment equal to the actual cost depreciated in accordance with rule 5123:2-7-18 of the Administrative Code for nonextensive renovation. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(iii) Interest expense incurred on money borrowed for capital assets that qualify for nonextensive renovation.

(iv) Depreciation expense for costs paid or reimbursed by any government agency, if that part of the prospective per diem rate is used to reimburse the government agency and a loan provides for repayment over a time-limited period. These capital assets must qualify for nonextensive renovation.

(v) Amortization expense of financing costs.

(b) The cost of nonextensive renovation directly related to the amortization of leasehold improvements that meet the criteria for nonextensive renovation in accordance with this rule. These costs shall be expensed over the lesser of the remaining life of the lease, but not less than five years, or the useful life of the improvement as specified in rule 5123:2-7-18 of the Administrative Code. If the useful life of the improvement is less than five years, it may be amortized over its useful life. Options on leases will not be considered. Lessees who report leasehold improvements and who leave the program before the minimum amortization period is complete will not receive reimbursement for the balance of unamortized costs.

(2) The cost of nonextensive renovation directly attributable to the purchase of property and equipment costs from one related party to another through common ownership or control shall be based upon the lesser of the actual purchase of property and equipment costs or the actual costs of the related party.

(D) Criteria for treatment as a nonextensive renovation

(1) The following shall apply in order to determine if a project qualifies for treatment as a nonextensive renovation.

(a) The project meets the definition of nonextensive renovation set forth in paragraph (B)(2) of this rule.

(b) The project does not increase the number of licensed beds.

(c) If the ICFIID relocates beds within the current structure of the building, the construction for the relocated beds shall be considered a nonextensive renovation if it meets the other criteria specified in this rule unless the project meets the requirements of extensive renovation.

(d) The ICFIID obtained approval of the project as a nonextensive renovation from the department prior to the effective date of this rule.

(e) The ICFIID has satisfied all requirements for notice to the department upon completion of the project as set forth in paragraph (F) of this rule.

(2) A nonextensive renovation project shall be started within six months after the date the department grants approval. For the purposes of this rule, "started" means the physical work has begun on the project at the site of the ICFIID. Preliminary work such as planning, agency approval, feasibility surveys, and architectural drawings are not considered "started."

(3) A nonextensive renovation project shall be completed within eighteen months after it is started. The total cost of all portions of the nonextensive renovation project completed within eighteen months after it is started must satisfy the per-bed cost requirement set forth in paragraph (B)(2) of this rule.

(4) Failure to satisfy the conditions set forth in paragraphs (D)(1) to (D)(3) of this rule shall result in the costs of the project being reported as costs of ownership in lieu of nonextensive renovation.

(E) Additional notice requirements

Additional notice to the department is required during the course of the construction of the approved nonextensive renovation if:

(1) The completion of the nonextensive renovation project is delayed or accelerated by more than four months from the estimated date of completion.

(2) The actual cost of construction exceeds the approved cost by the greater of ten per cent or two thousand dollars.

(a) Upon receiving notice of the increase in the cost of construction, the department may approve the additional project costs for inclusion as a nonextensive renovation. In reviewing a project for approval under this paragraph, the department shall apply the criteria specified in paragraph (D) of this rule.

(b) If the department does not approve the additional cost of construction, expenses related to all costs of construction in excess of the approved amount shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the increase in the cost of construction, expenses related to all costs of construction in excess of the approved amount shall be reported as costs of ownership.

(3) The actual amount financed exceeds the approved amount financed by the greater of ten per cent or two thousand dollars.

(a) Upon receiving notice of the increase in the amount financed, the department may approve the increase in the amount financed for inclusion as a nonextensive renovation. In reviewing a project for approval under this paragraph, the department shall apply the criteria specified in paragraph (D) of this rule.

(b) If the department does not approve the additional amount financed, interest expense related to all amounts financed in excess of the approved amount shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the increase in the amount financed, interest expense related to all amounts financed in excess of the approved amount shall be reported as costs of ownership.

(4) The actual interest rate exceeds the projected interest rate by two or more percentage points.

(a) Upon receiving notice of the increase in the interest rate, the department may approve the interest expense associated with the increased interest rate for inclusion as a nonextensive renovation. In reviewing a project for approval under this paragraph, the department shall apply the criteria specified in paragraph (D) of this rule.

(b) If the department does not approve the increased interest rate, the interest expense associated with the incremental increase in the approved interest rate shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the increase in the interest rate, the interest expense associated with the incremental increase in the approved interest rate shall be reported as costs of ownership.

(5) There is any increase or decrease in the scope of the nonextensive renovation project.

(a) Upon receiving notice of the change in the scope of the nonextensive renovation project, the department may approve the project as revised if the change in scope bears a reasonable relationship to the approved nonextensive renovation project.

(b) If the department does not approve the project as revised, the additional costs associated with the change in scope shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the change in the scope of the project, the additional costs associated with the change in scope shall be reported as costs of ownership.

(6) Any change of cost causes the project to exceed the threshold for being considered an extensive renovation or to fall below the threshold for being considered a nonextensive renovation.

(F) Reporting a nonextensive renovation project on the cost report

(1) Before a nonextensive renovation or portion thereof can be reported on the cost report, notice of completion must be submitted to the department. The notice of completion shall include:

(a) The date the project or portion thereof was placed in service;

(b) Detailed depreciation and amortization schedules and a narrative explanation of any material differences between the expenses stated on the schedules and the estimated costs submitted for the project and prior-approved by the department; and

(c) A detailed reconciliation of actual financing cost to the projected financing cost in the request for approval of a nonextensive renovation.

(2) A nonextensive renovation may be reported on the cost report as each portion of the project is placed into service as long as the anticipated completion of the portions of the project is still within the period set forth in paragraphs (D)(2) and (D)(3) of this rule and in the aggregate satisfy the per-bed cost requirement set forth in paragraph (B)(2) of this rule.

(3) If the total cost of all the portions of the entire project that have been placed into service within the period set forth in paragraphs (D)(2) and (D)(3) of this rule do not satisfy the per-bed cost requirement set forth in paragraph (B)(2) of this rule, the costs and related expenses for all the portions of the project that have been reported as a nonextensive renovation shall be reported as costs of ownership.

Replaces: 5123:2-7-25

Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.03 , 5124.171
Prior Effective Dates: 01/10/2013

5123-7-27 Intermediate care facilities for individuals with intellectual disabilities - request for rate reconsideration.

(A) Purpose

This rule establishes a process for an intermediate care facility for individuals with intellectual disabilities (ICFIID) or a group or association of ICFIID providers to request reconsideration of an ICFIID's per diem payment rate pursuant to section 5124.38 of the Revised Code.

(B) Submission of request

(1) In addition to the circumstances referenced in section 5124.38 of the Revised Code, reconsideration of an ICFIID's per diem payment rate may be requested:

(a) On the basis of a possible error in the calculation of the rate; or

(b) Upon direct admission of a resident from a department-operated ICFIID, on the basis of extreme hardship on the admitting ICFIID.

(2) A request for rate reconsideration shall be submitted:

(a) In the case of a possible error in the calculation of the rate, within thirty calendar days after the later of the initial payment of the rate or the receipt of the rate-setting calculation.

(b) In the case of direct admission of a resident from a department-operated ICFIID, within ninety calendar days after admission.

(3) A request for rate reconsideration for items referenced in this rule or in section 5124.38 of the Revised Code shall be submitted in writing via email to cr-icf@dodd.ohio.gov.

(a) The request shall indicate the reason for rate reconsideration.

(b) In the case of a possible error in the calculation of the rate, the request shall include a detailed explanation of the possible error and the proposed corrected calculation and references to the relevant sections of the Revised Code and/or rules of the Administrative Code as appropriate.

(c) In the case of direct admission of a resident from a department-operated ICFIID, the request shall include a detailed summary of the facts supporting the request, including demonstration of the increased costs and the requested adjusted per diem rate.

(C) Consideration of the request

(1) The department shall respond in writing within sixty calendar days of receiving a written request for rate reconsideration. If the department requests additional information to determine whether a rate adjustment is warranted, the ICFIID shall respond in writing and provide additional supporting documentation within thirty calendar days of receipt of the request for additional information. The department shall respond in writing within sixty calendar days of receiving the additional information.

(2) If the department grants a rate adjustment due to an error in the calculation of the rate, the adjustment shall be implemented retroactively to the initial service date for which the rate is effective.

(3) If the department grants a rate adjustment due to direct admission of a resident from a department-operated ICFIID, the adjustment shall be implemented the first day of the first month the former resident of a department-operated ICFIID resides in the admitting ICFIID.

(a) The adjusted rate shall be time-limited to no longer than twelve consecutive months and may span fiscal years. There shall be no extensions granted beyond the initial twelve months. The rate adjustment shall be rescinded earlier than twelve months should the admitted former resident of a department-operated ICFIID permanently leave the ICFIID for any reason.

(b) The maximum amount available for each admitted former resident of a department-operated ICFIID shall be no more than fifty dollars per day, with the rate determined by dividing fifty dollars by the number of filled beds in the admitting ICFIID including the bed occupied by the former resident of a department-operated ICFIID. The resulting amount will be added to the ICFIID's per diem rate until the end of the state fiscal year.

(c) If the twelve consecutive months cross a state fiscal year, the calculation in paragraph (C)(3)(b) of this rule will be repeated at the beginning of the next state fiscal year and the adjusted per diem rate will remain in effect until the end of the twelfth consecutive month from the date the first adjusted per diem rate was applied.

(4) If the department grants a rate adjustment to an ICFIID that subsequently undergoes a change of operator, the adjusted rate shall remain in place as though a change of operator had not occurred.

(5) The department's decision at the conclusion of the rate reconsideration process shall not be subject to any administrative proceedings under Chapter 119. or any other provision of the Revised Code.

Replaces: 5123:2-7-27, 5123:2-7-28

Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.03 , 5124.38
Prior Effective Dates: 01/10/2013

5123-7-30 Intermediate care facilities for individuals with intellectual disabilities - exception review process for individual assessment form data.

(A) Purpose

This rule sets forth a process by which the department shall conduct exception reviews related to individual assessment form data submitted by an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(B) Definitions

(1) "Annual facility average case mix score" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(2) "Case mix score" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(3) "Exception review" means a review conducted of an ICFIID by qualified intellectual disability professionals, registered nurses, or other licensed or certified health professionals employed by or under contract with the department for purposes of identifying inaccuracies related to the individual assessment form data submitted by the ICFIID in accordance with rule 5123-7-20 of the Administrative Code, which result in inaccurate case mix scores being used to calculate an ICFIID's direct care rate. Exception reviews shall be conducted before the annual rates are established pursuant to section 5124.15 of the Revised Code. Exception reviews shall be conducted in accordance with applicable provisions of the medicaid program.

(4) "Exception review tolerance level" means an acceptable level of variance in the calculation of the ICFIID's quarterly facility average case mix score. The variance is calculated as a percentage of the difference between the score based on exception review findings compared to the score based on the individual assessment form data submitted by the ICFIID for that quarter. The exception review tolerance level is a two per cent difference between the quarterly facility average case mix score based on exception review findings and the quarterly facility average case mix score based on individual assessment form data submitted by the ICFIID.

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

(6) "Quarterly facility average case mix score" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(7) "Resident assessment classification system" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(C) Selection and review process

(1) The department shall select an ICFIID for exception review based on:

(a) The findings of a certification survey conducted by the Ohio department of health that may indicate that the ICFIID is not accurately assessing residents which may result in inaccurate classification of the residents in the resident assessment classification system;

(b) A risk analysis of an ICFIID with a noticeable change in the frequency distribution of the residents in the resident assessment classification system classifications not attributable to a change in resident population or a significant change in the ICFIID's average case mix score not attributable to a change in resident population or an ICFIID for which other data indicate that the individual assessment form data submitted by the ICFIID may not result in accurate classification of the residents in the resident assessment classification system; or

(c) Prior resident assessment performance of the ICFIID, including, but not limited to, ongoing problems with assessment submission deadlines, error rates, incorrect assessment dates, and apparent unchanged assessment practices following the department's review performed pursuant to section 11 of House Bill 303 of the 129th General Assembly or a subsequent exception review.

(2) The department may contact an ICFIID during the selection process for clarification of information. The ICFIID may be able to satisfactorily resolve the department's concerns and avert an exception review.

(3) At the discretion of the department, an exception review may be conducted on- site at an ICFIID or by desk review except that an exception review shall be conducted on-site at an ICFIID when so requested by the ICFIID.

(D) Requirements for persons conducting exception reviews

(1) Qualified intellectual disability professionals, registered nurses, and other licensed or certified health professionals employed by or under contract with the department shall successfully complete department-approved training in administration of the individual assessment form prior to conducting exception reviews.

(2) Persons conducting exception reviews shall meet the following conditions:

(a) During the period of their employment or contract with the department, reviewers must neither have nor be committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of an ICFIID which they review in Ohio. Employment of a member of a reviewer's family by an ICFIID that the reviewer does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of an ICFIID.

(b) Reviewers shall not review any ICFIID that has been a client or employer of the reviewer during the previous twelve months.

(c) Reviewers shall not review any ICFIID where a member of the reviewer's family is a current resident.

(3) When a team of department reviewers conducts an on-site exception review, the team shall be led by a qualified intellectual disability professional.

(E) Prior notice

The department shall notify an ICFIID by telephone at least five calendar days prior to an exception review. At the discretion of the department, the review team may reschedule the exception review if appropriate key personnel of the ICFIID are unavailable on the originally scheduled date of an on-site exception review.

(F) Access to persons and information

An ICFIID selected for exception review shall provide department reviewers with reasonable access to residents, professional and unlicensed direct care staff, staff who assess residents, and residents' completed individual assessment forms, as well as other documentation regarding residents' care needs and treatment. An ICFIID shall also provide the department with sufficient information to be able to contact residents' attending or consulting physicians, other professionals from all disciplines who have observed, evaluated, or treated residents such as contracted therapists, and residents' family/significant others. These sources of information may help to validate information provided on the individual assessment form data submitted to the department. Verification activities may include reviewing residents' individual assessment forms and supporting documentation, conducting interviews with staff knowledgeable about the resident, and observing or interviewing the resident.

(G) Exception review sample

An exception review shall be conducted of a pre-selected random, targeted, or combination sample of completed individual assessment forms from the reporting quarter. If the results of the pre-selected sample indicate inaccuracies which require a larger sample, the department may expand the sample.

(H) Exit conference

At the conclusion of an exception review , department reviewers shall conduct an exit conference with representatives of the ICFIID. At the discretion of the department, the exit conference may be conducted on-site at the ICFIID or by telephone. Reviewers shall share preliminary findings and/or concerns about verification or failure to verify resident assessment classification system classifications for reviewed records. At the time of the exit conference, the ICFIID shall be afforded an opportunity to present additional information or items which depict the needs of residents for whom the ICFIID contests the sample findings.

(I) Written summary of exception review findings

All exception reviews shall include a written summary of exception review findings. The department shall send a copy of the written summary of findings to the ICFIID.

(J) Records retention

All exception review reports shall be retained by the department for at least six years from the date the exception review report is final.

(K) Calculation or recalculation of resident case mix scores

If the exception review tolerance level is exceeded, the department shall use the exception review findings to calculate or recalculate resident case mix scores, quarterly facility average case mix scores, and annual facility average case mix scores. Calculations or recalculations shall apply only to records actually reviewed by the department and shall not be based on extrapolations of findings to unreviewed records. Rates calculated based on exception review findings may result in an increase or decrease compared to the rate based on the ICFIID's assessment of information.

(L) Reconsideration

(1) An ICFIID may submit a written request for reconsideration to the department not later than thirty calendar days after it receives the written summary of exception review findings pursuant to paragraph (I) of this rule. The request shall include:

(a) A detailed explanation of the items in the assessment results that the ICFIID disputes;

(b) Copies of relevant supporting documentation from specific resident records; and

(c) The ICFIID's proposed resolution of the disputes.

(2) Qualified intellectual disability professionals, registered nurses, or other licensed or certified health professionals employed by or under contract with the department, other than those who conducted the exception review, shall consider all of the information submitted by the ICFIID, the historic results of the assessments, and any other information determined necessary for consideration.

(3) The department shall issue a written decision regarding reconsideration within thirty calendar days of receiving the request.

(4) The department's decision is final and not subject to further appeal.

(5) When calculating an ICFIID's case mix scores, the department shall use any resident case mix scores adjusted as a result of a rate consideration determination.

Replaces: 5123:2-7-30

Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.03 , 5124.198
Prior Effective Dates: 10/01/2013

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

(A) Purpose

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

(B) Definitions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(C) Calculating direct care costs

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

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

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

(D) Resident assessment classification system

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

(a) Medical;

(b) Behavioral; and

(c) Adaptive skills.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(E) Relative resource weights

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

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

(b) Licensed practical nurses;

(c) Occupational therapists;

(d) Program specialists;

(e) Qualified intellectual disability professionals;

(f) Registered nurses;

(g) Social workers/counselors; and

(h) Speech therapists.

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

(a) Resident acuity group one = 2.75.

(b) Resident acuity group two = 1.86.

(c) Resident acuity group three = 1.43.

(d) Resident acuity group four = 1.31.

(e) Resident acuity group five = 1.12.

(f) Resident acuity group six = 1.00.

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

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

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

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

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

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

(F) Quarterly facility average case mix score

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

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

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

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

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

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

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

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

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

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

(G) Annual facility average case mix score

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

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

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

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

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Effective: 7/8/2018
Five Year Review (FYR) Dates: 07/08/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.03 , 5124.19 to 5124.193