5165.25 [Renumbered from 5111.244] Quality incentive payments for qualifying nursing facilities.

(A) As used in this section:

(1) "Complaint surveys" has the same meaning as in 42 C.F.R. 488.30.

(2) "Customer satisfaction survey" means the annual survey of long-term care facilities required by section 173.47 of the Revised Code.

(3) "Deficiency" has the same meaning as in 42 C.F.R. 488.301.

(4) "Exempted hospital discharge" has the same meaning as in 42 C.F.R. 483.106(b)(2)(i).

(5) "Family satisfaction survey" means a customer satisfaction survey, or part of a customer satisfaction survey, that contains the results of information obtained from the families of a nursing facility's residents.

(6) "Minimum data set" means the standardized, uniform comprehensive assessment of nursing facility residents that is used to identify potential problems, strengths, and preferences of residents and is part of the resident assessment instrument required by the "Social Security Act," section 1919(e)(5), 42 U.S.C. 1396r(e)(5).

(7)

"Nurse aide" has the same meaning as in section 3721.21 of the Revised Code.

(8) "Resident satisfaction survey" means a customer satisfaction survey, or part of a customer satisfaction survey, that contains the results of information obtained from a nursing facility's residents.

(9) "Room mirror" means a mirror that is located in either of the following rooms:

(a) A resident bathroom if the sink used by a resident after the resident uses the resident bathroom is in the resident bathroom;

(b) A resident's room if the sink used by a resident after the resident uses the resident bathroom is in the resident's room.

(10) "Room sink" means a sink that is located in either of the following rooms:

(a) A resident bathroom if the sink used by a resident after the resident uses the resident bathroom is in the resident bathroom;

(b) A resident's room if the sink used by a resident after the resident uses the resident bathroom is in the resident's room.

(11) "Standard survey" has the same meaning as in 42 C.F.R. 488.301.

(12) "Special focus facility list" means the list of nursing facilities that the United States department of health and human services creates under the special focus facility program required by the "Social Security Act," section 1919(f)(10), 42 U.S.C. 1396r(f)(10).

(13) "Substantial wall" means a permanent structure that reaches from floor to ceiling and divides a semiprivate room into two distinct living spaces, each with its own window.

(14) "Table B of the special focus facility list" means the table included in the special focus facility list that identifies nursing facilities that have not improved.

(B)

(1) Each fiscal year, the department of medicaid shall determine each nursing facility's quality incentive payment . Subject to divisions (B)(2) and (3) of this section, the per medicaid day amount of a quality incentive payment paid to a nursing facility provider shall be the product of the following:

(a) The number of points the provider's nursing facility is awarded for meeting accountability measures under this section;

(b) Three dollars and twenty-nine cents.

(2) The maximum quality incentive payment that may be paid to a nursing facility provider for fiscal year 2014 shall be sixteen dollars and forty-four cents per medicaid day.

(3) The maximum quality incentive payment that may be paid to a nursing facility provider for fiscal year 2015 and each fiscal year thereafter shall be the following:

(a) Sixteen dollars and forty-four cents if at least one of the points awarded to the nursing facility for meeting accountability measures is for an accountability measure identified in division (D)(9), (10), (11), (12), or (14) of this section;

(b) Thirteen dollars and sixteen cents if division (B)(3)(a) of this section does not apply.

(C) For fiscal year 2014 only and subject to division (E) of this section, the department shall award each nursing facility participating in the medicaid program one point for each of the following accountability measures the facility meets:

(1) The facility's overall score on its resident satisfaction survey is at least eighty-six.

(2) The facility's overall score on its family satisfaction survey is at least eighty-eight.

(3) The facility satisfies the requirements for participation in the advancing excellence in America's nursing homes campaign.

(4) The facility had neither of the following on the facility's most recent standard survey conducted not later than the last day of the calendar year immediately preceding the fiscal year for which the point is to be awarded or any complaint surveys conducted in the calendar year immediately preceding the fiscal year for which the point is to be awarded:

(a) A health deficiency with a scope and severity level greater than F;

(b) A deficiency that constitutes a substandard quality of care.

(5) The facility offers at least fifty per cent of its residents at least one of the following dining choices for at least one meal each day:

(a) Restaurant-style dining in which food is brought from the food preparation area to residents per the residents' orders;

(b) Buffet-style dining in which residents obtain their own food, or have the facility's staff bring food to them per the residents' directions, from the buffet;

(c) Family-style dining in which food is customarily served on a serving dish and shared by residents;

(d) Open dining in which residents have at least a two-hour period to choose when to have a meal;

(e) Twenty-four-hour dining in which residents may order meals from the facility any time of the day.

(6) At least fifty per cent of the facility's residents are able to take a bath or shower as often as they choose.

(7) The facility has at least both of the following scores on its resident satisfaction survey:

(a) With regard to the question in the survey regarding residents' ability to choose when to go to bed in the evening, at least eighty-nine;

(b) With regard to the question in the survey regarding residents' ability to choose when to get out of bed in the morning, at least seventy-six.

(8) The facility has at least both of the following scores on its family satisfaction survey:

(a) With regard to the question in the survey regarding residents' ability to choose when to go to bed in the evening, at least eighty-eight;

(b) With regard to the question in the survey regarding residents' ability to choose when to get out of bed in the morning, at least seventy-five.

(9) All of the following apply to the facility:

(a) At least seventy-five per cent of the facility's residents have the opportunity, following admission to the facility and before completing or quarterly updating their individual plans of care, to discuss their goals for the care they are to receive at the facility, including their preferences for advance care planning, with a member of the residents' health care teams that the facility, residents, and residents' sponsors consider appropriate.

(b) The facility records the residents' care goals, including the residents' advance care planning preferences, in their medical records.

(c) The facility uses the residents' care goals, including the residents' advance care planning preferences, in the development of the residents' individual plans of care.

(10) Not more than thirteen and thirty-five hundredths per cent of the facility's long-stay residents report severe to moderate pain during the minimum data set assessment process.

(11) Not more than five and seventy-three hundredths per cent of the facility's long-stay, high-risk residents have been assessed as having one or more stage two, three, or four pressure ulcers during the minimum data set assessment process.

(12) Not more than one and fifty-two hundredths per cent of the facility's long-stay residents were physically restrained as reported during the minimum data set assessment process.

(13) Less than seven and seventy-eight hundredths per cent of the facility's long-stay residents had a urinary tract infection as reported during the minimum data set assessment process.

(14) The facility uses a tool for tracking residents' admissions to hospitals.

(15) An average of at least fifty per cent of the facility's medicaid-certified beds are in private rooms.

(16) The facility has accessible resident bathrooms, all of which meet at least two of the following standards and at least some of which meet all of the following standards:

(a) There are room mirrors that are accessible to residents in wheelchairs, can be adjusted so as to be visible to residents who are seated or standing, or both.

(b) There are room sinks that are accessible to residents in wheelchairs and have clearance for wheelchairs.

(c) There are room sinks that have faucets with adaptive or easy-to-use lever or paddle handles.

(17) The facility does both of the following:

(a) Maintains a written policy that prohibits the use of overhead paging systems or limits the use of overhead paging systems to emergencies, as defined in the policy;

(b) Communicates the policy to its staff, residents, and families of residents.

(18) The facility has a score of at least ninety on its resident satisfaction survey with regard to the question in the survey regarding residents' ability to personalize their rooms with personal belongings.

(19) The facility has a score of at least ninety-five on its family satisfaction survey with regard to the question in the survey regarding residents' ability to personalize their rooms with personal belongings.

(20) The facility does both of the following:

(a) Maintains a written policy that requires consistent assignment of nurse aides and specifies the goal of having a resident receive nurse aide care from not more than eight different nurse aides during a thirty-day period;

(b) Communicates the policy to its staff, residents, and families of residents.

(21) The facility's staff retention rate is at least seventy-five per cent.

(22) The facility's turnover rate for nurse aides is not higher than sixty-five per cent.

(23) For at least fifty per cent of the resident care conferences in the facility, a nurse aide who is a primary caregiver for the resident attends and participates in the conference.

(D) For fiscal year 2015 and each fiscal year thereafter and subject to division (E) of this section, the department shall award each nursing facility participating in the medicaid program one point for each of the following accountability measures the facility meets:

(1) The facility's overall score on its resident satisfaction survey is at least eighty-seven and five-tenths.

(2) The facility's overall score on its family satisfaction survey is at least eighty-five and nine-tenths.

(3) The facility satisfies the requirements for participation in the advancing excellence in America's nursing homes campaign.

(4) Both of the following apply to the facility:

(a) The facility had not been listed on table B of the special focus facility list for eighteen or more consecutive months during any time during the calendar year immediately preceding the fiscal year for which the point is to be awarded.

(b) The facility had neither of the following on the facility's most recent standard survey conducted not later than the last day of the calendar year immediately preceding the fiscal year for which the point is to be awarded or any complaint surveys conducted in the calendar year immediately preceding the fiscal year for which the point is to be awarded:

(i) A health deficiency with a scope and severity level greater than F;

(ii) A deficiency that constitutes a substandard quality of care.

(5) The facility does all of the following:

(a) Offers at least fifty per cent of its residents at least one of the following dining choices for at least two meals each day:

(i) Restaurant-style dining in which food is brought from the food preparation area to residents per the residents' orders;

(ii) Buffet-style dining in which residents obtain their own food, or have the facility's staff bring food to them per the residents' directions, from the buffet;

(iii) Family-style dining in which food is customarily served on a serving dish and shared by residents;

(iv) Open dining in which residents have at least a two-hour period to choose when to have a meal;

(v) Twenty-four-hour dining in which residents may order meals from the facility any time of the day.

(b) Maintains a written policy specifying the manner or manners in which residents' dining choices for meals are offered;

(c) Communicates the policy to its staff, residents, and families of residents.

(6) The facility does all of the following:

(a) Enables at least fifty per cent of the facility's residents to take a bath or shower when they choose;

(b) Maintains a written policy regarding residents' choices in bathing;

(c) Communicates the policy to its staff, residents, and families of residents.

(7) The facility has at least both of the following scores on its resident satisfaction survey:

(a) With regard to the question in the survey regarding residents' ability to choose when to go to bed in the evening, at least eighty-nine;

(b) With regard to the question in the survey regarding residents' ability to choose when to get out of bed in the morning, at least seventy-six.

(8) The facility has at least both of the following scores on its family satisfaction survey:

(a) With regard to the question in the survey regarding residents' ability to choose when to go to bed in the evening, at least eighty-eight;

(b) With regard to the question in the survey regarding residents' ability to choose when to get out of bed in the morning, at least seventy-five.

(9) Not more than thirteen and thirty-five hundredths per cent of the facility's long-stay residents report severe to moderate pain during the minimum data set assessment process.

(10) Not more than five and sixteen hundredths per cent of the facility's long-stay, high-risk residents have been assessed as having one or more stage two, three, or four pressure ulcers during the minimum data set assessment process.

(11) Not more than one and fifty-two hundredths per cent of the facility's long-stay residents were physically restrained as reported during the minimum data set assessment process.

(12) Less than seven per cent of the facility's long-stay residents had a urinary tract infection as reported during the minimum data set assessment process.

(13) The facility does both of the following:

(a) Uses a tool for tracking residents' admissions to hospitals;

(b) Annually reports to the department data on hospital admissions by month for all residents.

(14) Both of the following apply:

(a) At least ninety-five per cent of the facility's long-stay residents are vaccinated against pneumococcal pneumonia, decline the vaccination, or are not vaccinated because the vaccination is medically contraindicated.

(b) At least ninety-three per cent of the facility's long-stay residents are vaccinated against seasonal influenza, decline the vaccination, or are not vaccinated because the vaccination is medically contraindicated.

(15) An average of at least fifty per cent of the facility's medicaid-certified beds are in either, or in a combination of both, of the following:

(a) Private rooms;

(b) Semiprivate rooms to which all of the following apply:

(i) Each room provides a distinct territory for each resident occupying the room.

(ii) Each distinct territory has a window and is separated by a substantial wall from the other distinct territories in the room.

(iii) Each resident is able to enter and exit the distinct territory of the resident's room without entering or exiting another resident's distinct territory.

(iv) Complete visual privacy for each distinct territory may be obtained by drawing a curtain or other screen.

(16) The facility obtains at least a ninety-five per cent compliance rate with requesting resident reviews required by 42 C.F.R. 483.106(b)(2)(ii) for individuals who are exempted hospital discharges.

(17) The facility does both of the following:

(a) Maintains a written policy that requires consistent assignment of nurse aides and specifies the goal of having a resident receive nurse aide care from not more than twelve different nurse aides during a thirty-day period;

(b) Communicates the policy to its staff, residents, and families of residents.

(18) The facility's staff retention rate is at least seventy-five per cent.

(19) The facility's turnover rate for nurse aides is not higher than sixty-five per cent.

(20) For at least fifty per cent of the resident care conferences in the facility, a nurse aide who is a primary caregiver for the resident attends and participates in the conference.

(21) All of the following apply to the facility:

(a) At least seventy-five per cent of the facility's residents have the opportunity, following admission to the facility and before completing or quarterly updating their individual plans of care, to discuss their goals for the care they are to receive at the facility, including their preferences for advance care planning, with a member of the residents' health care teams that the facility, residents, and residents' sponsors consider appropriate.

(b) The facility records the residents' care goals, including the residents' advance care planning preferences, in their medical records.

(c) The facility uses the residents' care goals, including the residents' advance care planning preferences, in the development of the residents' individual plans of care.

(22) The facility does both of the following:

(a) Maintains a written policy that prohibits the use of overhead paging systems or limits the use of overhead paging systems to emergencies, as defined in the policy;

(b) Communicates the policy to its staff, residents, and families of residents.

(E)

(1) To be awarded a point for meeting an accountability measure under division (C) or (D) of this section other than the accountability measure identified in divisions (C)(4) and (D)(4)(b) of this section, a nursing facility must meet the accountability measure in the calendar year immediately preceding the fiscal year for which the point is to be awarded.

(2) The department shall award points pursuant to divisions (C)(1), (7), and (18) and (D)(1) and (7) of this section to a nursing facility only if a resident satisfaction survey was initiated under section 173.47 of the Revised Code for the nursing facility in the calendar year immediately preceding the fiscal year for which the points are to be awarded.

(3) The department shall award points pursuant to divisions (C)(2), (8), and (19) and (D)(2) and (8) of this section to a nursing facility only if a family satisfaction survey was initiated under section 173.47 of the Revised Code for the nursing facility in the calendar year immediately preceding the fiscal year for which the points are to be awarded.

(4) The department shall award points pursuant to divisions (D)(21) and (22) of this section only for fiscal year 2015.

(5) Not later than July 1, 2013, the department shall adjust the score used for the purpose of division (C)(8)(b) of this section in a manner that causes at least fifty per cent of nursing facilities to meet division (C)(8)(b) of this section.

(F)

Not later than July 1, 2014, the department shall submit, in accordance with section 101.68 of the Revised Code, recommendations to the general assembly for accountability measures to replace the accountability measures identified in divisions (D)(21) and (22) of this section.

(G)

Rules adopted under section 5165.02 of the Revised Code may specify what is meant by "some" as that word is used in division (C)(16) of this section.

Renumbered from § 5111.244 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.60, SB 264, §1, eff. 7/1/2012.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 7/1/2011.

Effective Date: 07-01-2005; 06-30-2006

Related Legislative Provision: See 129th General AssemblyFile No.60, SB 264, §6