department of health and social services
Division of Medicaid and Medical Assistance
PROPOSED
PUBLIC NOTICE
Long Term Care Nursing Facilities
In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code), and with 42 CFR §447.205, and under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Medicaid and Medical Assistance is proposing to amend the Title XIX Medicaid State Plan regarding the reimbursement methodology for nursing facilities. Additionally, the proposed rule is technical in nature to change a reference from the HCFA (Health Care Financing Administration) to the CMS (Centers for Medicare and Medicaid Services).
Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Sharon L. Summers, Policy and Program Development Unit, Division of Medicaid and Medical Assistance, 1901 North DuPont Highway, P.O. Box 906, New Castle, Delaware 19720-0906 by October 31, 2005.
The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.
Summary of Proposed Amendment
Title of Regulation
Methods and Standards for Establishing Payment Rates – Prospective Reimbursement System for Long Term Care Facilities
Statutory Authority
42 CFR Part 447, Subpart C – Payment for Inpatient Hospital and Long-Term Care Facility Services
Amending the Following State Plan Pages
Attachment 4.19-D and Attachments
Summary of Proposed Changes
DSS PROPOSED REGULATION #05-50
REVISIONS:
ATTACHMENT 4.19-D
Page 1
State Plan Under Title XIX of the Social Security Act
STATE OF DELAWARE
Methods And Standards For Establishing Payment Rates
Prospective Reimbursement System for Long Term Care Facilities
I. General Provisions
A. Purpose
This plan establishes a reimbursement system for long-term care facilities that complies with federal requirements, including but not limited to:
B. Reimbursement Principles
1. Providers of nursing facility care shall be reimbursed prospectively determined per diem rates based on a patient based classification system. Providers of ICF-MR and ICF-IMD services shall be reimbursed prospectively determined per diem rates.
ATTACHMENT 4.19-D
Page 2
2. The Delaware Medicaid Program shall reimburse qualified providers of long-term care based on the individual Medicaid recipient's days of care multiplied by the applicable per diem rate for that patient's classification less any payments made by recipients or third parties.
II. Rate Determination for Nursing Facilities
A. Basis for Reimbursement
Per Diem reimbursement for nursing facility services shall be composed of five prospectively determined rate components that reimburse providers for primary patient care, secondary patient care, support services, administration, and capital costs.
The primary patient care component of the per diem rate is based on the nursing care costs related specifically to each patient's classification. In addition to assignment to case mix classifications, patients may qualify for supplementary primary care reimbursement based on their characteristics and special service needs. Primary care component reimbursement for each basic patient classification will be the same for each facility within a group. A schedule of primary rates, including rate additions, is established for each of three groups of facilities:
Payment for the secondary, support, administrative, and capital costs comprise the base rate, and is unique to each facility. Provider costs are reported annually to Medicaid and are used to establish rate ceilings for the secondary, support, and administrative cost centers in each provider group.
The sections that follow provide specific details on rate computation for each of the five rate components.
B. Rate components
Payment for services based on the sum of five rate components. The rate components are defined as:
ATTACHMENT 4.19-D
Page 3
C. Excluded Services
Those services to residents of private long term care facilities that are ordinarily billed directly by practitioners will continue to be billed separately and are not covered by the rate component categories. This includes prescription drugs, Medicare Part B covered services, physician services, hospitalization and dental services, laboratory, radiology, and certain ancillary therapies.
For public facilities, laboratory, radiology, prescription drugs, physician services, dental services, and ancillary therapies are included in the per diem.
Costs of training and certification of nurse aides are billed separately by the facilities as they are incurred, and reimbursed directly by Medicaid.
D. Primary Payment Component Computations
The primary patient care rate component is based on a patient index system in which all nursing home patients are classified into patient classes. The lowest resource intensive clients are placed in the lowest class.
ATTACHMENT 4.19-D
Page 4
The Department will assign classes to nursing home patients. Initial classification of patients occurs through the State's pre-admission screening program. These initial classifications will be reviewed by Department nurses within 31 to 45 days after assignment. Patient classification will then be reviewed twice a year. Facilities will receive notices from the Department concerning class changes and relevant effective dates.
1. In order to establish the patient classification for reimbursement, patients are evaluated and scored by Medicaid review nurses according to the specific amount of staff assistance needed in Activity of Daily Living (ADL) dependency areas. These include Bathing, Eating, Mobility/Transfer/Toileting. Potential scores are as follows:
0 - Independent
1 - Supervision (includes verbal cueing and occasional staff standby)
2 - Moderate assistance (requires staff standby/physical presence)
3 - Maximum Assistance
Patients receiving moderate or maximum assistance will be considered "dependent" in that ADL area. Patients receiving supervision will not be considered dependent.
Reimbursement is determined by assigning the patient to a patient classifications based on their ADL scores or range of scores.
Each patient classification is related to specific nursing time factors. These time factors are multiplied by the 75th percentile nurse wage in each provider group to determine the per diem rate for each classification.
2. Patients receiving an active rehabilitative/preventive program as defined and approved by the Department shall be reimbursed at the next higher patient class. For qualifying patients at the highest level, the facility will receive an additional IO percent of the primary care rate component. an additional 20% of the primary care rate component.
To be considered for the added reimbursement allowed under this provision, a facility must develop and prepare an individual rehabilitative/preventive care plan. This plan of care must contain rehabilitative/preventive care programs as described in a Department approved list of programs. The services must seek to address specific activity of daily living and other functional problems of the patient. The care plan must also indicate specific six month and one-year patient goals, and must have a physician's approval.
ATTACHMENT 4.19-D
Page 5
The Department will evaluate new facility-developed rehabilitative/preventive care plans during its patient classification reviews of nursing homes.
Interim provisional approval of plans can be provided by Department review nurses. When reviewed, the Department will examine facility documentation on the provision of rehabilitative/preventive services to patients with previously approved care plans as well as progress towards patient goals.
3. Patients exhibiting disruptive psycho social behaviors on a frequent basis as defined and classified by the Department shall receive an additional 10 percent of the primary care rate component for the appropriate classification.
The specific psychosocial behaviors that will be considered for added reimbursement under this provision are those that necessitate additional nursing staff intervention in the provision of personal and nursing care. Such behaviors include: verbal and physically disruptive actions, inappropriate social behavior, non-territorial wandering, and any other similar patient problems as designated by the Department.
Facilities must have complete documentation on frequency of such behaviors in a patient's chart for the Department to consider the facility for added reimbursement under this provision. This documentation will be evaluated during patient classification reviews of a nursing home.
4. Patient class rates are determined based on the time required to care for patients in each classification, and nursing wage, fringe benefit, and training costs tabulated separately for private facilities in New Castle County, private facilities in Kent and Sussex Counties, and public facilities statewide.
Primary rates are established by the following methodology:
The cost report used in the calculations will represent the fiscal year ending June 30th of the previous reimbursement year. The Delaware reimbursement year, for purposes of rate setting, is from October 1 through September 30 January 1 through December 31 for private facilities and October 1 through September 30 for State facilities.
ATTACHMENT 4.19-D
Page 6
This is calculated by first dividing total pay by total hours for each nursing classification (RN, LPN, Aide) in each facility, then arraying the representative 75th percentile wages of each facility them to determine the 75th percentile within each provider group. Based on cost data from each provider group, hourly wage rates are adjusted to include hourly training and fringe benefit costs within each provider group.
The primary component of the Medicaid nursing home rate is determined by multiplying the 75th percentile hourly nursing wage for RNs, LPNs, and Aides by standard nursing time factors for each of the base levels of patient acuity.
E. Non-primary Rate Component Computations
Facility rates for the four non-primary components of secondary, support, administrative, and capital are computed from annual provider cost report data on reimbursable costs. Reimbursable costs are defined to be those that are allowable based on Medicare principles, according to HIM 15. Costs applicable to services, facilities, and supplies furnished to a provider by commonly owned, controlled or related organizations shall not exceed the lower cost of comparable services purchased elsewhere.
ATTACHMENT 4.19-D
Page 7
The cost report used in the calculations will represent the fiscal year ending June 30th of the previous reimbursement year. The Delaware reimbursement year, for purposes of rate setting is from October 1 through September 30 January 1 through December 31 for private facilities and October 1 through September 30 for State facilities.
The discussion that follows explains rate computation for the secondary, support, administrative and capital payment centers.
1. Secondary patient care rates are reimbursed according to the cost of care determined prospectively up to a calculated ceiling (115 percent of median per diem costs). Three steps are required:
2. Support service component rates are determined in a manner that parallels the secondary component rate calculation process. However, the ceiling is set at 110 percent of median support costs per day for the appropriate category of facility. In addition, facilities, which maintain costs below the cap, are entitled to an incentive payment 25 percent of the difference between the facility’s actual per day cost and the applicable cap, up to a maximum incentive of 5 percent of the cap amount.
* “New facility” is defined as: (1) New construction built to provide a new service of either intermediate or skilled nursing care for which the existing facility has never before been certified, or (2) construction of an entirely new facility totally and administratively independent of an existing facility.
ATTACHMENT 4.19-D
Page 8
3. Administrative component rates are determined in a manner parallel to the secondary component. However, the ceiling is set at 105 percent of median costs per day. A facility is entitled to an incentive payment of 50 percent of the difference between its actual costs and the cap. The incentive payment is limited to 10 percent of the ceiling amount.
4. Capital component rates are determined prospectively and are subject to a rate floor and rate ceiling. The dollar amounts representing the 20th percentile of actual per diem capital cost (floor) and the 80th percentile of actual per diem capital cost (ceiling) are calculated. If the facility's costs are greater than or equal to the floor, and less than or equal to the ceiling, the facility's prospective rate is equal to its actual cost. If the facility's costs are below the floor, the prospective rate is equal to the lower of the floor or actual cost plus twenty-five percent of actual cost. If the facility's costs are greater than the ceiling, the prospective rate is equal to the higher of the ceiling or ninety-five percent of actual cost. Costs associated with revaluation of assets of a facility will not be recognized.
The capital component is also subject to the occupancy standards as set forth in section II.E. of State Plan Amendment 4.19-D. The capital component rate is calculated on a statewide basis.
5. Where services are currently contracted by the nursing facility to a practitioner, additional services may be billed directly. These services are not covered by the rate component categories for private facilities, but may be included in the rate for public facilities. These services include therapies, physician services, dental services and prescription drugs.
F. Computation of Total Rate from Components
A facility's secondary, support, administrative, and capital payments will be summed and called its basic rate. The total rate for a patient is then determined by adding the primary rate for which a patient qualifies to the facility's basic rate component. The basic payment amount will not vary across patients in a nursing home. However, the primary payment depend will depend on a patient's class and qualification for added rehabilitative/preventive and/or psychosocial reimbursement.
G. OBRA '87 Additional Costs
1. Nurse Aide Training and Certification
Providers of long-term care services will be reimbursed directly for the reasonable costs of training, competency testing and certification of nurse aides in compliance with the requirements of OBRA '87. The training and competency testing must be in a program approved by the Delaware Department of Health and Social Services, Division of Public Health. A "Statement of Reimbursement Cost of Nurse Aide Training" is submitted to the state by each facility quarterly.
ATTACHMENT 4.19-D
Page 9
Costs reported on the Statement of Reimbursement Cost are reimbursed directly and claimed by the State as administrative costs. They include:
The following costs of nurse aide training are considered operational, and will be reported annually on the Medicaid cost report. These costs will be reimbursed through the Primary cost component of the per diem rate:
2. Additional Nurse Staff Requirements
Additional nurse staff required by a nursing facility to comply with the requirements of OBRA '87 will be reimbursed under the provisions of the Delaware Medicaid Patient Index Reimbursement System (PIRS). This system makes no distinction between levels of care for reimbursement. Nursing costs are derived from average hourly wage, benefit, and training cost data provided on the Nursing Wage Survey submitted by each facility. Prospective rates for each patient acuity classification are calculated by these costs by the minimum nursing time factors. Although representative of actual costs incurred, these prospectively determined rates are independent of the number employed or the number of staff vacancies at any given time.
ATTACHMENT 4.19-D
Page 10
3. Additional Non-Nursing Requirements
The Delaware Medicaid reimbursement system will recognize the incremental costs of additional staff and services incurred by nursing facilities to comply with the mandates of OBRA '87. Prospective rate calculations will be adjusted to account for costs incurred on or after October 1, 1990.
Where services are currently contracted by the nursing facility to a practitioner, additional services may be billed directly. These services are not covered by the rate component categories (for private facilities, but may be included in the rate for public facilities.) These services include therapies, physician services, dental services, and prescription drugs.
A supplemental schedule to the Statement of Reimbursement Costs (Medicaid Cost Report) will be submitted by each facility to demonstrate projected staff and service costs required to comply with OBRA'87. For the rate year beginning October 1, 1990, facilities may project full year costs onto prior year reported actual costs to be included in the rate calculation.
The supplemental schedule will be used to project costs incurred for programs effective October 1, 1990 into the prospective reimbursement rates. Where nursing care facilities indicate new and anticipated staff positions, those costs will be included with the actual SFY '90 costs when calculating the reimbursement rates effective October 1, 1990.
Additional staff requirements include dietitian, medical director, medical records, activities personnel, and social worker.
H. Hold Harmless Provision
For the first year under the patient index reimbursement system the Department will have in effect a hold-harmless provision. The purpose of the provision is to give facilities an opportunity to adjust their operations to the new system. Under this provision, no facility will be paid less by Medicaid under the patient index system than it would have been paid had Federal Fiscal Year 1988 rates, adjusted by an inflation factor, been retained.
For the period October 1, 1990 to September 30, 1991, the Department will have in effect a hold-harmless provision with respect to capital reimbursement rates. The purpose of this provision is to give facilities an opportunity to adjust their operations to the new system. Under this provision, facilities will be paid the greater of the rate under the prospective capital rate methodology or the rate based on reimbursable costs. Beginning October 1, 1991, all facilities will be subject to the prospective capital rate methodology described in Section II, E.4.
ATTACHMENT 4.19-D
Page 11
I. Annual Rate Recalculation
1. Primary Payment Component
Rates for the primary patient care component will be rebased annually. Two sources of provider-supplied data will be used in this rate rebasing:
The 75th percentile wages will be redetermined annually from the wage and salary survey, and the standard nurse time factors will be applied for each patient classification. The cost report and wage and salary survey will be for the previous year ending June 30.
2. Non-Primary Payment Components
The payment caps for the secondary, support, and administrative components will be rebased every fourth year using the computation methods specified in Section E above. For the interim periods between rebasing, the payment caps will be inflated annually based on reasonable inflation estimates as published by the Department. Facility-specific payment rates for these cost centers shall then be calculated using these inflated caps and cost report data from the most recently available cost reporting period.
The capital floor and ceiling will be rebased annually.
ATTACHMENT 4.19-D
Page 12
3. Inflation Adjustment
Per Diem caps for primary, secondary, support and administrative cost centers will be adjusted each year by inflation indices. The inflation indices are obtained from the Department of Economics of the University of Delaware and include both regional and national health care-specific economic trends. The inflation forecast is based on the U.S. Consumer Price Indexed. Factors reviewed on the demand side include recent growth rates in the money supply, employment, and business and government debt, as well as the state of the business cycle. Current capacity utilization rates and new capital spending plans, production delivery delays, employment to population ratios, wages, and trends in energy, housing, and food are studies on the supply side. The forecast is also confirmed by reviewing the Consumer Estimates and Columbia University Leading Index of Inflation, interest rates in the futures markets, the Commodity Research Bureau’s Index of Future Prices, and the trade weighted price of the dollar. will be obtained from a recognized source and based on an appropriate index for the primary cost center and the following cost centers: secondary, support and administrative.
The inflation factors are applied to the actual nursing wage rates to compensate for the annual inflation in nursing costs. This adjustment is made before the nurse training and benefits are added and the wages are multiplied by the standard nurse time factors.
Cost center caps are used to set an upper limit on the amount a provider will be reimbursed for the costs in the secondary, support, and administrative cost centers. Initially, these caps are computed by determining the median value of the provider’s actual daily costs, then adjusting upwardly according to the particular cost center. The Secondary cost center cap is 115% of the provider group median, and Administrative costs are capped at 105% of the median. Delaware Medicaid will recalculate non-primary cost center caps every three years fourth year. The next rebase will be for rates effective January 1, 2008. In interim rate years, these cost center caps will not be recomputed. Instead, cost center caps will be adjusted by inflation factors. The inflation index provided by the University of Delaware a recognized source will be applied to the current cap in each cost center in each provider group to establish the new cap. The actual reported costs will be compared to the cap. Facilities with costs above the cap will receive the amount of the cap.
ATTACHMENT 4.19-D
Page 13
J. Medicare Aggregate Upper Limitations
The State of Delaware assures HCFA CMS that in no case shall aggregate payments made under this plan, inclusive of DEFRA capital limitations, exceed the amount that would have been paid under Medicare principles of reimbursement. As a result of a change of ownership, on or after July 18, 1984, the State will not increase payments to providers for depreciation, interest on capital and return on equity, in the aggregate, more than the amount that would be recognized under section 1861(v)(1)(0) of the Social Security Act. Average projected rates of payment shall be tested against such limitations. In the event that average payment rates exceed such limitations, rates shall be reduced for those facilities exceeding Medicare principles as applied to all nursing facilities.
III. Rate Determination ICF/MR and ICF/IMD Facilities
Delaware will recalculate the prospective per diem rates for ICF/MRs and ICF/IMDs annually for the reimbursement year, of October through September 30 January 1 through December 31 for private facilities and October 1 through September 30 for public facilities. ICF/MR and ICF/IMD facilities shall be reimbursed actual total per diem costs determined prospectively up to a ceiling. The ceiling is set at the 75th percentile of the distribution of costs of the facilities in each class. There are four (4) classes of facilities, which are:
1. Public ICF/MR facilities of 8 beds or less.
2. Public ICF/MR facilities of greater than 8 beds.
3. Private ICF/MR facilities of 60 beds or less.
4. Public ICF/IMD facilities.
An inflation factor (as described in II.H.3 above) will be applied to prior year’s costs to determine the current year’s rate.
IV. Rate Reconsideration
A. Primary Rate Component
Long-term care providers shall have the right to request a rate reconsideration for alleged patient misclassification relating to the Department’s assignment of the case mix classification. Conditions for reconsideration are specified in the Department’s nursing home appeals process as specified in the long-term care provider manual.
ATTACHMENT 4.19-D
Page 14
1. Exclusions from Reconsideration
Specifically excluded from patient class reconsiderations are:
2. Procedures for Filing
Facilities shall submit requests for reconsiderations within sixty days after patient classifications are provided to a facility. All requests shall be submitted in writing and must be accompanied by supporting documentation as required by the Department.
3. Patient Reclassifications
Any reclassification resulting from the reconsideration process will become effective on the first day of the month following such reclassification.
B. Non-Primary Rate Components
Long-term care providers shall have the right to request a rate reconsideration for any alleged Department miscalculation of one or more non-primary payment rates. Miscalculation is defined as incorrect computation of payment rates from provider supplied data in annual cost reports.
1. Exclusions from Reconsideration
Specifically excluded from rate consideration are:
ATTACHMENT 4.19-D
Page 15
2. Procedures for Filing
Rate reconsiderations shall be submitted within sixty days after payment rate schedules are provided to a facility. All requests shall be submitted in writing and must be accompanied by supporting documentation as requested by the Department.
3. Rate Adjustments
Any rate adjustments resulting from the reconsideration process will take place on the first day of the month following such adjustment. Rate adjustments resulting from this provision will only affect the facility that had rate miscalculations. Payment ceilings and incentive amounts for other facilities in a peer group will not be altered by these adjustments.
V. Reimbursement for Super Skilled Care
A higher rate will be paid for individuals who need a greater level of skilled care than that which is currently reimbursed in Delaware nursing facilities. For patients in the Super Skilled program prior to 4/1/93, the rate will be determined as follows:
A summary of each individual who qualified under the Medicaid program’s criteria for a “Super Skilled” level of care will be sent to local nursing facilities, which have expressed an interest in providing this level of care. They will be asked to submit bids, within a specific time frame, for their per diem charge for caring for the individual. The Medicaid program will review the bids and select the one that most meets the needs of the patient at the lowest cost.
Effective 4/1/93, all new patients who would have formerly been placed in a super skilled level will be placed in one of the patient class levels and reimbursed as any other client. The Medicaid program will pay outside of the per diem rate for the exceptional costs of their care, such as ventilator equipment and special supplies required.
VI. Reporting and Audit Requirements
A. Reporting
All facilities certified to participate in the Medicaid program are required to maintain cost data and submit reports on the form and in the format specified by the Department. Such reports shall be filed annually. Cost reports are due within ninety days of the close of the state fiscal year. All Medicaid participating facilities shall report allowable costs on a state fiscal year basis, which begins on July 1 and ends the following June 30. The allowable costs recognized by Delaware are those defined by Medicare principles.
ATTACHMENT 4.19-D
Page 16
In addition, all facilities are required to complete and submit an annual nursing wage survey on a form specified by the Department. All facilities must provide nursing wage data for the time periods requested on the survey form.
For patients in the Super Skilled program, prior to 4/1/93 annual Super Skilled bids will be considered the cost report for Super Skilled services. The nursing facility cost report must be adjusted to reflect costs associated with care for Super Skilled patients.
Failure to submit timely cost reports or nursing wage surveys within the allowed time periods when the facility has not been granted an extension by the Department, shall be grounds for suspension from the program. The Department may levy fines for failure to submit timely data as described in Section II.D. of the General Instructions to the Medicaid nursing facility cost report.
B. Audit
The Department shall conduct a field audit of participating facilities, in accordance with Federal regulation and State law. Both cost reports and the nursing wage surveys will be subject to audit.
Overpayments identified and documented as a result of field audit activities, or other findings made available to the Department, will be recovered. Such overpayments will be accounted for on the Quarterly Report of Expenditures as required by regulation.
Rate revisions resulting from field audit will only affect payments to those facilities that had an identified overpayment. Payment ceilings and incentive payments for other facilities within a peer group will not be altered by these revisions.
C. Desk Review
All cost reports and nursing wage surveys shall be subjected to a desk review annually. Only desk reviewed cost report and nursing wage survey data will be used to calculate rates.
VII. Reimbursement for Out-of-State Facilities
Facilities located outside of Delaware will be paid the lesser of the Medicaid reimbursement rate from the state in which they are located or the highest rate established by Delaware for comparably certified non-state operated facilities as specified above.
ATTACHMENT 4.19-D
Page 17
VIII. Reimbursement of Ancillary Service for Private Facilities
Oxygen, physical therapy, occupational therapy, and speech therapy will be reimbursed on a fee-for-service basis. The rates for these services are determined by a survey of all enrolled facilities’ costs. The costs are then arrayed and a cap set at the median rate. Facilities will be paid the lower of their cost or the cap. The cap will be recomputed every three years based on new surveys.
The Delaware Medicaid Program’s nursing home rate calculation, the Patient Index Reimbursement System, complies with requirements found in the Nursing Home Reform Act and all subsequent revisions. A detailed description of the methodology and analysis used in determining the adjustment in payment amount for nursing facilities to take into account the cost of services required to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident eligible for benefits under Title XIX is found in Attachment A.
DELAWARE MEDICAID PROGRAM
ESTIMATE OF THE COST INCREASES INCURRED BY NURSING FACILITY
IN MEETING THE REQUIREMENTS OF OBRA '87
I. TRAINING, CERTIFICATION AND CONTINUING EDUCATION FOR NURSE AIDES
|
# Aides |
Cost/Aide |
Total Cost |
|||
|
A. |
Prior to October 1, 1990 |
||||
|
Competency Evaluation |
2041 |
$50 |
$102.050 |
||
|
75 hour Training (10%) |
204 |
Average fee for training |
$160 |
$32,640 |
|
|
Staff Salaries – Testing |
2041 |
Average $6.82/hr x 6 hrs |
$41 |
$83,681 |
|
|
Staff Salaries – Training |
204 |
Average $6.82/hr x 75 hrs x 80% |
$409 |
$83,436 |
|
|
Travel Costs |
700 |
$.30/mi x 34 mi / 5 persons |
$3 |
$2,100 |
|
|
Total Cost |
$303.907 |
||||
|
Cost per Aide |
$149 |
||||
|
Avg # Aides per facility |
33 |
||||
|
Avg Cost per facility |
$4,914 |
Information from DE Office of Licensing and Certification indicates that most currently employed nurse aides were able to take the certification examination prior to October 1, 1990 without the 75 hour training program. An estimate of 10% requiring the training is used here.
Average staff salaries are derived from the Nurse Wage Survey, July 1989, and projected forward to 1990.
Nurse aide training and certification costs will be reimbursed directly as administrative costs from billing submitted by each nursing facility.
|
# Aides |
Cost/Aide |
Total Cost |
|||
|
B. |
After October 1, 1990 |
||||
|
Competency Evaluation |
680 |
33% Turnover / year |
$50 |
$34,000 |
|
|
75 hour Training (100%) |
680 |
Average fee for training |
$160 |
$108,800 |
|
|
Staff Salaries – Testing |
680 |
Average $6.82/hr x 6 hrs |
$41 |
$27,880 |
|
|
Staff Salaries – Training |
680 |
Average $6.82/hr x 75 hrs x 80% |
$409 |
$278,120 |
|
|
Travel Costs |
230 |
$.30/mi x 34 mi / 5 persons |
$3 |
$690 |
|
|
Total Costs |
|
$449,490 |
|||
|
Cost per Aide |
$661 |
||||
|
Avg # Aides per facility |
33 |
||||
|
Avg Cost per facility |
$21,813 |
Continuing education for nurse aides will be reported on the annual cost report and will be reimbursed as part of the per diem.
Annual staff turn-over estimate of 33Z is derived from staffing experience of facilities.
II. ADDITIONAL NURSE STAFF REQUIREMENTS
A. Nursing Staff
1. RN on Day Shift # Facilities Currently Meeting Requirement
# Facilities That Must Increase Staff to Comply With Requirement
o No financial impact of this additional staff requirement because all facilities are currently meeting minimum staffing requirement.
2. RN/LPN on all shifts #Facilities Currently Meeting Requirement 29
#Facilities That Must Increase Staff to Comply With Requirement
3 Total Cost per Facility 1.7 FTE x 2080 hrs/FTE x $15.30/hr Salary/Benefit/Training $54,101
Current reimbursement under the Delaware Patient Index Reimbursement System makes no distinction between Skilled and Intermediate levels of care. The three facilities which must increase their staff to comply with the new regulations have always been paid on the same basis as those facilities which exceeded the new staffing requirement. The nursing time factors in the Medicaid time matrix are sufficient to reimburse for the required staffing.
Three of 29 private facilities in Delaware must increase their nursing staff in order to meet the new requirements. Two of the three facilities will continue to receive reimbursement exceeding their costs providing that they maintain their current patient mix. The third facility currently has costs exceeding reimbursement due to several factors. Significant factors include their corporate policy to accept low care patients, their 72% occupancy rate, and higher than average nursing salaries. By making only minor adjustments to the patient mix, this facility could increase the. average daily reimbursement per patient from $20.94 to $26.75. Their costs will increase from $22.62 to $26.62 as a result of the additional nursing staff required.
Resident Assessment
Avg 87 pts/facility x 25 minutes/pt/year @ $16.98/hr = $615.53 per Facility
o The PIRS nursing time requirements matrix has been adjusted to account for the additional nursing time required to conduct Resident Assessment. Time for assessment and documentation was originally included in the nursing time requirements for RN and LPN at each level of patient accuity. Additional time will be included when calculating the Oct 1, 1990 rates to account for the new requirements. The amount of time added to the matrix was calculated by estimating the time required for assessment per patient per year and dividing by the number of annual available patient days per patient.
C. Plans Of Care
Avg 87 pts/facility x 30 minutes/pt/year @ $16.98/hr = $738.63 per Facility
The PIRS nursing time requirements matrix has been adjusted to account for the additional nursing time required to conduct Plans of Care. Time for plans of care and documentation was originally included in the nursing time requirements for IN and LPN at each level of patient acuity. Additional time will be included when calculating the Oct 1, 1990 rates to account for the new requirements. The amount of time added to the matrix was calculated by estimating the time required for plans of care per patient per year and dividing by the number of annual available patient days per patient.
III. EXTENDED PATIENT SERVICES
A. Dietary: No cost increase is expected as a result of the new
No cost increase is expected as a result of the new requirements
Current State certification standards require the level of
Dietary standards required by OBRA.
The PIRS reimbursement system will reflect any increase in staffing.
B. Pharmacy: No cost increase is expected as a result of the new requirements
Current State certification standards require the level of Pharmacy standards required by OBRA. The FIRS reimbursement system will reflect any increase in staffing.
C. Dental Services: Delaware does not currently cover Dental Care under the State Plan. No cost impact is expected.
D. Medical Records: Nursing time for conducting Patient Assessment and coordinating Plans of Care will has been expanded in the Nursing Time Requirements Matrix. This accounts for the additional time required to manage medical records.
Please refer to the explanation of the Additional Nursing Staff Requirements above.
E. Activities Personnel: 8 Facilities - P.T. Activities Director @ $23,400 annually
8 facilities expect to expand their activities staff, although they currently employ an Activities Director.
All Delaware facilities currently meet this requirement by employing an an qualified Activities Director on staff. Many facilities also have activities personnel in addition to the Director.
The estimates of the number of facilities effected by this requirement and the cost of a part time Activities Director were derived from a telephone survey of 9 facilities and information from the state nursing facilities association.
F. Social Worker: > 120 beds 4 Facilities - F.T. Social Worker @ $31,200 annually
< 120 beds 11Facilities - P.T. Social Worker @
$23,400
4 of 10 facilities over 120 beds will incur costs to upgrade their social work activities.
11 of 22 facilities under 120 beds must upgrade their social work program by increasing their social work staff.
The estimates of the number of facilities effected by this requirement and the cost of Social Workers were derived from a telephone survey of 9 facilities and information from the state nursing facilities association.
G. Physical Therapy: 1753 ICI beds x 90% occupancy = 1578 patients x 20% increase = 316 patients Therapist treats 6 pts/hr @ avg $35/hr x 2 times/week/pt = $11.67/pt/week Total Cost 316 patients x $11.67/pt/week = $3,688/week total
Average Cost per Facility 11 pts @ $11.67/pt/week = $128.37/wk = $6,675/yr.
On-site therapy will continue to be billed directly as a contracted ancillary service, and will not be part of the per diem reimbursement rate.
ICF as well as SNF patients are currently receiving therapy as needed. An increase of about 20% utilization is anticipated, primarily for ICF patients.
Estimates of additional costs were derived from information from the Delaware Division of Public Health, Office of Health Facilities Licensing and Certification, and a review of therapy reimbursement.
IV. MEDICAL DIRECTOR
Average $66/hour for contractual services x 5 hours per month
$330 per month x 12 months = $3,960 per year for Medical Director
All Delaware nursing facilities are currently required to have Medical Director. Many will need to expand the responsibilities of the designated position.
12 facilities to increase Medical Director hours under contract from an average of $720/ mo to $1050/ mo. Increase represents $3,960 per facility per year.
The cost estimate for the Medical Director was based on information from the Medicaid review nurse, who projected the number of hours required and the average hourly reimbursement, and called a number of facilities to determine how this requirement would be met. The number of facilities effected was estimated by the state nursing facilities association.
V. RESIDENT’S RIGHTS
A. Resident Personal Funds: 8 hours/day x 1.5 days/mo x 12 mo/yr x $12.50/hr = $1,800 per year
Estimated 20 facilities will increase their bookkeeping staff to maintain records of interest bearing accounts, calculate interest, and produce quarterly statements.
Most likely approach to this requirement will be to employ temporary bookkeeping services.
Other facilities will absorb this requirement into their current bookkeeping staff.
This is the estimate of the Medicaid review nurse, who contacted a number of facilities to determine how this requirement would be met.
B. Other Resident’s Rights:
The following patient’s rights are not expected to result in additional costs for the nursing facilities:
1. Notice of Rights and Services
2. Rights of Incompetent Residents
3. Transfer and Discharge Rights
4. Access and Visitation Rights
5. Equal Access to Quality Care
6. Admissions Policy
No additional costs are anticipated for nursing facilities to implement other resident’s rights. Most state regulations concerning specific patient’s rights are the same as or more stringent than the Federal requirements. Those rights that are not addressed specifically as individual requirements in the state regulations, are protected by the Delaware’s Patient Bill of Rights.
STATE OF DELAWARE
STATEMENT OF REIMBURSEMENT COST FOR SKILLEDAND INTERMEDIATE CARE NURSING FACILITIES TITLE XIX
1. FOR THE PERIOD: TO:
2. NAME OF FACILITY
STREET ADDRESS
CITY, STATE, ZIP CODE
3. Name and telephone number of person to contact in case of questions concerning this report:
NAME:
TITLE:
TELEPHONE NUMBER:
4. TYPE OF ENTITY: (check one only)
A. Corporation
B. Individual Proprietorship
C. Non-Profit Organization
D. Partnership
E. State Facility
F. Other (Describe)
Under penalties of perjury, I declare that I have examined this Statement of Reimbursement Cost, including accompanying schedules, statements and adjustments and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than facility personnel) is based on all information of which preparer has any knowledge.
5. Your signature: Date: Title:
6. Preparer's signature: Date: Company or Organization Name:
Street address:
City, State, Zip Code:
