Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Abuse"
means any of the following which
				  occurs as a result of the willful or negligent acts or omissions of a nursing
				  facility employee:
1. Physical injury
				to, or injury which is at a variance with the history given of the injury, or
				unreasonable confinement or unreasonable punishment or assault as defined in
				Iowa Code section 708.1 of a resident.
2. The commission of a sexual offense under
				Iowa Code chapter 709 or Iowa Code section
				726.2 or
				728.12, subsection 1, or sexual
				exploitation under Iowa Code chapter 235B, as a result of the acts or omissions
				of the facility employee responsible for the care of the resident with or
				against a resident.
3. Exploitation
				of a resident which means the act or process of taking unfair advantage of a
				resident or the resident's physical or financial resources for one's own
				personal or pecuniary profit without the informed consent of the resident,
				including theft, by the use of undue influence, harassment, duress, deception,
				false representation or false pretenses.
4. The deprivation of the minimum food,
				shelter, clothing, supervision, physical or mental health care, or other care
				necessary to maintain a resident's life or health.
"Advance directive"
means a written
				  instruction, such as a living will or durable power of attorney for health
				  care, recognized under state law and related to the provision of health care
				  when the resident is incapacitated.
"Allowable costs"
means the price a prudent,
				  cost-conscious buyer would pay a willing seller for goods or services in an
				  arm's-length transaction, not to exceed the limitations set out in
				  rules.
"Beginning eligibility date"
means date of
				  an individual's admission to the facility or date of eligibility for medical
				  assistance, whichever is the later date.
"Case mix"
means a measure of the intensity
				  of care and services used by similar residents in a facility.
"Case-mix index"
means a numeric score
				  within a specific range that identifies the relative resources used by similar
				  residents and represents the average resource consumption across a population
				  or sample.
"Civil penalty"
shall mean a civil money
				  penalty not to exceed the amount authorized under Iowa Code section
				  135C.36 for health care facility
				  violations.
"Clinical experience"
means application or
				  learned skills for direct resident care in a nursing facility.
"Clock hour"
means 60 minutes.
"Complete replacement"
means completed
				  construction on a new nursing facility to replace an existing licensed and
				  certified nursing facility. The replacement facility shall have no more
				  licensed beds than the facility being replaced and shall be located either in
				  the same county as the facility being replaced or within 30 miles from the
				  facility being replaced.
"Cost normalization"
refers to the process
				  of removing cost variations associated with different levels of resident case
				  mix. Normalized cost is determined by dividing a facility's per diem direct
				  care component costs by the facility cost report period case-mix index.
"Denial of critical care"
is a pattern of
				  care in which the resident's basic needs are denied or ignored to such an
				  extent that there is imminent or potential danger of the resident suffering
				  injury or death, or is a denial of, or a failure to provide the mental health
				  care necessary to adequately treat the resident's serious social maladjustment,
				  or is a gross failure of the facility employee to meet the emotional needs of
				  the resident necessary for normal functioning, or is a failure of the facility
				  employee to provide for the proper supervision of the resident.
"Department"
means the Iowa department of
				  human services.
"Direct care component"
means the portion of
				  the Medicaid reimbursement rates that is attributable to the salaries and
				  benefits of registered nurses, licensed practical nurses, certified nursing
				  assistants, rehabilitation nurses, and contracted nursing services. "Direct
				  care component" also includes costs related to therapy services provided to
				  residents during inpatient stays and not billed as an outpatient
				  service.
"Discharged resident"
means a resident whose
				  accounts and records have been closed out and whose personal effects have been
				  taken from the facility. When a resident is discharged, the facility shall
				  notify the department via Form 470-0042, Case Activity Report.
"Facility"
means a licensed nursing facility
				  certified in accordance with the provisions of
				  42 CFR
				  483.5 as amended to December 4, 2017, to
				  provide health services and includes hospital-based nursing facilities that are
				  Medicare-certified and provide only skilled level of care and swing-bed
				  hospitals unless stated otherwise.
"Facility-based nurse aide training program"
means a nurse aide training program that is offered by a nursing facility and
				  taught by facility employees or under the control of the licensee.
"Facility cost report period case-mix index"
is the average of quarterly facility wide average case-mix indices, carried to
				  four decimal places. The quarters used in this average will be the quarters
				  that most closely coincide with the financial and statistical reporting period.
				  For example, a 01/01/2000-12/31/2000 financial and statistical reporting period
				  would use the facility wide average case-mix indices for quarters ending
				  03/31/00, 06/30/00, 09/30/00 and 12/31/00.
"Facility wide average case-mix index"
is
				  the simple average, carried to four decimal places, of all resident case-mix
				  indices based on the last day of each calendar quarter.
"Informed consent"
means a resident's
				  agreement to allow something to happen that is based on a full disclosure of
				  known facts and circumstances needed to make the decision intelligently, i.e.,
				  with knowledge of the risks involved or alternatives.
"Iowa Medicaid enterprise"
means the entity
				  comprised of department staff and contractors responsible for the management
				  and reimbursement of Medicaid services.
"Laboratory experience"
means practicing
				  care-giving skills prior to contact in the clinical setting.
"Level I review"
means screening to identify
				  persons suspected of having mental illness or intellectual disability as
				  defined in 42 CFR
				  483.102 as amended to July 1, 2014.
"Level II review"
means the evaluation of a
				  person identified in a Level I review to determine whether nursing facility
				  services and specialized services are needed.
"Major renovations"
means new construction
				  or facility improvements to an existing licensed and certified nursing facility
				  in which the total depreciable asset value of the new construction or facility
				  improvements exceeds $750,000. The $750,000 threshold shall be calculated based
				  on the total depreciable asset value of new construction or facility
				  improvements placed into service during a two-year period ending on the date
				  the last asset was placed into service. When the property costs of an asset
				  have been included in a facility's financial and statistical report that has
				  already been used in a biennial rebasing, the costs of that asset shall not be
				  considered in determining whether the facility meets the $750,000
				  threshold.
"Managed care organization"
means an entity
				  that (1) is under contract with the department to provide services to Medicaid
				  recipients and (2) meets the definition of "health maintenance organization" as
				  defined in Iowa Code section
				  514B.1.
"Medicaid average case-mix index"
is the
				  simple average, carried to four decimal places, of all resident case-mix
				  indices where Medicaid is known to be the per diem payor source on the last day
				  of the calendar quarter.
"Minimum data set"
or
"MDS"
refers to a federally required resident assessment tool. Information from the
				  MDS is used by the department to determine the facility's case-mix index for
				  purposes of normalizing per diem allowable direct care costs as provided by
				  paragraph 81.6(16)
"b,"
for determining the Medicaid average
				  case-mix index to adjust the direct care component pursuant to paragraphs
				  81.6(16)
"c"
and
"e,"
the excess payment
				  allowance pursuant to paragraph 81.6(16)
"d,"
and the limits on
				  reimbursement components pursuant to paragraph 81.6(16)
"f."
MDS is described in subrule 81.13(9).
"Minimum food, shelter, clothing, supervision,
				  physical or mental health care, or other care"
means that food,
				  shelter, clothing, supervision, physical or mental health care, or other care
				  which, if not provided, would constitute denial of critical care.
"Mistreatment"
means any intentional act, or
				  threat of an act, coupled with the apparent ability to execute the act, which
				  causes or puts another person in fear of mental anguish, humiliation,
				  deprivation or physical contact which is or will be painful, insulting or
				  offensive. Actions utilized in providing necessary treatment or care in
				  accordance with accepted standards of practice are not considered
				  mistreatment.
"New construction"
means the construction of
				  a new nursing facility that does not replace an existing licensed and certified
				  facility and that requires the provider to obtain a certificate of need
				  pursuant to Iowa Code chapter 135, division VI.
"Non-direct care component"
means the
				  portion of Medicaid reimbursement rates attributable to administrative,
				  environmental, property, and support care costs reported on the financial and
				  statistical report.
"Non-facility-based nurse aide training
				  program"
means a nurse aide training program that is offered by an
				  organization that is not licensed to provide nursing facility services.
"Non-state government owned nursing
				  facility"
or
"NSGO nursing facility"
is a nursing
				  facility owned by a governmental entity that is not the state.
"Nurse aide"
means any individual who is not
				  a licensed health professional or volunteer providing nursing or
				  nursing-related services to residents in a nursing facility.
"Nurse aide registry"
means Nurse Aide
				  Registry, Department of Inspections and Appeals, Third Floor, Lucas State
				  Office Building, Des Moines, Iowa 50319.
"Nurse aide training and competency evaluation
				  programs (NATCEP)"
are educational programs approved by the department
				  of inspections and appeals for nurse aide training as designated in subrule
				  81.16(3).
"Nursing facility level of care"
means that
				  the following conditions are met:
1.
				The presence of a physical or mental impairment which restricts the member's
				daily ability to perform the essential activities of daily living, bathing,
				dressing, and personal hygiene, and impedes the member's capacity to live
				independently.
2. The member's
				physical or mental impairment is such that self-execution of required nursing
				care is improbable or impossible.
"PASRR"
means a Level I screening or a Level
				  II evaluation for mental illness or intellectual disability for all persons who
				  live in or seek entry to a Medicaid-certified nursing facility, as required by
				  42 CFR Part 483 , Subpart C, as amended to July 1, 2014.
"Patient-day-weighted median cost"
means the
				  per diem cost of the nursing facility that is at the median per diem cost of
				  all nursing facilities based on patient days provided when per diem allowable
				  costs are ranked from low to high. A separate patient-day-weighted median cost
				  amount shall be determined for the direct care and non-direct care
				  components.
"Physical abuse"
means any nonaccidental
				  physical injury, or injury which is at variance with the history given of it,
				  suffered by a resident as the result of the acts or omissions of a person
				  responsible for the care of the resident.
"Physical injury"
means damage to any bodily
				  tissue to the extent that the tissue must undergo a healing process in order to
				  be restored to a sound and healthy condition, or damage to any bodily tissue to
				  the extent that the tissue cannot be restored to a sound and healthy condition,
				  or damage to any bodily tissue which results in the death of the person who has
				  sustained the damage.
"Poor performing facility (PPF)"
is a
				  facility designated by the department of inspections and appeals as a poor
				  performing facility (PPF) based on surveys conducted by the department of
				  inspections and appeals pursuant to subrule 81.13(1). A facility shall be
				  designated a PPF if it has been cited for substandard quality of care on the
				  current standard survey and it:
1. Has
				been cited for substandard quality of care or immediate jeopardy on at least
				one of the previous two standard surveys;
2. Has a history of substantiated complaints
				during the last two years;
3. Has a
				current deficiency for not having a quality assurance program; or
4. Does not have an effective quality
				assurance program as defined in paragraph
				81.13(19)
"o."
"Primary instructor"
means a registered
				  nurse responsible for teaching a state-approved nurse aide training
				  course.
"Program coordinator"
means a registered
				  nurse responsible for administrative aspects of a state-approved nurse aide
				  training course.
"Rate determination letter"
means the letter
				  that is distributed quarterly by the Iowa Medicaid enterprise to each nursing
				  facility notifying the facility of the facility's Medicaid reimbursement rate
				  calculated in accordance with this rule and of the effective date of the
				  reimbursement rate.
"Skilled nursing facility level of care"
means that the following conditions are met:
1. The member's medical condition requires
				skilled nursing services or skilled rehabilitation services as defined in
				42 CFR
				409.31(a),
				409.32, and
				409.34.
2. Services are provided in accordance with
				the general provisions for all Medicaid providers and services as described in
				rule 441-79.9 (249A).
3. Documentation submitted for review
				indicates that the member has:
a. A physician
				order for all skilled services.
b.
				Services that require the skills of medical personnel, including registered
				nurses, licensed practical nurses, physical therapists, occupational
				therapists, speech pathologists, or audiologists.
c. An individualized care plan that
				identifies support needs.
d.
				Confirmation that skilled services are provided to the member.
e. Skilled services that are provided by, or
				under the supervision of, medical personnel as described above.
f. Skilled nursing services that are needed
				and provided seven days a week or skilled rehabilitation services that are
				needed and provided at least five days a week.