The case mix classification system is defined in terms of recipient condition, functional performance in activities of daily living (ADL), and level of staff intervention. The classification system is divided into four clinical categories which are further subdivided based on ADL scores that measure functional performance for eating, transferring, and toileting. The combination of clinical categories and ADL measurements yields an array of 11 Texas Index for Level of Effort (TILE) case-mix classifications.

1. (1) Assessment period. Completion of the Client Assessment Review and Evaluation (CARE) form for assignment of a clinical category or ADL score must be based on the recipient's status in the facility during four weeks immediately preceding the assessment date, except in any of the following instances:

   1. (A) If the recipient has experienced a change in clinical or functional status during the past four weeks and the change appears permanent, the assessment is made on the current (changed) status.
   2. (B) If the recipient has been admitted or readmitted to a facility during the past four weeks, the assessment is based on the status since admission or readmission.
   3. (C) The condition or event which precipitates the need for rehabilitative therapy/restorative nursing may have occurred no more than six months prior to the assessment period. An admission or transfer into a facility could qualify as an event.

2. (2) Documentation. The documentation in the clinical record must be descriptive and quantitative to allow the accurate completion of the CARE form items relating to the recipient's condition(s), treatment(s), and the ADLs of eating, transferring, and toileting.

   1. (A) In the absence of required facility documentation, the Texas Department of Human Services (DHS) nurse reviewers will use available data, staff interviews, and nursing observation to assign ADL scores.
   2. (B) The required documentation must appear in the clinical record during the assessment period to qualify for a clinical category. Lack of documentation will result in a change to an assessment item for a clinical category.
   3. (C) Lack of, conflicting, or altered documentation could be the basis for an adjustment in TILE.
   4. (D) Suspected fraudulent documentation, such as falsified or fabricated medical records, will result in a referral for investigation to the Medicaid Provider Sanctions Division of the Health and Human Services Commission, as required as part of the state's methods for identification, investigation and referral for fraud under Chapter 79, Subchapter V (relating to Fraud or Abuse Involving Medical Providers) and 42 CFR, Part 455 (concerning Program Integrity: Medicaid).

3. (3) Clinical categories. Each recipient is assigned to one of the following four clinical categories based on qualifying conditions or treatments.

   1. (A) The heavy-care group. To qualify for the heavy-care clinical group, a recipient must have at least one of the following conditions or be receiving at least one of the following treatments, with supporting documentation in the clinical record, and the recipient must have a total ADL score of at least six out of a possible nine.

      1. (i) Coma. Persistent unconsciousness and unresponsiveness from which a resident cannot be aroused must be documented in the assessment period.
      2. (ii) Quadriplegia. Neurologic disorder causing paralysis of the four extremities, excluding loss of movement caused solely by contractures. Paralysis is defined as loss of power of voluntary movement in a muscle through injury or disease of its nerve supply. A description of the recipient's functional abilities and limitations must be documented in the clinical record in the assessment period.
      3. (iii) Stage III or IV decubitus with physician-ordered decubitus care and/or wound dressings twice a day. Decubitus covered by eschar is considered Stage IV. Decubitus must be described and care/dressings must be documented in the assessment period.
      4. (iv) Non-oral administration of 60% or more of the recipient's nourishment. Times, amount, and types of feeding must be documented in the assessment period.
      5. (v) Daily oral or nasal suctioning, which must be documented daily in the assessment period.
      6. (vi) Daily tracheostomy care or suctioning, excluding self-care, which must be documented daily in the assessment period.

   2. (B) The rehabilitation/restorative group. To qualify for the rehabilitation/restorative clinical group, a recipient must receive TILE 202 restorative nursing care as follow-up to rehabilitation therapy. The TILE 202 restorative nursing and rehabilitation therapy must meet the following criteria with supporting documentation in the clinical record.

      1. (i) The rehabilitation therapy must be:

         1. (I) physical or occupational therapy, ordered by a physician, and provided by a licensed therapist or by certified or licensed occupational or physical therapy assistants (COTA/LPTA) under the supervision of a licensed therapist. Positioning, splinting, decubitus ulcer care, and training nursing staff (as in a functional maintenance program) are excluded from the TILE 202, even if provided by an occupational therapist or physical therapist;

         2. (II) initiated due to an identifiable, documented event, i.e., an illness, injury or physical change or an exacerbation of a chronic illness in the past six months with an associated change in ADL functioning. The functional change must be documented through one of the following:

            (-a-) a description of the event or illness and the recipient's functional status before and after the event; or

            (-b-) completion of a Minimum Data Set 2.0 Significant Change and an updated care plan;

         3. (III) expected to result in the recipient's making significant, measurable, functional progress, which must be documented in the therapy goals;
         4. (IV) provided on a one-to-one basis three times per therapy week for at least two therapy weeks; and
         5. (V) reimbursed by Medicare, Medicaid rehabilitative services, or another third party payor.

      2. (ii) The TILE 202 restorative nursing must:

         1. (I) be provided as part of a restorative care plan, based upon the therapist's written plan of care and developed by the restorative team, which must include the therapist and a registered nurse;
         2. (II) begin during the assessment period;
         3. (III) begin within 14 days of the therapist's written restorative plan of care;
         4. (IV) be provided for a minimum of 24 sessions within eight therapy weeks, and must continue as long as clinically indicated; and

         5. (V) be supported by a Restorative Nursing Care Program form, or similar form containing the same elements, which must document each restorative session and the recipient's response to the restorative plan through:

            (-a-) a weekly note by the nursing or therapy staff (as appropriate); and

            (-b-) a written monthly review by the licensed nursing staff or, if services were supervised or delivered by a licensed therapist, a licensed therapist.

      3. (iii) A recipient will be considered to be properly classified in this clinical group if all criteria in clauses (i) and (ii) of this subparagraph are met except clause (i)(IV) and (V) of this subparagraph, which must be met within three months of the date of assessment;
      4. (iv) Payment will be recouped on recipients who do not meet TILE 202 restorative nursing criteria.

   3. (C) The clinically unstable group. To qualify for the clinically unstable group, a recipient must have at least one of the following conditions during the assessment period, with the exception of an amputation, which must have occurred in the six months preceding the assessment date, or be receiving at least one of the following treatments during the assessment period.

      1. (i) Recent amputation of arms, legs, or parts thereof in the six months preceding the assessment date. Date and site of amputation must be documented in the clinical record.
      2. (ii) Seizures, which occurred in the facility, in the assessment period. A description of the seizure and nursing interventions must be documented in the clinical record.
      3. (iii) Dehydration with documented intake/output monitoring (including frequency and amounts of output) on at least two shifts per day. Dehydration that was diagnosed, treated, and resolved outside the facility and is no longer symptomatic is excluded. The signs, symptoms, interventions, and measures taken to prevent recurrence must be documented in the assessment period.
      4. (iv) Acute, symptomatic urinary tract infection (UTI) with a documented intake and output (including frequency and amounts of output) on three shifts a day. UTIs that were diagnosed, treated and resolved outside the facility and are no longer symptomatic and UTIs identified by urinalysis alone are excluded. The signs, symptoms, interventions and measures taken to prevent recurrence must be documented in the assessment period.
      5. (v) Incontinence or a foley catheter, with an individualized bowel or bladder rehabilitation program requiring staff intervention at least three times per day. The program must assess the cause of the incontinence and the rehabilitative potential, and document the interventions and outcomes. The care plan must include the individualized goals and approaches that reflect both the resident and nursing participation in the process. Frequency of staff intervention must be documented.
      6. (vi) Daily oxygen administration, which must be documented daily in the assessment period.
      7. (vii) Respiratory therapy, ordered by a physician, performed by licensed nursing staff or a respiratory therapist, received at least three times per day, and documented in the assessment period. Respiratory therapy includes nebulizers, percussion, cupping, postural drainage, updrafts, and intermittent positive pressure breathing (IPPB) treatments, but excludes inhalers.
      8. (viii) Wound dressing applied to an open wound at least two times per day, excluding simple skin tears and closed abrasions. A description of the wound and the treatment, including frequency, must be documented in the assessment period.

   4. (D) The clinically stable group. This clinical group includes all recipients who do not qualify clinically for the heavy-care, rehabilitation/restorative, or clinically unstable group, and who have an ADL score between 3 and 9. The clinically stable group includes a mental/behavioral condition subgroup. A recipient qualifies for this subgroup if:

      1. (i) they have an ADL score of exactly three; and

      2. (ii) they have at least one of the following cognitive or behavioral characteristics:

         1. (I) incoherent/frequent disorientation requiring daily staff intervention. Orientation problems must be described in the clinical record in the assessment period, including the staff intervention required and its frequency; or
         2. (II) daily disruptive or aggressive behavior, requiring immediate staff intervention. The behaviors must be described in the clinical record, in the assessment period, including the frequency and the required staff intervention.

4. (4) Computation of the ADL scale. The ADL scale is used to assess recipients' daily functional abilities in eating, transferring and toileting. The facility nurse assessors rate these activities with a value of one to five on the CARE form. The CARE form values are recoded by DHS into a three-point system. The recoding results in points that range from one to three for each item and totals from three to nine for all three items. A recipient's total points for all three ADLs are used to determine case-mix classifications within the clinical categories. The ADLs and their corresponding points on the TILE nine-point scale are:

   1. (A) Transferring, or the process of moving between positions, such as to or from a bed, a chair, or a standing position, but excluding to and from the toilet.

      1. (i) One TILE point is given for recipients rated as:

         1. (I) Independent; no staff assistance required, but recipient may use equipment such as railings, trapeze, etc.
         2. (II) Pro re nata (PRN); recipient requires PRN assistance for transfers.
      2. (ii) Two TILE points are given for recipients rated as "one to transfer"; requires one person continuously for physical or verbal assist on 60% or more of the transfers. When assistance is required and for what reason must be documented in the assessment period.

      3. (iii) Three TILE points are given for recipients rated as:

         1. (I) Two to transfer; requires assistance of two or more staff during the entire activity on 60% or more of the transfers. When assistance is required and for what reason must be documented in the assessment period.
         2. (II) Not Transferred; may be transferred to a stretcher or chair once a week or less, excluding transfers to bath or toilet.

   2. (B) Eating, including the use of an enteral or parenteral tube, but excluding tray set up and food preparation.

      1. (i) One TILE point is given for recipients rated as:

         1. (I) Independent or recipient has chosen not to receive nutrition.
         2. (II) Intermittent assistance; requires verbal or physical assistance less than 60% of the time.

      2. (ii) Two TILE points are given for recipients rated as:

         1. (I) Being trained to feed themselves. An assessment of the retraining potential and a description of the training program must be documented in the clinical record in the assessment period. The retraining program must include a minimum of training at two meals per day.
         2. (II) Requiring assistance to syringe or spoon feed for 60% or more of the time. The type of assistance, when the assistance is required, and for what reason must be documented in the clinical record.
      3. (iii) Three TILE points are given for recipients rated as receiving non-oral feedings for 60% or more of the recipient's nutrition using a tube such as a naso-gastric tube, gastrostromy tube, percutaneous endoscopic gastrostromy tube, or administration of total parenteral nutrition via a central line. The frequency, amounts, routes, and times the non-oral feedings were administered must be documented in the clinical record.

   3. (C) Toileting, or the process of elimination including the use of a bedpan, urinal, bedside commode, or toilet, or ostomy or incontinent care.

      1. (i) One TILE point is given for recipients rated as:

         1. (I) Independent, including the use of special equipment or performing of own incontinent care, self-catheterization, ostomy care.
         2. (II) Requires assistance but can be left alone for privacy. Assistance may include transferring on and off the commode, cleansing after elimination, adjusting clothing, or washing hands.
      2. (ii) Two TILE points are given for recipients rated as incontinent or having an indwelling catheter, including staff-administered ostomy care, incontinence care using protective padding, incontinence briefs, changing clothes, or a propped urinal. A description of what staff are required to do 60% or more of the time must be documented in the clinical record.

      3. (iii) Three TILE points will be given for recipients rated as:

         1. (I) Requiring physical or verbal assist or supervision during entire toileting process, excluding incontinent care, and cannot be left alone. The functional, medical, or behavioral reason the recipient cannot be left alone must be documented in the clinical record in the assessment period.
         2. (II) Receiving scheduled toileting by the staff every two hours during waking hours, or more often if needed by the resident, as incontinence management. Recipient does not initiate process and stays dry 60% or more of the time as the result of staff-initiated scheduled toileting. A description of staff actions and whether the resident was wet or dry each time he/she was taken to the toilet must be documented in the clinical record in the assessment period. Recipients who receive in and out catheterization by the staff two or more times each day are included in this category.
5. (5) Special cases. A recipient who qualifies for more than one of the 11 TILE case-mix groups is classified in the group with the highest case-mix index and associated per diem rate. If a provider incorrectly or incompletely reports data necessary for TILE determination, the recipient is temporarily classified in the default group until the data are corrected.

6. (6) Case-mix classifications. Case-mix classifications are determined by the clinical group in combination with the ADL score as follows:

   1. (A) TILE 201; heavy care and an ADL score of 8-9;
   2. (B) TILE 203; heavy care and an ADL score of 6-7;
   3. (C) TILE 202; rehabilitation and an ADL score of at least 3;
   4. (D) TILE 204; clinically unstable and an ADL score of 7-9;
   5. (E) TILE 205; clinically stable and an ADL score of 7-9;
   6. (F) TILE 206; clinically unstable and an ADL score of 4-6;
   7. (G) TILE 207; clinically stable and an ADL score of 5-6;
   8. (H) TILE 208; clinically unstable and an ADL score of 3;
   9. (I) TILE 209; clinically stable and an ADL score of 4;
   10. (J) TILE 210; clinically stable, an ADL score of exactly 3, and includes a mental/behavioral subcategory;
   11. (K) TILE 211; clinically stable and an ADL score of 3;
   12. (L) Default TILE; provider incorrectly or incompletely reports data necessary for TILE determination.
7. (7) Required signatures. The assessment form must be signed by the director of nurses or the acting director of nurses and the facility nurse assessor, one of whom has received TILE training, as required by §19.2412 of this title (relating to Texas Index for Level of Effort (TILE) Assessments). These signatures certify the information claimed is accurate and complete and subject to penalties for falsification, as provided in 42 Code of Federal Regulations, Part 1003.

Source Note:The provisions of this §371.212 adopted to be effective January 15, 1997, 21 TexReg 11970; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308.