1. (a) Recipient assessment. Facility nurse assessors assess recipients for TILE determination by completing Texas Nursing Facility Client Assessment, Review, and Evaluation (CARE) forms. These assessments establish TILE classifications as described in paragraphs (1)-(8) of this subsection. Effective April 1, 1995, nurse assessors must have completed a Texas Department of Human Services (DHS) TILE training course and must be registered with the National Heritage Insurance Company (NHIC).

   1. (1) Preadmission assessments do not establish a TILE classification.

   2. (2) Admissions assessments establish TILE classifications as follows:

      1. (A) If the resident has not previously attained a permanent medical necessity, the nurse assessor submits an admission assessment within 20 calendar days of admission, as provided in §19.2403 (relating to Utilization Review Process). The admission assessment establishes a medical necessity (MN) and a TILE classification for 180 days.
      2. (B) If the resident has previously attained a permanent MN, the admission assessment is completed on an abbreviated form which sets TILE only.
   3. (3) One medical necessity review (MNR) is required 180 days after the effective date of the admission assessment. If the MNR indicates an MN for nursing facility care, DHS will notify the facility of the permanent MN. This notification becomes a part of the resident's permanent medical record. A permanent MN will be lost only if a resident is discharged to home for over 30 days. The MNR may also establish a new TILE classification.
   4. (4) After the establishment of permanent MN, residents with a 211 TILE require no further assessment unless there is a change in their condition. All other TILE levels require a review every 180 days.
   5. (5) If a recipient's medical condition deteriorates to the extent that he qualifies for a different TILE, the provider may submit an off-cycle assessment. Only two off-cycle assessments for any one recipient are permitted per year, one from January through June and one from July through December. The assessment sets a new schedule for submission of forms if permanent MN has been achieved. Prior to permanent MN, the assessment will not set a new schedule for submission of forms.

   6. (6) A new CARE form may be submitted for the purpose of allowing a provider to correct errors previously made in the assessment portion of the form (Items 30, 31, and 50-99). The submission of the correction does not change the schedule for submission of forms or necessarily change the TILE group. Corrections must be submitted within 60 days from the date of assessment on the incorrect form. DHS will not accept requests for changes submitted:

      1. (A) over 60 days from the date of assessment on the incorrect form; or
      2. (B) after notification of an on-site review date.
   7. (7) If a recipient experiences a significant change related to mental illness, mental retardation, and/or a related condition which indicates that the recipient might benefit from specialized services, an off-cycle request for a recipient Preadmission Screening and Resident Review (PASARR) must be submitted to the local DHS PASARR office using a CARE form.

   8. (8) A facility may submit a request for retroactive payment in the following instances:

      1. (A) when a facility provides care for a recipient for a period of time not covered by an effective MN determination at admission or by assessment CARE forms between reviews (see §19.2413 of this title (relating to Reconsideration of Medical Necessity Determination and Effective Dates)); or
      2. (B) if a recipient is found to be otherwise eligible for Medicaid for the three months prior to the month of his date of application for Medicaid assistance (see §19.2408 of this title (relating to Retroactive Medical Necessity Determinations)).

2. (b) Review and appeal of case-mix assessments. DHS nurse reviewers conduct desk reviews and in-depth, on-site reviews of Texas Nursing Facility CARE forms completed by providers to verify TILE and medical necessity information. The assessment forms of a minimum of ten Medicaid recipients, excluding TILE 211, will be reviewed, unless the low census of a nursing facility precludes the review of ten forms. Forms expired over 12 months will not be reviewed.

   1. (1) DHS nurse reviewers notify facilities in advance of routine on-site visits regarding the recipients whose medical records will be reviewed, the time period covered by the review, the parts of the record to be reviewed, and the accommodations necessary for the review. Facilities receive a minimum of two working days' notice prior to a routine visit. Less than two days notice may be given to facilities whose last two on-site visits resulted in monitoring, compliance, or vendor hold. No notice is required for visits for investigation of TILE issues, including suspected fraud, or for visits requested by another state agency. If nurse reviewers are prevented from conducting a review based on a facility's actions, TILE rates on the recipients chosen for review will be lowered to the default TILE rate until the review can be accomplished.

   2. (2) When a DHS nurse reviewer determines that the TILE classification or permanent MN determination is not substantiated and/or does not accurately reflect the recipient's status, the reviewer will discuss the error and propose corrections with facility staff and make appropriate corrections during the review. An exit conference is held with facility staff following the review. Additional documentation to support the facility's assessments may be presented at any time during the review process or the exit conference, and adjustments may be made. The facility administrator is given formal notification of all TILE changes within 15 working days of the exit conference.

      1. (A) DHS recoups funds previously paid to the provider under incorrect TILE classification. DHS pays the nursing facility any increase due to a change in TILE classification.
      2. (B) The change in TILE classification and per diem rate is effective retroactively to the "effective date" of the assessment reviewed.
      3. (C) The change in MN determination is effective on the date of the review. If discharge results, the procedures in §19.502 of this title (relating to Transfer and Discharge) must be followed.

   3. (3) If a DHS nurse reviewer and a facility nurse assessor are unable to agree about an assessment, the provider may request a reconsideration by a DHS nurse supervisor.

      1. (A) The request for the reconsideration and all documentation supporting the requested changes must be received by the regional nurse supervisor within 15 days of receipt of formal notification of TILE changes.
      2. (B) The regional nurse supervisor or a state office nurse will review all material submitted by the provider and all information collected during the Utilization and Assessment Review (UAR) review.
      3. (C) The TILE classification and associated per diem rate specified by the DHS nurse reviewer remain in effect during the reconsideration period.
      4. (D) If the reconsideration establishes that DHS has changed a TILE classification in error, DHS corrects the error retroactively.

   4. (4) If the provider disagrees with the findings of the regional nurse supervisor, the provider may initiate a formal appeal, as stated in Chapter 79, Subchapter Q of this title (relating to Contract Appeals Process) by submitting a request to the Director, Hearings Department, Mail Code W-613, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 within 15 days of receipt of notification of the results of the reconsideration.

      1. (A) The TILE classification and associated per diem rate specified by the regional nurse supervisor remain in effect during the formal contract appeal.
      2. (B) If the contract appeal process establishes that DHS has changed a TILE classification in error, DHS corrects the error retroactively.

3. (c) Monitoring. TILE error rates on the assessment forms reviewed which exceed 20% may result in a facility's undergoing a monitoring period. Decisions to institute monitoring will be made by the Utilization and Assessment Review (UAR) staff in state office.

   1. (1) During the monitoring period, facilities must submit all Texas Nursing Facility CARE forms to DHS nurse reviewers. Forms may not be submitted to NHIC either electronically or by mail.
   2. (2) The length of the monitoring period is 60 days. If accuracy of forms is still at an unacceptable level at the end of 60 days, DHS may give a one-time, 30-day extension, if the facility has shown an attempt to improve their accuracy. If forms are not accurate at the end of 90 days, DHS places the facility on compliance.

4. (d) Compliance.

   1. (1) A decision to place a facility on compliance will be made by UAR staff in state office. Compliance may result when a facility has a 20% or greater error rate on the current assessment forms reviewed and one of the following:

      1. (A) a 20% or greater error rate by the end of a monitoring period;
      2. (B) lack of documentation regarding key assessment items;
      3. (C) a history of noncompliance; or
      4. (D) medical records which contain alterations in areas designed to lower the TILE level and increase the payment.
   2. (2) Within a 30-day compliance period, facilities must complete new assessment forms on all recipients not in the original review. Facilities may not submit forms to NHIC electronically or by mail.
   3. (3) If a facility has a 20% or greater error rate by the end of the compliance period, vendor payments to the facility will be held until the facility has less than a 20% error rate.
   4. (4) The facility nurse assessor and the director of nurses must attend a DHS TILE training course within 60 days of the beginning of the compliance period.

Source Note:The provisions of this §371.214 adopted to be effective July 1, 1996, 21 TexReg 4408; amended 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.