1. (a) Nursing facility nurse assessors assess recipients for TILE determination by completing Texas Nursing Facility Client Assessment, Review, and Evaluation (CARE) forms. The nursing facility and hospice nurse assessors assess hospice recipients who are residing in nursing facilities for TILE determination by completing the Texas Nursing Facility CARE forms. Hospice recipients residing in nursing facilities must have all eligibility forms submitted prior to Texas Department of Human Services (DHS) paying nursing facility room and board to the hospice provider. These assessments establish TILE classifications as described in paragraphs (1)-(8) of this subsection. Nursing facility nurse assessors must complete and pass the Texas Health and Human Services Commission (Commission) TILE training course with a minimum score of 70%. The nurse's license number will be registered with the National Heritage Insurance Company (NHIC). Hospice nurse assessors may complete the Commission's Texas TILE training course.

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

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

      1. (A) If the nursing facility resident has not previously attained a permanent medical necessity or if an individual is simultaneously admitted to a nursing facility as a hospice recipient, the nurse assessor submits an admission assessment within 20 calendar days of admission, as provided in the Texas Administrative Code (TAC), Title 40, Part 1, Chapter 19, Subchapter Y, §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 nursing facility 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 changes to the extent that he qualifies for a different TILE, an off-cycle assessment may be submitted. If a nursing facility resident becomes a hospice recipient, an off-cycle assessment must be submitted. Only two off-cycle assessments for any one nursing facility resident or hospice recipient residing in a nursing facility are permitted per calendar year, one from January through June and one from July through December. The off-cycle assessment for a nursing facility resident that becomes a hospice recipient is not included in the two allowable off-cycle assessments. The assessment sets a new schedule for submission of forms if permanent MN has been achieved. Before 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 correcting 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. The Commission 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 that indicates that the recipient might benefit from specialized services, a 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 as provided in TAC, Title 40, Part 1, Chapter 19, Subchapter Y, §19.2413 (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 as provided in TAC, Title 40, Part 1, Chapter 19, Subchapter Y, §19.2408 (relating to Retroactive Medical Necessity Determinations).
      3. (C) The effective date for a retroactive payment for a hospice recipient may not be prior to June 1, 2001.
2. (b) Nursing facilities with new directors of nurses, nurse managers and nurse assessors may request a one time 60-day waiver to complete the TILE assessments. At the end of the 60-day waiver period, the nursing facility director of nurses, nurse manager and nurse assessor must complete and pass the Commission TILE training course with a minimum score of 70%. The Commission assumes cost for the initial TILE training course. The facility or individual shall assume the cost of any additional required training and testing for the same individual.

3. (c) Review and appeal of case-mix assessments. Commission nurse reviewers conduct desk reviews and in-depth, on-site reviews of Texas Nursing Facility CARE forms completed by nursing facility and hospice staff to verify TILE and medical necessity information. The assessment forms and the entire medical record of a minimum of ten Medicaid recipients, excluding TILE 211, will be reviewed. Forms expired over 12 months will not be reviewed.

   1. (1) Commission nurse reviewers will notify nursing facilities and hospice providers a minimum of two working days prior to routine on-site visits. They will be given information regarding the recipients whose medical records will be reviewed, the time period covered by the review and the accommodations necessary for the review. No notice is required for facilities whose last two on-site visits resulted in corrective action; visits for investigation of TILE issues, including suspected fraud; or visits requested by another state agency. For routine onsite visits, nurse reviewers must be given prompt access to information and resources necessary to conduct the TILE review. Failure to do so may result in the nursing facility being classified in the Default TILE 212 until the visit can be conducted. Once the visit is conducted and the facility demonstrates the medical necessity of a higher TILE classification, the default TILE 212 will be released retroactive to the date of the event that prompted the default. A default TILE will not be applied in the event of unforeseen environmental conditions.

   2. (2) When a Commission nurse reviewer determines that the TILE classification is not substantiated and/or does not accurately reflect the recipient's status, the reviewer will discuss the error and give the provider an opportunity to submit additional documentation to support the item claimed. An exit conference is held with the nursing facility staff following the review. Hospice staff may attend if hospice recipients are reviewed. Additional documentation, staff interviews and nursing observation to support nursing facility resident and hospice recipient assessments may be presented at any time during the review process or the exit conference, and adjustments may be made. The nursing facility administrator and hospice provider are given formal notification of all TILE changes within 15 working days of the exit conference.

      1. (A) At the direction of the Commission, DHS recoups funds previously paid to the nursing facility and/or hospice provider under incorrect TILE classification. At the direction of the Commission, DHS pays the nursing facility and/or the hospice provider 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. (3) If a Commission nurse reviewer and a facility or hospice nurse assessor are unable to agree about an assessment, either provider may submit a reconsideration request to the Commission's state office nurse specialist.

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

   4. (4) If the provider disagrees with the findings of the state office nurse specialist, the provider may initiate a formal appeal, as stated in Title 40, Chapter 79, Subchapter Q (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 state office nurse specialist remain in effect during the formal contract appeal.
      2. (B) If the contract appeal process establishes that the Commission has changed a TILE classification in error, the Commission will direct DHS to correct the error retroactively.

4. (d) TILE error rates on the assessment forms reviewed which exceed 20% may result in a facility's undergoing a monitoring period.

   1. (1) During the monitoring period, nursing facilities may not submit Texas Nursing Facility CARE forms to NHIC either electronically or by mail. All Texas Nursing Facility CARE forms, which include both nursing facility residents and hospice recipients residing in nursing facilities, must be submitted to the Commission nurse reviewers.
   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, the Commission 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, the Commission places the facility on compliance.

5. (e) Compliance may result when a facility has a 20% or greater error rate on the current assessment forms reviewed and one of the following: a 20% or greater error rate by the end of a monitoring period; lack of documentation regarding key assessment items; a history of noncompliance; or medical records that contain alterations in areas designed to lower the TILE level and increase the payment.

   1. (1) Within a 30 to 45-day compliance period, facilities must complete new Texas Nursing Facility CARE forms on all recipients not in the original review.
   2. (2) During the compliance period, facilities may not submit Texas Nursing Facility CARE forms to NHIC either electronically or by mail. All Texas Nursing Facility CARE forms, which include both nursing facility residents and hospice recipients residing in nursing facilities, must be submitted to Commission nurse reviewers.
6. (f) If a facility has a 20% or greater error rate by the end of the compliance period, the Commission will direct DHS to hold vendor payments to the facility until the facility has less than a 20% error rate. A decision to place a facility on vendor hold will be made by UR staff in state office.
7. (g) The nursing facility nurse assessor and the director of nurses must complete and pass the Commission TILE training course with a minimum score of 70% within 60 days of the beginning of the compliance period or vendor hold. If a score of 70% or higher is not achieved by the director of nurses or facility nurse assessor, the nursing facility will remain on corrective action until such time as the acceptable score of 70% is achieved.

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; amended to be effective July 15, 2001, 26 TexReg 4989.