SECTION 353.1304. Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019  


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  • (a) Introduction. This section establishes the quality metrics that may be used in the Quality Incentive Payment Program (QIPP) for nursing facilities (NFs) on or after September 1, 2019.

    (b) Definitions. The following definitions apply when the terms are used in this section. Terms that are used in this and other sections of this subchapter may be defined in §353.1301 (relating to General Provisions) or §353.1302 (relating to Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019) of this subchapter.

    (1) Baseline--A NF-specific initial standard used as a comparison against NF performance in each metric throughout the eligibility period to determine progress in the QIPP quality metrics. For example, for MDS-based measures, the facility's baselines will be set at the most recently available four-quarter average for each metric.

    (2) Benchmark--A metric-specific initial standard set prior to the start of the eligibility period and used as a comparison against a NF's progress throughout the eligibility period. For example, for MDS-based measures, the benchmarks will be set at the most recently published CMS National Average for each metric.

    (c) Quality metrics. For each eligibility period, HHSC will designate one or more of the following quality metrics for each QIPP capitation rate component.

    (1) Quality assurance and performance improvement (QAPI) meetings. Monthly meetings in which the NF reviews its CMS-compliant plan for maintaining and improving safety and quality in the NF. QAPI meetings must contribute to a NF's ongoing development of improvement initiatives regarding clinical care, quality of life, and consumer choice. For the eligibility period beginning September 1, 2019, QAPI meetings have been designated as the quality metric for Component 1.

    (2) MDS-based measures. Measures listed in CMS' Five-Star Quality Rating System and based on Minimum Data Set (MDS) assessment data. Within the Five-Star Quality Rating System, HHSC can select any MDS-based measure as long as there are viable data sources available for timely calculations related to the measure. For the eligibility period beginning September 1, 2019, the following five MDS-based measures may be used in Components Three and Four:

    (A) high-risk long-stay residents with pressure ulcers;

    (B) percent of residents who received an antipsychotic medication (long-stay);

    (C) percent of residents with decreased independent mobility;

    (D) percent of residents with urinary tract infections; and

    (E) percent of residents appropriately given the pneumonia vaccine.

    (3) Recruitment and retention program. A program that includes a plan developed by the NF to improve recruitment and retention of staff and monitor outcomes related thereto. For the eligibility period beginning September 1, 2019, the recruitment and retention plan will be used in Component Two.

    (4) RN staffing metrics. Registered nurse (RN) hours beyond and non-concurrent with the CMS-mandated eight hours of RN on-site coverage each day. On-site hours must be met by an RN, Advanced Practice Registered Nurse (APRN), Nurse Practitioner (NP), Physician Assistant (PA), or physician (Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)). Telehealth services can be used to meet some or all of the RN staffing metrics when a NF has telehealth policies and procedures developed in accordance with subsection (g) of this section. For the eligibility period beginning September 1, 2019, the following two RN staffing metrics will be used in Component Two:

    (A) four hours of additional RN coverage per day; and

    (B) eight hours of additional RN coverage per day. A NF that meets the eight hours of additional RN coverage per day will automatically qualify for the metric described in subparagraph (A) of this paragraph.

    (5) Infection control program. A program that improves antibiotic stewardship and measures outcomes through the use of infection control and data elements. For the eligibility period beginning September 1, 2019, the infection control program will be used in Component Four, and the program will consist of the following infection control and data elements:

    (A) whether a facility:

    (i) has identified leadership individuals for antibiotic stewardship;

    (ii) has created written policies on antibiotic prescribing;

    (iii) has an antibiotic use report generated by a pharmacy within last 6 months;

    (iv) audits (monitors and documents) adherence to hand hygiene (HH);

    (v) audits (monitors and documents) adherence to personal protective equipment (PPE) use;

    (vi) has an infection control coordinator who has received infection control training;

    (vii) has infection prevention policies that are evidence-based and reviewed at least annually;

    (viii) has a current list of reportable diseases;

    (ix) knows points of contact at local or state health departments for assistance;

    (B) the number of:

    (i) vaccines administered to residents and employees;

    (ii) residents with facility acquired Clostridium difficile diagnosis;

    (iii) residents on antibiotic medications;

    (iv) residents with multi-drug resistant organisms; and

    (C) select infection rates.

    (6) Other metrics related to improving the quality of care for Texas Medicaid NF residents. HHSC may develop additional metrics for inclusion in QIPP if there is a specific systemic data-supported quality concern impacting Texas Medicaid NF residents. Any metric developed for inclusion in QIPP will be evidence-based and will be presented to the public for comment in accordance with subsection (e) of this section.

    (d) Performance requirements. For each eligibility period, HHSC will specify the performance requirement that will be associated with the designated quality metric. Achievement of performance requirements will trigger payments for the QIPP capitation rate components as described in §353.1302 of this subchapter. For some quality metrics, achievement is tested merely on a met versus unmet basis. Other metrics require a certain level of improvement, such as reaching a quarterly percentage goal. The following performance requirements are associated with the quality metrics described in subsection (c) of this section.

    (1) QAPI meetings. Each month, a NF must attest on a form designated by HHSC that it convened a QAPI meeting. The NF must submit the form to HHSC by the first business day following the end of the month. Each quarter, HHSC will validate a random sample of the attestation forms. The NF that submitted the attestation form must provide the supporting documentation stated in the attestation form.

    (2) MDS-based measures. A NF must show a five percent relative improvement on a quarterly basis over the baseline or exceed the benchmark for the selected measure.

    (A) Baseline improvement is measured against quarterly targets determined by HHSC prior to the eligibility period.

    (B) A NF that exceeds the benchmark for a measure qualifies for the payment from any related component. A NF that exceeds the benchmark may decline in performance and still qualify for a payment from the related component as long as the NF continues to exceed the benchmark for the measure.

    (3) Recruitment and retention program. During the first month of the eligibility period, a NF must submit its recruitment and retention plan to HHSC. If substantive changes are made to the recruitment and retention plan, an update of the plan must be submitted to HHSC during the month in which the changes take effect.

    (A) Failure to submit the recruitment and retention plan in the first month of the eligibility period will result in not meeting the metric for that month for the related component.

    (B) Each subsequent month, a NF will submit to HHSC documentation produced during the development of self-direct staffing goals and in the monitoring of staffing outcomes, in accordance with the NF's recruitment and retention plan.

    (C) Each quarter, HHSC will validate a random sample of recruitment and retention plans and outcome monitoring documentation. The NF that submitted the plan must provide supporting documentation, including policies and outcomes.

    (4) RN staffing metrics. A NF meets the RN staffing metrics by showing that the facility was staffed at the required number of hours for at least 90 percent of the days in the reporting period.

    (5) Infection control program. Each quarter, a NF must report:

    (A) the presence of a number of infection control elements to exceed a quarterly benchmark. For the eligibility period beginning September 1, 2019, the NF must report the presence of seven of the nine elements in subsection (c)(5)(A) of this section to meet the metric; and

    (B) all required data elements regarding infection control tracking in subsection (c)(5)(B) and (C) of this section.

    (6) Other metrics related to improving the quality of care for Texas Medicaid NF residents. If HHSC develops additional metrics for inclusion in QIPP, the associated performance requirements will be presented to the public for comment in accordance with subsection (e) of this section.

    (e) Notice and hearing.

    (1) HHSC will publish notice of the proposed metrics and their associated performance requirements no later than December 31 of the calendar year that precedes the first month of the eligibility period. The notice must be published either by publication on HHSC's Internet web site or in the Texas Register. The notice required under this section will include the following:

    (A) instructions for interested parties to submit written comments to the HHSC regarding the proposed metrics and performance requirements; and

    (B) the date, time, and location of a public hearing.

    (2) Written comments will be accepted within 15 business days of publication. There will also be a public hearing within that 15-day period to allow interested persons to present comments on the proposed metrics and performance requirements.

    (f) Final quality metrics and performance requirements will be provided through the QIPP webpage on HHSC's website on or before February 1 of the calendar year that also contains the first month of the eligibility period.

    (g) Telehealth. In order for a NF to use telehealth services to meet some or all of the RN staffing metric, the following requirements must be met:

    (1) the telehealth services must be both audio and visual in nature;

    (2) the telehealth services must be provided by an RN, APRN, NP, PA, or physician (MD or DO); and

    (3) The NF must have policies and procedures for such services. The NF's policy must include the following:

    (A) how the NF arranges telehealth services;

    (B) how the NF trains staff regarding the availability of services, implementation of services, and expectations for the use of these services; and

    (C) how the NF documents telehealth services including initiation of services, the services provided, and the outcome of services.

Source Note: The provisions of this §353.1304 adopted to be effective December 30, 2018, 43 TexReg 8079