SECTION 353.610. Minimum Performance Standards for Nursing Facilities that Participate in the STAR+PLUS Program

(a) Purpose. The purpose of this section is to establish minimum performance standards applicable to nursing facility providers that participate in the STAR+PLUS program.

(b) Definitions. The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise:

(1) CMS--Centers for Medicare & Medicaid Services. The federal agency responsible for administering Medicare and overseeing state administration of Medicaid.

(2) Corrective actions--Actions taken for the purpose of correcting undesirable clinical performance; may also be called a corrective action plan or a performance improvement plan (PIP).

(3) HHSC--The Texas Health and Human Services Commission or its designee.

(4) Long stay quality measure--The CMS long stay quality measure specifications are based on nursing home (NH) residents whose episode is greater than or equal to 101 cumulative days in the NH at the end of the target period.

(5) MDS--Minimum data set. A federally mandated standardized clinical assessment of all residents in certified nursing facilities.

(6) Minimum performance standards--Standards applicable to a nursing facility that participates in the STAR+PLUS program that represent the minimal clinical performance expected, based on evidence-based guidelines and analysis.

(7) Nursing facility--A convalescent or nursing home or related institution licensed under Health and Safety Code Chapter 242, that provides long-term services and supports to recipients and that participates in the STAR+PLUS program.

(8) STAR+PLUS Managed Care Organization--An organization under contract with HHSC to manage delivery of Medicaid services to members in the STAR+PLUS program.

(9) STAR+PLUS Program--This term has the meaning set forth in §354.4003 of the title (relating to Definitions).

(c) HHSC establishment and monitoring of minimum performance standards.

(1) HHSC establishes the following CMS nursing facility long stay quality measures from the MDS and associated HHSC benchmarks as the minimum performance standards for evaluating the performance of a nursing facility:

(A) N028.02 Percent of residents whose need for help with activities of daily living has increased. The benchmark is 30%. Nursing facilities do not meet the benchmark if HHSC determines that more than 30% of residents have an increased need for help with activities of daily living.

(B) N015.03 Percent of high-risk residents with pressure ulcers. The benchmark is 17%. Nursing facilities do not meet the benchmark if HHSC determines that more than 17% of high-risk residents have pressure ulcers.

(C) N016.03 Percent of residents assessed and appropriately given the seasonal influenza vaccine. The benchmark is 77%. Nursing facilities do not meet the benchmark if HHSC determines that less than 77% of residents were assessed and appropriately given the seasonal influenza vaccine.

(D) N020.02 Percent of residents assessed and appropriately given the pneumococcal vaccine. The benchmark is 80%. Nursing facilities do not meet the benchmark if HHSC determines that less than 80% of residents were assessed and appropriately given the pneumococcal vaccine.

(E) N035.03 Percent of residents whose ability to move independently worsened. The benchmark is 31%. Nursing facilities do not meet the benchmark if HHSC determines that more than 31% of residents have a worsened ability to move independently.

(2) HHSC compares the performance of a nursing facility on each of the minimum performance standard measures listed in paragraph (1) of this subsection to the associated HHSC benchmarks to determine if a facility meets or does not meet the required minimum performance standards.

(3) HHSC makes the minimum performance standard measures and the associated HHSC benchmarks available on the HHSC website.

(4) HHSC monitors the performance of a nursing facility on an annual basis in accordance with the minimum performance standard measures and the associated HHSC benchmarks.

(5) HHSC may require a nursing facility that does not meet the minimum performance standard benchmarks to take corrective actions.

(6) HHSC monitors a nursing facility that has been required to initiate corrective actions in accordance with the minimum performance standard measures and the associated HHSC benchmarks and follows up with the nursing facility regarding its performance, as appropriate.

(d) HHSC coordination with Medicaid Managed Care Organizations (MCOs).

(1) HHSC shares minimum performance standards data results with STAR+PLUS MCOs, as appropriate.

(2) STAR+PLUS MCOs may act on the data, as appropriate.

Source Note: The provisions of this §353.610 adopted to be effective June 1, 2023, 48 TexReg 2693