Section 147.175  Minimum Data Set (MDS) Integrity

a)         The Department shall conduct reviews to determine the accuracy of resident assessment information transmitted in the Minimum Data Set (MDS) that are relevant to the determination of reimbursement rates.  Such reviews may, at the discretion of the Department, be conducted electronically or in the facility.

b)         The Department shall quarterly select, at random, a number of facilities in which to conduct on-site reviews.  The Department may select facilities for on-site review based upon facility characteristics, past performance, or the Department's experience.  This may include, but is not limited to, analysis of case mix profile of nursing facilities in regard to frequency in distribution of the residents in identified reimbursement categories.  In addition, the Department may use findings of the licensing and certification survey conducted by IDPH indicating the facility is not accurately assessing residents.  It may also include resident assessments submitted by the provider that do not meet submission deadlines, facilities with a high percentage of corrections and facilities with high submission error rates.

c)         Electronic review.  The Department shall conduct quarterly an electronic review of MDS data for eligible individuals to identify facilities for on-site review.

d)         On-site review.  The Department shall conduct an on-site review of MDS data for eligible individuals.

1)         On-site reviews may be conducted with respect to residents or facilities that are identified pursuant to subsection (b) or (c) of this Section. Such review may include, but shall not be limited to, the following:

A)        Review of resident records and supporting documentation, as identified in Section 147.200, observation and interview, to determine the accuracy of data relevant to the determination of reimbursement rates.

B)        Review and collection of information necessary to assess the need for a specific service or care area.

C)        Review and collection of information from the facility that will establish the direct care staffing level.  The amount of staff available in the facility shall be sufficient to carry out the number and frequency of restorative programs identified for reimbursement.

2)         The number of residents in any selected facility for whom information is reviewed may, at the sole discretion of the Department, be limited or expanded.

3)         Upon the conclusion of any review, the Department shall conduct a meeting with facility management to discuss preliminary conclusions of the review.  If facility management disagrees with those preliminary conclusions, facility management may, at that time, provide additional documentation to support their position.

e)         Corrective action.  Upon the conclusion of the review and the consideration of any subsequent supporting documentation provided by the facility, the Department shall notify the facility of its final conclusions, both with respect to accuracy of data and recalculation of the facility's reimbursement rate.

1)         Data Accuracy

A)        Final conclusions with respect to inaccurate data shall be referred to the Department of Public Health.

B)        The Department, in collaboration with the Department of Public Health, shall make available additional training in the completion of resident assessments and the coding and transmission of MDS records.

2)         Recalculation of Reimbursement Rate.  The Department shall determine if reported MDS data or facility staffing data that were subsequently determined to be unverifiable would cause the direct care component of the facility's rate to be calculated differently when using the accurate data.  No change in reimbursement required as a result of a review shall take effect before July 1, 2004.  Prior to the record review of residents receiving skills training, the following components of this Part will be reviewed to ensure compliance:

A)        Skills training shall be provided by staff that are paid by the facility and have been trained in leading skills groups by a Department approved trainer.

B)        A private room shall be available with no other programs or activities going on at the same time.  The environment shall be conducive to learning in terms of comfort, noise, and other distractions.

C)        Schedules shall be presented that identify residents and reflect the facility's ability to provide the sessions in increments of a minimum of 30 minutes for each skills training (not including time to assemble and settle).  The sessions shall be scheduled at least three times per week.

D)        Training shall utilize a well-developed, structured curriculum and specific written content developed in advance to guide each of the sessions.

3)         In the event one or more of these components are not in place, the recalculated rate may be extrapolated to the entire population receiving this service.

4)         When problems are noted in 30 percent of the population of residents receiving skills training during the record review, the recalculated rate may be extrapolated to the entire population receiving this service.  When the recalculated rate has been extrapolated to the entire population, the facility shall obtain prior approval from the Department before future reimbursement for skills training is allowable.  The Department shall have up to 90 days to determine this approval.

5)         When problems are noted in 30 percent of coded responses to the sample population for other services areas, the review may be expanded to up to 100 percent for those service areas.  The original sample population is defined as 20%, or no less than 10, of the eligible residents pursuant to Section 147.150(b). 

6)         In addition, the facilities with widespread problems in restorative and psychosocial adaptation may be subject to follow up reviews to ensure problems are corrected.

7)         A facility's rate will be subject to change if the recalculation of the direct care component rate, as a result of using MDS data that are verifiable:

A)        Increases the rate by more than one percent.  The rate is to be changed, retroactive to the beginning of the rate period, to the recalculated rate.

B)        Decreases the rate by more than one percent.  The rate is to be changed, retroactive to the beginning of the rate period, to the recalculated rate.

C)        Decreases the rate by more than ten percent in addition to the rate change specified in this subsection (e)(7).  The direct care component of the rate shall be reduced, retroactive to the beginning of the rate period, by $1 for each whole percentage decrease in excess of two percent.

8)         Any evidence or suspicion of deliberate falsification or misrepresentation of MDS data shall be referred to the Department's Inspector General and the Department of Public Health.

f)          Appeals.  Facilities disputing any rate change may submit an appeal request pursuant to 89 Ill. Adm. Code 140.830.

(Source:  Amended at 32 Ill. Reg. 8614, effective May 29, 2008)