Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule sets forth application procedures
and general certification requirements for nursing facilities certified under
the Title XIX (Medicaid) program and skilled nursing facilities under Title
XVIII (Medicare), and procedures to be followed by nursing facilities when
requesting a nurse staffing waiver.
PUBLISHER'S NOTE: The secretary of state has
determined that the publication of the entire text of the material which is
incorporated by reference as a portion of this rule would be unduly cumbersome
or expensive. This material as incorporated by reference in this rule shall be
maintained by the agency at its headquarters and shall be made available to the
public for inspection and copying at no more than the actual cost of
reproduction. This note applies only to the reference material. The entire text
of the rule is printed here.
(1) Definitions.
(A) Certification shall mean the
determination by the Missouri Department of Health and Senior Services, or the
Centers for Medicare and Medicaid Services, that a licensed skilled nursing or
intermediate care facility (SNF/ICF) licensed under Chapter 198, RSMo, or an
ICF for person with mental retardation (ICF/MR), is in substantial compliance
with all federal requirements and is approved to participate in the Medicaid or
Medicare programs.
(B) CMS shall
mean the Centers for Medicare and Medicaid Services of the U.S. Department of
Health and Human Services.
(C) Cost
reporting year shall mean the facility's twelve (12)-month fiscal reporting
period covering the same twelve (12)-month period that the facility uses for
its federal income tax reporting.
(D) Distinct part shall mean a portion of an
institution or institutional complex that is certified to provide SNF or NF
services. A distinct part must be physically distinguishable from the larger
institution and must consist of all beds within the designated area. The
distinct part may be a separate building, floor, wing, ward, hallway or several
rooms at one end of a hall or one side of a corridor.
(E) Department shall mean the Missouri
Department of Health and Senior Services.
(F) ICF/MR shall mean intermediate care
facility for persons with mental retardation.
(G) Medicaid shall mean Title XIX of the
federal Social Security Act.
(H)
Medicare shall mean Title XVIII of the federal Social Security Act.
(I) Nursing facility (NF) shall mean an SNF
or ICF licensed under Chapter 198, RSMo which has signed an agreement with the
Department of Social Services to participate in the Medicaid program and which
is certified by the department. As used within the contents of this rule,
licensed SNFs, SNF/ICF and ICFs participating in the Medicaid program are
subject to state and federal laws and regulations for participation as an N
F.
(J) Section for Long Term Care
(SLTC) shall mean that section of the department responsible for licensing and
regulating long-term care facilities licensed under Chapter 198,
RSMo.
(K) Skilled nursing facility
(SNF) shall mean an SNF licensed under Chapter 198, RSMo which has a signed
agreement with the CMS to participate in the Medicare program and which has
been recommended for certification by the department.
(L) Title XVIII shall mean the Medicare
program as provided for in the federal Social Security Act.
(M) Title XIX shall mean the Medicaid program
as provided for in the federal Social Security Act.
(2) An operator of an SNF or ICF licensed by
the department electing to be certified as a provider of skilled nursing
services under the Title XVIII (Medicare) or NF services under the Title XIX
(Medicaid) program of the Social Security Act; or an operator of a facility
electing to be certified as an ICF/MR facility under Title XIX shall submit
application materials to the department as required by federal law and shall
comply with standards set forth in the Code of Federal
Regulations (CFR) of the United States Department of Health and Human
Services in 42 CFR chapter I V, part 483, subpart B for nursing homes and 42
CFR chapter IV, part 483, subpart I for ICF/MR facilities, as appropriate.
(A) For Medicaid, the application shall
include:
1. Long Term Care Facility
Application for Medicare and Medicaid, Form CMS-671 (12/02), incorporated by
reference in this rule and available through the Centers for Medicare and
Medicaid website: http://www.cms.hhs.gov/forms/ [File Link Not Available], or
by mail at: Centers for Medicare and Medicaid Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850;
2. Form DA-113, Bed Classification for
Licensure and Certification by Category (8-05), incorporated by reference in
this rule and available through the department's website:
www.dhss.mo.gov, or by mail at:
Department of Health and Senior Services Warehouse, Attention General Services
Warehouse, PO Box 570, Jefferson City, MO 65102-0570, telephone: (573)
526-3861.
(B) For
Medicare, the application shall include:
1.
Long Term Care Facility Application for Medicare and Medicaid;
2. Expression of Intermediary Preference Form
(8-05), incorporated by reference in this rule and avail-able through the
department's website:
www.dhss.mo.gov, or by mail at: Department
of Health and Senior Services Warehouse, Attention General Services Warehouse,
PO Box 570, Jefferson City, MO 65102-0570, telephone: (573) 526-3861;
3. Form DA-113, Bed Classification for
Licensure and Certification by Category;
4. Three (3) copies of Health Insurance
Benefit Agreement, Form CMS-1561 (07/01), incorporated by reference in this
rule and available through the Centers for Medicare and Medicaid website:
http://www.cms.hhs.gov/forms/ [File Link Not Available], or by mail at: Centers
for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD
21244-1850;
5. Three (3) copies of
Assurance of Compliance, Form HHS-690 (5/97), incorporated by reference in this
rule and available through the Centers for Medicare and Medicaid website:
http://www.cms.hhs.gov/forms [File Link Not Available], or by mail at the U.S.
Department of Health and Human Services, 200 Independence Avenue, SW,
Washington, DC 20201, telephone: (202) 619-0257; Toll Free: 1 (877)
696-6775.
6. The forms incorporated
by reference in subsections (2)(A) and (B) do not include any later amendments
or additions.
(C) SNFs
or NFs which are newly certified or which are undergoing a change of ownership
shall submit an initial certification fee in the amount up to one thousand
dollars ($1,000) as stipulated by the department in writing to the operator
following receipt of the properly completed application material referenced in
section (2). The amount for the initial certification fee shall be the prorated
portion of one thousand dollars ($1,000) with prorating based on the month of
receipt of the application in relation to the beginning of the next federal
fiscal year. This initial certification fee shall be nonrefundable and a
facility shall not be certified until the fee has been paid.
(D) All SNFs or NFs certified to participate
in the Medicaid or Medicare program(s) shall submit to the department an annual
certification fee of one thousand dollars ($1,000) prior to October 1 of each
year. If the fee is not received by that date each year, a late fee of fifty
dollars ($50) per month shall be payable to the department. If payment of any
fees due is not received by the department by the time the facility license
expires or by December 31 of that year, whichever is earlier, the department
shall notify the Division of Medical Services and the CMS recommending
termination of the Medicaid or Medicare agreement as denial of license will
occur as provided in
19 CSR
30-82.010 and section
198.022,
RSMo.
(3) Application
material shall be signed and dated and submitted to the department's SLTC
licensure unit at least fourteen (14) working days prior to the date the
facility is ready to be surveyed for compliance with federal regulations
(Initial Certification Survey). The operator or authorized representative shall
notify the appropriate department regional office by letter or by phone as to
the date the facility will be ready to be surveyed. There shall be at least two
(2) residents in the facility before a survey can be conducted. The facility
shall already be licensed or with licensure in process shall be in compliance
with all state rules.
(4) Any
facility certified for participation as an NF in the Title XIX Medicaid program
electing to participate in the Title XVIII Medicare program shall submit an
application signed and dated by the operator or his or her authorized
representative to the department's SLTC central office licensure unit. The
department will recommend Medicare certification to the CMS effective the date
the application material is received by the department or a subsequent date if
requested by the provider, provided the facility was in compliance with all
federal and state regulations for SNFs at the last survey conducted by the
department and provided the facility's application is complete and has been
approved by the Medicare fiscal intermediary.
(5) Any facility certified for participation
in the Medicare program wishing to participate in the Medicaid program shall
submit a signed and dated application to the department central office. The
department will certify the facility for Medicaid participation effective the
date the application is received by the department or a subsequent date
requested by the provider, provided the facility was in compliance with all
federal regulations at the last survey conducted by the department and the
application is complete.
(6) For
newly certified facilities, the facility will be certified for either Medicare
or Medicaid participation effective the date the facility receives a license at
the proper level or the date the facility achieves substantial compliance with
the federal participation requirements, whichever is the later date. The
application shall be completed. For certification in the Title XVIII (Medicare)
program, the Medicare fiscal intermediary must approve the application and the
CMS must concur with the department's recommendation.
(7) The department shall conduct federal
surveys in SNFs, NFs and ICF/MR facilities, utilizing regulations and
procedures contained in-
(A)
The
State Operations Manual (SOM) (HCFA Publication 7);
(B) The Survey and Certification Regional
letters received by the department from the CMS;
(C) For SNFs and NFs, federal regulation 42
CFR chapter IV, part 483, subpart B; and
(D) For ICF/MR facilities, federal regulation
42 CFR chapter IV, part 483, subpart I.
(8) A facility, in its application, shall
designate the number of beds to be certified and their location in the
facility. A facility can be wholly or partially certified. If partially
certified, the beds shall be in a distinct part of the facility and all beds
shall be contiguous.
(9) If a
facility certified to participate in the Title XIX (Medicaid) or Title XVIII
(Medicare) program elects to change the size of its distinct part, it must
submit a written request to the Licensure/Certification Unit or the ICF/MR Unit
of the department, as applicable. The request shall specify the room numbers
involved, the number of beds in each room and the facility cost reporting year
end date. The request must include a floor diagram of the facility and a signed
DA-113 form, Bed Classification for Licensure and Certification by Category. A
facility is allowed two (2) changes in the size of its distinct part during the
facility cost reporting year. This may be two (2) increases or one (1) increase
and one (1) decrease. It may not be two (2) decreases. The first change can be
done only at the beginning of the facility cost reporting year and the second
change can be done effective at the beginning of a facility cost reporting
quarter within that facility cost reporting year. All requests must be
submitted to the Licensure/Certification Unit or the ICF/MR Unit of the
department at least forty-five (45) days in advance. Any facility wishing to
eliminate its distinct part to go to full certification may do so effective at
the beginning of the next facility cost reporting quarter with forty-five (45)
days notice. The distinct part may be reestablished only at the beginning of
the next facility cost reporting year. A facility may change the location of
the distinct part with thirty (30) days notice to the Licensure/Certification
Unit or the ICF/MR Unit of the department.
(10) If a facility certified to participate
in the Title XIX (Medicaid) or Title XVIII (Medicare) program undergoes a
change of operator, the new operator shall submit an application as specified
in section (2) of this rule. The application shall be submitted within five (5)
working days of the change of operator. For applications made for the Title XIX
(Medicaid) program, the department shall provide the application to the
Division of Medical Services of the Department of Social Services so that a
provider agreement can be negotiated and signed. For applications made for the
Title XVIII (Medicare) program, the department shall provide the application to
the CMS. Certification status will be retained unless or until formally
denied.
(11) If it is determined by
the department that a facility certified to participate in Medicaid or Medicare
does not comply with federal regulations at the time of a federal survey,
complaint investigation or state licensure inspection, the department shall
take enforcement action using the regulations and procedures contained in the
following sources:
(A) 42 CFR chapter IV,
part 431, subparts D, E and F;
(B)
42 CFR chapter I V, part 442;
(C)42
U.S.C. Section 1395i-3;
(D)42
U.S.C. Section 1396(r);
(E)
Sections
198.026
and
198.067,
RSMo; and
(F)
13
CSR 70-10.015 and
13
CSR 70-10.030.
(12) If a facility certified to participate
in the Medicaid Title XIX program has been decertified as a result of
noncompliance with the federal requirements, the facility can be readmitted to
the Medicaid program by submitting an application for initial participation in
the Medicaid program. After having received the application, the department
shall conduct a survey at the earliest possible date to determine if the
facility is in substantial compliance with all federal participation
requirements. The effective date of participation will be the date the facility
is found to substantially comply with all federal requirements.
(13) If a change in the administrator or the
director of nursing of a facility occurs, the facility shall provide written
notice to the department's SLTC central office licensure unit within ten (10)
calendar days of the change. The notice shall show the effective date of the
change, the identity of the new director of nursing or administrator and a copy
of his or her license or the license number. Change of administrator
information shall be submitted as a notarized statement by the operator in
accordance with section
198.018,
RSMo.
(14) An NF may request a
waiver of nurse staffing requirements to the extent the facility is unable to
meet the requirements including the areas of twenty-four (24)-hour licensed
nurse coverage, the use of a registered nurse for eight (8) consecutive hours
seven (7) days per week and the use of a registered nurse as director of
nursing.
(A) Requests for waivers shall be
made in writing to the director of the Section for Long Term Care.
(B) Requests for waivers will be considered
only from facilities licensed under Chapter 198, RSMo as ICFs which do not have
a nursing pool agency that is within fifty (50) miles, within state boundaries,
and which can supply the needed nursing personnel.
(C) The department shall consider each
request for a waiver and shall approve or disapprove the request in writing
postmarked within thirty (30) working days of receipt or, if additional
information is needed, shall request from the facility the additional
information or documentation within ten (10) working days of receipt of the
request.
(D) Approval of a nurse
waiver request shall be based on an evaluation of whether the facility has been
unable, despite diligent efforts-including offering wages at the community
prevailing rate for nursing facilities- to recruit the necessary personnel.
Diligent effort shall mean prominently advertising for the necessary nursing
personnel in a variety of local and out-of-the-area publications, including
newspapers and journals within a fifty (50)-mile radius, and which are within
state boundaries; contacts with nursing schools in the area; and participation
in job fairs. The operator shall submit evidence of the diligent effort
including:
1. Copies of newspapers and
journal advertisements, correspondence with nursing schools and vocational
programs, and any other relevant material;
2. If there is a nursing pool agency within
fifty (50) miles which is within state boundaries and the agency cannot
consistently supply the necessary personnel on a per diem basis to the
facility, the operator shall submit a letter from the agency so
stating;
3. Copies of current
staffing patterns including the number and type of nursing staff on each shift
and the qualifications of licensed nurses;
4. A current Resident Census and Condition of
Residents, Form CMS-672 (10/98), incorporated by reference in this rule and
available through the Centers for Medicare and Medicaid website:
http://www.cms.hhs.gov/forms/ [File Link Not Available], or by mail at: Centers
for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD
21244-1850. This rule does not incorporate any subsequent amendments or
additions;
5. Evidence that the
facility has a registered nurse consultant required under
19
CSR 30-85.042 and evidence that the facility has made
arrangements to assure registered nurse involvement in the coordination of the
assessment process as required under
42 CFR
483.20(3);
6. Location of the nurses' stations and any
other pertinent physical feature information the facility chooses to
provide;
7. Any other information
deemed important by the facility including personnel procedures, promotions,
staff orientation and evaluation, scheduling practices, benefit programs,
utilization of supplemental agency personnel, physician-nurse collaboration,
support services to nursing personnel and the like; and
8. For renewal requests, the information
supplied shall show diligent efforts to recruit appropriate personnel
throughout the prior waiver period. Updates of prior submitted information in
other areas are acceptable.
(E) In order to meet the conditions specified
in federal regulation
42 CFR 483.30,
the following shall be considered in granting approval:
1. There is assurance that a registered nurse
or physician is available to respond immediately to telephone calls from the
facility for periods of time in which licensed nursing services are not
available;
2. There is assurance
that if a facility requesting a waiver has or admits after receiving a waiver
any acutely ill or unstable residents requiring skilled nursing care, the
skilled care shall be provided in accordance with state licensure rule
19
CSR 30-85.042; and
3. The facility has not received a Class I
notice of noncompliance in resident care within one hundred twenty (120) days
of the waiver request or the department has not conducted an extended survey in
the facility within one (1) year of the waiver request. Any facility which
receives a Class I notice of noncompliance in resident care or an extended
survey while under waiver status will not have the waiver renewed unless the
problem has been corrected and steps have been taken to prevent recurrence. If
a facility received more than one (1) Class I notice of noncompliance in
resident care during a waiver period, the department will consider revocation
of the waiver.
(F) The
facility shall cooperate with the department in providing the proper
documentation. For renewal requests, the request and proper documentation shall
be submitted to the department at least forty-five (45) days prior to the
ending date of the current waiver period. If any changes occur during a waiver
period that affect the status of the waiver, a letter shall be submitted to the
deputy director of institutional services within ten (10) days of the changes.
The request for a waiver or renewal of a waiver shall be denied if the facility
fails to abide by these previously mentioned time frames.
(G) If a waiver request is denied, the
department shall notify the facility in writing and within twenty (20) days,
the facility shall submit to the department a written plan for how the facility
will recruit the required personnel. If appropriate personnel are not hired
within two (2) months, the department shall initiate enforcement
proceedings.
*Original authority: 660.050, RSMo 1984, amended 1988,
1992, 1993, 1994, 1995, 2001.
