Oregon Department of Human Services, Aging and People with Disabilities and Developmental Disabilities

Rule Rule 411-070-0005
Definitions


Unless the context indicates otherwise, the following definitions and the definitions in OAR 411-085-0005 (Definitions) apply to the rules in OAR chapter 411, division 070:

(1)

“Accrual Method of Accounting” means a method of accounting where revenues are reported in the period they are earned, regardless of when they are collected, and expenses are reported in the period they are incurred, regardless of when they are paid.

(2)

“Active Treatment” means the implementation of an individualized care plan developed under and supervised by a physician and other qualified mental health professionals that prescribes specific therapies and activities.

(3)

“Activities of Daily Living” means activities usually performed in the course of a normal day in an individual’s life such as eating, dressing, grooming, bathing, personal hygiene, mobility (ambulation and transfer), elimination (toileting, bowel, and bladder management), and cognition and behavior.

(4)

“Aging and People with Disabilities (APD)” means the program area of Aging and People with Disabilities, within the Department of Human Services.

(5)

“Alternative Services” mean individuals or organizations offering services to persons living in a community other than a nursing facility or hospital.

(6)

“Area Agency on Aging (AAA)” means the Department of Human Services designated agency charged with the responsibility to provide a comprehensive and coordinated system of services to seniors and individuals with disabilities in a planning and service area. For the purpose of these rules, the term Area Agency on Aging is inclusive of both Type A and Type B Area Agencies on Aging as defined in ORS 410.040 (Definitions for ORS 410.040 to 410.300, 410.320 and 410.619) and described in ORS 410.210 (Area agency advisory councils) to 410.300 (Transfer of state employees to type B agency).

(7)

“Augmented Rate” means the additional compensation to a nursing facility who qualifies for the Quality and Efficiency Incentive Program described in OAR 411-070-0437 (Quality and Efficiency Incentive Program). The augmented rate is a daily rate of $9.75 and is in addition to the rate a nursing facility would otherwise receive. The Department may pay the augmented rate to a qualifying facility for a period not to exceed four years from the date the facility purchases bed capacity under the Quality and Efficiency Incentive Program.

(8)

“Bariatric rate” means a rate paid for a Medicaid resident of a nursing facility if the resident meets the criteria described in OAR 411-070-0087 (Bariatric Criteria and Services).

(9)

“Basic Flat Rate Payment” and “Basic Rate” means the statewide standard payment rate for all long-term services provided to a Medicaid resident of a nursing facility, except for services reimbursed through another Medicaid payment source. The “Basic Rate” is the bundled payment rate, unless the resident qualifies for the complex medical rate, the ventilator assisted program rate, the bundled pediatric rate or the bariatric rate (instead of the basic rate).

(10)

“Bi-PAP” means bi-level positive airway pressure/spontaneous timed.

(11)

“Behavioral Health” means the program within the Health Systems Division (HSD) within the Oregon Health Authority (OHA), responsible for addictions and mental health services.

(12)

“Capacity” means licensed nursing beds multiplied by number of days in operation.

(13)

“Case Manager” means a Department of Human Services or Area Agency on Aging employee who assesses the service needs of an applicant, determines eligibility, and offers service choices to the eligible individual. The case manager authorizes and implements the service plan and monitors the services delivered.

(14)

“Cash Method of Accounting” means a method of accounting where revenues are recognized only when cash is received, and expenditures for expense and asset items are not recorded until cash is disbursed for them.

(15)

“Categorical Determinations” mean the provisions in the Code of Federal Regulations (42 CFR 483.130) for creating categories that describe certain diagnoses, severity of illness, or the need for a particular service that clearly indicates that admission to a nursing facility is normally needed or that the provision of specialized services is not normally needed.

(a)

Membership in a category may be made by the evaluator only if existing data on the individual is current, accurate, and of sufficient scope.

(b)

An individual with mental illness or developmental disabilities may enter a nursing facility without a PASRR Level II evaluation if criteria of a categorical determination are met as described in OAR 411-070-0043 (Pre-Admission Screening and Resident Review (PASRR))(2)(a) - (2)(c).

(16)

“Certification” and “Certification for the Categorical Determination of Exempted Hospital Discharge” means the attending physician has written orders for the individual to receive skilled services at the nursing facility.

(17)

“Certified Program” means a hospital, private agency, or an Area Agency on Aging certified by the Department of Human Services to conduct private admission assessments in accordance with ORS 410.505 (Definitions for ORS 410.505 to 410.545) through 410.530 (Department authority).

(18)

“Change of Ownership” means a change in the individual or legal organization that is responsible for the operation of a nursing facility. Change of ownership does not include changes in personnel, e.g., a change of administrators. Events that change ownership include, but are not limited to, the following:

(a)

The form of legal organization of the owner is changed (e.g., a sole proprietor forms a partnership or corporation);

(b)

The title to the nursing facility enterprise is transferred to another party;

(c)

The nursing facility enterprise is leased or an existing lease is terminated;

(d)

Where the owner is a partnership, any event occurs which dissolves the partnership;

(e)

Where the owner is a corporation, it is dissolved, merges with another corporation that is the survivor, or consolidates with one or more other corporations to form a new corporation; or

(f)

The facility changes management via a management contract.

(19)

“Compensation” means the total of all benefits and remuneration, exclusive of payroll taxes and regardless of the form, provided to or claimed by an owner, administrator, or other employee. Compensation includes, but is not limited to:

(a)

Salaries paid or accrued;

(b)

Supplies and services provided for personal use;

(c)

Compensation paid by the facility to employees for the sole benefit of the owner;

(d)

Fees for consultants, directors, or any other fees paid regardless of the label;

(e)

Key man life insurance;

(f)

Living expenses, including those paid for related persons; or

(g)

Gifts for employees in excess of federal Internal Revenue Service reporting guidelines.

(20)

“Complex Medical Payment” and “Complex Medical” means the statewide standard supplemental payment rate for a Medicaid resident of a nursing facility whose service is reimbursed at the basic rate if the resident needs one or more of the medication procedures, treatment procedures, or rehabilitation services listed in OAR 411-070-0091 (Complex Medical Add-On Services), for the additional licensed nursing services needed to meet the resident’s increased needs.

(21)

“Continuous” means more than once per day, seven days per week. Exception: If only skilled rehabilitative services and no skilled nursing services are required, “continuous” means at least once per day, five days per week.

(22)

“Costs Not Related to Resident Services” means costs that are not appropriate or necessary and proper in developing and maintaining the operation of a nursing facility. Such costs are not allowable in computing reimbursable costs. Costs not related to resident services include, for example, cost of meals sold to visitors, cost of drugs sold to individuals who are not residents, cost of operation of a gift shop, and similar items.

(23)

“Costs Related to Resident Services” mean all necessary costs incurred in furnishing nursing facility services, subject to the specific provisions and limitations set out in these rules. Examples of costs related to resident services include nursing costs, administrative costs, costs of employee pension plans, and interest expenses.

(24)

“CPAP” means continuous positive airway pressure.

(25)

“CPI” means the consumer price index for all items and all urban consumers.

(26)

“Day of Admission” means an individual being admitted, determined as of 12:01 a.m. of each day, for all days in the calendar period for which an assessment is being reported and paid. If an individual is admitted and discharged on the same day, the individual is deemed present on 12:01 a.m. of that day.

(27)

“Department” means the Department of Human Services (DHS).

(28)

“Developmental Disability” means “developmental disability” as defined in OAR 411-320-0020 (Definitions and Acronyms) and described in OAR 411-320-0080 (Application and Eligibility Determination).

(29)

“Direct Costs” mean costs incurred to provide services required to directly meet all the resident nursing and activity of daily living service needs. Direct costs are further defined in OAR 411-070-0359 (Allowable Costs) and OAR 411-070-0465 (Uniform Chart of Accounts). Examples: The person who feeds food to the resident is directly meeting the resident’s needs, but the person who cooks the food is not. The person who is trained to meet the resident’s needs incurs direct costs whereas the person providing the training is not. Costs for items that are capitalized or depreciated are excluded from this definition.

(30)

“DRI Index” means the “HCFA or CMS Nursing Home Without Capital Market Basket” index, which is published quarterly by DRI/McGraw - Hill in the publication, “Global Insight Health Care Cost Review”.

(31)

“Essential Nursing Facility” means a nursing facility that serves predominantly rural and frontier communities as designated by the Office of Rural Health that is located more than 32 miles from another nursing facility or from a hospital that has received a formal notice of Critical Access Hospital (CAH) designation from the Centers for Medicare and Medicaid Services and that is currently contracted to provide swing bed services for Medicaid-eligible individuals.

(32)

“Exempted Hospital Discharge” for PASRR means an individual seeking temporary admission to a nursing facility from a hospital as described in OAR 411-070-0043 (Pre-Admission Screening and Resident Review (PASRR))(2)(a).

(33)

“Facility” or “Nursing Facility” means an establishment that is licensed and certified by the Department of Human Services as a nursing facility. A nursing facility also means a Medicaid certified nursing facility only if identified as such.

(34)

“Fair Market Value” means the price for which an asset would have been purchased on the date of acquisition in an arms-length transaction between a well-informed buyer and seller, neither being under any compulsion to buy or sell.

(35)

“Generally Accepted Accounting Principles” mean the accounting principles approved by the American Institute of Certified Public Accountants.

(36)

“Goodwill” means the excess of the price paid for a business over the fair market value of all other identifiable, tangible, and intangible assets acquired, or the excess of the price paid for an asset over its fair market value.

(37)

“Health Systems Division (HSD)” means a Division, within the Oregon Health Authority, responsible for coordinating the medical assistance programs within the State of Oregon including, but not limited to the Oregon Health Plan Medicaid demonstration and the State Children’s Health Insurance Program.

(38)

“Historical Cost” means the actual cost incurred in acquiring and preparing a fixed asset for use. Historical cost includes such planning costs as feasibility studies, architects’ fees, and engineering studies. Historical cost does not include “start-up costs” as defined in this rule.

(39)

“Hospital-Based Facility” means a nursing facility that is physically connected and operated by a licensed general hospital.

(40)

“Indirect Costs” mean the costs associated with property, administration, and other operating support (real property taxes, insurance, utilities, maintenance, dietary (excluding food), laundry, and housekeeping). Indirect costs are further described in OAR 411-070-0359 (Allowable Costs) and OAR 411-070-0465 (Uniform Chart of Accounts).

(41)

“Individual” means a person who receives, or is expected to receive, nursing facility services.

(42)

“Intellectual Disability” means “intellectual disability” as defined in OAR 411-320-0020 (Definitions and Acronyms) and described in OAR 411-320-0080 (Application and Eligibility Determination).

(43)

“Interrupted-Service Facility” means an established facility recertified by DHS following decertification.

(44)

“Level I” means a component of the federal PASRR requirement. Level I refers to the identification of individuals who are potential nursing facility admissions who have indicators of mental illness or developmental disabilities (42 CFR 483.128(a)).

(45)

“Level II” means a component of the federal PASRR requirement. Level II refers to the evaluation and determination of whether nursing facility services and specialized services are needed for individuals with mental illness or developmental disability who are potential nursing facility admissions, regardless of the source of payment for the nursing facility service (42 CFR 483.128(a)). Level II evaluations include assessment of the individual’s physical, mental, and functional status (42 CFR 483.132).

(46)

“Level of Care Determination” means an evaluation of the intensity of a person’s health service needs. The level of care determination may not be used to require that the person receive services in a nursing facility.

(47)

“Medicaid Occupancy Percentage” means the total Medicaid bed days divided by total resident days.

(48)

“Mental Illness” means a major mental disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM IV-TR) limited to schizophrenic, paranoid and schizoaffective disorders, bipolar (manic-depressive), and atypical psychosis. “Mental Illness” for pre-admission screening means having both a primary diagnosis of a major mental disorder (schizophrenic, paranoid, major affective and schizoaffective disorders, or atypical psychosis) and treatment related to the diagnosis in the past two years. Diagnoses of dementia or Alzheimer’s are excluded.

(49)

“Necessary Costs” mean costs that are appropriate and helpful in developing and maintaining the operation of resident facilities and activities. Necessary costs are usually costs that are common and accepted occurrences in the field of long term nursing services.

(50)

“New Admission” for PASRR purposes means an individual admitted to any nursing facility for the first time. It does not include individuals moving within a nursing facility, transferring to a different nursing facility, or individuals who have returned to a hospital for treatment and are being admitted back to the nursing facility. New admissions are subject to the PASRR process (42 CFR 483.106(b)(1), (3), (4)).

(51)

“New Facility” means a nursing facility commencing to provide services to individuals.

(52)

“Nursing Aide Training and Competency Evaluation Program (NATCEP)” means a nursing assistant training and competency evaluation program approved by the Oregon State Board of Nursing pursuant to ORS chapter 678 and the rules adopted pursuant thereto.

(53)

“Nursing Facility Financial Statement (NFFS)” means Form DHS 35, or Form DHS 35A (for hospital-based facilities), and includes an account number listing of all costs to be used by all nursing facility providers in reporting to the Department of Human Services for reimbursement.

(54)

“Occupancy Rate” means total resident days divided by capacity.

(55)

“Official Bed Count Measurement” means the number of licensed nursing facility beds as of October 7, 2013 and the beds being developed by facilities that either applied to the Oregon Health Authority for a certificate of need between August 1, 2011 and December 1, 2012 or submitted a letter of intent under ORS 442.315 (Certificate of need)(7) between January 15, 2013 and January 31, 2013.

(56)

“Ordinary Costs” mean costs incurred that are customary for the normal operation.

(57)

“Oregon Medical Professional Review Organization (OMPRO)” means the organization that determines level of services, need for services, and quality of services.

(58)

“Pediatric Rate” means the statewide standard payment rate for all long term services provided to a Medicaid resident under the age of 21 who is served in a pediatric nursing facility or a self-contained pediatric unit.

(59)

“Perquisites” mean privileges incidental to regular wages.

(60)

“Personal Incidental Funds” mean resident funds held or managed by the licensee or other person designated by the resident on behalf of a resident.

(61)

“Placement” means the location of a specific place where health services can be adequately provided to meet the service needs.

(62)

“Pre-Admission Screening (PAS)” means the assessment and determination of a potential Medicaid-eligible individual’s need for nursing facility services, including the identification of individuals who can transition to community-based service settings and the provision of information about community-based alternatives. This assessment and determination is required when potentially Medicaid-eligible individuals are at risk for admission to nursing facility services. PAS may include the completion of the federal PASRR Level I requirement (42 CFR, Part 483, (C)-(E)), to identify individuals with mental illness or intellectual or developmental disabilities.

(63)

“Pre-Admission Screening and Resident Review (PASRR)” means the federal requirement, (42 CFR, Part 483, (C)-(E)), to identify individuals who have mental illness or developmental disabilities and determine if nursing facility service is required and if specialized services are required. PASRR includes Level I and Level II functions.

(64)

“Prior Authorization” means the local Aging and People with Disabilities or Area Agency on Aging office participates in the development of proposed nursing facility care plans to assure the facility is the most suitable service setting for the individual. Nursing facility reimbursement is contingent upon prior authorization.

(65)

“Private Admission Assessment (PAA)” means the assessment that is conducted for non-Medicaid residents as established by ORS 410.505 (Definitions for ORS 410.505 to 410.545) to 410.545 (Implementation of ORS 410.505 to 410.545 requires federal funding) and OAR chapter 411, division 071, who are potential admissions to a Medicaid-certified nursing facility. Service needs are evaluated, and information is provided about long-term service choices. A component of private admission assessment is the federal PASRR Level I requirement, (42 CFR, Part 483.128(a)), to identify individuals with mental illness or developmental disabilities.

(66)

“Provider” means an entity, licensed by Aging and People with Disabilities, responsible for the direct delivery of nursing facility services.

(67)

“Provider Preventable Condition (PPC)” means a condition listed below caused by the provider:

(a)

Foreign object retained after treatment;

(b)

Stage III and IV pressure ulcers;

(c)

Falls and trauma;

(d)

Manifestations of poor glycemic control;

(e)

Catheter-associated urinary tract infection;

(f)

Medication error; or

(g)

Surgical site or wound site infection.

(68)

“Quality and Efficiency Incentive Program” means the program described in OAR 411-070-0437 (Quality and Efficiency Incentive Program) designed to reimburse quality nursing facilities that voluntarily reduce bed capacity that increases occupancy levels and enhances efficiency with the goal of slowing the growth of system-wide costs.

(69)

“Reasonable Consideration” means an inducement that is equivalent to the amount that would ordinarily be paid for comparable goods and services in an arms-length transaction.

(70)

“Related Organization” means an entity that is under common ownership or control with, or has control of, or is controlled by the contractor. An entity is deemed to be related if it has 5 percent or more ownership interest in the other. An entity is deemed to be related if it has capacity derived from any financial or other relationship, whether or not exercised, to influence directly or indirectly the activities of the other.

(71)

“Resident” means a person who receives nursing facility services.

(72)

“Resident Days” mean the number of occupied bed days.

(73)

“Resident Review” means a review conducted by the Addictions and Mental Health Division for individuals with mental illness or by the Aging and People with Disabilities Division for individuals with developmental disabilities who are residents of nursing facilities. The findings of the resident review may result in referral to PASRR Level II (42 CFR 483.114).

(74)

“Restricted Fund” means a fund in which the use of the principal or principal and income is restricted by agreement with, or direction by, the donor to a specific purpose. Restricted fund does not include a fund over which the owner has complete control. The owner is deemed to have complete control over a fund that is to be used for general operating or building purposes.

(75)

“Specialized Services for Mental Illness” means mental health services delivered by an interdisciplinary team in an inpatient psychiatric hospital for treatment of acute mental illness.

(76)

“Specialized Services for Intellectual or Developmental Disabilities” means:

(a)

For individuals with intellectual or developmental disabilities under age 21, specialized services are equal to school services; and

(b)

For individuals with t intellectual or developmental disabilities over age 21, specialized services mean:

(A)

A consistent and ongoing program that includes participation by the individual in continuous, aggressive training and support to prevent loss of current optimal function;

(B)

Promotes the acquisition of function, skills, and behaviors necessary to increase independence and productivity; and

(C)

Is delivered in community-based or vocational settings at a minimum of 25 hours a week.

(77)

“Start-Up Costs” mean one-time costs incurred prior to the first resident being admitted. Start-up costs include, but are not limited to, administrative and nursing salaries, utility costs, taxes, insurance, mortgage and other interest, repairs and maintenance, training costs. Start-up costs do not include such costs as feasibility studies, engineering studies, architect’s fees, or other fees that are part of the historical cost of the facility.

(78)

“Supervision” means initial direction and periodic monitoring of performance. Supervision does not mean the supervisor is physically present when the work is performed.

(79)

“These Rules” mean the rules in OAR chapter 411, division 070.

(80)

“Title XVIII” and “Medicare” means Title XVIII of the Social Security Act.

(81)

“Title XIX,” “Medicaid,” and “Medical Assistance” means Title XIX of the Social Security Act.

(82)

“Uniform Chart of Accounts (Form DHS 35)” means a list of account titles identified by code numbers established by the Department of Human Services for providers to use in reporting their costs.

(83)

“Ventilator” means a device to provide breathing assistance to individuals. This includes both positive and negative pressure devices.

(84)

“Ventilator Assisted Program” means a program that provides services to residents who are dependent on an invasive mechanical ventilation as means of life support as defined in OAR 411-090-0110 (Definitions).

(85)

“Ventilator Assisted Program Unit” means a unit that meets the Ventilator Assisted Program criteria.
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Last accessed
Jun. 8, 2021