|(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
(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
(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
(C) percent of residents with decreased independent
(D) percent of residents with urinary tract infections;
(E) percent of residents appropriately given the pneumonia
(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
(A) whether a facility:
(i) has identified leadership individuals for antibiotic
(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
(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
(iii) residents on antibiotic medications;
(iv) residents with multi-drug resistant organisms;
(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
(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
(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
(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
(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