| (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.
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