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STATE OF OKLAHOMA
2nd Session of the 58th Legislature (2022)
HOUSE BILL 3480 By: Stark
AS INTRODUCED
An Act relating to long-term care facilities;
amending 63 O.S. 2021, Section 1-1925.2, which
relates to long-term care facility reimbursem ents;
modifying policy; and providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 63 O.S. 2021, Section 1-1925.2, is
amended to read as follows :
Section 1-1925.2 A. The Oklahoma Health Care Authority shall
fully recalculate and reimburse nursing facilities and Intermediate
Care Facilities for Individuals with Intellectual Disabilities
(ICFs/IID) from the Nursing Facility Quality of Care Fund beginning
October 1, 2000, the average actual, audited costs reflected in
previously submitted cost reports for the cost -reporting period that
began July 1, 1998, and ended June 30, 1999, inflated by the
federally published inflationary factors for the two (2) years
appropriate to reflect present-day costs at the midpoint of the July
1, 2000, through June 30, 2001, rate year.
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1. The recalculations provided for in this subsection shall be
consistent for both nursing facilities and Intermediate Care
Facilities for Individuals with Int ellectual Disabilities
(ICFs/IID).
2. The recalculated re imbursement rate shall be implemented
September 1, 2000.
B. 1. From September 1, 2000, through August 31, 2001, all
nursing facilities subject to the Nursing Home Care Act, in addition
to other state and federal requirements related to the staffing of
nursing facilities, shall maintain the following minimum direct -
care-staff-to-resident ratios:
a. from 7:00 a.m. to 3:00 p.m., one direct -care staff to
every eight residents, or major fraction thereof ,
b. from 3:00 p.m. to 11:00 p.m., one direct -care staff to
every twelve residents, or major fraction thereof, and
c. from 11:00 p.m. to 7:00 a.m., one direct -care staff to
every seventeen residents, or major fraction thereof.
2. From September 1, 2001, t hrough August 31, 2003, nursing
facilities subject to the Nursing Home Care Act and Intermediate
Care Facilities for Individuals with Intellectual Disabilities
(ICFs/IID) with seventeen or more beds shall maintain, in addition
to other state and federal re quirements related to the staffing of
nursing facilities, the following minimum direct -care-staff-to-
resident ratios:
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a. from 7:00 a.m. to 3:00 p.m., one direct -care staff to
every seven residents, or major fraction thereof,
b. from 3:00 p.m. to 11:00 p.m. , one direct-care staff to
every ten residents, or major f raction thereof, and
c. from 11:00 p.m. to 7:00 a.m., one direct -care staff to
every seventeen residents, or major fraction thereof.
3. On and after October 1, 2019, nursing facilities subject to
the Nursing Home Care Act and Intermediate Care Facilities for
Individuals with Intellectual Disabilities (ICFs/IID) with sevente en
or more beds shall maintain, in addition to other state and federal
requirements related to the staffing of nursing facilitie s, the
following minimum direct -care-staff-to-resident ratios:
a. from 7:00 a.m. to 3:00 p.m., one direct -care staff to
every six residents, or major fraction thereof,
b. from 3:00 p.m. to 11:00 p.m., one direct -care staff to
every eight residents, or majo r fraction thereof, and
c. from 11:00 p.m. to 7:00 a.m., o ne direct-care staff to
every fifteen residents, or major fraction the reof.
4. Effective immediately, facilities shall have the option of
varying the starting times for the eight -hour shifts by one (1) hour
before or one (1) hour after the times designate d in this section
without overlapping shifts.
5. a. On and after January 1, 2020, a facility may implement
twenty-four-hour-based staff scheduling; provided,
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however, such facility shall continue to maintain a
direct-care service rate of at least two and n ine
tenths (2.9) hours of direct -care service per resident
per day, the same to be calculated based on average
direct care staff maintained over a twenty -four-hour
period.
b. At no time shall direct -care staffing ratios in a
facility with twenty -four-hour-based staff-scheduling
privileges fall below one direct -care staff to every
fifteen residents or major fraction thereof, and at
least two direct-care staff shall be on duty and awake
at all times.
c. As used in this paragraph, "twenty-four-hour-based-
scheduling" means maintaining:
(1) a direct-care-staff-to-resident ratio based on
overall hours of direct -care service per resident
per day rate of not less than two and ninety one -
hundredths (2.90) hour s per day,
(2) a direct-care-staff-to-resident ratio of at least
one direct-care staff person on duty to every
fifteen residents or major fraction thereof at
all times, and
(3) at least two direct-care staff persons on duty
and awake at all times.
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6. a. On and after January 1, 2004, the State Department of
Health shall require a facility to maintain the shift -
based, staff-to-resident ratios provided in paragraph
3 of this subsection if the facility has been
determined by the Department to be deficient with
regard to:
(1) the provisions of paragraph 3 of this subse ction,
(2) fraudulent reporting of staffing on the Quality
of Care Report, or
(3) a complaint or survey investigation that has
determined substandard quality of care as a
result of insufficient staf fing.
b. The Department shall require a facility described in
subparagraph a of this paragraph to achieve and
maintain the shift-based, staff-to-resident ratios
provided in paragraph 3 of this subsection for a
minimum of three (3) months before being consi dered
eligible to implement twenty -four-hour-based staff
scheduling as defined in subparagraph c of paragraph 5
of this subsection.
c. Upon a subsequent determination by the Department that
the facility has achieved and maintained for at least
three (3) months the shift-based, staff-to-resident
ratios described in paragraph 3 of this subsection,
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and has corrected any deficiency des cribed in
subparagraph a of this paragraph, the Department shall
notify the facility of its eligibility to implement
twenty-four-hour-based staff-scheduling privileges.
7. a. For facilities that utilize twenty-four-hour-based
staff-scheduling privileges, t he Department shall
monitor and evaluate facility compliance with the
twenty-four-hour-based staff-scheduling staffing
provisions of paragraph 5 of this subsection through
reviews of monthly staffing reports, results of
complaint investigations and inspect ions.
b. If the Department identifies any quality -of-care
problems related to insufficient staffing in such
facility, the Depart ment shall issue a directed plan
of correction to the faci lity found to be out of
compliance with the provisions of this subsect ion.
c. In a directed plan of correction, the Department shall
require a facility described in subparagraph b of this
paragraph to maintain shift-based, staff-to-resident
ratios for the following periods of time:
(1) the first determination shall require t hat shift-
based, staff-to-resident ratios be maintained
until full compliance is achieved,
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(2) the second determination within a two-year period
shall require that shift -based, staff-to-resident
ratios be maintained for a minimum period of
twelve (12) months, and
(3) the third determination within a two -year period
shall require that shift -based, staff-to-resident
ratios be maintained. The facility may apply for
permission to use twenty -four-hour staffing
methodology after two (2) years.
C. Effective September 1, 2002, facilities shall post the names
and titles of direct -care staff on duty each day in a conspicuous
place, including the name and title of the supervising nurse.
D. The State Commissioner of Health shall promulgate rules
prescribing staffing requirements for Intermediate Care Facilities
for Individuals with Intellectual Disabilities serving six or fewer
clients (ICFs/IID-6) and for Intermediate Care Facilities for
Individuals with Intellectual Disabilities serving sixteen or fewer
clients (ICFs/IID-16).
E. Facilities shall have the right to appeal and to the
informal dispute resolution process with regard to penalties and
sanctions imposed due to staffing noncompliance.
F. 1. When the state Medicaid program reimbursement rate
reflects the sum of Ninety-four Dollars and eleven cents ($94.11),
plus the increases in actual audited costs over and above the actual
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audited costs reflected in the cost reports submitted for the mos t
current cost-reporting period and the costs estimated by the
Oklahoma Health Care Authority to increase the direct -care, flexible
staff-scheduling staffing level from two and eighty -six one-
hundredths (2.86) hours per day per occupied bed to three and tw o-
tenths (3.2) hours per day per occupied bed, all nursing facilities
subject to the provisions of the Nursing Home Care Act and
Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICFs/IID) with seventeen or more beds, in addition to
other state and federal requirements related to the staffing of
nursing facilities, shall maintain direct -care, flexible staff -
scheduling staffing levels based on an overall three and two -tenths
(3.2) hours per day per occupied bed.
2. When the state Medicaid program reimbursement rate reflects
the sum of Ninety-four Dollars and eleven cents ($94.11), plus the
increases in actual audited costs over and above the actual audited
costs reflected in the cost reports submitted for the most current
cost-reporting period and the costs estimated by the Oklahoma Health
Care Authority to increase the direct -care flexible staff-scheduling
staffing level from three and two -tenths (3.2) hours per day per
occupied bed to three and eight -tenths (3.8) hours per day per
occupied bed, all nursing facilities subject to the provisions of
the Nursing Home Care Act and Intermediate Care Facilities for
Individuals with Intellectual Disabilities (ICFs/IID) with seventeen
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or more beds, in addition to other state and federal requ irements
related to the staffing of nursing facilities, shall maintain
direct-care, flexible staff -scheduling staffing levels based on an
overall three and eight -tenths (3.8) hours per day per occup ied bed.
3. When the state Medicaid program reimbursement rate reflects
the sum of Ninety-four Dollars and eleven cents ($94.11 ), plus the
increases in actual audited costs over and above the actual audited
costs reflected in the cost reports submitted fo r the most current
cost-reporting period and the costs est imated by the Oklahoma Health
Care Authority to increase the direct -care, flexible staff-
scheduling staffing level from three and eight -tenths (3.8) hours
per day per occupied bed to four and one -tenth (4.1) hours per day
per occupied bed, all nursing faci lities subject to the provisions
of the Nursing Home Care Act and Inte rmediate Care Facilities for
Individuals with Intellectual Disabilities (ICFs/IID) with seventeen
or more beds, in addition to o ther state and federal requirements
related to the staffin g of nursing facilities, shall maintain
direct-care, flexible staff -scheduling staffing levels based on an
overall four and one -tenth (4.1) hours per day per occupied bed.
4. The Commissioner shall promulgate rules for shift -based,
staff-to-resident ratios for noncompliant facilities denoting the
incremental increases refle cted in direct-care, flexible staff -
scheduling staffing levels.
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5. In the event that the state Medicaid program reimbursement
rate for facilities subject to the Nursing Home Care Act, a nd
Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICFs/IID) having seventeen or more beds is reduced
below actual audited costs, the requirements for staffing ratio
levels shall be adjusted to the appropriate levels provided i n
paragraphs 1 through 4 of this subsection.
G. For purposes of this subsection:
1. "Direct-care staff" means any nursing or therapy staff who
provides direct, hands -on care to residents in a nurs ing facility;
2. Prior to September 1, 2003, activity and social services
staff who are not providing direct, hands -on care to residents may
be included in the direct -care-staff-to-resident ratio in any shift.
On and after September 1, 2003, such persons shall not be included
in the direct-care-staff-to-resident ratio, regardless of their
licensure or certification status; and
3. The administrator shall not be counted in the direct -care-
staff-to-resident ratio regardless of the administrator 's licensure
or certification status.
H. 1. The Oklahoma Health Care Authority shall require all
nursing facilities subject to the provisio ns of the Nursing Home
Care Act and Intermediate Care Facilities for Individuals with
Intellectual Disabilities (ICFs/IID) with seventeen or more beds to
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submit a monthly report on staff ing ratios on a form that the
Authority shall develop.
2. The report shall document the extent to which such
facilities are meeting or are failing to meet the minimum direct -
care-staff-to-resident ratios specified by this section. Such
report shall be available to the public upon request.
3. The Authority may assess admin istrative penalties for the
failure of any facility to submit the report as required by the
Authority. Provided, however:
a. administrative penalties shall not accrue until the
Authority notifies the facility in writing that the
report was not timely subm itted as required, and
b. a minimum of a one-day penalty shall be assessed in
all instances.
4. Administrative penalties shall not be assessed for
computational errors made in preparing the report.
5. Monies collected from administrative penalties shall be
deposited in the Nursing Facility Quality of Care Fund and utilized
for the purposes specified in the Oklahoma Healthcare Ini tiative
Act.
I. 1. All entities regulated by this state that provide long-
term care services shall utilize a single assessment tool to
determine client services needs. The tool shall be developed by the
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Oklahoma Health Care Authority in consultation wit h the State
Department of Health.
2. a. The Oklahoma Nursing Facility Funding Advisory
Committee is hereby created and shall con sist of the
following:
(1) four members selected by the Oklahoma Association
of Health Care Providers,
(2) three members selecte d by the Oklahoma
Association of Homes and Services for th e Aging,
and
(3) two members selected by the State Council on
Aging.
The Chair shall be elected by the committee. No state
employees may be appointed to serve.
b. The purpose of the advisory commit tee will be to
develop a new methodology for calculating s tate
Medicaid program reimbursements to nursing facilities
by implementing facility-specific rates based on
expenditures relating to direct -care staffing. No
nursing home will receive less than the current rate
at the time of implementation of facility -specific
rates pursuant to this subparagraph.
c. The advisory committee shall be staffed and advised by
the Oklahoma Health Care Authority.
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d. The new methodology will be submitted for approval to
the Board of the Oklahoma Health Care Authority by
January 15, 2005, and shall be finalized by July 1,
2005. The new methodology w ill apply only to new
funds that become available for Medicaid nursing
facility reimbursement after the methodology of this
paragraph has been finalized. Existing funds paid to
nursing homes will not be subject to the methodology
of this paragraph. The m ethodology as outlined in
this paragraph will only be applied to any new funding
for nursing facilities appropriated above and b eyond
the funding amounts effective on January 15, 2005.
e. The new methodology shall divide the payment into two
components:
(1) direct care which includes allowable costs for
registered nurses, licensed practical nurses,
certified medication aides and ce rtified nurse
aides. The direct care component of the rat e
shall be a facility-specific rate, directly
related to each facility 's actual expenditures on
direct care, and
(2) other costs.
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f. The Oklahoma Health Care Authority, in calculating the
base year prospective direct care rate component,
shall use the following criteria:
(1) to construct an array of facility per diem
allowable expenditures on direct care, the
Authority shall use the most recent data
available. The limit on this array shall be no
less than the ninetieth percentile,
(2) each facility's direct care base-year component
of the rate shall be the lesser of the faci lity's
allowable expenditures on direct care or the
limit,
(3) other rate components shall be determined by the
Oklahoma Nursing Facility Funding Advisory
Committee in accordance with fe deral regulations
and requirements,
(4) prior to July 1, 2020, the Aut hority shall seek
federal approval to calculate the upper payment
limit under the authority of CMS utilizing the
Medicare equivalent payment rate, and
(5) if Medicaid payment rates to pr oviders are
adjusted, nursing home rates and Intermediate
Care Facilities for Individuals with Intellectual
Disabilities (ICFs/IID) rates shall not be
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adjusted less favorably than the average
percentage-rate reduction or increase applicable
to the majority of other provider groups.
g. (1) Effective October 1, 2019, if suffic ient funding
is appropriated for a rate increase, a new
average rate for nursing facilities shall be
established. The rate shal l be equal to the
statewide average cost as derived from a udited
cost reports for SFY 2018, ending June 30, 2018,
after adjustment for inflation. After such new
average rate has been established, the facility
specific reimbursement rate shall be as follows:
(a) amounts up to the existing base rate amount
and shall continue to be distributed as a
part of the base rate in accordance wit h the
existing State Plan, and
(b) to the extent the new rate exceeds the rate
effective before the effective date of this
act, fifty percent (50%) of the resulting
increase on October 1 , 2019, shall be
allocated toward an increase of the existing
base reimbursement rate and distributed
accordingly. The remaining fifty percent
(50%) of the increase shall be allocated in
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accordance with the currently approved 70/30
reimbursement rate meth odology as outlined
in the existing State Plan .
(2) Any subsequent rate increases, as determined
based on the provisions set forth in this
subparagraph, shall be allocated in accordance
with the currently approved 70/30 reimbursement
rate methodology. The rate shall not exceed the
upper payment limit established by the Medi care
rate equivalent established by the federal CMS
Upon the effective date of this act , the Oklahoma
Health Care Authority shall submit a State Plan
Amendment to modify the current 70/ 30
reimbursement rate methodology to a 90/10
reimbursement rate methodology consistent with
the provisions allowed for in the existing 70/30
reimbursement rate methodology.
(3) The State Plan Amendment 90/10 reimbursement rate
methodology shall apply to al l state and federal
funds received, inclu ding, but not limited to,
American Rescue Plan Act of 2021 funding, and
subsequent federal funding as allow ed for by law
and any funds received from the State Treasury as
allowed for by law.
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h. Effective October 1, 2019, in coordination with the
rate adjustments identified in the preceding section,
a portion of the funds s hall be utilized as follows:
(1) effective October 1, 2019, the Oklahoma Health
Care Authority shall increase the personal needs
allowance for residents of nursing homes and
Intermediate Care Facilities for Individuals with
Intellectual Disabilities (ICFs/ IID) from Fifty
Dollars ($50.00) per month to Seventy -five
Dollars ($75.00) per month per resident. The
increase shall be funded by Medicaid nursi ng home
providers, by way of a reduction of eighty-two
cents ($0.82) per day deducted from the base
rate. Any additional cost shall be funded by the
Nursing Facility Quality of Care Fund, and
(2) effective January 1, 2020, all clinical employees
working in a licensed nursing facility shall be
required to receive at least four (4) hours
annually of Alzheimer 's or dementia training, to
be provided and paid for by the facilities.
3. The Department of Human Services shall expand its statewide
toll-free, Senior-Info Line for senior citizen services to include
assistance with or information on long -term care services in this
state.
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4. The Oklahoma Health Care Authority shall develop a nursing
facility cost-reporting system that reflects the most current costs
experienced by nursing and specialized fa cilities. The Oklahoma
Health Care Authority shall utilize the most current cost report
data to estimate costs in determining daily per diem rates.
5. The Oklahoma Health Care Authority shall provide access to
the detailed Medicaid payment audit adjustme nts and implement an
appeal process for disputed payment audit adjust ments to the
provider. Additionally, the Oklahoma Health Care Authority shall
make sufficient revisions to the nursing facility cost reporting
forms and electronic data input system so a s to clarify what
expenses are allowable and appropriate for inclusio n in cost
calculations.
J. 1. When the state Medicaid program reimbursement rate
reflects the sum of Ninety -four Dollars and eleven cents ($94.11 ),
plus the increases in actual audited costs, over and above the
actual audited costs reflected in the cost reports submitted for the
most current cost-reporting period, and the direct -care, flexible
staff-scheduling staffing level has been prospectively funded at
four and one-tenth (4.1) hours per day per occupied bed, the
Authority may apportion funds for the implementation of the
provisions of this section.
2. The Authority shall make applic ation to the United States
Centers for Medicare and Medicaid Service Services for a waiver of
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the uniform requirement on health-care-related taxes as permitted by
Section 433.72 of 42 C.F.R.
3. Upon approval of the waiver, the Authority shall develop a
program to implement the provisions of the waiver as it relates to
all nursing facilities.
SECTION 2. This act shall become effective November 1, 2022.
58-2-9281 KN 01/06/22