Okla. Stat. tit. 63, § 63-1-1925.2

Fund - Staffing ratios - Name and title posting - Rule promulgation

- Appeal - Nursing Facility Funding Advisory Committee.

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.

1. The recalculations provided for in this subsection shall be

consistent for both nursing facilities and Intermediate Care

Facilities for Individuals with Intellectual Disabilities

(ICFs/IID).

2. The recalculated reimbursement 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, through 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 requirements related to the staffing of

nursing facilities, the following minimum direct-care-staff-to-

resident ratios:

Oklahoma Statutes - Title 63. Public Health and Safety Page 714

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 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.

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 seventeen

or more beds shall maintain, in addition to other state and federal

requirements related to the staffing of nursing facilities, 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 major fraction thereof, and

c. from 11:00 p.m. to 7:00 a.m., one direct-care staff to

every fifteen residents, or major fraction thereof.

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 designated 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,

however, such facility shall continue to maintain a

direct-care service rate of at least two and nine

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
to maintain a

direct-care service rate of at least two and nine

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) hours 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

Oklahoma Statutes - Title 63. Public Health and Safety Page 715

(3) at least two direct-care staff persons on duty

and awake at all times.

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 subsection,

(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 staffing.

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 considered

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,

and has corrected any deficiency described 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, the 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 inspections.

b. If the Department identifies any quality-of-care

problems related to insufficient staffing in such

facility, the Department shall issue a directed plan

of correction to the facility found to be out of

compliance with the provisions of this subsection.

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:

Oklahoma Statutes - Title 63. Public Health and Safety Page 716

(1) the first determination shall require that shift-

based, staff-to-resident ratios be maintained

until full compliance is achieved,

(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
ing periods of time:

Oklahoma Statutes - Title 63. Public Health and Safety Page 716

(1) the first determination shall require that shift-

based, staff-to-resident ratios be maintained

until full compliance is achieved,

(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

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 two and eighty-six one-

hundredths (2.86) hours per day per occupied bed to three and two-

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

Oklahoma Statutes - Title 63. Public Health and Safety Page 717

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

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 eight-tenths (3.8) hours per day per occupied 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 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 eight-tenths (3.8) hours

per day per occupied bed to four and one-tenth (4.1) hours per day
ncreases 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 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 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 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 reflected in direct-care, flexible staff-

scheduling staffing levels.

5. In the event that the state Medicaid program reimbursement

rate for facilities subject to the Nursing Home Care Act, and

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 in

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 nursing 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.

Oklahoma Statutes - Title 63. Public Health and Safety Page 718

H. 1. The Oklahoma Health Care Authority shall require 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 to

submit a monthly report on staffing 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 administrative 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 submitted 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 Initiative

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

Oklahoma Health Care Authority in consultation with the State

Department of Health.

2. a. The Oklahoma Nursing Facility Funding Advisory

Committee is hereby created and shall consist of the

following:
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

Oklahoma Health Care Authority in consultation with the State

Department of Health.

2. a. The Oklahoma Nursing Facility Funding Advisory

Committee is hereby created and shall consist of the

following:

(1) four members selected by the Oklahoma Association

of Health Care Providers,

(2) three members selected by the Oklahoma

Association of Homes and Services for the 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 committee will be to

develop a new methodology for calculating state

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

Oklahoma Statutes - Title 63. Public Health and Safety Page 719

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.

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 will 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 methodology as outlined in

this paragraph will only be applied to any new funding

for nursing facilities appropriated above and beyond

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 certified nurse

aides. The direct care component of the rate

shall be a facility-specific rate, directly

related to each facility's actual expenditures on

direct care, and

(2) other costs.

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 facility'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 federal regulations

and requirements,

(4) prior to July 1, 2020, the Authority shall seek

federal approval to calculate the upper payment

limit under the authority of CMS utilizing the

Medicare equivalent payment rate, and

Oklahoma Statutes - Title 63. Public Health and Safety Page 720
onents shall be determined by the

Oklahoma Nursing Facility Funding Advisory

Committee in accordance with federal regulations

and requirements,

(4) prior to July 1, 2020, the Authority shall seek

federal approval to calculate the upper payment

limit under the authority of CMS utilizing the

Medicare equivalent payment rate, and

Oklahoma Statutes - Title 63. Public Health and Safety Page 720

(5) if Medicaid payment rates to providers are

adjusted, nursing home rates and Intermediate

Care Facilities for Individuals with Intellectual

Disabilities (ICFs/IID) rates shall not be

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 sufficient funding

is appropriated for a rate increase, a new

average rate for nursing facilities shall be

established. The rate shall be equal to the

statewide average cost as derived from audited

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

shall continue to be distributed as a part

of the base rate in accordance with 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

accordance with the currently approved 70/30

reimbursement rate methodology 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 Medicare

rate equivalent established by the federal CMS.

h. Effective October 1, 2019, in coordination with the

rate adjustments identified in the preceding section,

a portion of the funds shall 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

Oklahoma Statutes - Title 63. Public Health and Safety Page 721

Dollars ($75.00) per month per resident. The

increase shall be funded by Medicaid nursing 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
Fifty

Dollars ($50.00) per month to Seventy-five

Oklahoma Statutes - Title 63. Public Health and Safety Page 721

Dollars ($75.00) per month per resident. The

increase shall be funded by Medicaid nursing 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.

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 facilities. 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 adjustments and implement an

appeal process for disputed payment audit adjustments 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 as to clarify what

expenses are allowable and appropriate for inclusion 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 application to the United States

Centers for Medicare and Medicaid Service for a waiver of 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.