in-20240918-IR-405240088FRA: DIGEST NURSING FACILITY RULE

Final Rule LSA Document #24-88 DIGEST Sec. 1. (a) This rule sets forth payment procedures for services rendered to members covered by the Indiana health coverage program by nursing facilities. Payments referred to in this rule are contingent on the following: (b) The system of payment outlined in this rule is a prospective system. Cost limitations are contained in this rule and the IMPRM that establish parameters regarding the allowability of ordinary patient related costs and define reasonable nursing facility allowable costs. (c) An action that results in recoupment, rate reduction, or retrospective payment may be addressed through a prospective rate calculation, retroactive reprocessing of claims, or settlement process. Sec. 2. (a) The definitions in this section apply throughout this rule. (b) "Administrative component" means the portion of the Medicaid rate that reimburses providers for allowable administrative services and supplies, including prorated employee benefits based on salaries and wages. Allowable administrative services and supplies are the patient related costs necessary for the operation of a nursing facility, but cannot be directly associated with a specific member. (c) As set forth in section 6(e) of this rule, "allowable per patient day cost" means a ratio between allowable variable cost and patient days using each provider's actual occupancy from the most recently completed desk reviewed or field audited cost report, plus a ratio between allowable fixed costs and patient days using the greater of the minimum occupancy requirements, or each provider's actual occupancy rate from the most recently completed desk reviewed or field audited cost report. As set forth in section 6(d) of this rule, the term means a ratio between allowable cost and patient days using each provider's actual occupancy from the most recently completed desk review or field audited cost report using the greater of the minimum occupancy requirements, or each provider's actual occupancy rate from the most recently completed desk reviewed or field audited cost report. (d) "Bed days available" means the number of licensed beds reported during the cost reporting period multiplied by the number of calendar days in that period. If the number of licensed beds changed during a reporting period, the: (e) "Biannual" means a six (6) month period beginning January 1 and July 1. (f) "Capital component" means the portion of the Medicaid rate that reimburses providers for the use of allowable capital related items. Allowable capital related items are the patient related costs associated with a nursing facility's physical assets and related ownership costs. (g) "Case mix index" or "CMI" means a numerical value score that describes the relative resource use for each resident in the groups of the resident classification system prescribed by the office, as described in the MDS and Case Mix Index Supportive Documentation Manual, and based on an assessment of each resident. The facility CMI is based on the resident CMI, calculated on a facility average, time-weighted basis for the following: (h) "Children's nursing facility" means a nursing facility that, as of January 1, 2009, has: (i) "Cost report" refers to a presentation of financial data, including appropriate supplemental data and accompanying notes, derived from accounting records and intended to communicate the provider's economic resources or obligations at a point in time, or changes to that data at that time, in compliance with the reporting requirements of this rule. (j) "Delinquent MDS resident assessment" means an assessment that is inactive or expired due to exceeding maximum thresholds set by the office for filing and inclusion in the time-weighted CMI calculation. This determination is made as described for required filing in the MDS and Case Mix Index Supportive Documentation Manual. (k) "Desk review" means a review and application of the regulations to a provider submitted cost report, including accompanying notes and supplemental information within the scope, as defined by the office. (l) "Direct care component" means the portion of the Medicaid rate that reimburses providers for allowable direct patient care services and supplies, including prorated employee benefits based on salaries and wages. Allowable direct patient care services and supplies are patient related costs associated with direct hands-on care or related support of a member. (m) "Employee benefits" means total allowable employee benefits costs from the most recently desk reviewed or field audited cost report, excluding owners' benefits as described in the IMPRM, unless specified otherwise. (n) "Field audit" means a review and application of the regulations to a provider submitted cost report, including accompanying notes and supplemental information within the scope, as defined by the office. (o) "Fixed costs" means the portion of each rate component based on the minimum occupancy requirements. (p) "Forms prescribed by the office" means either of the following: (q) "Generally accepted accounting principles" or "GAAP" means those accounting principles as established by the Financial Accounting Standards Board. (r) "IDOH" means the Indiana department of health. (s) "Indiana Medicaid provider reimbursement manual" or "IMPRM" means the policy document supporting the reporting requirements, allowable cost classifications, and calculation of the Medicaid rate. (t) "Indirect care component" means the portion of the Medicaid rate that reimburses providers for allowable indirect patient care services and supplies, including prorated employee benefits based on salaries and wages. Allowable indirect patient care services and supplies are patient related costs necessary in the care of a member, but not directly based on providing hands-on care. (u) "Inflation factor" means inflating costs using the CMS Nursing Home without Capital Market Basket Index, as published by IHS Markit, using the period prescribed by the office. (v) "Legacy system" means the historic system used to calculate the Medicaid nursing facility per patient day rate under section 6 of this rule. (w) "Medicaid patient days" means total Medicaid days from the most recently desk reviewed or field audited cost report. (x) "Minimum data set" or "MDS" means a core set of screening and assessment elements, including common definitions and coding categories, that forms the foundation of the comprehensive assessment for residents of long term care facilities certified to participate in Medicaid. The Indiana system uses the MDS 3.0 or later revisions as approved by CMS, as detailed in the MDS and Case Mix Index Supportive Documentation Manual. (y) "MDS and Case Mix Index Supportive Documentation Manual" means the policy document supporting the following: (z) "MDS review" means a formal official verification and methodical examination and review of resident assessment data and its supporting documentation by the office or their designee. (aa) "Nonemergency medical transportation" or "NEMT" means medical transportation to a covered service whenever needs are not immediate, such as to and from a doctor's office, a hospital, or other medical offices for covered care. NEMT services provided by ambulance providers are neither the financial responsibility of nursing facility providers and included in the nursing facility Medicaid per diem, nor covered under this definition. (bb) "Nursing facility census data collection form" means the form designated by the office for providers to file their monthly census information. (cc) "Ordinary patient related costs" means costs of allowable per diem services and supplies necessary in the delivery of patient care by similar providers in this state. Services or supplies Medicaid covers outside the per diem rate are not ordinary patient related costs. (dd) "Patient/member care" means those Medicaid program services delivered to a Medicaid enrolled member by a provider. (ee) "Patient days" means total patient days, inclusive of paid leave days, from the most recently desk reviewed or field audited cost report. (ff) "Prospective system" means the methodology used to calculate the Indiana Medicaid reimbursement per patient day rate under section 6 of this rule. (gg) "Quality program manual" means the policy document supporting the calculation of the total quality score. (hh) "Rate year" means the period beginning July 1 and ending June 30. (ii) "RSMeans Construction Cost Index" means the simple average of construction costs for Indiana cities listed in the Construction Cost Indexes with RSMeans Data, as published by Gordian. (jj) "Reasonable allowable costs" means the price a prudent, cost-conscious buyer pays a willing seller for goods or services in an arms length transaction, not to exceed the limitations set forth in this rule or other policy documents. (kk) "Rebase" means the process of reestablishing rate component medians, percentiles, prices, and reimbursement rates by incorporating the most recently completed desk or field audited qualifying Medicaid cost reports. (ll) "Rental rate" means a simple average of the United States Treasury bond ten (10) year amortization, constant maturity rate plus three percent (3%), in effect on the first day of the month the index is published for each of the twelve (12) months immediately preceding the rate effective date, as determined in section 6 of this rule. (mm) "Resident classification system" means the classification system used to classify residents into groups to determine CMI values and reimbursement levels, as supported by the MDS and Case Mix Index Supportive Documentation Manual. (nn) "Special care unit (SCU) for Alzheimer's disease or dementia" means the nursing facility that meets all the following requirements: (oo) "Therapy component" means the portion of each facility's direct costs for providing therapy services, including prorated employee benefits based on total salaries and wages, rendered to Medicaid residents not reimbursed by other payors. (pp) "Total quality score" means the sum of the quality points awarded to each nursing facility for the quality measures as described by the quality program manual. (qq) "Unsupported MDS resident assessment" means an assessment missing one (1) or more data items required to classify a resident through the resident classification system under the MDS and Case Mix Index Supportive Documentation Manual. (rr) "Ventilator program" means a nursing facility that meets all the following requirements: Sec. 3. (a) The basis of accounting under this rule is a comprehensive basis of accounting, other than GAAP. Costs and charges reported on the provider's cost report shall also be recorded on the provider's financial statements. Costs and charges shall be reported on the cost report under the following authorities, in the hierarchical order listed: (b) The provider's cost report shall be completed under the IMPRM and submitted using cost report forms prescribed by the office. The data elements and attachments identified in subdivisions (1) through (8) shall be completed to provide full financial disclosure. A complete cost report consists of the following items fully and properly completed: (c) For cost report periods ending March 31, 2023, or earlier, a provider shall submit a cost report to the office not later than the last day of the fifth calendar month after the end of the provider's reporting year. The cost report shall coincide with the fiscal year used by the provider to report federal income taxes. Nursing facilities certified to provide Medicare-covered skilled nursing facility services are required to submit a written copy of their Medicare cost report covering their most recently completed historical reporting period. (d) For cost report periods ending April 1, 2023, or later, a provider is required to maintain a fiscal year end of December 31. Each provider shall submit a cost report to the office not later than May 31 after the end of the provider's reporting year. Requirements regarding short period cost reports are as set forth in section 9 of this rule. Nursing facilities certified to provide Medicare-covered skilled nursing facility services are required to submit a written copy of their Medicare cost report covering their most recently completed historical reporting period. (e) The nursing facility census data collection form is required to be submitted monthly and is due thirty (30) days after the reporting month. The nursing facility census data collection form is required to be filed on the form prescribed by the office and in conformance with the instructions contained in that form. (f) Whenever multiple facilities or operations are owned by a single entity with a central office, the central office records shall be maintained as a separate set of records, with costs and revenues separately identified and appropriately allocated to individual facilities. Each central office entity shall file a cost report coinciding with the period for any individual facility receiving central office allocations. (g) A provider shall maintain financial records for at least three (3) years after the date of submission of cost reports to the office. Copies of financial records or supporting documentation shall be provided to the office on request. The accrual basis of accounting shall be used in the data submitted to the office, except for government operated providers otherwise required by law to use a different basis. The provider's accounting records shall establish a clear audit trail from their records to the costs reported on their cost reports submitted to the office. (h) A cost report submission shall contain full disclosure and reporting of revenue, expenses, and property clearly separated between Medicaid, non-Medicaid, patient, and nonpatient, including the following: (i) A provider shall maintain detailed property documentation, including documentation from a related party property company, to provide a permanent record of the historical costs and balances of facilities and equipment. Summaries of that documentation shall be submitted with each cost report, and a complete copy of the documentation shall be submitted to the office on request. (j) A provider shall report the patient related personnel costs and hours, as well as patient related contract costs, incurred to perform the function for which the provider was certified. Total personnel costs and total hours shall be reported for each employee. Hours for contracted staff are not required to be reported. (k) Payroll records shall be maintained by a provider to justify the staffing costs reported to the office. These records shall indicate: (l) Allocation of home office costs shall be reasonable, conform to GAAP, and be consistent between years. A change of central office allocation bases shall be approved by the office before the changes are implemented. Proposed changes in allocation methods shall be submitted to the office not less than ninety (90) days before the cost report due date. These costs are allowable only to the extent that the central office is providing services based on patient care, and the provider is able to demonstrate that the central office costs improved the efficiency, economy, and quality of member care. (m) Costs from non-bona fide separate related organizations, such as from operating divisions of the provider organization or central office, shall be maintained as a separate set of records, with costs separately identified and appropriately allocated to individual facilities. Costs from these related organizations shall be documented and allocated using the Medicaid Home Office Cost Report Form. Sec. 4. (a) The office shall perform a desk review or field audit of a submitted cost report to determine the reasonableness, appropriate classification, and allowability of reporting. The office may request documentation to justify the submitted cost report. (b) The office shall contact a provider to notify them that they have been selected for a field audit as follows: (c) If a field audit indicates a provider's records are inadequate to support data submitted to the office, or the additional requested documentation is not provided under the office's request and the office is unable to complete the audit, the following actions shall be taken: Sec. 5. (a) This section describes the treatment of nursing facility providers that have not previously been certified to participate in the Medicaid nursing facility program. (b) Rate requests to establish an initial rate for a new provider rate shall be filed by submitting an initial rate request to the office on or before the thirtieth day after notification of the enrollment date. (c) Initial rates shall be effective on the: (d) Initial rates shall be set at the sum of the following: (e) A provider shall remain under the initial rate calculation process until the first annual rebase period in which the provider has a desk or field audited cost report of six (6) months or more in length available for use in the rebase. (f) The initial monthly quality assessment value owed to the office shall be determined based on six (6) months of patient days from the required monthly nursing facility census data collection form provider filings. The initial monthly quality assessment value owed to the office shall remain in effect until the first annual rebase period in which the provider has a desk or field audited cost report of six (6) months or more in length available for use in the rebase. A retroactive settlement of the initial quality assessment total for unpaid periods shall occur after the provider's assessment value is determined by the office and the fiscal intermediary has established the monthly assessment receivable. (g) The assessment add-on is twelve dollars and twenty cents ($12.20) a patient day unless exempt from the assessment add-on, as noted in section 11 of this rule. Once the office collects six (6) months of patient days from the required monthly nursing facility census data collection forms, the office shall establish the provider specific assessment add-on and implement on the next rate effective date. (h) Providers are eligible to participate in the special care unit and ventilator programs and receive additional reimbursement if the qualifications in sections 2 and 7 of this rule are met. Sec. 6. (a) This section prescribes the detailed rate methodology calculation for each rate component. (b) Until June 30, 2024, the rate effective date of the annual rebase shall be the first July 1 after the first calendar quarter after a provider's fiscal year end. Beginning July 1, 2024, the annual rebase shall be each July 1 using the most recently desk or field audited cost reports, with a fiscal year ending not less than eighteen (18) months before the rate effective date. (c) The annual Medicaid per patient day rate shall be calculated as the sum of the: (d) The prospective system is as follows: (e) The legacy system is as follows: Sec. 7. (a) For purposes of this section, "Schedule Z" refers to the special facility qualification report, which shall be completed by a provider requesting reimbursement for an SCU or a ventilator program, or both, as follows: (b) The office shall increase Medicaid reimbursement to nursing facilities with a qualifying ventilator program. Additional Medicaid reimbursement shall be made to those facilities at a rate of eighty dollars ($80) an eligible Medicaid resident day. The additional reimbursement shall: (c) The office shall increase Medicaid reimbursement to nursing facilities with a qualifying SCU program. The additional Medicaid reimbursement shall be made to the facilities at a rate of twelve dollars ($12) an eligible Medicaid Alzheimer's and dementia resident day in their SCU. The additional reimbursement shall: (d) The office shall increase Medicaid reimbursement to all nursing facilities for NEMT through an add-on in the amount of one dollar and twenty-one cents ($1.21) a Medicaid resident day. Sec. 8. (a) Nursing facilities are required to electronically transmit MDS resident assessments in a complete, accurate, and timely manner as prescribed in the MDS and Case Mix Index Supportive Documentation Manual. An extension of the electronic MDS assessment due date may be granted by the office to a new operation attempting to submit MDS assessments for the first time if the: (b) If the office determines a nursing facility has a delinquent MDS resident assessment, the assessment shall be assigned the delinquent classification as prescribed in the MDS and Case Mix Index Supportive Documentation Manual. (c) The office shall adjust or revise MDS data items that an MDS review determines are unsupported to reflect a resident's highest functioning level supported by the MDS and Case Mix Index Supportive Documentation Manual. Incorporation of adjustments or revisions may result in a reclassification of the resident under the resident classification system. (d) For rates effective prior to June 30, 2024, after an MDS review, the office shall recalculate the facility's CMI. If the recalculated CMI results in a change to the established Medicaid rate: (e) For rates effective beginning July 1, 2024, and after, the result of an MDS review shall be applied as prescribed in section 12 of this rule. (f) CMIs are determined as prescribed in the MDS and Case Mix Index Supportive Documentation Manual for each resident to calculate the facility average CMI for all residents, as well as the facility average CMI for Medicaid residents. (g) The office shall provide each nursing facility with the following: (h) To determine the normalized allowable direct care costs from each facility's cost report, the office shall determine each facility's CMI for all residents that corresponds to the cost reporting period under the MDS and Case Mix Index Supportive Documentation Manual. Sec. 9. (a) The office shall be notified within thirty (30) days of a transaction affecting the following: (b) For transactions prior to July 1, 2023, a cost report shall be filed for the first fiscal year end after the transaction date in which the provider has at least six (6) full calendar months of actual historical data. The provider shall submit the cost report by the date identified on a change of ownership letter. (c) For transactions beginning July 1, 2023, the following shall apply: Sec. 10. (a) Common ownership exists when an individual, individuals, or any legal entity possesses ownership or equity of not less than five percent (5%) in a provider, as well as the institution or organization serving the provider. An individual is considered to own the interest of immediate family for the determination of percentage of ownership. For purposes of this subsection, the following individuals are considered immediate family: (b) Control exists where an individual or organization has the power, directly or indirectly, to influence or direct the actions or policies of an organization or institution, whether or not actually exercised. A general partner is considered to control an entity. (c) Transactions between related parties are not considered to have arisen through arms length negotiations. Costs applicable to services, facilities, and supplies issued to a provider by related parties shall not exceed the lower of the cost to the related party, or the price of comparable services, facilities, or supplies purchased as an arms length transaction in an open competitive market. An exception to this subsection may be granted by the office if requested in writing by the provider before the annual rebase effective date to which the exception is to apply. The provider's request shall include a comprehensive representation that each condition in subsection (d) has been met. This representation shall include the percentage of business the provider transacts with related and nonrelated parties based on revenue. When requested by the office, the provider shall submit documentation, such as invoices, standard charge master listings, and remittances, to prove the provider's charges for services, facilities, or supplies to related and nonrelated parties. (d) The office may grant an exception when a related organization meets all the following conditions: (e) A related party exception shall be granted for any period, up to the maximum period of two (2) years. (f) If a provider rents, leases, or purchases facilities or equipment from a related party property company, the historical cost to the related party, not to exceed fair market value, shall be used in computing the average historical cost of property of the median bed, except as described in this section for the sale of facilities between family members. (g) If a sale of facilities between family members meets the following conditions, the cost basis of the facility shall be recognized for the purpose of computing the average historical cost of property of the median bed under this rule as a bona fide sale arising from an arms length transaction, based on the limitations of subsection (h): (h) To establish a historical cost basis in the sale of facilities between family members, the buyer shall obtain a Member Appraiser Institute (MAI) appraisal. The MAI appraisal is based on the approval of the office. The appraisal shall be done within ninety (90) days of the date of the sale. The historical cost basis for purposes of determining the average historical cost of property of the median bed shall be the lower of the historical cost basis of the buyer or the MAI appraisal of facilities and equipment. (i) If a lease of facilities between family members under subsection (g) qualifies as a capitalized lease under the Statement of Financial Accountant Standards Number 13 as issued by the Financial Accounting Standards Board, the transaction shall be treated as a sale of facilities between family members for purposes of determining the average historical cost of property of the median bed. Sec. 11. (a) Under IC 16-28-15, the office shall collect a quality assessment from each nursing facility licensed under IC 16-28 as a comprehensive care facility. The census days used in the calculation shall be based on the most recently completed desk reviewed or field audited cost report or the nursing facility census data collection form, and the organization type shall be determined based on the organization's type at the rate effective date being established. Unless otherwise specified, the rate used is calculated as follows: (b) Under IC 16-28-15-7(2), the following nursing facilities shall be exempt from the quality assessment described in subsection (a): (c) For nursing facilities certified for participation in Medicaid under Title XIX of the federal Social Security Act (42 U.S.C. 1396 et seq.), the quality assessment shall be an allowable cost for cost reporting and auditing purposes. The quality assessment shall be included in Medicaid reimbursement as an add-on to the Medicaid rate. The add-on is determined by dividing the product of the assessment rate times total non-Medicare patient days by total patient days, from the most recently completed desk reviewed cost report. (d) For nursing facilities not certified for participation in Medicaid under Title XIX of the federal Social Security Act (42 U.S.C. 1396 et seq.), the facility shall remit the quality assessment to the state of Indiana within ten (10) days after the due date. If a nursing facility fails to pay the quality assessment under this subsection within ten (10) days after the date the payment is due, the nursing facility shall pay interest on the quality assessment at the same rate as determined under IC 12-15-21-3(6)(A). (e) The office shall notify each nursing facility of the amount of the facility's assessment after the amount has been computed. If the facility disagrees with the computation of the assessment, the facility shall request an administrative reconsideration by the office. The reconsideration request shall be as follows: (f) An assessment shall be calculated on an annual basis, with equal monthly amounts due on or before the tenth day of each calendar month. (g) A facility may file a request to pay the quality assessment on an installment plan. The request shall be as follows: (h) A facility that fails to pay the quality assessment due under this section within ten (10) days after the date the payment is due shall pay interest on the quality assessment at the same rate as determined under IC 12-15-21-3(6)(A). (i) The office shall offset the collection of the assessment fee for a facility as follows: (j) If a facility fails to: Sec. 12. (a) Rate reductions and corrective remedies shall be assessed on a per nursing facility basis. (b) Reimbursement lost because of an imposed rate reduction or corrective remedy cannot be recovered by the provider. (c) Rate reductions and corrective remedies may be addressed through a prospective rate calculation, retroactive reprocessing of claims, or settlement process. (d) Beginning April 1, 2024, the following events shall result in a reduction of the Medicaid per diem rate: (e) If a nursing facility cannot locate requested information in the field work – follow-up letter under subsection (d)(4), they shall supply a signed declaration, prescribed by the office, that they are unable to produce the requested documentation. This declaration shall be submitted at least one (1) day before the due date on the field work – follow-up letter to avoid the rate reduction. (f) Until March 31, 2024, a rate reduction shall be assessed as follows: (g) If the office determines, due to an MDS review, a nursing facility has unsupported MDS resident assessments, the following procedures shall be followed in applying a corrective remedy: Sec. 13. (a) A reconsideration request shall be in writing, and contain specific issues to be considered and the rationale for the provider's position. The provider shall timely request administrative reconsideration before filing an appeal. The events detailed in subdivisions (1) through (4) shall be communicated to nursing facilities through a formal letter, either through United States mail or a secure web portal, which begins the period for a timely request. The events are as follows: (b) Under IC 4-21.5-3-2(e), for a notification letter served through United States mail, the fifteen (15) day reconsideration period begins three (3) days after the date of the notification letter. (c) After completion of the reconsideration procedure under subsection (a), the provider may initiate an appeal under IC 4-21.5-3. The request for an appeal shall be signed by the nursing facility provider. Only issues raised by the provider through administrative reconsideration may be later raised in an appeal. (d) The office may take action to implement changes made under subsection (a) before the outcome of an appeal filed under subsection (c). (e) The office may implement Medicaid rates and recover overpayments from previous rate reimbursements, either through deductions of future payments or otherwise, before the outcome of the administrative appeal process as prescribed by IC 12-15-13-4(e). Sec. 1. (a) Nursing facilities certified to provide nursing facility care to Medicaid members are required to electronically transmit minimum data set (MDS) information for all each nursing facility residents resident to the office. Such MDS information shall include the resident's room number on all comprehensive or quarterly MDS assessments and tracking forms. The MDS data is used to establish and maintain a case mix system for Medicaid reimbursement to nursing facilities and other Medicaid program management purposes. (b) Nursing facilities certified to provide nursing facility care to Medicaid members are required to electronically transmit the end of therapy date for physical, occupational, and speech therapy services provided to a resident in a format specified by the office. Sec. 2. (a) The definitions in this section apply throughout this rule. (b) "Case mix reimbursement" means a system of paying nursing facilities according to the mix of residents in each facility, as measured by resident characteristics and service needs. Its function is to provide payment pay for resources needed to serve different types of residents. (c) "End of therapy date" means the date each therapy regimen ended for physical, occupational, or speech therapy, which is the last date the resident received the therapy treatment. (c) (d) "Minimum data set" or "MDS" means a core set of screening and assessment elements, including common definitions and coding categories, that forms the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicaid. The items in the MDS standardize communication about resident problems, strengths, and conditions: within (e) "Resident classification system" means the classification system used to classify residents into groups to determine reimbursement levels, as supported by the MDS and Case Mix Index Supportive Documentation Manual. Sec. 4. (a) The office shall publish Supporting documentation requirements for all the MDS data elements that are utilized used to classify nursing facility residents in accordance with under the RUG-IV resident classification system The requirements shall be are contained in the MDS and Case Mix Supportive Documentation Manual. Additional guidance may be published as a provider bulletin and may be updated by the office as needed. Any such Updates shall be made effective no not earlier than permitted under IC 12-15-13-6(a). (b) Nursing facilities shall maintain supporting documentation in the a resident's medical chart for all the MDS data elements that are utilized used to classify nursing facility residents in accordance with under the RUG-IV resident classification system. Such This supporting documentation shall be maintained by the nursing facility for all its residents in a manner way that is accessible allows availability and conducive to ease of access for review. Sec. 5. (a) The office shall periodically review the MDS assessments and supporting documentation data maintained by a nursing facilities facility for all its residents, regardless of payer type. The reviews shall be conducted as frequently as deemed considered necessary by the office, and each nursing facility shall be reviewed no not less frequently than every thirty-six (36) months. Advance notification of up to seventy-two (72) hours shall be provided by the office for all the MDS reviews, except for follow-up reviews that are intended to ensure compliance with validation improvement plans. Advance notification for follow-up reviews shall not be required. (b) All MDS assessments data, regardless of payer type, are subject to based on an MDS review. (c) When conducting the MDS reviews, the office shall consider all the MDS supporting documentation that is data provided by the nursing facility and is available to the reviewers prior to before the exit conference. MDS supporting documentation that is data provided by the nursing facility after the exit conference begins shall not be considered by the office. (d) The A nursing facility shall be required to produce, upon on request by the office, a computer generated copy of the MDS assessment that is transmitted in accordance with under section 1 of this rule, which shall be the basis for the MDS review. (e) Suspected intentional alteration of clinical documentation, or creation of documentation after MDS assessments data have been transmitted, shall be referred to the IMFCU Indiana Medicaid fraud control unit for investigation of possible fraud. Such an This investigation could may result in a felony or misdemeanor criminal conviction.