Ohio Home and Community-Based Service Waivers PCG Health 4/21/2018 Ohio Home and Community-Based Service Waivers Ohio Home Care Waiver Provider Education and Technical Assistance www.pcghealth.com www.pcghealth.com

Training Objectives Providers will understand the Ohio Administrative Code (OAC) rules regulating the Ohio Home Care Waiver (OHCW) Program. Providers will be knowledgeable of the required documentation within their waiver roles. Providers will be able to identify any issues or events that cause or could reasonably cause harm to a Waiver individual & the required reporting responsibilities to ensure the health and safety.

Waiver’s Target Population and Services PCG Health 4/21/2018 Waiver’s Target Population and Services The Ohio Home Care Waiver: Serves Medicaid eligible individuals under the age of 60 with long-term care needs that, in the absence of certain services, would require their needs to be met in a hospital or nursing facility. The Waiver service benefit package includes: Nursing - Personal Care Aide Services - Home Care Attendant Services - Adult Day Health Center Services - Home-Delivered Meals - Supplemental Adaptive and Assistive Devices - Supplemental Transportation - Out-of-Home Respite and Emergency Response Systems www.pcghealth.com

Training Overview Criminal Records, Background Checks, slides 6-11 5160-45-07 (Agency), 5160-45-08 (Non-agency), 5160-45-10 Provider Conditions of Participation, slides 12-29 5160-45-10 Provider- Type-Specific Requirements, slides 30-35 5160-46-04 and 5160-12-08 Developing your Clinical Records, slides 36-43 5160-46-04 and 5160-45-10 Person Centered Service Plans & Provider Billing, slides 44-58 5160-46-06 Structural Review, slides 59-64 5160-45-06 Incident Management and Reporting, slides 65-74 5160-45-05

Ohio Home Care Waiver Rules Please note, that this is not an all-inclusive list of Ohio Home Care Waiver rules. These rules are being highlighted as the most commonly referenced rules for the waiver programs and be found on LaWriter, see http://codes.ohio.gov/oac/

Criminal Records Background Checks 5160-45-10, 5160-45-07, 5160-45-08 Ohio Home Care Waiver

Criminal Records Background Checks Keeping waiver individuals safe begins with a quality, upstanding provider network.   It is for this reason that providers must undergo criminal record background checks upon enrolling as Medicaid providers, and again at certain times thereafter depending on whether you are a non-agency or agency provider.

Criminal Records Checks: Non-Agency Providers During the application process, then after becoming a non-agency provider, you will be informed by ODM before your anniversary date of you Medicaid provider agreement of the requirement to repeat the process. You must: Provide a set of fingerprint impressions Complete a criminal records check NOTE: This is a requirement for continued approval as a provider & you have 60 days to complete this process. To obtain a background check, you must go to a location that performs electronic Web Check A listing of Web Check agencies can be found on the Ohio Attorney General’s website at the following link, Web Check Community Listing: http://www.ohioattorneygeneral.gov/Business/Services-for-Business/WebCheck/Webcheck-Community-Listing OAC 5160-45-08

Criminal Records Checks: Non-Agency Providers, continued Provider background check(s) must be conducted by the Ohio Bureau of Criminal Identification and Investigation (BCI&I), The Web Check agencies will forward your fingerprint impressions and required document(s) to BCI&I If BCI&I does not receive the report within the required timeframe, ODM will move forward with revoking the provider’s agreement with the department Failure to submit the annual background check will lead to termination of the provider number Contact BCI&I by telephone at (877) 224-0043 for additional information. Background checks from BCI&I must be sent directly to this ODM address: The Ohio Department of Medicaid Attention: BCI Coordinator P.O. Box 183017 Columbus, Ohio  43218 OAC 5160-45-08

Criminal Records Checks: Agency Providers Agencies will complete a background check on new employees and as a condition of continued employment, agencies shall conduct a criminal records check of employees at least once every five years. Agency providers may not employ or continue to employ an employee if: An employee fails to submit a records check conducted by BCI&I, including failure to access and complete fingerprint impression sheet. An employee is included on the databases listed in the OAC including System for Award Management (SAM) Ohio Department of Developmental Disabilities (DODD) online abuser registry Internet- based sex offender & child- victim offender database Internet-based database of inmates State nurse aide registry & there is a statement detailing findings OAC 5160-45-07

Federal Bureau of Investigation (FBI) background checks, do you need one? New and existing providers are also required to submit a Federal Bureau of Investigation (FBI) background check in addition to the Ohio background check if any of the following applies: You have not lived in Ohio for the last five consecutive years ODM instructed you to obtain an FBI background check Background checks from either BCI&I and FBI must be sent directly to this ODM address: The Ohio Department of Medicaid Attention: BCI Coordinator P.O. Box 183017 Columbus, Ohio  43218

Conditions of Participation 5160-45-10 PCG Health 4/21/2018 Conditions of Participation 5160-45-10 Ohio Home Care Waiver www.pcghealth.com

Provider requirements: Conditions of Participation (COP) PCG Health Provider requirements: Conditions of Participation (COP) 4/21/2018 Ohio Department of Medicaid (ODM) – all administered waiver providers shall/ must: Maintain a professional relationship with individuals to whom they provide services Furnish services in a person- centered approach that follows the individual’s approved Person Centered Services Plan (PCSP), is attentive to the individual’s needs and maximizes the individual’s independence Refrain from any behavior that may detract from the goals, objectives and services outlined in the individual’s approved PCSP and / or may jeopardize the individual’s health & welfare Maintain an active, valid Medicaid Provider Agreement (5160-1-17.2) Ohio Administrative Code (OAC) 5160-45-10 www.pcghealth.com

Provider requirements: (COP) continued PCG Health Provider requirements: (COP) continued 4/21/2018 ODM –administered waiver providers must: Comply with all provider requirements, including but not limited to: Provider service specifications (5160-46-04 Waiver definitions) Criminal record checks, incident reporting, provider monitoring reviews, and oversight OAC 5160-45-10 www.pcghealth.com

Provider requirements per the COPs; coordinating services & missed visits You will work with the individual and case manager to coordinate service delivery, including, but not limited to: Agreeing to provide services in the amount, scope, location & duration the provider has the capacity to provide, and as specified on the individual's approved Person Centered Services Plan Participating in the development of a back -up plan in the event providers are unable to furnish services on the appointed date & time Contacting the back-up plan, the individual, and the case manger in the event the provider is unable to render services on the appointed date and time OAC 5160-45-10

More about coordinating services & missed visits In the case of an emergency, you must immediately activate the individual’s back -up plan set forth in the individual's approved PCSP, then contact the individual and Case Manager. To ensure that there is not a break in service delivery, you must verify their receipt of information about the absence. Please note that verifying the receipt of information is ONLY required for emergencies unplanned absences. In an event of a planned absence, you shall contact the individual and case manager no later than 72 hours prior to the absence & verify their receipt of information about the absence OAC 5160-45-10

Provider requirements per the COPs; notifications to the Case Manager PCG Health Provider requirements per the COPs; notifications to the Case Manager 4/21/2018 You need to report to the Case Management Agency within 24 hours when you are aware of issues that may affect the individual and/or any provider’s ability to render services as directed in the individual’s PCSP. Issues may include, but are not limited to the following: The individual consistently declines services The individual plans to, or moves to another residential address There are changes in the physical, mental, and/or emotional status of individual OAC 5160-45-10 www.pcghealth.com

Notifications to the Case Manager, continued.. PCG Health Notifications to the Case Manager, continued.. 4/21/2018 Reportable issues may include, but are not limited to the following: Changes in the individual’s environmental conditions The individual’s caregiver status has changed The individual no longer requires medically necessary services as defined in rule 5160-1-01 of the Administrative Code The individual’s actions toward you are threatening or you feel unsafe or threatened in the individual’s environment OAC 5160-45-10 www.pcghealth.com

Notifications to the Case Manager, continued.. Issues may include, but are not limited to the following: The individual is consistently non-compliant with physician orders including actions that may jeopardize their own health and welfare The individual’s requests conflict with his or her Person Centered Services Plan / or may jeopardize his or her health and welfare Any other situation that affects the individual’s health and welfare OAC 5160-45-10

PCG Health Contact information for the Case Management Agencies 4/21/2018 During normal business hours, providers must call or email the case manager using their contact information located on the individual’s Person Centered Services Plan. After hours, on the weekend or holidays, call the applicable number(s) below for further direction. Columbus region: CareSource (844) 832-0159 and CareStar (800) 616-3718 Cleveland region: CareSource (877) 209- 3154 and CareStar (800) 616-3718 Cincinnati region: Council on Aging (855) 372-6176 and CareStar (800) 616-3718 Marietta region: CareSource (855) 288-0003 and CareStar (800) 616-3718 www.pcghealth.com

Provider requirements per the COPs; keeping contact information current You need to make arrangements to accept all correspondence sent by ODM or it’s designee, including but not limited to certified mail You need to ensure that your contact information, including but not limited to address, telephone number, fax number & e-mail address are current. In the event of a change in contact information, you shall notify ODM via the Medicaid Information Technology System (MITS) & its designee, no later than 7 calendar days after such events occurred You need to provide & maintain a current e-mail address to ODM and its designee in order to receive electronic notification of any rule adoptions, amendments or rescissions, & any other communication from ODM or its designee PCG Provider Relations (877) 908-1746

What is My OhioHCP? This website organizes all of a provider’s important Ohio Home Care program information onto a private, individualized page. It includes important records including PCSP’s & structural review reports, news and updates, contact information, and more For log in issues contact PCG at 877-908-1746

Provider requirements per the COPs; how to discontinue Waiver services You need to submit written notification to the individual and ODM or its designee (Case Management Agency) at least 30 calendar days before the anticipated last date of service if you are terminating administered waiver services to the individual. Exceptions to the 30 day advanced notification: You must submit verbal and written notification to the individual and ODM or it’s designee at least ten days before the anticipated last date of service IF the individual: Has been admitted to the hospital Has been placed in an institutional setting Has been incarcerated ODM may waive advanced notification for you upon request and on a case-by-case basis. OAC 5160-45-10

Provider requirements per the COPs; prohibited actions At no time shall the ODM – Administered waiver service providers: Do anything that causes or may cause physical, verbal, mental, emotional distress or abuse to the individual, or behavior that may compromise the health & welfare of the individual Engage in an activity that may take advantage of or manipulate the individual or his or her authorized representative, family or household members, or may result in a conflict of interest exploitation, or any other advantage for personal gain Misrepresent yourself by the deliberate intent of your actions to deceive, either for profit or advantage OAC 5160-45-10

Provider Requirements per the COPs prohibited actions, continued While rendering services ODM –administered waiver service providers shall/ must not: Take the individual to your home Bring children, animals, friends, relatives, other individuals or anyone else to the individual's home Provide care to anyone other than the individual Smoke without the consent of the individual Sleep OAC 5160-45-10

Provider requirements per the COPs; prohibited actions, continued Use or be under the influence of alcohol, illegal drugs, chemical substances or controlled substances that may adversely affect your ability to furnish services Engage in any activity or conduct that may reasonably be interpreted as sexual in nature, regardless of whether or not it is consensual Engage in any behavior that my reasonably interpreted as inappropriate involvement in the individual’s personal beliefs or relationships Consume the individual’s food and/or drink without his or her offer and consent OAC 5160-45-10

Provider requirements per the COPs; prohibited actions, continued Engage in any that is not related to the services you are providing to the extent that the activity distracts, or interferes with, service delivery Including, but not limited to: Using electronic devices for personal or entertainment purposes including, but not limited to watching television, using the computer or playing games. Deliver services when you are medically, physically, or emotionally unfit. Engage in socialization with persons other than the individual. OAC 5160-45-10

Provider requirements per the COPs; prohibited actions, continued This includes but, is not limited to: Accepting, obtaining, attempting to obtain, borrow, or receive money or anything of value including, but not limited to gifts, tips, credit cards or other items Being designated on any financial account including, but not limited to bank accounts and credit cards OAC 5160-45-10

Provider requirements per the COPs; prohibited actions, continued This includes but, is not limited to continued: Using the Individual’s real or personal property Lending or giving money or anything of value Engaging in the sale or purchase of products, services or personal items Engaging in any activity that takes advantage of or manipulates ODM-administered waiver program rules OAC 5160-45-10

PCG Health 4/21/2018 Ohio Home Care Waiver: definitions of the covered services & provider requirements and specifications 5160-46-04 Ohio Home Care Waiver www.pcghealth.com

Registered Nurse (RN) & Licensed Practical Nurse (LPN) Requirements Nurses must: Maintain a valid Ohio nursing license Follow the Nurse Practice Act Obtain physician orders and be listed on physician’s orders and the PCSP prior to delivering services to any individual Ensure the physician’s order (plan of care) is updated at least once every 60 days Ensure all verbal orders are documented including date, time, and physician. Verbal orders need to be signed by the physician, or the order is not valid & nurses do not have the authorization to deliver services OAC 5160-46-04

Licensed Practical Nurse (LPN) Requirements Have a face-to-face visit at least every 60 days with the directing RN to evaluate the provision of waiver nursing services, LPN performance, and to assure services are being delivered in accordance with the approved Person Centered Services Plan Have a face-to-face visit at least every 120 days with directing RN, LPN, and individual/guardian to evaluate all of the above in addition to the individual’s satisfaction with care delivery The LPN must provide clinical notes, signed and dated by the LPN, documenting the face-to-face visits between the LPN and the directing RN Maintain documentation of plan of care review and physician orders by directing RN OAC 5160-46-04

Personal Care Aides (PCA) Requirements You must obtain a certificate of completion of either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health, or the medicare competency evaluation program for home health aides; or other equitant training program. Training on assisting individuals with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) needs. Basic home safety, and Universal precautions OAC 5160-46-04

Personal Care Aide (PCA) requirements; continuing education Both agency and non-agency PCAs must obtain and maintain first aid certification from a class that is not solely internet-based and includes hands-on training by a certified instructor Annually, PCAs must complete twelve hours of in-service continuing education on or before: An agency aide’s employment anniversary Agency and program specific orientations are exempt from the required 12 hours of continuing education. A non – agency aide’s Medicaid provider enrollment anniversary. Continuing education must be implemented immediately, and must be completed annually thereafter. OAC 5160-46-04

Agency Personal Care Aide (PCA) requirements Agency employed PCAs must receive supervision from an Ohio Licensed Registered Nurse (RN), or an Ohio Licensed Practical Nurse (LPN), at the direction of a RN at least every 60 days. These face-to-face consumer home visits must be documented in the individual’s record. OAC 5160-46-04

Developing your Clinical Records 5160-45-10, 5160-46-04 Ohio Home Care Waiver

Developing your Clinical Records, what is required? Non-agency waiver nursing & personal care aide service providers: Must leave a legible copy of the complete clinical record including the daily visit note & a copy of the PCSP in the individual’s home Must keep the original in your place of business Your place of business must be a location other than the individual’s residence Agencies, including Medicare- certified, or otherwise accredited agencies: Must maintain the clinical records at their place of business ALL clinical records are to be maintained in a confidential manner & maintained for a period of 6 years OAC 5160-46-04

Clinical Records for the individual must contain : Their name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health insurance identification numbers The individual’s medical history The name of individual's treating physician, which is also needed for billing A copy of the initial and all subsequent Person Centered Services Plan (PCSP) OAC 5160-46-04

Clinical Records for the individual must contain: Documentation of all drug & food interactions, allergies & dietary restrictions A copy of any advance directives including, but not limited to: Do Not Resituate (DNR) Medical Power of Attorney (POA) OAC 5160-46-04

Clinical Records: service/ visit records Service documentation is required for each visit and must contain all of the following: Your date of service Your arrival & departure times Tasks performed or not performed during each visit The dated signatures of both the provider & the individual verifying the service delivery upon completion of each service delivery OAC 5160-45-10, 5160-46-04

Clinical Records: service/ visit records continued Service documentation is required for each visit and must contain all of the following: Progress notes signed and dated by the provider documenting: All communications with the case manager, treating physician, or other members of the multidisciplinary team Documentation of any unusual events occurring during the visit Documentation of the general condition of the individual OAC 5160-45-10, 5160-46-04

Clinical Records: additional documentation for nurses A copy of all the initial and all subsequent plans of care specifying type, frequency, and duration of the nursing services being performed Plans of care must be recertified by the treating physician every 60 days, or more frequently when there is a significant change Documentation that the RN supervisor has reviewed the plans of care with the LPN OAC 5160-46-04

Clinical Records: discharge summary Home Health Aide Discharge Summary Must be signed & dated by the departing non-agency PCA or the RN supervisor of an agency PCA, at the point that personal care is no longer going to be provided, or when the individual no longer needs the personal care services The summary should include documentation regarding progress made toward achievement of goals as specified on the individual’s PCSP Nursing Discharge Summary Must be signed and dated by the departing nurse at the point the nurse is no longer going to provide services to the individual, or when the individual no longer needs nursing services Should include documentation regarding progress made toward goal achievement and indicate any recommended follow-ups or referrals OAC 5160-46-04

Person Centered Services Plan & Provider Billing 5160-46-04, 5160-46-06 Ohio Home Care Waiver

Person Centered Services Plan (PCSP) The Person Centered Services Plan is the document which identifies person-centered goals, objectives, and interventions including any authorized medically necessary services. As a provider of the Medicaid waiver program you are responsible to assure the following: Prior to delivery of any service(s), you must verify the individual’s Medicaid eligibility and that their PCSP is accurate and contains the following: The individual’s PCSP must list your name, the correct type of service(s) you agreed to provide, a correct procedure code for those services, and an approved start of care date You need to assure that the authorized hours listed on the goals page matches the authorization on the units page OAC 5160-46-04

Person Centered Services Plan (PCSP) Service authorizations are listed under “Methods” and “Units” sections of the Individual’s PCSP. The “Goals” section of the PCSP identifies the waiver service being provided The “Objective” section of the PCSP identifies what the individual hopes to achieve through implementation of interventions such as medically necessary services. The “Methods” section will detail the days, hours, and times you are authorized to work. The “Units” page of the PCSP identifies how many shifts are authorized, the services billing code, and the monthly cost of the service (if all of the services are delivered that month as authorized.)

Person Centered Services Plan (PCSP) The “Units” page of the PCSP identifies how many shifts are authorized, the services billing code, and the monthly cost of the service (if all of the services are delivered that month as authorized.) Any changes to an individual’s care or services must be updated on the individual’s PCSP and distributed to the service providers by the case manager. You may accept verbal approval from the Case Manager to make a change in schedule. However, you may not bill for these services until the PCSP has been updated with this written authorization.

Person Centered Services Plan (PCSP) PCG Health 4/21/2018 Person Centered Services Plan (PCSP) Providers should always verify that the information contained on PCSP is accurate on both the Goals page and Units page. www.pcghealth.com

Reimbursement Rates & Billing Procedures Providers must bill in accordance to the Ohio Home Care Waiver rules as it pertains to the base and unit rates outlined in Ohio Administrative Code 5160-46-06 Base Rate means the amount reimbursed by Ohio Medicaid for the first 35 to 60 minutes of service delivered time. Unit Rate means the amount reimbursed by Ohio Medicaid for each 15 minutes of service delivered when the visit is: Greater than 60 minutes in length Ohio Medicaid will reimburse a maximum of one unit of service when the service delivery is equal to or less than 15 minutes in length Ohio Medicaid will reimburse a maximum of 2 units if the service delivery is 16 through 34 minutes in length OAC 5160-46-06

Reimbursement Rates & Billing Procedures When the initial visit is greater than sixty minutes For a visit in length beyond the initial hour of service, the base rate plus the rate amount for each 15‐minute unit over the initial one hour may be claimed for services performed which does not exceed the prescribed OAC limits (e.g., visits not more than 4 hours for home health; more than 4 hours for Private Duty Nursing; or the individual’s PCSP). Length of visit Your billing should reflect: 1 - 15 minutes One Unit 16 - 34 minutes Two Units 35 - 60 minutes One Base Unit 1 hour and 15 minutes One Base Unit + One Unit 1 hour and 30 minutes One Base Unit + Two Units

Reimbursement Rates: OAC 5160-46-06 Billing Code Service Base rate Unit rate T1002 Waiver nursing services provided by an agency RN $47.40 $8.72 Waiver nursing services provided by a non-agency RN $38.95 $7.03 T1003 Waiver nursing services provided by an agency LPN $40.65 $7.37 Waiver nursing services provided by a non-agency LPN $33.20 $5.88 T1019 Personal care aide services provided by an agency personal care aide $23.12 $3.84 Personal care aide services provided by a non-agency personal care aide $18.64 $2.95 Modifier Description Requirement U1 Infusion Therapy Must be used with code G0154 for the purpose of identifying home infusion therapy provided in accordance with OAC rule 5160-12-01. U2 Second Visit Must be used to identify the second visit for the same type of service made by a provider on a date of service per individual in accordance to OAC rule 5160-12-04. U3 Third Visit Must be used to identify the third or more visit for the same type of service made by a provider on a date of service per individual in accordance to OAC rule 5160-12-04. U5 Healthchek Must be used to identify the individual receiving services due to Healthchek in accordance to OAC rule 5160-12-01. HQ Group Visit Must be used to identify individual receiving services in accordance to OAC rule 5160-12-04. TD RN Visit Must be used to identify a visit conducted by a registered nurse (RN) for home health nursing service billed to Ohio Medicaid. TE LPN Visit Must be used to identify a visit conducted by a licensed practical nurse (LPN) for home health nursing service billed to Ohio Medicaid.

Service & Billing Overview Providers shall only bill for services when those services were delivered face-to-face with an individual or up to three individuals in a group setting. Providers shall not bill for services while the individual receives care at another healthcare setting, physician’s office, hospital, or extended care facility 5160-46-04

Service & Billing Overview, Cont’d Providers must submit billing claims to the individual’s insurance prior to billing Medicaid. If the cost of service is covered by insurance, the provider shall not submit any billing claims to Medicaid. Providers should review billing after each submission to assure accuracy of claims which includes service delivery dates, units billed reflects time on timesheets, and bank deposit is the same as what was billed. ODM has 30 days to make a payment from the date of a clean submission

Billing Accuracy / Remittance Advice- what should you look for? Ensure your claims have the correct code, date of service, and individual Ensure that the clinical documentation matches the appropriate individual, length of visit, date billed, and PAID amount Review your billing claims after each submission to assure all claims are submitted accurately, including the amount PAID If an overpayment is found or a claim was billed incorrectly, you have 60 days to resubmit a correction to the claim Remittance advice statements for claims prior to 08/02/2011 are available on the Medicaid portal at: https://Medicaidremit.ohio.gov/default/home.jsf All other remittance advice statements for claims submitted on or after 08/02/2011 are available through the MITS system.

Billing References for Agencies, Nurses, & PCA’s Reference Information: MITS Website: https://portal.ohmits.com/public/Providers/tabid/43/Default.aspx Provider home page, log-in, enrollment, set-up/ registration Web Portal Eligibility Verification: http://Medicaid.ohio.gov/Portals/0/Providers/Training/MITS_Eligibility_V erify_Quick_Guide.pdf Explains how to read the Web Portal eligibility screen Provider Billing: http://Medicaid.ohio.gov/PROVIDERS/Training/BasicBilling.aspx Website contains training on how to adjust overpayments.

Billing References for Agencies, Nurses, & PCA’s Provider Training: http://ohiohcbs.pcgus.com/ Website contains a wealth of information and online training opportunities. Billing training is provided by ODM’s ombudsman unit. To request said Training or Consultation provided by ODM’s ombudsman unit contact 614-644-1399. For Claims issues contact 800-686-1516 Ordering, Referring, Prescribing Numbers (ORP) Info: http://Medicaid.ohio.gov/PROVIDERS/EnrollmentandSupport/Provider Enrollment/ORP.aspx

ICD-10 Resources Public Consulting Group (PCG): http://ohiohcbs.pcgus.com/ Centers for Medicare and Medicaid Services (CMS): www.cms.gov/ICD10 Ohio Department of Medicaid (ODM): http://www.Medicaid.ohio.gov/PROVIDERS/Billing/ICD10.aspx

Structural Review 5160-45-06 Ohio Home Care Waiver PCG Health 4/21/2018 Structural Review 5160-45-06 Ohio Home Care Waiver www.pcghealth.com

Structural Reviews of Providers Waiver providers are subject to Structural Reviews to evaluate provider compliance with all applicable Ohio Administrative Codes. Medicare-certified/ or otherwise accredited agencies are subject to reviews in accordance with their certification & accreditation bodies, and therefore shall be exempt from a regularly scheduled structural review. If requested to do so by the Ohio Department of Medicaid (ODM) or its designee (PCG), agencies shall submit a copy of their updated certification and/or accreditation, and shall make available to ODM or its designee within 10 business days, all review reports and accepted plans of correction from the certification and/or accreditation Note: All ODM-administered waiver providers may be subject to an announced or unannounced Structural Review at any time as determined by ODM or its designee. OAC 5160-45-06

Structural Reviews of Providers, how often will you participate? All other ODM-administered waiver providers shall be subject to Structural Reviews by ODM or its designee during each of the first three years.Thereafter, reviews shall be conducted annually unless, at the discretion of ODM, biennial reviews may be conducted, when all of the following apply: You had no findings during your most recent Structural Review You were not substantiated to be the violator in an incident described in rule 5160-45-05 You were not the subject of more than one provider occurrence during the previous 12 months You do not live with an individual receiving ODM-administered waiver services OAC 5160-45-06

Structural Reviews, what should you expect at the review? Structural reviews must be conducted in person between the provider & ODM or its designee with an ODM approved structural review tool The Structural Review shall not occur while you are providing services to an individual The Structural Review process consists of the following activities: Except for unannounced reviews, you shall be notified in advance of the review to arrange a mutually agreeable time, date & location for the review You shall be notified of the time period for which the review is being conducted OAC 5160-45-06

Structural Reviews, what should you expect, continued… The Structural Review process consists of the following activities continued: You shall be provided with a list of the type of documents required for the review You shall ensure the availability of the required documents & maintain the confidentiality of information about the individual enrolled in the ODM-administered waiver The Structural Review shall include an evaluation of your compliance with Chapters 5160-45 and 5160-46 of the Ohio Administrative Code OAC 5160-45-06

Structural Reviews, what should you expect? A unit of service verification shall be conducted to assure that all waiver services are authorized, delivered, & reimbursed in accordance with the approved PCSP for the individual receiving services At the conclusion of the review you shall receive: an exit conference containing preliminary findings, any individual remediation, & other required follow-up You will receive a written findings report summarizing the overall outcome of the structural review, specifying the administrative code rules that are the basis for which non-compliance has been determined, and outline the specific findings of noncompliance that you must address in a plan of correction, including any individual remediation OAC 5160-45-06

Incident Management & Reporting 5160-45-05 PCG Health 4/21/2018 Incident Management & Reporting 5160-45-05 Ohio Home Care Waiver www.pcghealth.com

Incident Management, what is an incident? An incident is an alleged, suspected, or actual event that is not consistent with routine care of and/or delivery to an individual. Incidents include, but are not limited to, all of the following: Abuse: actions towards the individual that could be reasonably be expected to result, in physical harm, pain, fear, or mental anguish. Types of abuse: physical harm, pain, fear, or mental anguish Neglect: when there is a duty to do so, failure to provide goods, services and/ or treatment necessary to assure the health and welfare of an individual Exploitation: the unlawful or improper act of using an individual or an individual’s resources for monetary or personal benefit, profit or gain. Death of an individual Hospitalization or emergency department visit (including observation) OAC 5160-45-05

What is an incident, continued Misappropriation: depriving, defrauding or otherwise obtaining the money, or real or personal property (including medications) of an individual by any means prohibited by law. Death of an individual Hospitalizations or emergency room visits including observation Unauthorized use of restraint, seclusion and/or restrictive intervention that does not result in, or cannot be reasonably be expected to result in, injury to the individual OAC 5160 45-05

Incidents include, continued: An unexpected crisis in the individual’s environment that results in the inability to assure the individual’s health & welfare in his or her primary place of residence Inappropriate service delivery including, but not limited to: Violations of the conditions of participation Services provided to an individual that are beyond your scope of practice Services delivered to the individual without, or not in accordance with the physician’s orders Medication administration errors OAC 5160-45-05

Incidents include, continued: Action on the part of the individual that place health & welfare of the individual at risk including, but not limited to: The individual cannot be located Activities that involve law enforcement Misuse of medications; and the use of illegal substances OAC 5160-45-05

Incident Reporting Responsibilities PCG Health 4/21/2018 Incident Reporting Responsibilities When you learn of a reportable incident; You must take immediate action to assure the health & welfare of the individual including, but not limited to seeking or providing medical attention CALL 911 You must notify the appropriate authority depending upon the nature of the incident. Examples include, but are not limited to the following: Law enforcement Adult / children’s protective agencies The licensure, certification board or accreditation body when the allegation involves a provider regulated by that entity OAC 5160-45-05 www.pcghealth.com

Requirement to review the Incident Management System’s OAC Upon entering into a Medicaid provider agreement, and annually thereafter, all providers must acknowledge in writing they have reviewed Ohio Administrative Code Rule 5160-45-05 Ohio department of Medicaid (ODM)-administered waiver program: incident management system. Reviewing the Incident Management & Reporting rule can be done one of two ways; You can review the rule (and all other rules we reviewed today) by visiting http://codes.ohio.gov/oac/5160-45-05; or You can watch a video at the following web address: http://ohiohcbs.pcgus.com/TrainingMaterials The next slide will show you where to find the link on the PCG Provider website. You are responsible to review the rule annually, you will not receive notification of this requirement. Keep documentation of the completion of this requirement in your records. OAC 5160-45-05

QUESTIONS Please email all waiver provider inquiries to: Ohiowaivers@pcgus.com Please email all My Care Ohio inquiries, comments & concerns to the Ohio Department of Medicaid: bmhc@medicaid.ohio.gov

Public Consulting Group, Inc. PCG Health 4/21/2018 Public Consulting Group, Inc. 155 E. Broad St. 8th Floor Columbus, Ohio 43215 (877) 908-1746, www.ohiohcbs@pcgus.com www.pcghealth.com