1. 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

2. 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.

3. 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

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

5. 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

6. Criminal Records Background Checks
, ,
Ohio Home Care Waiver

7. 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.

8. 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:
OAC

9. 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) 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
Columbus, Ohio  43218
OAC

10. 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

11. 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
Columbus, Ohio  43218

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

13. 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 ( )
Ohio Administrative Code (OAC)

14. 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 ( Waiver definitions)
Criminal record checks, incident reporting, provider monitoring reviews, and oversight
OAC

15. 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

16. 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

17. 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

18. 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 of the Administrative Code
The individual’s actions toward you are threatening or you feel unsafe or threatened in the individual’s environment
OAC

19. 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

20. PCG Health
Contact information for the Case Management Agencies
4/21/2018
During normal business hours, providers must call or 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) and CareStar (800)
Cleveland region:
CareSource (877) and CareStar (800)
Cincinnati region:
Council on Aging (855) and CareStar (800)
Marietta region:
CareSource (855) and CareStar (800)

21. 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 & 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 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)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. PCG Health
4/21/2018
Ohio Home Care Waiver: definitions of the covered services & provider requirements and specifications
Ohio Home Care Waiver

31. 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

32. 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

33. 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

34. 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

35. 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

36. Developing your Clinical Records,
Ohio Home Care Waiver

37. 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

38. 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

39. 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

40. 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 ,

41. 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 ,

42. 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

43. 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

44. Person Centered Services Plan & Provider Billing,
Ohio Home Care Waiver

45. 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

46. 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.)

47. 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.

48. 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.

49. 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
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

50. 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:
minutes
One Unit
minutes
Two Units
minutes
One Base Unit
1 hour and 15 minutes
One Base Unit + One Unit
1 hour and 30 minutes
One Base Unit + Two Units

51. 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 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 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 U5
Healthchek
Must be used to identify the individual receiving services due to Healthchek in accordance to OAC rule HQ
Group Visit
Must be used to identify individual receiving services in accordance to OAC rule 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.

52. 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

53. 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

54. 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:
All other remittance advice statements for claims submitted on or after 08/02/2011 are available through the MITS system.

55. Billing References for Agencies, Nurses, & PCA’s
Reference Information:
MITS Website:
Provider home page, log-in, enrollment, set-up/ registration
Web Portal Eligibility Verification: erify_Quick_Guide.pdf
Explains how to read the Web Portal eligibility screen
Provider Billing:
Website contains training on how to adjust overpayments.

57. Billing References for Agencies, Nurses, & PCA’s
Provider Training:
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
For Claims issues contact
Ordering, Referring, Prescribing Numbers (ORP) Info: Enrollment/ORP.aspx

58. ICD-10 Resources
Public Consulting Group (PCG):
Centers for Medicare and Medicaid Services (CMS):
Ohio Department of Medicaid (ODM):

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

60. 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

61. 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
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

62. 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

63. 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 and of the Ohio Administrative Code
OAC

64. 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

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

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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  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 or
You can watch a video at the following web address:
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

75. QUESTIONS
Please all waiver provider inquiries to: Please all My Care Ohio inquiries, comments & concerns to the Ohio Department of Medicaid:

76. Public Consulting Group, Inc.
PCG Health
4/21/2018
Public Consulting Group, Inc.
155 E. Broad St. 8th Floor Columbus, Ohio 43215
(877) ,