1. ODM Administered Waiver Program Rules
Ohio Administrative Code (OAC) Structural Review of Providers and Investigation of Provider Occurrences
OAC Provider Conditions of Participations
Heather Hire
March 4, 2015

2. What’s Changed?
July 1, 2013: The Ohio Department of Medicaid (ODM) became its own agency by separating from the Ohio Department of Job and Family Services.
OAC rules numbers changed from 5101:3- to 5160-
What changed in and
Reviewed and updated Code of Federal Regulation and US Codes cites
Changed all ODJFS references to ODM
Took out references to TDD Waiver
Rather than repeating the words of a referenced rule just the rule number is referenced
Changed the order of how the rules were set up
3/4/2015

3. Development
ODM has been convening an external stakeholder group since May 2013, for the purpose of reviewing OAC rules governing ODM-administered waivers. The workgroup generally met every two to four weeks (in-person and by phone) and has been responsible for the adoption, rescission and amendment of a number of rules thus far. Members include but is not limited to individuals enrolled on ODM-administered waiver, as well as members of the following organizations:
The Ohio Council for Home Care and Hospice
Public Consulting Group (PCG) (Provider Oversight Contractor)
Midwest Care Alliance
CareSource (Case Management Contractor) CareStar (Case Management Contractor)
Ohio Olmstead Task Force
Disability Rights Ohio
Council on Aging (Case Management Contractor)
Ohio Department of Aging
Ohio Department of Medicaid
Ohio Department of Developmental Disabilities
ODM also contacted several non-agency providers (i.e., nurses and personal care aides) for the purpose of soliciting comments regarding the proposed rules.
3/4/2015

4. Structural Reviews OAC 5160-45-06 February 1, 2015
All providers are subject to announced or unannounced structural reviews
Reviews must be conducted in person between the provider and/or ODM and its designee
All structural reviews must use an ODM-approved structural review tool
Structural Review will not be conducted while providing services to an individual
Except for unannounced reviews, the provider will be notified in advance
Providers will ensure availability of required documents and maintain confidentiality of the individual’s information
Incident reports and provider occurrences will be reviewed and findings of noncompliance will be addressed during the review
Reviews include an evaluation of compliance with OAC , -50 and -58
Unit of service evaluations will be conducted to assure that services are authorized, delivered and reimbursed in accordance with the all services plan
Reviewers determine if the provider has implemented all plans of correction that were approved since the last review
An exit conference will be conducted
A written findings report will be issued
3/4/2015

5. Structural Reviews
Medicare-certified and/or Otherwise-accredited Agencies
Are subject to reviews in accordance with their certification and accreditation bodies and are exempt from a regularly scheduled structural review.
Upon request a provider shall provide a copy of their updated certification and/or accreditation. This will include ALL review reports & accepted plans of correction from the certification and/or accreditation bodies.
3/4/2015

6. All Other Provider Types
Structural Reviews
All Other Provider Types
All waiver providers will have a structure review during each of the first three years of providing waiver services and annually thereafter unless ODM determines the provider meets all biennial criteria:
No findings during the most recent structural review
Not substantiated to be the violator in an incident
Not the subject of more than one provider occurrence during the previous twelve months and
Does not live with an individual
3/4/2015

7. Occurrences will be investigated by requesting documentation
Provider Occurrences
Any alleged, suspected or actual performance or operational issue that does not meet the definition of an incident
Provider eligibility
Service specification requirements
Billing issues, including overpayments and fraud
Occurrences will be investigated by requesting documentation
Provider will be notified of substantiated occurrences, including
Action or inaction that caused the occurrence
The rules that support the finding of noncompliance
What the provider must do to correct the findings including remediation or payment adjustments
3/4/2015

8. Structural Review and Provider Occurrences Plans of Corrections
Providers must accept letter
Providers have 45 Calendar Days to submit a plan of correction
If submitted plan of correction is unaccepted, provider will have 10 days to resubmit an acceptable plan of correct
Payment adjustment must be completed for overpayments
ODM may take action against a provider in accordance with OAC rule for failure to comply with any of the requirements set forth in this rule
3/4/2015

9. Provider Conditions of Participation OAC 5160-45-10
Maintain professional relationship with the individual
Provide services in a person-centered manner in accordance with the approved all services plan
Attentive to individual’s needs
Maximize the individual’s independence
Refrain from any behavior that detracts from the goals, objectives and services outlined in the all services plan and/or jeopardizes the individual’s health and welfare
3/4/2015

10. Conditions of Participation “Shall”
Maintain valid provider agreement
Comply with provider requirements
Enrollment
Service specifications
Criminal record checks
Incident reporting
Provider monitoring, reviews and oversight
3/4/2015

11. Conditions of Participation “Shall”
Deliver services professionally, respectfully and legally
Ensure individuals are protected from abuse, neglect, exploitation and other threats to their health, safety and well-being
Acknowledge in writing they have reviewed the incident management and related procedures rule
3/4/2015

12. Conditions of Participation “Shall”
Work with the individual and case manager to coordinate service delivery
Agree to provide services in the amount, scope, location and duration
Participate in the development of a back-up plan
Contact the individual and the case manager if unable to render the services
Provide documentation when requested
Participate in mandated or sponsored provider trainings
Be knowledgeable and comply with all federal and state laws including the 1996 Health Insurance Portability and Accountability Act (HIPAA)
Ensure contact information is up to date in the MITS system
Maintain and retain all required documentation for six years
Cooperate with all provider monitoring and oversight
WITH ALL PROVIDER M
3/4/2015

13. Conditions of Participation “Shall”
Notify ODM or its designee within 24 hours when aware of issues that may affect the individual
Individual consistently declines services
Individual plans to or has moved
Changes in the physical, mental and/or emotional status of the individual
Changes in the individual’s environmental conditions
Individual’s caregiver status has changed
Individual no longer requires medically necessary services
Individual’s actions toward the provider are threatening or the provider feels unsafe in the environment
Individual is consistently noncompliant with physician orders that may jeopardize his/her health and welfare
Individual’s requests conflict with his/her all services plan and/or may jeopardize his/her health and welfare
Any other situation that affects the individual’s health and welfare
WITH ALL PROVIDER M
3/4/2015

14. Conditions of Participation “Shall”
Accept all correspondence from ODM or its designee
Provide and maintain current address to receive electronic notification of rules or any other communication
Submit written notification within 30 calendar days to the individual and ODM or its designee to cease services
Exceptions
Verbal and written notification to individual and ODM/designee at least 10 days before the last date of service
Individual admitted to hospital
Individual place in institutional setting or
Individual has been incarcerated
Only ODM may waive advance notification
WITH ALL PROVIDER M
3/4/2015

15. Conditions of Participation “Shall Not”-at no time
Engage in any behavior that causes or may cause physical, verbal, mental or emotional abuse or distress to the individual
Engage in any other behavior that may compromise the health and welfare of the individual
WITH ALL PROVIDER M
3/4/2015

16. Conditions of Participation “Shall Not”- at no time
Engage in any activity or behavior that takes advantage of or manipulate the individual, his/her authorized representative, family or household members or may result in a conflict of interest, exploitation or personal gain
Misrepresentation
Accepting, obtaining, attempting to obtain, borrowing, or receiving money or anything of value
Being designated on any financial account
Using real or personal property of another
Using information of another
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 the rules
WITH ALL PROVIDER M
3/4/2015

17. Conditions of Participation “Shall Not”-at no time
Falsify the individual’s signature, including using copies of the signature
Make fraudulent, deceptive or misleading statements in the advertising, solicitation, administration or billing of services
Submit a claim while the individual is hospitalized, institutionalized or incarcerated
WITH ALL PROVIDER M
3/4/2015

18. Conditions of Participation “Shall Not”- while rendering services
Take the individual to the provider’s residence
Bring children, animals, friends, relatives, other individuals or anyone else to the individual’s place of residence
Provide care to persons other than the individual
Smoke without the consent of the individual
Sleep
Engage in any activity not related to the services
Using electronic devices for personal or entertainment purposes
Making or receiving personal communication
Socializing with persons other than the individual
WITH ALL PROVIDER M
3/4/2015

19. Conditions of Participation “Shall Not”- while rendering services
Deliver services when the provider is medically, physically or emotionally unfit
Use or be under the influence of alcohol, illegal drugs, chemical substances or controlled substances (that adversely affect the provider) while providing services
Engage in sexual activity or conduct whether or not it is consensual
Engage in behavior that is inappropriate involvement in the individual’s personal beliefs or relationships (religion, politics or personal issues)
Consume the individual’s food and/or drink without his/her offer or consent
WITH ALL PROVIDER M
3/4/2015

20. Conditions of Participation “Shall Not”
Be designated to serve or make decisions for the individual in any capacity involving a declaration for mental health treatment, general power of attorney, health care power of attorney, financial power of attorney, guardianship pursuant to court order, authorized representative or representative payee
WITH ALL PROVIDER M
3/4/2015

21. Conditions of Participation
All providers shall pay applicable federal, state, and local taxes
Failure to meet any of these requirements could lead to termination of the provider agreement
WITH ALL PROVIDER M
3/4/2015

22. QUESTIONS?
3/4/2015

23. Heather A. Hire, CPM Provider Oversight Manager Bureau of Long Term Care Services and Supports (614)
3/4/2015