Chapter 5101:3-12 Ohio Home Care Program

5101:3-12-01 Home health services: provision requirements, coverage and service specification.

(A) “Home health services” includes home health nursing, home health aide and skilled therapies as defined in paragraph (F) of this rule.

(B) Home health services are covered only if provided on a part-time and intermittent basis, which means:

(1) No more than a combined total of eight hours (thirty-two units) per day of home health nursing, home health aide, and skilled therapies except as specified in paragraph (G) of this rule;

(2) No more than a combined total of fourteen hours (fifty-six units) per week of home health nursing and home health aide services except as specified in paragraphs (C) and (G) of this rule; and

(3) Visits are not more than four hours (sixteen units). Most visits are usually less than two hours (eight units). Nursing visits over four hours (sixteen units) may qualify for coverage in accordance with rule 5101:3-12-02 of the Administrative Code.

(C) A combined total of twenty-eight hours (one hundred twelve units) per week of home health nursing and home health aide services is available to a consumer for up to sixty consecutive days from the date of discharge from an inpatient hospital stay of three or more covered days, if all of the following are met by the consumer as certified by the treating physician using the JFS 07137 “Certificate of Medical Necessity Home Care Certification” (rev. 7/2006):

(1) Consumer has a discharge date from an inpatient hospital stay of three or more covered days. For the purposes of this rule, a covered inpatient hospital stay is defined in rule 5101:3-2-03 of the Administrative Code and is considered one hospital stay when a consumer is transferred from one hospital to another hospital, either within the same building or to another location. The sixty days will begin once the consumer is discharged to the consumer’s place of residence or to a nursing facility as defined in paragraph (D) (3) of this rule, from the last inpatient stay whether or not the last inpatient stay was an inpatient hospital or inpatient rehabilitation unit of a hospital.

(2) Consumer has a comparable level of care as evidenced by either:

(a) Enrollment in a home and community based services (HCBS) waiver; or

(b) Has a medical condition that temporarily meets the criteria for an institutional level of care which are any of the following rules defined in rule 5101:3-3-05 of the Administrative Code for skilled level of care (SLOC), or defined in rule 5101:3-3-06 of the Administrative Code for intermediate level of care, or defined in rule 5101:3-3-07 of the Administrative Code for ICF/MR level of care. In no instance does this requirement constitute the determination of a level of care for waiver eligibility status, or admission into a medicaid covered long term care institution.

(3) Requires home health nursing or a combination of private duty nursing/home health nursing/waiver nursing/skilled therapy services at least once per week that is medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code.

(4) The consumer has had a covered inpatient hospital stay of three or more days, with the discharge date recorded on form JFS 07137 “Certificate of Medical Necessity Home Care Certification” (rev. 7/2006).

(D) The only provider of home health services is the MCRHHA (medicare certified home health agency) that meets the requirements in accordance with rule 5101:3-12-03 of the Administrative Code. In order for home health services to be covered, MCRHHAs must:

(1) Provide home health services that are appropriate given the consumer’s diagnosis, prognosis, functional limitations and medical conditions as ordered by the consumer’s treating physician for the treatment of the consumer’s illness or injury.

(2) Provide home health services as specified in the plan of care in accordance with rule 5101:3-12-03 of the Administrative Code. Home health services not specified in a plan of care are not reimbursable. Additionally the MCRHHA’s plan of care must provide the amount, scope, duration, and type of home health service as:

(a) Identified on the all services plan as defined in rule 5101:3-45-01 of the Administrative Code that is prior approved by ODJFS or the case management agency when a consumer is enrolled in an ODJFS-administered home and community based services (HCBS) waiver. Home health services that are not identified on the all services plan are not reimbursable; or

(b) Documented on the services plan when a consumer is enrolled in an ODA (Ohio department of aging) administered or an ODMR/DD (Ohio department of mental retardation and developmental disabilities) administered HCBS waiver. Home health services that are not documented on the services plan are not reimbursable.

(3) Provide home health services in the consumer’s place of residence, in a licensed child day-care center, or for a child three years and under in a setting where the child receives early intervention services (EI) as indicated in the individualized family service plan (IFSP).

(a) “Consumer’s place of residence” is wherever the consumer lives, whether the home is the consumer’s own dwelling, an apartment, an assisted living residence, a relative’s home, or an other type of living arrangement. The place of residence does not include a hospital, nursing facility, or intermediate care facility for the mentally retarded (ICR/MR).

(b) For the purposes of this chapter, “licensed child day-care center” means a “child day-care center” as defined in section 5104.01 of the Revised Code that is licensed pursuant to section 5104.03 of the Revised Code but does not include a licensed child day-care center that is the permanent residence of the licensee or administrator.

(4) Not provide home health nursing and home health aide services for the provision of habilitative care, or respite care, and not provide skilled therapies for the provision of maintenance care, habilitative care or respite care.

(a) “Maintenance care” is the care given to a consumer for the prevention of deteriorating or worsening medical conditions or the management of stabilized chronic diseases or conditions. Services are considered maintenance care if the consumer is no longer making significant improvement in his or her medical condition.

(b) “Habilitative care” is in accordance with Chapter 5101:3-1 of the Administrative Code.

(c) “Respite care” is the care provided to a consumer unable to care for himself or herself because of the absence or need for relief of those persons normally providing care.

(5) Bill for provided home health services in accordance with the visit policy in rule 5101:3-12-04 of the Administrative Code.

(6) Bill for provided home health services using the appropriate procedure code and applicable modifiers in accordance with rule 5101:3-12-05 of the Administrative Code.

(7) Bill after all documentation is completed for the services rendered during a visit in accordance with rule 5101:3-12-03 of the Administrative Code.

(E) Consumers who receive home health services must:

(1) Be under the supervision of a treating physician who is providing care and treatment to the consumer. The treating physician cannot be a physician whose sole purpose is to sign and authorize plans of care or who does not have direct involvement in the care or treatment of the consumer. A treating physician may be a physician who is substituting temporarily on behalf of a treating physician.

(2) Participate in the development of a plan of care along with the treating physician and the MCRHHA. An authorized representative may participate in the development of a plan of care in lieu of the consumer.

(3) Access home health services in accordance with the program for the all-inclusive care of the elderly (PACE) when the consumer participates in the PACE program.

(4) Access home health services in accordance with the consumer’s provider of hospice services when the consumer has elected the hospice benefit.

(5) Access home health services in accordance with the consumer’s managed care plan when the consumer is enrolled in a medicaid managed care plan.

(F) Covered home health services are:

(1) “Home health nursing” is a nursing service that requires the skills of and is performed by a registered nurse, or a licensed practical nurse at the direction of a registered nurse. The nurse performing the service must be employed or contracted by the MCRHHA providing the service. A service is not considered a nursing service merely because it is performed by a licensed nurse. Home health nursing services:

(a) Must be performed within the nurse’s scope of practice as defined in Chapter 4723. of the Revised Code and rules adopted there under.

(b) Must be provided and documented in accordance with the consumer’s plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(d) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer’s illness or injury.

(e) Are not covered when the visit is solely for the supervision of the home health aide.

(f) May include home infusion therapy for the administration of medications, nutrients or other solutions intravenously, or enterally. A visit made for the purpose of home infusion therapy must be billed using the U1 modifier in accordance with rule 5101:3-12-05 of the Administrative Code.

(2) “Home health aide” is a service that requires the skills of and is performed by a home health aide employed or contracted by the MCRHHA providing the service. Home health aide services:

(a) Are performed within the home health aide’s scope of practice as defined in 42 C.F.R. 484.36 (October 1, 2005). The home health aide cannot be the parent, step-parent, foster parent or legal guardian of a consumer who is under eighteen years of age, or the consumer’s spouse.

(b) Are provided and documented in accordance with the consumer’s plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(d) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer’s illness or injury.

(e) Must be necessary to facilitate the nurse or therapist in the care of the consumer’s illness or injury, or help the consumer maintain a certain level of health in order to remain in the home setting. Health related services can include:

(i) Bathing, dressing, grooming, hygiene, including shaving, skin care, foot care, ear care, hair, nail and oral care, that are needed to facilitate care or prevent deterioration of the consumer’s health, and including changing bed linens of an incontinent or immobile consumer.

(ii) Feeding, assistance with elimination including administering enemas (unless the skills of a home health nurse are required), routine catheter care, routine colostomy care, assistance with ambulation, changing position in bed, and assistance with transfers.

(iii) Performing a selected nursing activity or task as delegated in accordance with Chapter 4723-13 of the Administrative Code, and performed as specified in the plan of care.

(iv) Assistance with activities such as routine maintenance exercises and passive range of motion as specified in the plan of care. These activities are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed. The plan of care is developed by either a licensed nurse or therapist within their scope of practice.

(v) Performing routine care of prosthetic and orthotic devices.

(f) May also include incidental services along with health related services as listed in paragraph (F)(2)(d) of this rule, as long as they do not substantially extend the time of the visit.

(i) Incidental services are necessary household tasks that must be performed by anyone to maintain a home and can include light chores, consumer’s laundry, light house cleaning, preparation of meals, and/or taking out the trash.

(ii) The main purpose of a home health aide visit cannot be solely to provide these incidental services since they are not health related services.

(iii) Incidental services are to be performed only for the consumer and not for other people in the consumer’s covered place of residence.

(3) “Skilled therapies” are defined as physical therapy, occupational therapy, and speech-language pathology services that require the skills of and are performed by skilled therapy providers to meet the consumer’s medical needs, promote recovery, and ensure medical safety for the purpose of rehabilitation.

(a) “Skilled therapy providers” are licensed physical therapists, occupational therapists, speech-language pathologists, licensed physical therapy assistants (LPTA) under the direction of a physical therapist, or certified occupational therapy assistants (COTA) under the direction of a licensed occupational therapist who are contracted or employed by a MCRHHA.

(b) “Rehabilitation” is the care of a consumer with the intent of curing the consumer’s disease or improving the consumer’s condition by the treatment of the consumer’s illness or injury, or the restoration of a function affected by illness or injury.

(i) Must be provided to the consumer within the therapist’s or therapy assistant’s scope of practice in accordance with sections 4755.44, 4755.07, and 4753.07 of the Revised Code.

(ii) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer’s illness or injury.

(iii) Must be provided and documented in the consumer’s plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(iv) Must be reasonable in their amount, frequency, and duration. Treatment must be considered according to the accepted standards of medical practice to be safe and effective treatment for the consumer’s condition.

(v) Must be provided with the expectation of the consumer’s rehabilitation potential according to the treating physician’s prognosis of illness or injury. The expectation of the consumer’s rehabilitation potential is that the condition of the consumer will measurably improve within a reasonable period of time or the services are necessary to the establishment of a safe and effective maintenance program.

(vi) May include treatments, assessments and/or therapeutic exercises but cannot include activities that are for the general welfare of the consumer, including motivational or general activities for the overall fitness of the consumer.

(G) A consumer who meets the requirements in this paragraph may qualify for increased services. The MCRHHA must assure and document the consumer meets all requirements in this paragraph prior to increasing services. The U5 modifier must be used when billing in accordance to rule 5101:3-12-05 of the Administrative Code. The use of the U5 modifier indicates that all conditions of this paragraph were met. The consumer who meets the following requirements may receive an increase of home health services if he or she:

(1) Is under age twenty-one and requires services for treatment in accordance with Chapter 5101:3-14 of the Administrative Code for the healthchek program.

(2) Requires more than, as ordered by the treating physician:

(a) Eight hours (thirty two units) per day of any home health service, or a combined total of fourteen hours (fifty six units) per week of home health aide and home health nursing as specified in paragraph (B) of this rule; or

(b) A combined total of twenty-eight hours (one hundred twelve units) per week of home health nursing and home health aide for sixty days as specified in paragraph (C) of this rule.

(3) Has a comparable level of care as evidenced by either:

(a) Enrollment in a HCBS waiver; or

(b) A level of care evaluated initially and annually by ODJFS or its designee for a consumer not enrolled in a HCBS waiver. The criteria for an institutional level of care are any of the rules regarding the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code, intermediate level of care (ILOC) as defined in rule 5101:3-3-06 of the Administrative Code, or ICF/MR level of care as defined in rule 5101:3-3-07 of the Administrative Code. In no instance does this constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long term care institution; and

(4) Requires home health nursing or a combination of PDN/home health nursing/waiver nursing/skilled therapy visits at least once per week that is medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code as ordered by the treating physician.

Effective: 11/08/2007

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021

Prior Effective Dates: 4/4/77, 4/7/77, 12/21/77, 6/1/80, 5/1/87, 4/1/88, 5/15/89, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/1/93 (Emer), 7/30/93, 9/1/93, 1/1/96, 5/1/98, 7/1/98, 9/29/00, 3/1/02 (Emer), 5/30/02, 1/31/05, 9/1/05, 7/1/06

5101:3-12-02 Private duty nursing: services, provision requirements, coverage and service specification.

(A) “Private duty nursing (PDN)” is a continuous nursing service that requires the skills of and is performed by either a registered nurse or a licensed practical nurse at the direction of a registered nurse and is provided in one or more PDN visits. A continuous nursing visit (or PDN visit) is defined as a medically necessary visit that is more than four hours (more than sixteen units) but less than or equal to twelve hours (forty-eight units) in length. A service is not considered a nursing service merely because it was performed by a licensed nurse. For dates of service on or after 7/01/06, a covered PDN visit must meet the definition of paragraph (A) in rule 5101-3-12-04 of the Administrative Code and be more than four hours (more than sixteen units) in length but less than or equal to twelve hours (forty-eight units) in length, unless:

(1) An unusual, occasional circumstance requires a medically necessary visit of up to and including sixteen hours (sixty-four units); or

(2) Less than a two hour lapse between visits has occurred and the length of the PDN service requires an agency to provide a change in staff; or

(3) Less than a two hour lapse between visits has occurred and the PDN service is provided by more than one non-agency provider; or

(4) ODJFS or its designee has authorized PDN visits that are four hours or less length in accordance with rule 5101:3-12-02.3 of the Administrative Code.

(B) For PDN to be covered, the service:

(1) Must be performed within the nurse’s scope of practice as defined in Chapter 4723. of the Revised Code and rules adopted thereunder.

(2) Must be provided and documented in accordance with the consumer’s plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(3) Must be provided in a face-to-face encounter.

(4) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer’s illness or injury.

(5) May include home infusion therapy for the administration of medications, nutrients or other solutions intravenously or enterally. A visit made for the purpose of home infusion therapy must be billed using the U1 modifier in accordance with rule 5101:3-12-06 of the Administrative Code.

(6) Must be provided in the consumer’s place of residence unless it is medically necessary for a nurse to accompany the consumer in the community. The consumer’s place of residence is wherever the consumer lives, whether the residence is the consumer’s own dwelling, an apartment, assisted living facility, a relative’s home, or other type of living arrangement. The place of residence cannot include a hospital, nursing facility, or intermediate care facility for the mentally retarded (ICF-MR). The place of service in the community cannot include the residence or business location of the provider of PDN.

(7) Must not be provided for the provision of habilitative care. “Habilitative care” is referenced in Chapter 5101:3-1 of the Administrative Code.

(8) Must meet the criteria in accordance with this paragraph and paragraphs (A), (C) and (D) of this rule.

(9) For “children” (consumers under the age of twenty-one), must also meet the criteria in accordance with either paragraph (E) or (F) of this rule.

(10) For “adults” (consumers age twenty-one and older), must also meet the criteria in accordance with either paragraph (E) or (G) of this rule.

(C) The providers of PDN are: MCRHHAs (medicare certified home health agencies) that meet the requirements in accordance with rule 5101:3-12-03 of the Administrative Code, an otherwise accredited agency that meets the requirements in accordance with rule 5101:3-12-03.1 of the Administrative Code, and a non-agency nurse that meets the requirements in accordance with rule 5101:3-12-03.1 of the Administrative Code. In order for PDN to be covered, these providers must:

(1) Provide PDN that is appropriate given the consumer’s diagnosis, prognosis, functional limitations and medical conditions as documented by the consumer’s treating physician.

(2) Provide PDN as specified in the plan of care in accordance with rule 5101:3-12-03 of the Administrative Code. PDN services not specified in a plan of care are not reimbursable. Additionally, for consumers enrolled on an HCBS waiver, the providers of PDN services must provide the amount, scope, duration, and type of PDN service within the plan of care as:

(a) Identified on the all services plan that is approved by ODJFS or the case management agency when a consumer is enrolled in an ODJFS administered home and community based services (HCBS) waiver. PDN services not identified on the all services plan are not reimbursable; or

(b) Documented on the services plan when a consumer is enrolled in an ODA (Ohio department of aging) administered or an ODMR/DD (Ohio department of mental retardation and developmental disabilities) administered HCBS waiver. PDN services not documented on the services plan are not reimbursable.

(3) Bill for provided PDN services using the appropriate procedure code and applicable modifiers in accordance with rule 5101:3-12-06 of the Administrative Code.

(4) Bill for provided PDN services in accordance with the visit policy in rule 5101:3-12-04 of the Administrative Code, except as provided for in paragraph (A) of this rule.

(5) Bill after all documentation is completed for services rendered during a visit in accordance with rule 5101:3-12-03 of the Administrative Code.

(D) Consumers who receive PDN must:

(2) Participate in the development of a plan of care with the treating physician and the MCRHHA or other accredited agencies or non-agency registered nurse. An authorized representative may participate in the development of the plan of care in lieu of the consumer.

(3) Access PDN in accordance with the program for the all-inclusive care of the elderly (PACE) if the consumer participates in the PACE program.

(4) Access PDN in accordance with the consumer’s provider of hospice services if the consumer has elected hospice.

(5) Access PDN in accordance with the consumer’s managed care plan if the consumer is enrolled in a medicaid managed care plan.

(E) Post hospital – PDN:

(1) Any medicaid consumer, whether adult or child, may receive PDN services up to fifty-six hours (two hundred twenty-four units) per week, and up to sixty consecutive days from the date of discharge from an inpatient hospital stay of three or more covered days in accordance with rule 5101:3-2-03 of the Administrative Code. For purposes of this rule, a covered inpatient hospital stay is considered one hospital stay when a consumer is transferred from one hospital to another hospital, either within the same building or to another location.

(a) The sixty days will begin once the consumer is discharged from the hospital to the consumer’s place of residence as defined in paragraph (B)(6) of this rule, from the last inpatient stay whether or not the last inpatient stay was in an inpatient hospital or inpatient rehabilitation unit of a hospital.

(b) The sixty days will begin once the consumer is discharged from a hospital to a nursing facility. PDN is not available while residing in a nursing facility.

(2) The treating physician or a hospital discharge planner or a registered nurse acting under the orders of the treating physician certifies the medical necessity of PDN services using the JFS 07137 “Home Care Physician Certification Form” (rev. 7/2006). PDN is available to consumers only if they have a medical need comparable to a skilled level of care as evidenced by a medical condition that temporarily reflects the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code. In no instance do these requirements constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long-term care institution.

(3) The PDN service must not be for the provision of maintenance care. “Maintenance care” is the care given to a consumer for the prevention of deteriorating or worsening medical conditions or the management of stabilized chronic diseases or conditions. Services are considered maintenance care if the consumer is no longer making significant improvement in his or her medical condition.

(4) All requirements must be met in paragraph (E) of this rule as well as all the requirements in paragraphs (A), (B), (C) and (D) of this rule.

(5) Consumers who require additional PDN with or without a hospitalization may access PDN through either paragraph (F) or (G) of this rule.

(F) Child – PDN:

(1) A child may qualify for PDN services if he or she meets the requirements within paragraph (F) of this rule.

(a) Is under age twenty-one and requires services for treatment in accordance with Chapter 5101:3-14 of the Administrative Code for the healthchek program.

(b) Requires (as ordered by the treating physician) continuous nursing including the provision of on-going maintenance care. Services cannot be for habilitative care as defined in paragraph (B)(7) of this rule.

(i) Enrollment in a HCBS waiver; or

(ii) A comparable institutional level of care as evaluated initially and annually by ODJFS or its designee for a consumer not enrolled in a HCBS waiver. The criteria for an institutional level of care are any of the rules regarding the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code, intermediate level of care (ILOC) as defined in rule 5101:3-3-06 of the Administrative Code, or ICF/MR level of care as defined in rule 5101:3-3-07 of the Administrative Code. In no instance do these criteria constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long-term care institution.

(2) The provider of PDN services must assure and document the consumer meets all requirements in paragraph (F) of this rule prior to requesting and billing for the PDN services.

(3) The U5 modifier must be used when billing in accordance with rule 5101:3-12-06 of the Administrative Code. The use of the U5 modifier indicates that all conditions of paragraph (F) of this rule were met, PDN authorization was obtained and the consumer continued to meet medical necessity criteria.

(4) The child must have a PDN authorization obtained in accordance with rule 5101:3-12-02.3 of the Administrative Code and approved by ODJFS or its designee to establish medical necessity and the consumer’s comparable level of care. ODJFS or its designee will conduct a face-to-face encounter and/or review of documentation. In an emergency, PDN services may be delivered and PDN authorization obtained after the delivery of services when the services are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, and the services are required to protect the health and welfare of the consumer. A request for PDN authorization is made as follows:

(a) For a child not enrolled in a HCBS waiver, the provider of PDN must submit the request to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider of the amount, scope and duration of services authorized.

(b) For a child enrolled in an ODMR/DD or ODA-administered waiver, the provider of PDN must submit the request to the case manager of the HCBS waiver, who will be forwarded to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider and the case manager of the amount, scope and duration of services authorized.

(c) For a child enrolled in an ODJFS-administered waiver, the case manager will authorize PDN services through the all services plan.

(5) All requirements must be met in paragraph (F) of this rule as well as all the requirements in paragraphs (A), (B), (C) and (D) of this rule.

(G) Adult – PDN: The adult consumer who meets the following requirements may receive PDN services.

(1) The adult is age twenty-one or older.

(2) The adult requires (as ordered by the treating physician) continuous nursing including the provision of on-going maintenance care. Services cannot be for habilitative care as defined in paragraph (B)(7) of this rule.

(3) The adult has a comparable level of care as evidenced by either:

(a) Enrollment in a HCBS waiver; or

(b) A comparable institutional level of care as evaluated initially and annually by ODJFS or its designee for a consumer not enrolled in a HCBS waiver. The criteria for an institutional level of care are any of the rules regarding the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code, intermediate level of care (ILOC) as defined in rule 5101:3-3-06 of the Administrative Code, or ICF/MR level of care as defined in rule 5101:3-3-07 of the Administrative Code. In no instance does this constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long term care institution.

(4) The provider of PDN services must assure and document the consumer meets all requirements in paragraph (G) of this rule prior to providing PDN. Providers must bill using the U6 modifier in accordance with rule 5101:3-12-06 of the Administrative Code. The use of the U6 modifier indicates that all conditions of paragraph (G) of this rule were met, PDN authorization was obtained and the consumer continued to meet medical necessity criteria.

(5) The adult must have a PDN authorization obtained in accordance with rule 5101:3-12-02.3 of the Administrative Code and approved by ODJFS or its designee to establish medical necessity and the consumer’s comparable level of care. ODJFS or its designee will conduct a face-to-face encounter and/or review of documentation. In an emergency, PDN services may be delivered and PDN authorization obtained after the delivery of services when the services are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, and the services are required to protect the health and welfare of the consumer. A request for PDN authorization is made as follows:

(a) For an adult not enrolled in a HCBS waiver, the provider of PDN must submit the request to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider of the amount, scope and duration of services authorized.

(b) For an adult enrolled in an ODMR/DD or ODA-administered waiver, the provider of PDN must submit the request to the case manager of the HCBS waiver, who will forward the request to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider and the case manager of the amount, scope and duration of services authorized.

(c) For an adult enrolled in an ODJFS-administered waiver, the case manager will authorize PDN services through the all services plan.

(6) All requirements must be met in paragraph (G) of this rule as well as all the requirements in paragraphs (A), (B), (C) and (D) of this rule.

(H) Consumers subject to medical determinations made by ODJFS or its designee pursuant to this rule will be afforded notice and hearing rights to the extent afforded in division 5101:6 of the Administrative Code.

Replaces: Part of 5101:3-12-01, 5101:3-12-02, 5101:3-12-03, 5101:3-12-04, 5101:3-12-05, 5101:3-12-06

Effective: 09/28/2006

R.C. 119.032 review dates: 09/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.85

5101:3-12-02.1 Provision for consumers enrolled in and providers who provide the core plus benefit package services.

(A) Core plus benefit package will no longer be available as of the effective date of this rule. The core plus benefit package was defined in Chapter 5101:3-12 of the Administrative Code prior to the effective date of this rule.

(B) Consumers who were enrolled in the core plus benefit package, for any time period during the one hundred twenty days preceding the effective date of this rule, will have an eligibility determination made by ODJFS or its designated case management agency (CMA) in accordance with rule 5101:3-45-15 of the Administrative Code to determine if the consumer is eligible for an ODJFS-administered waiver.

(C) If a consumer is determined ineligible for an ODJFS-administered waiver or the consumer chooses not to enroll in an ODJFS-administered waiver, the consumer will be afforded notice and hearing rights in accordance with division-level 5101:6 of the Administrative Code.

Effective: 07/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.85

5101:3-12-03 Medicare certified home health agencies (MCRHHA): qualifications and requirements.

(A) A medicare certified home health agency (MCRHHA) that meets the requirements in accordance with this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(B) MCRHHAs are required:

(1) To be certified for medicare participation by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrative Code.

(2) To meet the conditions of participation in accordance with 42 C.F.R. 484

(October 1, 2005).

(3) To implement policy components for home health and private duty nursing as specified in the “Medicare Benefit Policy Manual, Chapter Seven: Home Health Services” (August 12, 2005) for the following sections:

(a) “Determination of Coverage” section 20;

(b) “Content of the Plan of Care” section 30.2 to “Under the Care of a Physician” section 30.3; and

(4) To comply with all applicable requirements for medicaid providers in Chapter 5101:3-1 of the Administrative Code.

(5) To comply with all federal, state and local laws and regulations.

(1) To have back up staff available to provide services when the agency’s regularly scheduled staff cannot or do not meet their obligation to provide services.

(2) To submit written notification to the consumer at least thirty days prior to the last date of service when terminating a service unless:

(a) The consumer’s treating physician has discontinued home health services;

(b) The treating physician has been notified that goals have been met;

(d) The consumer or another person has harmed or threatened to harm the MCRHHAs staff;

(e) The consumer requested that services be terminated;

(f) The consumer has been enrolled in a medicaid managed care plan (MCP).

(3) To contact the consumer’s medicaid MCP to request prior authorization for home health and PDN services.

(4) To maintain documentation on all aspects of services provided in accordance with this chapter. All documentation must be complete prior to billing for services provided in accordance with this chapter. This includes but is not limited to:

(a) Clinical records (including all signed orders) as specified in paragraph (B) of this rule.

(b) Time keeping records that indicate the date and time span of the services provided during a visit, and the type of service provided.

(c) To obtain the completed and signed JFS 07137 “Certificate of Medical Necessity Home Care Certification” (rev. 7/2006), which certifies the medical necessity for services in accordance with paragraph (C) of rule 5101:3-12-01 or paragraph (B) of rule 5101:3-12-02 of the Administrative Code.

Effective: 11/08/2007

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021

Prior Effective Dates: 4/7/77, 5/1/87, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer) 10/30/92, 7/1/93 (Emer), 9/1/93, 1/1/96, 7/1/98, 9/29/00, 9/1/05, 7/1/06

5101:3-12-03.1 Non-agency nurses and otherwise accredited agencies: qualifications and requirements.

“Non-agency nurses” and “otherwise accredited agencies” who meet the qualifications and requirements of this rule can provide private duty nursing (PDN) in accordance with rule 5101:3-12-02 of the Administrative Code.

(A) A “non-agency nurse” that meets the requirements in accordance with this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code. A non-agency nurse is required:

(1) To be a registered nurse or licensed practical nurse at the direction of a registered nurse practicing within the scope of his or her nursing license pursuant to Chapter 4723. of the Revised Code as an independent provider.

(2) To comply with the requirements of an MCRHHA in accordance to rule 5101:3-12-03 of the Administrative Code except for paragraphs (A), (B)(1) and (C)(1) of rule 5101:3-12-03 of the Administrative Code.

(3) To not be related to the consumer.

(4) To meet all conditions of participation in paragraph (C) and (D) of rule 5101:3-45-10 of the Administrative Code.

(B) An “otherwise accredited agency” that meets the requirements in accordance with this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code. An other accredited agency is required:

(1) To have and maintain joint commission on accreditation of healthcare organizations (JCAHO) accreditation or community health accreditation program (CHAP) accreditation for private duty nursing services.

(2) To comply with the requirements of MCRHHA in accordance to rule 5101:3-12-03 of the Administrative Code except for paragraphs (A) and (B)(1) of rule 5101:3-12-03 of the Administrative Code.

(C) Providers of PDN services who are also providers of waiver services to a waiver consumer enrolled in a home and community based services (HCBS) waiver must comply with all applicable requirements including those set forth by the HCBS waiver rule(s).

Effective: 07/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.85

5101:3-12-04 Home health and private duty nursing: visit policy.

Reimbursement of home health services or private duty nursing (PDN) in accordance with this chapter is on a per visit basis.

(A) A “visit” is the duration of time that a covered home health service or private duty nursing service is provided in a face to face encounter to one or more medicaid consumer(s) at the same residence on the same date during the same time period; and

(1) Begins with the provision of a covered service and ends when the face to face encounter ends; and

(2) Must have a lapse of time of two or more hours between any previous or subsequent visit for the provision of the same covered service unless the length of a private duty nursing visit requires an agency to provide a change in staff; and

(3) Must have a lapse of two or more hours between the provision of home health nursing or private duty nursing service.

(B) When a consumer is enrolled in a home and community based services (HCBS) waiver and is receiving consecutive home health or PDN service(s) with waiver service(s) that have the same scope of service, there must be a lapse of time of two or more hours between the services. A “scope” of a service includes the definition of the service and the conditions that apply to its provision and the provider who renders the service(s).

(1) As a separate line item. The number of lines/procedure codes must reflect the number of visits provided with one line equaling one visit.

(2) To reflect the length of the visit where one unit equals fifteen minutes. Units must be rounded down if the number of minutes is seven or less and rounded up if over seven minutes.

(D) A “group visit” is a visit where the service(s) is provided to more than one person. During a group visit:

(1) The ratio of an individual provider or an employee of a provider to the people being served may never exceed one to three.

(2) An entire visit is considered a group visit even if only a portion of the visit met the definition of a group visit.

(3) A modifier HQ must be used when billing for a group visit to identify each group setting in accordance with rule 5101:3-12-05 of the Administrative Code.

(E) A “multiple visit” is when the provision of the same home health service or PDN by the same provider occurs on the same date of service for the same consumer separated by a lapse of two hours. Multiple visits must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code due to the functional limitations and/or medical condition of the consumer as documented in the plan of care, and if the consumer is enrolled in HCBS waiver, the services plan or all services plan. Documentation must support the medical need for multiple visits. After the initial visit multiple visits must either be billed with a U2 modifier for the second visit or U3 for the third or any subsequent visit.

Replaces: Part of 5101:3-12-06, 5101:3-12-10

Effective: 07/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.85

Prior Effective Dates: 4/7/77, 5/1/87, 4/1/88, 5/15/89, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/1/93 (Emer), 7/30/93, 9/1/93, 1/1/96, 7/1/98, 9/29/00, 9/1/05

5101:3-12-05 Reimbursement: home health services.

(A) Home health services are delivered and billed in accordance with this chapter by medicare certified home health agencies (MCRHHA). Home health service rates are identified in appendix A to this rule.

(B) The amount of reimbursement for a visit shall be the lesser of the provider’s billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and unit rate found in appendix A to this rule using the number of units of service (one unit equals fifteen minutes) that were provided during a visit in accordance with this chapter as follows:

(1) Each visit must be less than or equal to four hours (sixteen units).

(2) For a visit that is less than one hour (four units) the medicaid maximum is the amount of the base rate.

(3) For a visit that is over one hour (four units) the medicaid maximum is the amount of the base rate plus the unit rate amount for each unit over one hour (four units), but not to exceed four hours (sixteen units).

(C) The amount of reimbursement for a visit shall be the lesser of the provider’s billed charge or seventy-five per cent of the total medicaid maximum as specified in paragraph (B) of this rule when billing with the modifier HQ “group setting” for group visits.

(D) The modifiers set forth in appendix B must be used to provide additional information in accordance with this chapter.

(E) Reimbursement must be provided in accordance with paragraphs (A) to (D) of rule 5101:3-1-60 of the Administrative Code.

(F) A MCRHHA will not be reimbursed for home health services provided to a consumer that duplicates same or similar services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplemental recipient or medicaid consumer resides, such as an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility is paid to provide personal care or nursing services, then home health services are not reimbursable by medicaid.

(G) A MCRHHA will be reimbursed for home health services provided to a consumer if the provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility) stating that the facility/home is not responsible for providing the same or similar home health services to the consumer.

(H) Home health services provided to the consumer enrolled in the assisted living HCBS waiver in accordance with rule 5101:3-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

Appendix A Home Health Services

Rates effective for dates of service prior to July, 1 2008.

Code Description Base Rate Unit Rate

G0154 Home Health Nursing, each 15 minutes $55.00 $5.70

G0156 Home Health Nursing Aide, each 15 minutes $24.00 $3.00

G0151 Physical Therapy, each 15 minutes $70.00 $4.50

G0152 Occupational Therapy, each 15 minutes $70.00 $4.50

G0153 Speech-Language Pathology, each 15 minutes $70.00 $4.50

Rates effective for dates of service on and after July 1, 2008.

Code Description Base Rate Unit Rate

G0154 Home Health Nursing, each 15 minutes $56.65 $5.87

G0156 Home Health Nursing Aide, each 15 minutes $24.72 $3.09

G0151 Physical Therapy, each 15 minutes $72.10 $4.64

G0152 Occupational Therapy, each 15 minutes $72.10 $4.64

G0153 Speech-Language Pathology, each 15 minutes $72.10 $4.64

1 unit = 15 minutes

Appendix B Visit Modifiers

Information Modifiers

Modifier Description Requirement

U1 Infusion Therapy Must be used when code G0154 is used for the purpose of home infusion therapy in accordance with rule 5101:3-12-01 of the Administrative Code.

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 consumer in accordance to rule 5101:3-12-03 of the Administrative Code.

U3 Third Visit or More 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 consumer in accordance to rule 5101:3-12-03 of the Administrative Code.

U5 Healthchek Must be used to identify the consumer receiving services due to Healthchek in accordance to rule 5101:3-12-01 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.85

Prior Effective Dates: 5/1/87, 4/1/88, 5/15/89, 7/1/98, 7/1/06

5101:3-12-06 Reimbursement: private duty nursing services.

(A) Private duty nursing (PDN) services are delivered and billed as PDN visits in accordance with rules 5101:3-12-02, 5101:3-12-2.3 and 5101:3-12-04 of the Administrative Code. The services are provided by medicare certified home health agencies, “otherwise accredited agencies,” or “non-agency nurses.” PDN service rates are identified in appendix A to this rule.

(D) The modifiers set forth in appendix B to this rule must be used to provide additional information in accordance with this chapter.

(E) Reimbursement must be provided in accordance with paragraphs (A) to (D) of rule 5101:3-1-60 of the Administrative Code.

(F) Providers of PDN will not be reimbursed for PDN services provided to a consumer that duplicate services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplemental recipient or medicaid consumer resides, such as an adult foster home, adult family home, adult group home, ICF/MR, residential care facility, community alternative home, or other facility is paid to provide nursing services, then PDN services are not reimbursable by medicaid.

(G) Providers of PDN will be reimbursed for PDN services provided to a consumer if the provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility) stating that the facility/home is not responsible for providing the same or similar PDN services to the consumer.

(H) PDN services provided to the consumer enrolled in the assisted living HCBS waiver in accordance with rule 5101:3-1-60 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

Appendix A Private Duty Nursing Service

Rates effective for dates of service prior to July 1, 2008.

Code Description Base Rate Unit Rate

T1000 Private Duty Nursing, each 15 minutes $55.00 $5.70

Rates effective for dates of service on and after July 1, 2008.

Code Description Base Rate Unit Rate

T1000 Private Duty Nursing, each 15 minutes $56.65 $5.87

1 unit = 15 minutes

Appendix B Modifier Descriptions

Information Modifiers

Modifier Description Requirement

U1 Infusion therapy Must be used when code T1000 is used for the purpose of home infusion therapy in accordance with rule 5101:3-12-02 of the Administrative Code.

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 consumer in accordance with rule 5101:3-12-03 of the Administrative Code.

U3 Third visit or more 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 consumer in accordance with rule 5101:3-12- 03 of the Administrative Code.

U4 12 hours to 16 hours per visit Must be used when a visit is more than twelve hours but does not exceed sixteen hours in accordance with rule 5101:3-12-02 of the Administrative Code.

U5 Healthchek Must be used to identify consumer receiving increased services due to Healthchek in accordance to rule 5101:3-12-02 of the Administrative Code.

U6 PDN authorization Must be used to identify consumer receiving increased services in accordance to rule 5101:3-12-02 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 09/28/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.85

Prior Effective Dates: 5/1/87, 4/1/88, 5/15/89, 7/1/98, 6/30/06 (Emer), 9/28/06

5101:3-12-07 Reimbursement: exceptions.

Home health and private duty nursing (PDN) service providers may be reimbursed when circumstances outside the provider’s control result in any of the exceptions set forth in this rule. The provider shall maintain written documentation that includes the date, the time (if available), the content of the communication, the contact name, and the contact information (e.g., telephone number, fax number, email address, or mailing address).

(A) Requirements of paragraphs (D)(2) of rule 5101:3-12-01 and (C)(2) of rule 5101:3-12-02 of the Administrative Code do not have to be met if either paragraph (A)(1), (A)(2), or (A)(3) of this rule applies:

(1) Services are not identified on the all services plan when the consumer is enrolled in an ODJFS-administered waiver, and the provider has documented attempts to work with the case manager and the case manager’s supervisors to identify the services on the all services plan. Documentation shall include written proof of the provider’s attempts to obtain the all services plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the all services plan.

(2) Services are not documented on the services plan when the consumer is enrolled in an ODA- or ODMR/DD-administered waiver, and the provider has documented attempts to work with the case manager and the case manager’s supervisors to identify the services on the services plan. Documentation shall include written proof of the provider’s attempts to obtain the services plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the services plan.

(3) The provider verified and documented before providing services that either paragraph (A)(3)(a) or (A)(3)(b) of this rule applies.

(a) The consumer was not enrolled in a home and community-based services (HCBS) waiver at the initiation of services and every six months thereafter. And the case manager cannot produce documentation that the provider was notified that the consumer had become enrolled in an HCBS waiver.

(b) The consumer was not enrolled in an HBCS waiver and subsequently, at any point during, the delivery of services, the provider became aware of the consumer’s enrollment and the provider notified the case manager and requested that the services be identified on the plan. And the case manager cannot produce documentation that the provider was notified that the consumer had become enrolled in an HCBS waiver.

(B) Requirements of paragraphs (F) of rule 5101:3-12-05 and (F) of rule 5101:3-12-06 of the Administrative Code do not have to be met if either paragraph (B)(1) or (B)(2) of this rule applies.

(1) The provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility) stating that the facility/home is not responsible for providing the same or similar home health or PDN services to the consumer.

(2) Home health and/or PDN services provided to the consumer enrolled in the assisted living HCBS waiver in accordance with rule 5101:3-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

Effective: 08/02/2007

R.C. 119.032 review dates: 08/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.85

5101:3-12-08 Quality assurance and monitoring of the ohio home care program. [Rescinded]

Rescinded eff 8-13-07

5101:3-12-09 Individual cost cap for consumers in the core-plus and ODHS waiver benefit packages. [Rescinded]

Rescinded eff 2-15-07

5101:3-12-10 Reimbursement of core home care services. [Rescinded]

Rescinded eff 7-01-06

5101:3-12-11 Home services facilitation. [Rescinded]

Rescinded eff 8-13-07

5101:3-12-12 Consumer options under the Ohio home care program. [Rescinded]

Rescinded eff 8-13-07

5101:3-12-13 Ohio home care waiver enrollment and waiting list process. [Rescinded]

Rescinded eff 7-1-06

5101:3-12-15 Transitions HCBS waiver. [Rescinded]

Rescinded eff 7-1-06

5101:3-12-25 Criminal records checks involving agency-employed providers of ODJFS-administered waiver services. [Rescinded]

Rescinded eff 11-19-07

5101:3-12-26 Criminal records checks involving independent providers of ODJFS-administered waiver services. [Rescinded]

Rescinded eff 11-19-07

5101:3-12-28 Enrollment process for ODJFS-administered waiver service providers.

(A) All ODJFS-administered waiver service providers must meet the eligibility requirements set forth in rule 5101:3-12-05 of the Administrative Code. Any person who wants to provide waiver services in an ODJFS-administered waiver must complete the service provider application process set forth in this rule and receive enrollment approval from ODJFS.

(B) All applicants must submit a complete and accurate service provider application packet to ODJFS or to the entity designated by ODJFS to receive and process such packets. Each applicant must submit with their service provider application packet a signed statement affirming that the applicant received and read all Administrative Code provisions governing the Ohio home care program.

(C) ODJFS will review the service provider application packet to verify the following information for each provider type.

(1) For each medicare-certified home health agency, ODJFS will verify the agency’s current medicare certification status, and that the agency and/or the agency’s primary officer, director, or owner is not on the U.S. department of health and human services’ exclusionary participant list.

(2) For each other accredited home health agency, ODJFS will verify the agency’s current accreditation status, and that the agency and/or the agency’s primary officer, director, or owner is not on the U.S. department of health and human services’ exclusionary participant list.

(3) For each waiver independent daily living aide, ODJFS will verify the following:

(a) The aide has successfully completed the nurse aide competency evaluation conducted by the Ohio department of health under section 3721.31 of the Revised Code, or has successfully completed and passed the home health aide competency evaluation as specified in 42 CFR Part 484 (as effective on July 1, 2004);

(b) The aide is not listed on the U.S. department of health and human services’ exclusionary participant list;

(c) The aide has successfully completed a criminal records check as enumerated in rule 5101:3-12-26 of the Administrative Code and, if applicable, the consumer has implemented the personal character standards enumerated in paragraph (D) of rule 5101:3-12-26 of the Administrative Code; and

(d) The aide is not listed on the Ohio department of mental retardation and developmental disabilities’ (ODMR/DD) abuser registry.

(4) For each waiver independent daily living non-aide, ODJFS will verify the following:

(a) The non-aide has successfully completed a criminal records check as enumerated in rule 5101:3-12-26 of the Administrative Code, and if applicable, the consumer has implemented the personal character standards enumerated in paragraph (D) of rule 5101:3-12-26 of the Administrative Code;

(b) The non-aide is not listed on the U.S. department of health and human services’ exclusionary participant list; and

(5) For each independent home care nurse, ODJFS will verify the following:

(a) The nurse has a valid and active RN or LPN license in the state of Ohio;

(b) An appropriate license is held by an LPN supervisor;

(d) The nurse has successfully completed a criminal records check as enumerated in rule 5101:3-12-26 of the Administrative Code and, if applicable, the consumer has implemented the personal character standards enumerated in paragraph (D) of rule 5101:3-12-26 of the Administrative Code;

(e) The nurse is not listed on the U.S. department of health and human services’ exclusionary participant list; and

(f) The nurse is not listed on the ODMR/DD abuser registry.

(6) For each ODJFS-administered HCBS waiver provider of other waiver services, ODJFS will verify that the entity or organization meets the requirements specified in paragraphs (I) (2) and (I) (3) or (J) of rule 5101:3-12-05 of the Administrative Code.

(D) ODJFS will not process a service provider application packet if the packet does not contain information necessary to complete the required verifications. ODJFS will not process a service provider application packet if the applicant does not submit the signed statement as required by section (B) of this rule. ODJFS will notify the applicant in writing of any missing information, and will provide the applicant thirty calendar days to provide the required documentation. If the applicant does not submit the required documentation within thirty calendar days, the service provider application process will be terminated.

(E) ODJFS will review all information and make a determination regarding the applicant’s eligibility for enrollment. If ODJFS determines the applicant is ineligible for enrollment, the applicant is entitled to appeal rights in accordance with rule 5101:3-1-17.6 of the Administrative Code.

HISTORY: Eff. 7-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.85

Rule amplifies: RC 5111.02

R.C. 119.032 review dates: 07/01/2009

5101:3-12-29 Consumer incident reporting.

(A) ODJFS will operate an incident management, investigation and response system (IMIRS). This rule sets forth the standards and procedures for operating the IMIRS. This rule applies to ODJFS and providers of waiver services for ODJFS-administered waivers. ODJFS may contract with other agencies or entities to perform one or more investigatory functions under this rule.

(B) ODJFS will maintain the secure and confidential storage of ODJFS-approved occurrence reporting forms, and ODJFS-approved incident narrative forms, and any associated investigation reports and related documents. All such documents will be filed according to the name of the consumer, and in an area separate from the involved consumer’s clinical record.

(1) Physical, emotional, mental and/or sexual abuse of a consumer;

(2) Neglect of a consumer;

(3) Abandonment of a consumer;

(4) Exploitation of a consumer;

(5) Death of a consumer;

(6) Accident or injury of a consumer which may or may not result in hospitalization or emergency room visit;

(7) Inappropriate delivery of services to a consumer, with health and safety implications;

(8) Services provided to a consumer that are beyond the provider’s scope of practice, with health and safety implications;

(9) Services delivered to a consumer without physician’s orders, that may have health and safety implications;

(10) Errors in the administration of medication to the consumer, with health and safety implications;

(11) Alleged illegal activity by the consumer resulting in documented police intervention;

(12) Consumer’s inappropriate use or abuse of substances which may result in health and safety implications;

(13) Theft of consumer’s money;

(14) Theft of consumer’s personal property; and

(15) Theft of consumer’s medication.

(D) Reporting, notification and response requirements of “Level 1” incidents

(1) If an ODJFS-administered waiver provider learns of a “Level 1” incident, the provider must report the incident to ODJFS within twenty-four hours.

(2) If ODJFS receives a report of an incident, ODJFS will contact the appropriate investigatory or law enforcement authority which may include one or more of the following: (a) The law enforcement agency having jurisdiction over the location at which the incident occurred, if the “Level 1” incident includes conduct that would constitute a possible criminal act, including abuse or neglect.

(b) The public children services agency (PCSA) and/or the public adult protective services units having jurisdiction over the location where the consumer resides, if applicable.

(c) The county board of mental retardation and developmental disabilities (CBMR/DD) for all allegations of abuse, neglect and other major unusual incidents as specified in section 5123.61 of the Revised Code. This notification must be made following all reporting mandates as outlined by ODMR/DD.

(d) The consumer’s local mental health case manager, if such services are identified on the all services plan. This notification must be made following reporting mandates as outlined by the Ohio department of mental health.

(e) The Ohio department of health or Ohio board of nursing, if appropriate.

(E) Investigation requirements for “Level 1” incidents ODJFS will conduct investigations of “Level 1” incidents as follows: (1) ODJFS will review all available information to determine if there are adequate safeguards to protect the consumer’s health and welfare.

(2) ODJFS will not delegate the investigation of the following types of incidents to a contractor:

(a) “Level 1” incidents that include an allegation that an employee of the contractor is responsible for the death, or abuse, or neglect of a consumer; or

(b) “Level 1” incidents of a consumer’s death where the circumstances of the death are suspicious in nature.

(3) ODJFS will review the information gathered in the investigation, and may consider the recommendations of any contractor, to determine if the reported incident is substantiated.

(F) Substantiated “Level 1” incidents involving ODJFS-administered waiver service providers

(1) Upon substantiation of “Level 1” incident(s), the ODJFS-administered waiver service provider will be notified by ODJFS via certified mail with a cease and desist letter. The letter will:

(a) Outline the alleged behavior or practice to be stopped;

(b) Specify the Administrative Code rule that supports the noncompliance finding(s);

(c) Specify what the provider must do to correct the finding(s); and (d) Specify the date a plan of correction must be submitted to ODJFS, not to exceed fifteen calendar days after the date the letter was mailed.

(2) If ODJFS finds the provider’s plan of correction acceptable, it shall approve the plan and confirm to the provider in writing that the plan addresses the issues of noncompliance outlined in the cease and desist order. If ODJFS determines that it cannot approve the provider’s plan of correction, it will inform the provider of this determination in writing, require the provider to submit a new plan of correction, and specify the required actions that must be included in the new plan of correction. The provider must submit the new plan of correction by the date specified by ODJFS.

(3) ODJFS will impose sanctions upon the provider in accordance with rule 5101:3-12-08 of the Administrative Code if the provider:

(a) Has not followed the plan of correction and/or successfully achieved the plan’s desired results;

(b) Has not submitted a plan of correction or has not had a plan of correction approved;

(d) Has failed to protect consumers from repeated and substantiated “Level 1” incidents; and/or

(e) Has created a serious and immediate threat to the health and/or safety of the consumer.

(G) At its discretion, for technical assistance or oversight, ODJFS will conduct a separate, independent review or investigation of a “Level 1” incident investigated by a contractor.

(H) “Level 2” incidents will include, but not be limited to:

(1) Errors in the administration of medication to the consumer, without health and safety implications;

(2) Alleged illegal activity occurring in the consumer’s environment without law enforcement intervention;

(3) A consumer’s exposure to or diagnosis of communicable disease;

(4) A consumer’s family or environmental crisis;

(5) Loss of a consumer’s informal (unpaid) caregiver or family member; and/or

(6) A consumer’s unplanned hospital or nursing home stay.

(I) Reporting, notification and response requirements for “Level 2” incidents.

(1) If an ODJFS-administered waiver provider learns of a “Level 2” incident, the provider must report the incident to ODJFS within twenty-four hours.

(2) If ODJFS receives a report of an incident, ODJFS will contact the appropriate investigatory or law enforcement authority which may include one or more of the following:

(a) The law enforcement agency having jurisdiction over the location at which the incident occurred, if the “Level 2” incident includes conduct that would constitute a possible criminal act, including abuse or neglect.

(b) The PCSA and/or the public adult protective services units having jurisdiction over the location where the consumer resides, if applicable.

(c) Contact the CBMR/DD for all allegations of major unusual incidents as specified in section 5123.61 of the Revised Code. This notification must be made in accordance with all reporting mandates as outlined by ODMR/DD.

(e) The Ohio department of health or Ohio board of nursing, as appropriate.

(J) Investigatory requirements for “Level 2” incidents ODJFS will conduct investigations of “Level 2” incidents as follows:

(1) ODJFS will review all available information to determine if there are adequate safeguards for the consumers health and welfare.

(2) ODJFS will review the information gathered in the investigation, and may consider recommendations of any contractor, to determine if the “Level 2” incident is substantiated.

(K) Substantiated “Level 2” incidents involving ODJFS-administered waiver service providers

(1) Upon substantiation of a “Level 2” incident, the ODJFS-administered waiver service provider will be notified by ODJFS via certified mail with a cease and desist letter. The letter will:

(a) Outline the alleged behavior or practice to be stopped;

(b) Specify the Administrative Code rule that supports the noncompliance finding;

(d) The date a plan of correction must be submitted to ODJFS, not to exceed thirty calendar days after the date the letter was mailed.

(3) ODJFS will impose sanctions upon the provider in accordance with rule 5101:3-12-08 of the Administrative Code if the provider:

(a) Has not followed the plan of correction and/or successfully achieved the plan’s desired results;

(b) Has not submitted a plan of correction or has not had a plan of correction approved;

(d) Has failed to protect consumers from repeated and substantiated “Level 2” incidents; and/or

(e) Has created a serious and immediate threat to the health and/or safety of the consumer.

(L) At its discretion, and for technical assistance or oversight, ODJFS will conduct a separate, independent review or investigation of a “Level 2” incident investigated by a contractor.

(M) ODJFS will provide a written summary of the investigative findings to the reporter of a “Level 1” or “Level 2” incident, unless it may jeopardize the health and safety of the consumer. Adherence to all consumer confidentiality and HIPAA regulations shall be assured.

(N) ODJFS will determine when to close cases of suspected abuse, neglect, death and exploitation as well as any other “Level 1” incident investigated by the department.

(O) ODJFS will be responsible for ensuring that all cases have been properly closed and may request further review if necessary.

HISTORY: Eff. 7-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.85

Rule amplifies: RC 5111.01, 5111.02

R.C. 119.032 review dates: 07/01/2009

5101:3-12-30 Monitoring under ODJFS-administered home and community-based service waivers.

(A) Every ODJFS-administered waiver provider will submit to regularly scheduled monitoring. The monitoring will include:

(1) Structural review of compliance with rules 5101:3-12-05, 5101:3-12-06, 5101:3-12-07, 5101:3-1-172, 5101:3-1-173, and 5101:3-12-25 or 5101:3-12-26 of the Administrative Code, as determined by the appropriate provider type; and

(2) Continuous monitoring of provider compliance and performance through the provider occurrence process enumerated in paragraph (D) of this rule.

(B) ODJFS may contract with other agencies or entities to perform one or more functions enumerated in this rule.

(1) ODJFS will conduct an annual face-to-face structural review of all ODJFS-administered waiver providers using the ODJFS structural compliance review tool, beginning from the first date of service delivery, with the exception of the following:

(a) For medicare certified home health agencies and JCAHO or CHAP accredited agencies, the results of the respective certifying or accrediting body will serve as the required structural review.

(b) For home modifications, vehicle modifications, equipment and supplies and emergency response system providers, the structural review will occur annually through the second year of service delivery, and biennially thereafter.

(2) ODJFS may conduct a structural review as a result of reported provider occurrences as defined in paragraph (D) of this rule.

(3) The structural review will include no less than the following:

(a) A telephone call or a written announcement establishing the date, time and location of the review.

(b) An evaluation of compliance in accordance with paragraph (A) of this rule.

(d) An evaluation of the ODJFS-administered waiver provider’s implementation of any/all plans of correction.

(e) An exit conference with agency/provider staff or with the independent provider.

(4) For the structural review, ODJFS will gather unit of service verification samples. These will consist of:

(a) Ten per cent of the agency-based provider’s current ODJFS-administered waiver service delivery records for each service, with a minimum of three and a maximum of thirty records per service/per provider.

(b) Three months of clinical records and supporting documentation per consumer for all independent providers. In cases where the independent provider services more than one ODJFS-administered waiver consumer, the structural review will examine three months of clinical records and supporting documentation up to a maximum of six consumers. The findings of this limited review may result in an expanded review of records.

(5) The unit of service verification audit described in paragraph (C) (3) (c) of this rule will include a comparison of services authorized, delivered and billed as it relates to the consumer’s all services plan. ODJFS will report any/all provider overpayments to the department’s surveillance and utilization review section. Providers will return any overpayment of funds to ODJFS.

(6) ODJFS will conduct a combined structural review for all agency-based ODFJS-administered waiver providers that provide both daily living and nursing services. The total sample will equal the required sample as set forth in paragraphs (C) (4) (a) and (C) (4) (b) of this rule.

(7) ODJFS reserves the right to conduct unannounced structural reviews at any time to evaluate alleged health and/or safety issues, provider occurrences and/or performance concerns. The provider will cooperate by accommodating ODJFS, meeting, making available appropriate meeting space, records and/or other documents requested as part of the review.

(8) ODJFS will complete one structural review tool per service for each consumer record contained in the review sample, as described in paragraphs (C) (4) (a) and (C) (4) (b) of his rule.

(9) After the structural review has been conducted, ODJFS will issue a written report to the provider. The report will summarize the overall outcome of the compliance review, list specific rule citations where noncompliance has been determined, and outline specific requirements or actions that must be addressed in a plan of correction. ODJFS may issue an abbreviated written report when identifying consumer health and/or safety issues.

(10) No later than forty-five calendar days after ODJFS mails the written report described in paragraph (C) (9) of this rule, the provider must submit to ODJFS a plan of correction for all identified noncompliance findings. If ODJFS issues an abbreviated written report identifying consumer health and/or safety issues, the provider’s plan of correction must be submitted to ODJFS within five working days after it was mailed.

(11) If ODJFS finds the provider’s plan of correction acceptable, it shall approve the plan and confirm to the provider that the plan addresses the issues of noncompliance outlined in ODJFS’ written report. If ODJFS determines that it cannot approve the provider’s plan of correction, it will inform the provider of this determination in writing, require the provider to submit a new plan of correction, and specify the required actions that must be included in the new plan of correction. The provider must submit the new plan of correction by the date specified by ODJFS.

(12) ODJFS may impose sanctions upon the provider in accordance with rule 5101:3-12-08 of the Administrative Code in the event the provider: (a) Has not followed the plan of correction and/or successfully achieved the plan’s desired results.

(b) Has not complied with the timeframes enumerated in this rule.

(d) Did not cooperate in meeting face-to-face for the structural review.

(e) Did not make service delivery and/or clinical records available.

(f) Did not submit a satisfactory plan of correction, or upon request, resubmit a satisfactory plan of correction.

(D) Provider occurrence process

(1) Provider occurrence means:

(a) Consumer care violations;

(b) Provider billing violations;

(d) Substandard provider performance.

(2) ODJFS will investigate provider occurrences and gather supporting documentation upon discovery of any such occurrence.

(3) ODJFS may gather any of the following information as part of the investigation:

(a) Clinical and/or progress notes from the provider;

(b) Case management documentation from the consumer’s file;

(d) The all services plan;

(e) MMIS billing information;

(f) Doctor’s orders;

(g) Prior occurrence reports;

(h) Consumer/family documentation;

(i) Any other relevant supporting documentation.

(4) If ODJFS decides to substantiate the occurrence, it will notify the provider via certified mail with a cease and desist letter. The letter will:

(a) Outline the alleged behavior or practice which must be stopped by the provider;

(b) Specify the Administrative Code rule cites that support the noncompliance finding;

(d) Specify the date on which the provider must submit a plan of correction to ODJFS, not to exceed thirty calendar days after the date the letter was mailed.

(5) If ODJFS finds the provider’s plan of correction acceptable, it shall approve the plan and confirm to the provider that the plan addresses the issues of noncompliance outlined in the cease and desist order. If ODJFS determines that it cannot approve the provider’s plan of correction, it will inform the provider of this determination in writing, require the provider to submit a new plan of correction, and specify the required actions that must be included in the new plan of correction. The provider must submit the new plan of correction by the date specified by ODJFS..

(6) The provider may request technical assistance from ODJFS to correct deficiencies or findings of noncompliance at any time.

(7) ODJFS may conduct a structural review as outlined in paragraph (C) of this rule to evaluate the provider’s implementation of the plan of correction.

(8) ODJFS reserves the right to conduct unannounced provider structural reviews at any time to evaluate provider occurrences. The provider will cooperate by accommodating ODJFS, meeting, making available appropriate meeting space, records, and/or other documents that may be requested as a part of the review.

(9) ODJFS may impose sanctions upon the provider in accordance with rule 5101:3-12-08 of the Administrative Code in the event the provider:

(a) Has not followed the plan of correction and/or successfully achieved the plan’s desired results;

(b) Has not complied with the time frames outlined in paragraph (D) of this rule;

(d) Has created a serious and immediate threat to the health and/or safety of the consumer.

(10) All allegations of medicaid fraud will be processed by ODJFS using supporting documentation enumerated in subparagraph (D) (3) of this rule, and shall be immediately referred to the medicaid fraud control unit (MFCU) of the Ohio attorney general’s office.

(11) All allegations of provider overpayment will be processed by ODJFS. The occurrence reporting form, along with the supporting documentation as enumerated in subparagraph (D) (3) of this rule will be forwarded to the surveillance and utilization review section. Overpayments will be returned to ODJFS.

(12) ODJFS will review a provider’s occurrence reports prior to conducting a structural compliance review. Documented noncompliance will be addressed during the review.

HISTORY: Eff. 7-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.85

Rule amplifies: RC 5111.02

R.C. 119.032 review dates: 07/01/2009

5101:3-12-35 Non-medicaid Ohio access success project. [Rescinded]

Rescinded eff 10-1-05