5101:3-45-09 ODJFS-administered waivers: quality assurance monitoring and oversight of ODJFS-administered waiver service providers and the contracted case management agency.

(A) ODJFS shall conduct ongoing quality assurance monitoring and oversight of ODJFS-administered waiver service providers to determine that each ODJFS-administered waiver service provider is doing the following:

(1) Meeting its responsibility to assure the consumer's health and welfare in the delivery of ODJFS-administered waiver services; and

(2) Complying with all applicable federal and state laws.

(B) ODJFS shall conduct ongoing quality assurance monitoring and oversight of the case management agency (CMA) selected to furnish case management services and provider oversight for the ODJFS-administered waiver programs to determine that the CMA is doing the following:

(1) Meeting its responsibility to assure the health and welfare of each ODJFS-administered waiver consumer; and

(2) Complying with the terms and conditions of its contract with ODJFS, and all applicable federal and state laws.

(C) Quality assurance monitoring and oversight activities shall include, but are not limited to, interviews with consumers, providers and CMA staff, visits to the provider's and CMA's place of business for the purpose of examining or collecting records, reviews of documentation, annual structural reviews, and consumer satisfaction surveys.

(1) The provider or CMA subject to a quality assurance monitoring and oversight review shall cooperate fully with all requests made by ODJFS, including the following:

(a) Furnishing workspace to ODJFS employees for the purpose of conducting reviews of consumer records;

(b) Making all requested information available at the time of the review; and

(c) Making staff available to answer questions ODJFS may have.

(2) Failure to comply with paragraph (C) (1) of this rule shall subject the provider or CMA to immediate action pursuant to paragraph (D) of this rule.

(D) At the conclusion of its quality assurance monitoring and oversight review, ODJFS shall do the following:

(1) Notify the provider or CMA, in writing, of its findings.

(2) If determined appropriate, propose termination of the provider's medicaid provider agreement pursuant to section 5111.06 of the Revised Code and rule 5101:3-1-17.6 of the Administrative Code.

(3) If determined appropriate, propose suspension or termination of the CMA's contract with ODJFS in accordance with the terms and conditions set forth in the CMA's contract.

(4) If determined appropriate, request that the provider or CMA prepare and submit a plan of correction within timeframes prescribed by ODJFS. The plan of correction shall set forth the action(s) to be taken to correct each finding identified by ODJFS, and establish a target date by which the corrective action must be completed. If ODJFS does not approve the submitted plan of correction, ODJFS may request a new plan of correction, or take other action determined to be appropriate.

(5) If determined appropriate, provide technical assistance to the provider or CMA.

(6) If determined appropriate, refer the provider or CMA to any of the following entities for further investigation.

(a) The ODJFS surveillance and utilization review section or other program area(s) within ODJFS;

(b) The Ohio attorney general;

(c) The Ohio department of health, or another licensure, certification or credentialing body; or

(d) The appropriate law enforcement agency.

Replaces: 5101:3-12-08

Effective: 08/13/2007
R.C. 119.032 review dates: 08/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85
Prior Effective Dates: 7/1/98