Chapter 5123:2-13 Individual Facility Waivers

5123:2-13-01 Individual options waiver - Definitions.

As used throughout rules adopted under Chapter 5123:2-13 of the Administrative Code, the following definitions shall apply:

(A) “County board” means a county board of mental retardation and developmental disabilities established under Chapter 5126 of the Revised Code.

(B) “Department” means the Ohio department of mental retardation and developmental disabilities as established by section 121.02 of the Revised Code.

(D) “Individual” means a person with mental retardation and/or developmental disabilities.

(E) “Individual options waiver” means a waiver approved under the authority of section 1915 (c) of the “Social Security Act,” 49 Stat. 620 (1935), 42 U.S.C.A. 1396n, as amended, under which federal reimbursement is provided for designated home and community-based services to eligible individuals, which is administered by the department pursuant to an interagency agreement with ODJFS.

(F) “ICF/MR” means an intermediate care facility for the mentally retarded.

(G) “Interagency agreement” means the contract between ODJFS and the department entered into under section 5111.871 of the Revised Code.

(H) “ODJFS” means the Ohio department of job and family services as established by section 121.02 of the Revised Code.

HISTORY: Eff 6-2-95 (Emer.); 8-31-95; 12-7-95, 8-18-96, 7-12-97; 5-7-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.87, 5123.04

Rule amplifies: RC 5111.87, 5123.04

Replaces: part of 5123:1-2-04 and 5123:1-2-07

RC 119.032 REVIEW DATE: 5-7-09

5123:2-13-02 Individual options waiver - Eligibility criteria for initial and continued enrollment.

(A) The purpose of this rule is to establish eligibility criteria for initial and continued enrollment in the individual options waiver.

(B) Eligibility criteria In order to be eligible for the individual options waiver, the individual shall meet the following criteria:

(1) Except as provided in paragraph (B)(2) of this rule, the individual must be determined to have an ICF/MR level of care pursuant to rule 5101:3-3-07 of the Administrative Code and choose to receive home and community-based waiver services as an alternative to services provided in an ICF/MR.

(2) The individual is not required to be determined to have an ICF/MR level of care pursuant to rule 5101:3-3-07 of the Administrative Code if either of the following apply:

(a) The individual resides in a general nursing facility, requires specialized services as determined in accordance with rule 5123:2-14-01 of the Administrative Code and chooses to receive home and community-based waiver services as an alternative to services provided in a general nursing facility.

(b) The individual was deinstitutionalized from a general nursing facility as a result of the preadmission screening and resident review process mandated by Pub. L. 100-203, Nursing Home Reform Act, Omnibus Budget Reconciliation Act (OBRA), 1987, as amended by OBRA, 1990, 42 U.S.C. Section 1396(e)(7) and requires specialized services as determined in accordance with rule 5123:2-14-01 of the Administrative Code.

(3) The individual must meet the financial medicaid eligibility criteria set forth in Chapter 5101:1-39 of the Administrative Code.

(4) The individual’s health and welfare needs, met by formal supports, informal supports and home and community-based services, must be assured.

(5) The projected annual cost of home and community-based services for the individual must not cause the aggregate cost cap for home and community-based services set forth in the individual options waiver as approved by the centers for medicare and medicaid services to be exceeded. If the annual cost of an individual’s home and community-based services is projected to cause the aggregate cost cap to be exceeded, the individual shall be denied enrollment.

(C) Other requirements An individual who is eligible for the individual options waiver must, in addition to the requirements of this rule, meet all requirements set forth in any rule governing a specific individual options waiver service in order to receive that service.

HISTORY: 6-2-95 (Emer.); 8-31-95; 12-7-95; 8-18-96; 7-12-97; Replaces: part of 5123:1-2-04, eff. 6-21-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5123.04, 5111.871, 5123.04

Rule amplifies: RC 5123.04, 5111.871

R.C. 119.032 review dates: 06/21/2009

5123:2-13-03 Individual options waiver - Allocation of home and community-based services waiver state matching funds.

(A) Purpose The purpose of this rule is to establish procedures for the allocation of home and community-based services waiver state matching funds for the individual options waiver.

(B) Subject to available appropriations, the department may allocate to county boards state matching funds to be used to fund home and community-based waiver services for individuals enrolled in the individual options waiver.

(C) When an individual enrolled in the individual options waiver moves from one county in this state to another county in this state, the department shall reduce the amount the department allocates pursuant to this rule to the county board serving the county the individual left by the amount and to the extent required by section 5123.0410 of the Revised Code. The department shall increase the amount allocated pursuant to this rule to the county board serving the county to which the individual moved by the same amount.

(D) The department may require a county board to provide written reports or other information regarding the funds a county board or provider receives pursuant to this rule. The department shall provide prior written notification of the data elements and format required.

(E) The department may audit any funds a county board or provider receives pursuant to this rule, including any source documentation supporting the receipt and disbursement of such funds.

HISTORY: Eff 6-2-95 (Emer.); 8-31-95; 7-12-97; 5-7-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.871, 5123.04

Rule amplifies: RC 5111.871, 5123.04, 5123.0410, sec. 71.02 of ASHB 95 of the 125th General Assembly

REPLACES: part of OAC 5123:01-02-07

RC 119.032 REVIEW DATE: 5-7-09

5123:2-13-04 Individual options waiver - homemaker/personal care.

(A) Purpose

The purpose of this rule is to specify the service definition for homemaker/personal care and to set forth the certification standards required under section 5123.16 of the Revised Code for providers of homemaker/personal care services to individuals enrolled in the HCBS individual options waiver administered by the department.

(B) Definitions

(1) “Applicant” means a person or government entity that has submitted to the department an application for certification to provide homemaker/personal care services under the individual options waiver.

(2) “Agency provider” means a person or government entity that provides homemaker/personal care services under the individual options waiver other than an individual provider.

(3) “Direct contact” means exercising supervision or control over the individual enrolled in the individual options waiver and for whom a provider will be providing homemaker/personal care services.

(4) “Homemaker/personal care (HPC)” means the coordinated provision of a variety of services, supports and supervision necessary for the health and welfare of an individual which enables the individual to live in the community. These are tasks directed at increasing the independence of the individual within his/her home or community. The service includes tasks directed at the individual’s immediate environment that are necessitated by his or her physical or mental condition (includes emotional and/or behavioral), and is of a supportive or maintenance type. This service does not include tasks supporting the individual provided through center-based day habilitation. Without this service, alone or in combination with other waiver services, the individual would require institutionalization.

(a) The homemaker/personal care provider performs such tasks as assisting the individual with activities of daily living, personal hygiene, dressing, feeding, transfer, and ambulatory needs or skills development. Skill development is intervention that focuses on both preventing the loss of skills and enhancing skills that are already present that will lead to greater independence within the residence or the community. The provider may also perform homemaking tasks for the individual. These tasks may include cooking, cleaning, laundry and shopping, among others. Homemaking and personal tasks are combined into a single service titled homemaker/personal care because, in actual practice, a single individual provides both services and does so as part of the natural flow of the day. For example, the provider may prepare a dish and place it in the oven to cook (homemaking), assist the individual in washing up before a meal and assist him/her to the table (personal care), put the prepared meal on the table (homemaking) and assist the individual in eating (personal care). Segregating these activities into discrete services is impractical.

(b) Services provided include the following:

(i) Basic personal care and grooming, including bathing, care of the hair and assistance with clothing;

(ii) Assistance with bladder and/or bowel requirements or problems, including helping the individual to and from the bathroom or assisting the individual with bedpan routines;

(iii) Assisting the individual with self-medication or provision of medication administration for prescribed medications, and assisting the individual with, or performing health care activities;

(iv) Performing household services essential to the individual’s health and comfort in the home (e.g. necessary changing of bed linens or rearranging of furniture to enable the individual to move about more easily in his/her home);

(v) Assessing, monitoring and supervising the individual to ensure the individual’s safety, health and welfare;

(vi) Light cleaning tasks in areas of the home used by the individual;

(vii) Preparation of a shopping list appropriate to the individual’s dietary needs and financial circumstances, performance of grocery shopping activities as necessary and preparation of meals;

(viii) Personal laundry;

(ix) Incidental neighborhood errands as necessary, including accompanying the individual to medical and other appropriate appointments and accompanying individuals for short walks outside the home.

(i) Participate in the individual’s individual service plan (ISP) meetings if and when the individual requests them to attend;

(ii) Perform tasks and duties according to the ISPs;

(iii) Recognize changes in the individual’s condition and behavior as well as safety and sanitation hazards, report to the service and support administrator and record them in the individual’s written record;

(iv) Document all services provided to and on behalf of the individual;

(v) Monitor incidents and take immediate actions when necessary to ensure the health, safety and welfare of individuals and provide notice to the county board.

(d) Homemaker/personal care agency providers shall provide administrative oversight as required by section 5126.14 of the Revised Code.

(e) For purposes of section 5126.281 of the Revised Code and rules adopted under that section, homemaker/personal care services shall not be deemed to be services provided under a family support services program established under section 5126.11 of the Revised Code or subject to section 5126.11 of the Revised Code or rules adopted under that section.

(5) “Homemaker/personal care subcontracted service” means any program or service provided pursuant to a subcontract, which program or service is designed and operated primarily to serve individuals with mental retardation or a developmental disability, including a program or service provided by an entity licensed or certified by the department. For purposes of certification under this rule, a generic community service or other program or service available to the general public (e.g., lawn care or house cleaning services) is not subject to homemaker/personal care requirements when said service is subcontracted.

(6) “Individual provider” means a self-employed person who provides homemaker/personal care services under the individual options waiver and does not employ, either directly, or through a contract, anyone else to provide such services.

An applicant for individual provider certification for homemaker/personal care services shall meet all of the following requirements in order to ensure the health and welfare of individuals receiving homemaker/personal care services.

(1) The applicant shall be at least eighteen years of age.

(2) The applicant shall submit an application in accordance with rule 5123:2-9-09 of the Administrative Code.

(3) Criminal background check

(a) The applicant shall submit to the department written evidence that a background investigation has been completed in accordance with section 5126.281 of the Revised Code and rule 5123:2-1-05.1 of the Administrative Code.

(b) The department shall deny certification to any applicant who has been convicted of or pled guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code, unless the applicant meets the standards set forth in paragraph (N) or (R) of rule 5123:2-1-05.1 of theAdministrative Code.

(4) Abuser registry

(a) The department shall determine whether the applicant’s name appears on the abuser registry established under sections 5123.50 to 5123.54 of the Revised Code.

(b) The department shall deny certification to any applicant if the applicant’s name appears on the abuser registry.

(5) Nurse aide registry

The department shall contact the Ohio department of health to inquire whether the nurse aide registry established under section 3721.32 of the Revised Code reveals that its director has made a determination of abuse, neglect, or misappropriation of property of a resident of a long-term care facility or residential care facility by the person.

(6) Cardiopulmonary resuscitation (CPR)

The applicant shall provide to the department evidence of a valid certification in CPR.

(7) Training relating to incidents adversely affecting health and safety

The applicant shall submit to the department documentation that the applicant has completed training in the requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety.

(8) Assurance on prevention of incidents adversely affecting health and safety

The applicant shall provide to the department written assurance that the applicant shall take all reasonable steps necessary to prevent the occurrence or reoccurrence of incidents adversely affecting health and safety.

(9) Training in individual rights

The applicant shall submit to the department documentation that the applicant has completed training in the provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code.

(10) Assurance for ongoing training

The applicant shall provide to the department written assurance that the applicant will receive training in accordance with paragraph (J) of this rule.

(11) Assurance for behavior supports

The applicant shall provide to the department written assurance that the applicant will comply with the requirements of behavior supports established under rules adopted by the department.

(12) Assurance for substitute coverage

The applicant shall provide to the department written assurance acknowledging that the applicant will:

(a) Arrange for substitute coverage, if necessary, only from a list of homemaker/personal care certified providers supplied by the department and as identified in the individual’s ISP;

(b) Notify the individual or legally responsible persons in the event that substitute coverage is necessary; and

(c) Notify the person identified in the ISP when substitute coverage is not available to allow such person to make other arrangements.

(13) Assurance for medication administration and the performance of health care tasks

The applicant shall provide to the department written assurance that the applicant shall not administer any medication to or perform health care tasks for the individual unless the applicant meets the applicable requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters.

(14) Assurance for coordination of services

The applicant shall provide to the department written acknowledgement of the applicant’s ongoing responsibility to coordinate with designated persons and family members, where appropriate, to ensure the provision of services in accordance with the ISP.

(15) Assurance for individual needs

The applicant shall provide to the department written assurance that the applicant shall only agree to provide services to any individual whose needs the applicant can meet.

(16) Assurance for ISP compliance

The applicant shall provide to the department written assurance that the applicant shall implement homemaker/personal care services in accordance with the ISP.

(17) Assurance for provider eligibility

The applicant shall provide to the department written assurance that the applicant shall not provide homemaker/personal care services to his/her minor child (under age eighteen) or to his/her spouse.

(D) Standards and requirements for continuing certification of individual providers

After being certified in accordance with paragraph (C) of this rule, all individual providers of homemaker/personal care services shall meet all of the following requirements in order to ensure the health and welfare of individuals receiving homemaker/personal care services:

(1) Criminal background check

(a) An individual provider shall report to the department if he or she is ever formally charged with, convicted of, or pleads guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code.

The individual provider shall make such report, in writing, not later than fourteen calendar days after the date of such charge, conviction or guilty plea.

(b) The individual provider shall comply with section 5126.281 of the Revised Code and rule 5123:2-1-05.1 of the Administrative Code.

(c) The department may initiate revocation proceedings for any individual provider who has failed to report in accordance with paragraph (D)(1)(a) of this rule that he or she was charged with, convicted of or pled guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code.

(d) The department shall initiate revocation proceedings for any individual provider who has been convicted of or pled guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code, unless the individual provider meets the standards set forth in paragraph (N) or (R) of rule 5123:2-1-05.1 of the Administrative Code.

(2) Abuser registry

The department shall initiate revocation proceedings for any individual provider whose name has been placed on the abuser registry established under sections 5123.50 to 5123.54 of the Revised Code.

(3) CPR

The individual provider shall maintain a valid certification in CPR.

(4) Training relating to incidents adversely affecting health and safety

(a) At least annually, the individual provider shall complete training in the requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety.

(b) The individual provider shall maintain documentation of such training in accordance with paragraph (J)(8) of this rule and present such documentation upon request by ODJFS, the department, or the county board.

(5) Incidents adversely affecting health and safety

The individual provider shall comply with the requirements of rule 5123:2-17-02 of the Administrative Code, except that the individual provider is not required to comply with the following provisions of rule 5123:2-17-02 of the Administrative Code:

(a) The development and implementation of a policy and procedure for the internal review, remedy, and prevention of major unusual incidents required under paragraph (F)(1) of that rule;

(b) The analysis of major unusual incidents to identify patterns and trends required under paragraph (G)(1) of that rule;

(d) The completion of analysis and implementation of corrective measures required under paragraph (G)(5) of that rule;

(e) The development and implementation of a policy and procedure on unusual incident notification required under paragraph (H)(1) of that rule; and

(f) The development and implementation of a written policy and procedure for the internal review of unusual incidents required under paragraph (H)(2) of that rule.

(6) Prevention of incidents adversely affecting health and safety

The individual provider shall take all reasonable steps necessary to prevent the occurrence or reoccurrence of incidents adversely affecting health and safety.

(7) Training in individual rights

(a) At least annually, the individual provider shall complete training in the provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code.

(8) Behavior supports

(a) The individual provider shall comply with the requirements of behavior support established under rules adopted by the department.

(b) If there is an individual behavior support plan, the individual provider shall be trained in the components of the plan.

(c) The individual provider shall maintain documentation of such training in accordance with paragraph (J)(8) of this rule and present such documentation upon request by ODJFS, the department, or the county board.

(9) Substitute coverage

The individual provider shall:

(a) Arrange for substitute coverage, if necessary, only from a list of homemaker/personal care certified providers supplied by the department and as identified in the individual’s ISP;

(b) Notify the individual or legally responsible persons in the event that substitute coverage is necessary;

(c) Notify the person identified in the ISP when substitute coverage is not available to allow such person to make other arrangements.

(10) Medication administration and performance of health care tasks

The individual provider shall not administer any medication to or perform health care tasks for the individual unless the individual provider meets the applicable requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters.

(11) Coordination of services

The individual provider shall coordinate with designated persons and family members, where appropriate, to ensure the provision of services in accordance with the ISP.

(12) Individual needs

The individual provider shall only agree to provide services to any individual whose needs the individual provider can meet.

(13) ISP compliance

(a) The individual provider shall implement homemaker/personal care services in accordance with the ISP.

(b) The need for assistance with medications or health care tasks as identified in paragraph (D)(10) of this rule shall be specified in the ISP. The presence of a behavior support plan and the requirements for training as identified in paragraph (D)(8)(b) of this rule shall be specified in the ISP.

(14) Provider eligibility

The individual provider shall not provide homemaker/personal care services to his/her minor child (under age eighteen) or to his/her spouse.

(15) Continuing education/training

The individual provider shall receive annual continuing education/training as specified in paragraph (J) of this rule.

(16) Evidence of department certification

The individual provider shall maintain documentation from the department of the individual provider’s certification under this rule.

(E) Standards and requirements for initial certification of agency providers

An applicant for agency provider certification for homemaker/personal care services shall meet all of the following requirements in order to ensure the health and welfare of individuals receiving homemaker/personal care services:

(1) The applicant shall submit an application in accordance with rule 5123:2-9-09 of the Administrative Code.

(2) Assurance for chief executive officer or a person responsible for administration

The applicant shall provide to the department written assurance that the applicant has employed a chief executive officer or a person responsible for administration who has either a bachelor’s degree from an accredited institution or at least two years experience in mental retardation or developmental disabilities, health care, social services, or homemaker/personal care.

(a) The chief executive officer or person responsible for administration shall be responsible for the following functions:

(i) Personnel matters;

(ii) Supervision of employees;

(iii) Program services; and

(iv) Financial management.

(b) The applicant shall have written policies and procedures that address the applicant’s management practices in the following areas:

(i) Confidentiality of individuals’ records;

(ii) Individual satisfaction;

(iii) A description of internal monitoring and evaluating procedures to improve services delivered;

(iv) A table of organization;

(v) Staff training plan;

(vi) A requirement that employees who have direct contact with individuals receiving homemaker/personal care must be at least eighteen years of age.

(3) Criminal background check

The applicant shall provide to the department written assurance that the applicant has complied with the requirements for background investigations established under section 5126.281 of the Revised Code and rule 5123:2-1-05.1 of the Administrative Code.

(4) Abuser registry

(a) For employees, subcontractors of the applicant, and employees of subcontractors who provide specialized services to an individual with mental retardation or a developmental disability as defined in division (G) of section 5123.50 of the Revised Code, the applicant shall provide to the department written assurance that, as of the date of the application, no such persons are listed on the abuser registry established pursuant to sections 5123.50 to 5123.54 of the Revised Code.

(b) The applicant shall provide to the department written assurance that the applicant will follow the requirements of sections 5123.50 to 5123.54 of the Revised Code.

(5) Nurse aide registry

For employees, subcontractors of the applicant, and employees of subcontractors who provide specialized services to an individual with mental retardation or a developmental disability as defined in division (G) of section 5123.50 of the Revised Code, the applicant shall provide to the department written assurance that, as of the date of the application, no such persons are listed on the nurse aide registry established under section 3721.32 of the

Revised Code indicating that the director of the Ohio department of health has made a determination of abuse, neglect, or misappropriation of property of a resident of a long-term facility or residential care facility by the person.

(6) Certification in CPR

The applicant shall provide to the department written assurance that at least one person with a valid certification in CPR shall be present when an individual is receiving any homemaker/personal care program or service that requires the provider to be in direct contact with an individual.

(7) Assurance for ongoing training

The applicant shall provide to the department written assurance that all employees who will have direct contact with individuals receiving homemaker/personal care services will receive training in accordance with paragraph (J) of this rule.

(8) Training relating to incidents adversely affecting health and safety

The applicant shall provide to the department written assurance that all employees who will have direct contact with individuals receiving homemaker/personal care services have completed training in the requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety.

(9) Assurance on prevention of incidents adversely affecting health and safety

(10) Training in individual rights

The applicant shall provide to the department written assurance that all employees who will have direct contact with individuals receiving homemaker/personal care services have completed training in the provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code.

(11) Assurance for behavior supports

The applicant shall provide to the department written assurance that the applicant will comply with the requirements of behavior supports established under rules adopted by the department.

(12) Assurance for substitute coverage

The applicant shall provide to the department written assurance acknowledging that the applicant will:

(a) Arrange for substitute coverage, if necessary, only from a list of homemaker/personal care certified providers supplied by the department and as identified in the individual’s ISP;

(b) Notify the individual or legally responsible persons in the event that substitute coverage is necessary; and

(c) Notify the person identified in the ISP when substitute coverage is not available to allow such person to make other arrangements.

(13) Assurance for medication administration and the performance of health care tasks

The applicant shall provide to the department written assurance that all medication administration and the performance of health care tasks shall be carried out in accordance with the applicable requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters.

(14) Assurance for program management

(15) Assurance for individual needs

The applicant shall provide to the department written assurance that the applicant shall only agree to provide services to any individual whose needs the applicant can meet.

(16) Assurance for ISP compliance

The applicant shall provide to the department written assurance that the applicant shall implement homemaker/personal care services in accordance with the ISP.

(17) Assurance for provider eligibility

The applicant shall provide to the department written assurance that neither the applicant nor any employee of the applicant shall provide homemaker/personal care services to his/her minor child (under age eighteen) or his/her spouse.

(F) Standards and requirements for continuing certification of agency providers

After being certified in accordance with paragraph (E) of this rule, all agency providers of homemaker/personal care services shall meet all of the following requirements in order to ensure the health and welfare of individuals receiving homemaker/personal care services:

(1) Chief executive officer or a person responsible for administration

The agency provider shall employ a chief executive officer or a person responsible for administration who has either a bachelor’s degree from an accredited institution or at least two years experience in mental retardation or developmental disabilities, health care, social services, or homemaker/personal care.

(a) The chief executive officer or person responsible for administration shall be responsible for the following functions:

(i) Personnel matters;

(ii) Supervision of employees;

(iii) Program services; and

(iv) Financial management.

(b) The agency provider shall have written policies and procedures that address the agency provider’s management practices in the following areas:

(i) Confidentiality of individuals’ records;

(ii) Individual satisfaction;

(iii) A description of internal monitoring and evaluating procedures to improve services delivered;

(iv) A table of organization;

(v) Staff training plan;

(vi) A requirement that employees who have direct contact with individuals receiving homemaker/personal care services must be at least eighteen years of age.

(2) Criminal background check

(a) The agency provider shall require any employee in a direct services position as defined in section 5123.281 of the Revised Code to report, in writing, to the agency provider if the employee is ever formally charged with, convicted of, or pleads guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code not later than fourteen calendar days after the date of such charge, conviction or guilty plea.

(b) The agency provider shall comply with section 5126.281 of the Revised Code and rule 5123:2-1-05.1 of the Administrative Code.

(3) Abuser registry

The agency provider shall follow the requirements of sections 5123.50 to 5123.54 of the Revised Code and assure that subcontractors who provide specialized services as defined in division (G) of section 5123.50 of the Revised Code shall meet the requirements of sections 5123.50 to 5123.54 of the Revised Code.

(4) Nurse aide registry

Prior to hiring an employee, the agency provider shall contact the Ohio department of health to inquire whether the nurse aide registry established under section 3721.32 of the Revised Code reveals that its director has made a determination of abuse, neglect, or misappropriation of property of a resident of a long-term care facility or residential care facility by the person.

(5) CPR

The agency provider shall provide evidence that at least one person with a valid certification in CPR is present when the individual is receiving any homemaker/personal care program or service that requires the provider to be in direct contact with an individual.

(6) Training relating to incidents adversely affecting health and safety

(a) The agency provider shall provide evidence that all employees who have direct contact with individuals receiving homemaker/personal care services have completed training in the requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety. Such training shall be completed at least annually.

(b) The agency provider shall maintain documentation of such training in accordance with paragraph (J)(8) of this rule and present such documentation upon request by ODJFS, the department, or the county board.

(c) The agency provider shall ensure that all employees who have direct contact with individuals receiving homemaker/personal care services shall comply with the requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety.

(7) Prevention of incidents adversely affecting health and safety

The applicant shall take all reasonable steps necessary to prevent the occurrence or reoccurrence of incidents adversely affecting health and safety.

(8) Training in individual rights

(a) The agency provider shall provide evidence that all employees who will have direct contact with individuals receiving homemaker/personal care services have completed training in the provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code. Such training shall be completed at least annually.

(9) Behavior supports

(a) All employees of the agency provider shall comply with the requirements of behavior supports established under rules adopted by the department.

(b) If there is an individual behavior support plan, the employees of the agency provider responsible for implementing the plan shall be trained in the components of the plan.

(c) The agency provider shall maintain documentation of such training in accordance with paragraph (J)(8) of this rule and present such documentation upon request by ODJFS, the department, or the county board.

(10) Substitute coverage

The agency provider shall:

(a) Arrange for substitute coverage, if necessary, only from a list of homemaker/personal care certified providers supplied by the department and as identified in the individual’s ISP;

(b) Notify the individual or legally responsible persons in the event that substitute coverage is necessary; and

(c) Notify the person identified in the ISP when substitute coverage is not available to allow such person to make other arrangements.

(11) Medication administration and the performance of health care tasks

The agency provider shall provide evidence that all medication administration and the performance of health care tasks are carried out in accordance with the applicable requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters.

(12) Program management

The agency provider shall coordinate with designated persons and family members, where appropriate, to ensure the provision of program management services in accordance with section 5126.14 of the Revised Code.

(13) Individual needs

The agency provider shall not agree to provide services to any individual whose needs the agency provider cannot meet.

(14) ISP compliance

(a) The agency provider shall implement homemaker/personal care services in accordance with the ISP.

(b) The need for assistance with medications or health care tasks as identified in paragraph (F)(11) of this rule shall be specified in the ISP. The presence of a behavior support plan and the requirement for training as identified in paragraph (F)(9)(b) of this rule shall be specified in th ISP.

(15) Provider eligibility

Neither the agency provider nor any employee of the agency provider shall provide homemaker/personal care services to his/her minor child (under age eighteen) or his/her spouse.

(16) Continuing education/training

All employees of agency providers who have direct contact with individuals receiving homemaker/personal care services shall receive annual continuing education/training in accordance with paragraph (J) of this rule.

(17) Evidence of department certification

The agency provider shall maintain documentation from the department of the agency provider’s certification under this rule.

(G) Standards and requirements for county boards

(1) On or after July 1, 2005, no county board shall be certified to provide homemaker/personal care services or enter into a medicaid provider agreement with ODJFS for homemaker/personal care services.

(2) On or after July 1, 2005, no county board shall provide homemaker/personal care services as a subcontractor.

(3) In the event that there is no certified private person or entity willing and able to provide homemaker/personal care services, a county board may provide homemaker/personal care services through an independent contractor who is employed in another capacity by the county board. Such independent contractor shall comply with the requirements of sections 5126.032, 5126.033, and 5123.64 of the Revised Code.

(4) If a county board was certified to provide homemaker/personal care prior to July 1, 2005 on the effective date of this rule, the county board shall submit a written plan to the department within six months of the effective date of this rule that outlines the county board’s transition plan to no longer provide homemaker/personal care indicating that the transition will be completed within one year from the date the plan is submitted to the department.

(5) As of the effective date of this rule, the Lorain county board may continue to provide or subcontract to provide homemaker/personal care services for no more than the number of individuals it served on July 1, 2005.

(H) Standards and requirements for initial and continuing certification of licensed providers

An applicant for certification to provide homemaker/personal care services as a licensed provider shall meet all of the following requirements in order to ensure the health and welfare of the individuals receiving homemaker/personal care services:

(1) The applicant shall submit an application in accordance with rule 5123:2-9-09 of the Administrative Code.

(2) The applicant shall provide to the department written assurance acknowledging that the applicant will:

(a) Arrange for substitute coverage, if necessary, only from a list of homemaker/personal care certified providers supplied by the department and as identified in the individual’s ISP;

(b) Notify the individual or legally responsible persons in the event that substitute coverage is necessary;

(c) Notify the person identified in the ISP when substitute coverage is not available to allow such person to make other arrangements.

(3) The licensed provider shall meet all of the requirements set forth in and have a license issued under section 5123.19 of the Revised Code.

(4) Upon meeting such requirements and the issuance of such license, the application shall be processed by the department and the licensed provider shall be approved in accordance with rule 5123:2-9-09 of the Administrative Code.

(5) In order to maintain certification under this rule, the licensed provider shall maintain its license in accordance with section 5123.19 of the Revised Code, and maintain a current medicaid provider agreement with ODJFS, and comply with the requirements for substitute coverage set forth in paragraph (H)(2) of this rule.

(I) Subcontractors

Individual providers shall not subcontract the provision of homemaker/personal care services. Agency providers may subcontract the provision of homemaker/personal care services in accordance with the following requirements:

(1) All subcontractors for homemaker/personal care subcontracted services that are individual providers shall meet the requirements of the following paragraphs of this rule:

(a) Paragraph (C)(1) – applicant shall be at least eighteen years old;

(b) Paragraphs (C)(3) and (D)(1) – criminal background check;

(d) Paragraph (C)(5) – nurse aide registry;

(e) Paragraphs (C)(6) and (D)(3) – CPR;

(f) Paragraphs (C)(7) and (D)(4) – training relating to incidents adversely affecting health and safety;

(g) Paragraphs (C)(8) and (D)(6) – prevention of incidents adversely affecting health and safety;

(h) Paragraphs (C)(9) and (D)(7) – training in individual rights;

(i) Paragraphs (C)(11) and (D)(8) – behavior supports;

(j) Paragraphs (C)(13) and (D)(10) – medication administration and the performance of health care tasks;

(k) Paragraphs (C)(15) and (D)(12) – individual needs;

(l) Paragraphs (C)(16) and (D)(13) – ISP compliance;

(m) Paragraphs (C)(17) and (D)(14) – provider eligibility;

(2) All subcontractors for homemaker/personal care subcontracted services that are agency providers shall meet the requirements of the following paragraphs of this rule:

(a) Paragraphs (E)(3) and (F)(2) – criminal background check;

(b) Paragraphs (E)(4) and (F)(3) – abuser registry;

(d) Paragraphs (E)(6) and (F)(5) – CPR;

(e) Paragraphs (E)(8) and (F)(6) – training relating to incidents adversely affecting health and safety;

(f) Paragraphs (E)(9) and (F)(7) – prevention of incidents adversely affecting health and safety;

(g) Paragraphs (E)(10) and (F)(8) – training in individual rights;

(h) Paragraphs (E)(11) and (F)(9) – behavior supports;

(i) Paragraphs (E)(13) and (F)(11) – medication administration and performance of health care tasks;

(j) Paragraphs (E)(15) and (F)(13) – individual needs;

(k) Paragraphs (E)(16) and (F)(14) – ISP compliance;

(l) Paragraphs (E)(17) and (F)(15) – provider eligibility

(3) The agency provider shall give the county board notice of all subcontracts for homemaker/personal care services.

(4) The agency provider shall enter into a written contract with the subcontractor.

(5) An agency provider that subcontracts the provision of homemaker/personal care services shall ensure that the subcontractor complies with all applicable requirements of this rule.

(J) Training

(1) Individual providers and all employees of agency providers who have direct contact with individuals receiving homemaker/personal care services shall receive annual training in accordance with the requirements of this paragraph.

(2) Each individual provider shall be required to obtain at least eight hours of continuing education/training every year after the individual provider has been certified.

(3) An agency provider shall ensure that each employee of the agency provider who has direct contact with individuals receiving homemaker/personal care services receives at least eight hours of continuing education/training every year based on the employee’s date of hire.

(4) An employee of an agency provider or individual provider shall be deemed to have met the requirements in paragraph (J)(2) or (J)(3) of this rule if such employee is scheduled for training and the training is completed within thirty days of the deadline.

(5) Carryover

(a) Any hours in excess of the amounts required in paragraphs (J)(2) and (J)(3) of this rule cannot be carried over to any subsequent year.

(b) An employee of an agency provider may transfer hours of continuing education/training from one agency provider to another provided that the employee has proper documentation that the training was completed.

(6) Continuing education/training shall be designed to enhance the skills and competencies of the individual provider or employees of the agency provider relevant to their job responsibilities.

(a) The continuing education/training areas shall include annual training in:

(i) Identification and response to incidents adversely affecting an individual’s health and safety;

(ii) Individual rights.

(b) Other topics may include, but are not limited to:

(i) CPR;

(ii) Behavior supports;

(iii) Medication administration and performance of health care tasks;

(iv) Occupational safety and health administration (OSHA) requirements;

(v) Other areas that enhance the skills and competencies of the individual provider or employee of an agency provider relevant to his/her job responsibilities.

(7) Continuing education/training may be structured or unstructured and may include, but not be limited to, the following:

(a) Lectures, seminars or formal course work;

(b) Workshops and conferences;

(d) Visitations and observations of other facilities, services and programs;

(e) Distance learning and other electronic means of learning;

(f) Video and other audio-visual training; and

(g) Staff meetings.

(8) The provider shall maintain a written record, which may include an electronic record, of each person’s continuing education/training. This information shall be presented upon request by ODJFS, the department, or the county board.

Documentation shall include the following:

(a) The name of the person receiving the training;

(b) Date(s) of training;

(d) Training topic;

(e) Instructor’s name, if applicable;

(f) Brief description of the content of the training.

(K) Denial, suspension or revocation of certification

(1) Failure to comply with the standards set forth in this rule for initial certification of providers may result in denial of certification by the department pursuant to rule 5123:2-9-09 of the Administrative Code.

(2) After being certified in accordance with this rule, providers shall comply with the continuing certification standards set forth in this rule. Providers shall be subject to monitoring and compliance reviews conducted by the county board and/or the department as set forth in rule 5123:2-9-08 of the Administrative Code. Failure to comply with the standards set forth in this rule for continuing certification of providers may result in corrective action by the department up to and including suspension or revocation of certification as set forth in rule 5123:2-9-08 of the Administrative Code.

(3) When denying, suspending, or revoking certification under this rule, the department shall comply with the notice and hearing requirements of Chapter 119. of the Revised Code.

(L) Notwithstanding the requirements of this rule, individual and agency providers certified as individual options providers on the effective date of this rule, will have one year from the effective date of this rule to come into compliance with paragraphs (D), (F), (I), and

(J) of this rule.

Effective: 04/20/2006

R.C. 119.032 review dates: 07/01/2010

Promulgated Under: 119.03

Statutory Authority: 5123.04, 5123.16, 5126.08, 5111.871

Rule Amplifies: 5123.04, 5123.045, 5123.16, 5126.08, 5111.871

Prior Effective Dates: 7/24/95, 7/1/05

5123:2-13-05 Individual options waiver - transportation mileage.

(A) Purpose

The purpose of this rule is to set forth the certification standards required under section 5123.045 of the Revised Code for providers who are claiming mileage reimbursement to transport individuals enrolled in the individual options waiver.

(B) Definitions

(1) “Agency provider” means a person or governmental entity that provides transportation mileage services under the individual options waiver other than an individual provider.

(2) “Applicant” means a person or governmental entity that has submitted to the department an application for certification to provide transportation mileage services to individuals enrolled in the individual options waiver.

(3) “Individual provider” means a self-employed person who provides transportation mileage services under the individual options waiver and does not employ, either directly, or through a contract, anyone else to provide such services.

(4) “Provider” means an individual provider or agency provider that:

(a) Is certified by the department to provide transportation mileage services pursuant to this rule; and

(b) Has a medicaid provider agreement from the Ohio department of job and family services that covers that service.

(5) “Transportation mileage” means a transportation service offered by a provider, other than medical transportation available through Ohio’s approved medicaid state plan and non-medical transportation as defined in rule 5123:2-9-18 of the Administrative Code. Payment rates for transportation mileage are contained in rule 5123:2-9-06 of the Administrative Code.

(1) The applicant shall submit an application to the department in accordance with rule 5123:2-9-09 of the Administrative Code.

(2) The applicant shall provide written assurance that each driver of the vehicle shall:

(a) Possess a valid driver’s license and evidence of valid liability insurance coverage and be eighteen years of age or older;

(b) Have proof of current successful completion of “American Red Cross” or equivalent first aid training and a cardiopulmonary resuscitation certificate or an emergency medical technician certificate at the time of employment and thereafter;

(c) Provide evidence that he/she is not listed on the abuser registry established pursuant to sections 5123.50 to 5123.54 of the Revised Code;

(d) Provide evidence that he/she is not listed on the nurse aide registry established pursuant to section 3721.32 of the Revised Code indicating that the director of the Ohio department of health has made a determination of abuse, neglect, or misappropriation of property of a resident of a long-term facility or residential facility by the person;

(e) Complete training at the time of employment and annually thereafter in the provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(f) Complete training at the time of employment and annually thereafter in the requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety of individuals receiving waiver services;

(g) Undergo a background investigation in accordance with section 5126.281 of the Revised Code and rules 5123:2-1-05 to 5123:2-1-05.1 of the Administrative Code;

(h) Have not been convicted of or pleaded guilty to any of the offenses listed in paragraph (J) of rule 5123:2-1-05.1 of the Administrative Code, unless the requirements of paragraph (N) or paragraph (R) of that rule have been met;

(i) Report, in writing, to the provider, if he/she is ever formally charged with, convicted of, or pleads guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code no later than fourteen calendar days after the date of such charge, conviction, or guilty plea.

(3) An individual provider shall report to the department if he/she is ever formally charged with, convicted of, or pleads guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code. The individual provider shall make such report, in writing, no later than fourteen calendar days after the date of such charge, conviction, or guilty plea.

(D) Commercial vehicles

Owners and operators of commercial vehicles, including buses, livery vehicles, and taxicabs, that are available for public use and also are used to provide transportation services to home and community-based services waiver enrollees are not subject to the requirements of paragraph (C)(2) or paragraph (C)(3) of this rule. Owners and operators of these types of vehicles are required to meet all federal, state, and local requirements pertaining to the maintenance and operation of these vehicles as well as the fares charged for their use.

(E) Subcontractors and employees of providers

(1) Agency providers seeking certification to provide transportation mileage services to individual options waiver enrollees through the use of subcontractors and/or employees shall assure that the subcontractors, employees of the subcontractors, and/or employees of the certified agency provider meet all requirements of this rule, unless the subcontract involves the use of one or more vehicle types described in paragraph (D) of this rule, in which case the subcontractor and the subcontractor’s employees are subject to the requirements of this rule only to the extent that the subcontract involves vehicles that are not of the type described in paragraph (D) of this rule.

(2) Individual providers shall neither subcontract the provision of transportation mileage services nor employ anyone else to provide such services.

(F) Training documentation

Providers shall maintain a written record, which may include an electronic record, to verify that they, their employees, subcontractors, and employees of subcontractors meet all certification requirements contained in this rule. This information shall be maintained for each person who has received required training and/or has met other related certification standards. This information shall be presented, upon request by the department or the Ohio department of job and family services.

(G) Certification and denial, suspension, or revocation of certification

(1) Upon receipt of all assurances contained in this rule and a determination of their completeness, the department may issue an initial certification to applicants wishing to provide transportation mileage services to individual options waiver enrollees. The department, at the time of issuance of the initial certification, shall communicate the duration of the certification and conditions for renewal of the certification to the certified provider.

(2) The department may deny the certification application for good cause or for failure to comply with the standards set forth in this rule pursuant to rule 5123:2-9-09 of the Administrative Code.

(3) The department may initiate revocation proceedings for any individual provider who has failed to report in accordance with paragraph (C) of this rule that he/she was charged with, convicted of, or pleaded guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code.

(4) The department shall initiate revocation proceedings for any individual provider who has been convicted of or pleaded guilty to any of the offenses listed in division (E) of section 5126.28 of the Revised Code, unless the individual provider meets the standards set forth in paragraph (N) or paragraph (R) of rule 5123:2-1-05.1 of the Administrative Code.

(5) After being certified in accordance with this rule, providers shall comply with the continuing certification standards set forth in this rule. Certified providers shall be subject to monitoring and compliance reviews conducted as set forth in rule 5123:2-9-08 of the Administrative Code. Failure to comply with the standards set forth in this rule for continuing certification of the certified provider, its employees, and subcontractors may result in corrective action by the department, up to and including suspension or revocation of provider certification as set forth in rule 5123:2-9-08 of the Administrative Code.

(6) When denying, suspending, or revoking certification under this rule, the department shall comply with the notice and hearing requirements of Chapter 119. of the Revised Code.

Effective: 01/01/2007

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

Promulgated Under: 119.03

Statutory Authority: 5123.04, 5123.045

Rule Amplifies: 5123.04, 5123.045

5123:2-13-06 Individual options waiver - adult foster care.

(A) Purpose

The purpose of this rule is to establish adult foster care as a service under the individual options waiver, specify the service definition and requirements, establish the certification standards required under section 5123.16 of the Revised Code for providers of the service, establish the documentation requirements, and establish the standards governing payments for the service.

(B) Definitions

(1) “Adult” means an individual eighteen years of age or older.

(2) “Adult foster care” means personal care and supportive services (e.g., homemaker, chore, and medication oversight to the extent permitted under state law) provided in a private home by an unrelated, principal care giver who lives in the home and whose primary, legal residence is that home. Adult foster care is furnished to adults who receive these services in conjunction with residing in the home. Adult foster care services, their associated activities, and skill development proximate the rhythm of life that naturally occurs as part of living in the family home. Homemaker and chore services are furnished to the individual as a component of adult foster care. Due to the environment provided by foster care, segregating these activities into discrete services is impractical.

(3) “Adult foster care provider” means a provider of adult foster care who meets the requirements under rule 5123:2-13-04 of the Administrative Code and is certified to provide homemaker/personal care under that rule.

(4) “Agency provider” means a provider of adult foster care services under the individual options waiver other than an individual provider.

(5) “Homemaker/personal care” means the waiver service as defined in rule 5123:2-13-04 of the Administrative Code.

(6) “Individual provider” means a self-employed person who provides adult foster care services under the individual options waiver and does not employ, either directly or through a contract, anyone else to provide such services.

(7) “Individual with mental retardation or other developmental disability” means a person with “mental retardation” or “developmental disability” as those terms are defined in section 5126.01 of the Revised Code.

(8) “Institutional respite” means home and community-based services provided to individuals unable to care for themselves, furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care, in facilities certified as intermediate care facilities for the mentally retarded or other facilities licensed by the department under section 5123.19 of the Revised Code.

(9) “ISP” means the individual service plan, a written description of the services, supports, and activities to be provided to an individual.

(10) “ODDP” means the Ohio developmental disabilities profile, the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual compared to others.

(11) “ODJFS” means the Ohio department of job and family services as established by section 121.02 of the Revised Code.

(12) “Payment authorization for waiver services” (PAWS) means the process followed and format used to communicate the amount and payment for each waiver service that has been established by the ISP.

(13) “Related by blood or marriage” means parents; grandparents, including grandparents with the prefix “great,” “great-great,” “grand,” or “great-grand;” siblings; aunts, uncles, nephews, and nieces, including such relatives with the prefix “great,” “great-great,” “grand,” or “great-grand;” stepparents or stepsiblings; and spouses and former spouses of individuals related by blood or adoption.

(14) “Service and support administrator” (SSA) means a person, regardless of title, employed by or under subcontract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(1) The total number of individuals (including participants served under the waiver) with mental retardation or other developmental disability living in the home shall not exceed four.

(2) Unless the home is licensed under section 5123.19 of the Revised Code, the adult foster care provider shall not provide adult foster care services under the waiver to more than three of the individuals living in the home.

(3) Individual providers of adult foster care shall reside in the home where services are delivered and that home shall be their primary, legal residence.

(4) Agency providers of adult foster care shall either reside in the home where services are delivered and that home shall be their primary, legal residence or they shall employ or subcontract with a principal care giver who shall reside in the home where services are delivered and that home shall be the principal care giver’s primary, legal residence.

(5) Neither providers of adult foster care nor principal care givers of adult foster care shall be related by blood, adoption, or marriage to an individual receiving adult foster care services.

(6) Neither providers of adult foster care nor principal care givers of adult foster care shall be the full guardian of an individual receiving adult foster care services.

(D) Supports provided as a component of adult foster care may include the following:

(1) Basic personal care and grooming, including bathing, care of the hair, and assistance with clothing.

(2) Assistance with bladder and/or bowel requirements or problems, including helping the individual to and from the bathroom or assisting the individual with bedpan routines.

(3) Assisting the individual with self-medication or provision of medication administration for prescribed medications and assisting the individual with, or performing, health care activities.

(4) Performing household services essential to the individual’s health and comfort in the home (e.g., necessary changing of bed linens or rearranging of furniture to enable the individual to move about more easily in his/her home).

(5) Assessing, monitoring, and supervising the individual to ensure the individual’s safety, health, and welfare.

(6) Light cleaning tasks in areas of the home used by the individual.

(7) Preparation of a shopping list appropriate to the individual’s dietary needs and financial circumstances, performance of grocery shopping activities as necessary, and preparation of meals.

(8) Personal laundry.

(9) Incidental neighborhood errands as necessary, including accompanying the individual to medical and other appropriate appointments, and accompanying the individual for short walks outside the home.

(10) Skill development to prevent the loss of skills and enhance skills that are already present that lead to greater independence and community integration.

(E) Adult foster care service limitations

(1) Individuals who choose to receive personal care services and supports in adult foster care settings shall receive adult foster care in lieu of homemaker/personal care except as provided in paragraph (F) of this rule. The SSA shall explain the implications of this choice to the individual.

(2) Adult foster care is not available to individuals who are eligible to receive reimbursement for foster care under Title IV-E as amended by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L. 104-193 and the Balanced Budget Act of 1997, P.L. 105-33.

(3) Adult foster care shall not be billed on the same day as homemaker/personal care.

(F) Homemaker/personal care services and limitations

(1) Individuals may receive homemaker/personal care when the individual chooses services that take place outside the foster care setting and the services are provided by a certified homemaker/personal care provider. An example would be overnight summer camp.

(a) An agency provider may subcontract for these services. If the agency provider opts to subcontract, the daily rate for adult foster care may be billed by the adult foster care provider for that day.

(b) In situations where an agency provider does not choose to subcontract for these services or in situations where an individual served by an individual provider seeks homemaker/personal care services outside of the adult foster care setting, the adult foster care provider shall not bill for adult foster care services on a day when homemaker/personal care is rendered. This prohibition exists regardless of whether claims for homemaker/personal care are submitted to the department for the entire twenty-four hour period or for a lesser amount of time that day.

(2) In circumstances where a principal care giver of adult foster care is temporarily unavailable to provide services, substitute coverage may be provided as follows:

(a) In the individual’s foster care setting or in another community setting agreed to by the individual.

(b) For individual providers, a certified homemaker/personal care provider is arranged to deliver substitute coverage and the service is billed as homemaker/personal care. Individual providers shall work with the individual’s SSA to arrange for substitute coverage when needed.

(c) For agency providers, an adult foster care provider is arranged to deliver substitute coverage and the service is billed as adult foster care.

(3) Homemaker/personal care shall not be billed on the same day as adult foster care.

(4) Individual providers of adult foster care shall not bill homemaker/personal care for services to individuals for whom they provide adult foster care.

(G) Respite services

An individual who receives adult foster care may also choose to use institutional respite services during a short-term absence or need for relief of the principal care giver.

(H) Provider qualifications

(1) Providers of adult foster care shall complete an application and meet the applicable individual options waiver homemaker/personal care certification requirements (i.e., individual, agency, or licensed facility) as outlined in rule 5123:2-13-04 of the Administrative Code.

(2) Providers currently certified to deliver individual options waiver homemaker/personal care services are only required to complete and submit to the department the adult foster care service application.

(3) A county board shall not be certified to provide adult foster care services or enter into a medicaid provider agreement with ODJFS for adult foster care services.

(I) Subcontractors

(1) Individual providers of adult foster care shall not subcontract the provision of adult foster care services.

(2) Agency providers of adult foster care may subcontract the provision of adult foster care services in accordance with paragraph (I) of rule 5123:2-13-04 of the Administrative Code.

(J) Adult foster care shall be identified as a service in the individual’s written ISP prior to the service being delivered and in the PAWS submitted to the department.

(K) Individuals who receive adult foster care services may make a request for prior authorization under rule 5101:3-41-12 of the Administrative Code. For individuals with an assigned ODDP funding range of one or two, a request for an authorized funding range adjustment shall be sent to the department so that adult foster care services in rate band one shall result for that individual (as the adult foster care rate band one exceeds the amounts in ODDP funding ranges one and two.) In no instance shall the prior authorization result in a per diem rate in excess of rate band four as contained in appendix A to this rule.

(L) Documentation requirements

(1) Notwithstanding paragraph (B) of rule 5123:2-9-05 of the Administrative Code, service documentation, meaning the maintenance of all records and information on one or more documents, including documents that can be printed from electronic software programs, shall be maintained in such a manner as to fully disclose the nature and extent of the services delivered.

(2) Service documentation for adult foster care shall include each of the following to validate medicaid reimbursement:

(a) Date of service.

(b) Place of service.

(d) Medicaid identification number of the recipient(s).

(e) Name of provider.

(f) Provider identifier/contract number.

(g) Written or electronic signature of the person delivering the service or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(h) Type of service.

(i) Number of individuals sharing services that day.

(j) Forms that identify, for the individual, service(s) and support delivered as a component of adult foster care as specified on the recipient’s approved ISP. The forms shall include all of the above and shall be checked off and initialed by the provider for each date of service.

(M) Payment standards

(1) Notwithstanding the requirements of paragraphs (D)(1), (D)(8), (D)(9), (D)(10),

(D)(11), and (D)(12) of rule 5123:2-9-06 of the Administrative Code, payment for adult foster care services shall be at a daily rate established by an independent model, adjusted by each county’s cost of doing business category. Payment rates are contained in appendix A to this rule.

(2) Payment for one individual shall be at one hundred percent of the daily rate for the range assigned by the ODDP.

(3) Payment for a group size of two individuals shall be at eighty-five percent of the daily rate for the range for each individual.

(4) Payment for a group size of three individuals shall be at seventy-five percent of the daily rate for the range for each individual.

(5) Payment for a group size of four individuals shall be at sixty-five percent of the daily rate for the range for each individual.

(6) The base rate paid to a provider of adult foster care shall be adjusted to reflect the number of individuals sharing the service, regardless of funding source.

(7) Providers shall be reimbursed at the lesser of their usual and customary rate (UCR) or the statewide payment rate for each waiver service that is delivered. The department shall establish a mechanism through which providers shall communicate their usual and customary rates (UCRs) to the department. A single provider may charge different UCRs for the same service when the service is provided in different geographic areas of the state. In this instance, the UCRs charged shall be declared for each cost of doing business category described in appendix B to this rule that identifies the counties in which the provider intends to provide specific services. Upon notification of a provider’s UCR or change in UCR, the department shall provide notice to the appropriate county board.

(8) Agency providers of adult foster care may bill for each day the individual receives adult foster care through the agency.

(9) Individual providers of adult foster care may bill for each day the adult foster care service is delivered. Adult foster care shall not be billed on the same day as homemaker/personal care.

(10) Payment for adult foster care does not include room and board, items of comfort or convenience, or costs for the maintenance, upkeep, and improvement of the foster home.

(11) ODJFS retains the final authority, based on the recommendation of the department, to establish payment rates for all waiver services included in HCBS waivers administered by the department.

APPENDIX A

SERVICE CODES AND PAYMENT RATES FOR ADULT FOSTER CARE

Billing Unit: Daily

Service Codes: Adult Foster Care – Agency Provider: AFA

Adult Foster Care – Individual Provider: AFO

Reimbursement Rate: Listed below by cost of doing business (CODB) category.

Payment for one individual shall be at one hundred percent of the daily rate for the range assigned by the ODDP.

Payment for a group size of two individuals shall be at eighty-five percent of the daily rate for the range for each individual.

Payment for a group size of three individuals shall be at seventy-five percent of the daily rate for the range for each individual.

Payment for a group size of four individuals shall be at sixty-five percent of the daily rate for the range for each individual.

No more than three individuals shall receive adult foster care in unlicensed foster homes. No more than four individuals shall receive adult foster care in licensed foster homes.

CODB Category ODDP Range Agency Provider Daily Rate Individual Provider Daily Rate

1 $ 106.35 $ 89.18

2 $ 106.35 $ 89.18

3 $ 106.35 $ 89.18

4 $ 109.76 $ 92.66

5 $ 130.22 $ 113.52

6 $ 155.80 $ 139.58

7 $ 155.80 $ 139.58

8 $ 155.80 $ 139.58

19 $ 155.80 $ 139.58

1 $ 107.46 $ 90.11

2 $ 107.46 $ 90.11

3 $ 107.46 $ 90.11

4 $ 110.90 $ 93.62

5 $ 131.57 $ 114.69

6 $ 157.41 $ 141.03

7 $ 157.41 $ 141.03

8 $ 157.41 $ 141.03

9 $ 157.41 $ 141.03

1 $ 108.56 $ 91.03

2 $ 108.56 $ 91.03

3 $ 108.56 $ 91.03

4 $ 112.04 $ 94.58

5 $ 132.92 $ 115.87

6 $ 159.02 $ 142.48

7 $ 159.02 $ 142.48

8 $ 159.02 $ 142.48

9 $ 159.02 $ 142.48

1 $ 109.66 $ 91.96

2 $ 109.66 $ 91.96

3 $ 109.66 $ 91.96

4 $ 113.17 $ 95.54

5 $ 134.27 $ 117.04

6 $ 160.64 $ 143.92

7 $ 160.64 $ 143.92

8 $ 160.64 $ 143.92

9 $ 160.64 $ 143.92

1 $ 110.76 $ 92.88

2 $ 110.76 $ 92.88

3 $ 110.76 $ 92.88

4 $ 114.31 $ 96.50

5 $ 135.62 $ 118.22

6 $ 162.25 $ 145.37

7 $ 162.25 $ 145.37

8 $ 162.25 $ 145.37

9 $ 162.25 $ 145.37

1 $ 111.86 $ 93.81

2 $ 111.86 $ 93.81

3 $ 111.86 $ 93.81

4 $ 115.45 $ 97.46

5 $ 136.97 $ 119.40

6 $ 163.87 $ 146.81

7 $ 163.87 $ 146.81

8 $ 163.87 $ 146.81

9 $ 163.87 $ 146.81

1 $ 112.97 $ 94.73

2 $ 112.97 $ 94.73

3 $ 112.97 $ 94.73

4 $ 116.58 $ 98.42

5 $ 138.32 $ 120.57

6 $ 165.48 $ 148.26

7 $ 165.48 $ 148.26

8 $ 165.48 $ 148.26

9 $ 165.48 $ 148.26

1 $ 114.07 $ 95.65

2 $ 114.07 $ 95.65

3 $ 114.07 $ 95.65

4 $ 117.72 $ 99.38

5 $ 139.67 $ 121.75

6 $ 167.10 $ 149.71

7 $ 167.10 $ 149.71

8 $ 167.10 $ 149.71

9 $ 167.10 $ 149.71

APPENDIX B

COST OF DOING BUSINESS CATEGORIES AND FACTORS

Factor Counties in Category

Category 1 0.9651 Adams

Athens

Belmont

Gallia

Guernsey

Harrison

Jefferson

Meigs

Monroe

Pike

Ross

Scioto

Tuscarawas

Vinton

Washington

Category 2 0.9751 Carroll

Crawford

Defiance

Highland

Hocking

Jackson

Lawrence

Mercer

Morgan

Muskingum

Noble

Paulding

Perry

Van Wert

Wyandot

Category 3 0.9851 Allen

Auglaize

Brown

Clinton

Columbiana

Coshocton

Fayette

Hancock

Holmes

Knox

Marion

Morrow

Putnam

Richland

Seneca

Shelby

Williams

Category 4 0.9951 Ashland

Darke

Erie

Fairfield

Fulton

Hardin

Henry

Huron

Licking

Logan

Mahoning

Pickaway

Sandusky

Stark

Trumbull

Wood

Category 5 1.0051 Ashtabula

Champaign

Clark

Delaware

Greene

Lucas

Madison

Miami

Montgomery

Ottawa

Preble

Union

Wayne

Category 6 1.0151 Clermont

Franklin

Geauga

Lake

Lorain

Medina

Portage

Summit

Category 7 1.0251 Butler

Cuyahoga

Warren

Category 8 1.0351 Hamilton

Effective: 10/01/2007

R.C. 119.032 review dates: 10/01/2012

Promulgated Under: 119.03

Statutory Authority: 5123.04, 5123.049

Rule Amplifies: 5123.04, 5123.049, 5123.16

5123:2-13-07 Individual options waiver - homemaker/personal care daily billing unit for congregate settings where individuals share services.

(A) Purpose

The purpose of this rule is to establish a reimbursement process for homemaker/personal care (HPC) when individuals share the services of the same provider in the same setting as part of the home and community-based services (HCBS) individual options waiver. This rule builds on concepts and definitions in rule 5123:2-9-06 and other rules of the Administrative Code. This rule provides a process for those individuals/settings that qualify, which shall be used instead of the billing requirements outlined in rule 5123:2-9-06 of the Administrative Code.

(B) Definitions

(1) “Cost projection instrument” means the analytical tools used by county boards of mental retardation and developmental disabilities (county boards), providers, and individuals to determine the total estimated number of direct service hours and total planned HPC costs based on individual service plans (ISPs) for individuals who are sharing HPC services by the same provider within the same site. These tools shall be validated by the Ohio department of mental retardation and development disabilities (ODMRDD) to be in compliance with rates and other components of rule 5123:2-9-06 of the Administrative Code. The cost projection instrument shall include those elements approved by ODMRDD.

(2) “Daily billing unit” means the amount of a provider’s reimbursement that is apportioned to each individual who lives in the residence and shares HPC services with others. The daily billing unit is determined via the ODMRDD web-based calculation tool in accordance with planning information entered by the county board and actual service information entered by the provider of HPC services.

(3) “Direct service hours” means the direct staff time spent delivering HPC services. A direct service hour is comprised of four fifteen-minute billing units. As defined in rule 5123:2-9-06 of the Administrative Code, a “fifteen-minute billing unit” means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time.

(4) “Service documentation” means the maintenance of all records and information on one or more documents, including documents that may be printed from electronic software programs, kept in a manner as to fully disclose the nature and extent of services delivered and must include the items defined in paragraph (G) of this rule to validate medicaid reimbursement.

(5) “Site span” means a period of time where there are no changes to the estimated total costs or estimated total direct service hours for a site where individuals share HPC services of a provider. An individual may have one or more site spans during one waiver span.

(1) Individuals who receive HPC services and supports in adult foster care settings shall receive services as defined in rule 5123:2-13-06 of the Administrative Code. The service and support administrator (SSA) shall explain to the individual that adult foster care is in lieu of HPC except as provided in paragraph (E) of rule 5123:2-13-06 of the Administrative Code. A daily billing unit for HPC shall not be billed on the same day as adult foster care.

(2) Individuals who do not share the HPC services of the same provider in the same setting are required to remain on the fifteen-minute unit approach outlined in rule 5123:2-9-06 of the Administrative Code. Examples include:

(a) Individuals who live alone; and

(b) Individuals who live with their family and do not share the HPC services of a provider with others.

(3) Individuals who share occasional or time-limited services of a provider in addition to their primary residential provider are required to remain on the fifteen-minute unit approach outlined in rule 5123:2-9-06 of the Administrative Code for the occasional or time-limited HPC services of their non-residential provider. Examples include but are not limited to:

(a) Individuals who live together and share HPC services of an agency or individual provider and who use a second HPC provider for recreational activities;

(b) Individuals who live in different homes who travel with an agency or individual provider who is not their residential provider to a recreational event such as bowling, respite, or camp on a monthly or weekly basis; and

(D) Calculation of the individual daily billing unit

(1) The Ohio developmental disabilities profile (ODDP) shall be administered for the individual by the SSA in accordance with rule 5123:2-9-06 of the Administrative Code and ODMRDD written guidelines. Administration of the ODDP establishes the funding range for the individual.

(2) The process shall be followed in accordance with rule 5123:2-9-06 of the Administrative Code, including the base rates, whether or not the individual meets the criteria for the medical and behavioral add-ons, necessary staffing ratios, number of service units, on-site/on-call (OSOC), prior authorization requests as necessary, and explanation of due process rights.

(3) For situations where there is at least one staff person serving more than one individual during sleep hours and of those individuals, at least one individual’s ISP calls for HPC routine through the sleep hours, while at the same time at least one other individual has a need for OSOC, the provider shall be reimbursed at the HPC routine rate as set forth in rule 5123:2-9-06 of the Administrative Code, which shall be determined by the number of awake staff and the number of individuals who are receiving HPC routine. The cost of that rate shall be apportioned so that the individuals receiving OSOC shall be charged the OSOC rate as set forth in rule 5123:2-9-06 of the Administrative Code and the individuals receiving HPC routine shall be charged an equal share of the remainder of the cost. The following examples are provided to illustrate how the rates are determined and how the cost of those rates is apportioned. The examples utilize rates in rule 5123:2-9-06 of the Administrative Code for cost of doing business factor one.

(a) Example 1. Four individuals live together and have one staff person during sleep hours. One individual receives HPC routine and the other three individuals receive OSOC.

Example 1

HPC routine base rate 1:1 $4.52

OSOC 1:4 $3.24

Individual 1 (1/4 of OSOC 1:4) $.81

Individual 2 (1/4 of OSOC 1:4) $.81

Individual 3 (1/4 of OSOC 1:4) $.81

Individual 4 (HPC base rate – remainder) $2.09

Total reimbursement for 1 staff $4.52

(b) Example 2. Five individuals live together and have one staff person during sleep hours. Two individuals receive HPC routine and the other three individuals receive OSOC.

Example 2

HPC routine base rate 1:2 $4.83

OSOC 1:5 $3.24

Individual 1 (1/5 of OSOC 1:5) $.648

Individual 2 (1/5 of OSOC 1:5) $.648

Individual 3 (1/5 of OSOC 1:5) $.648

Individual 4 (HPC base rate – 1/2 remainder) $1.443

Individual 5 (HPC base rate – 1/2 remainder) $1.443

Total reimbursement for 1 staff $4.83

(4) Using a cost projection instrument that has been validated by ODMRDD, the SSA or other county board designee, with input from members of the individual’s ISP team, shall project the service utilization for the individuals who share services based on factors including but not limited to: a typical usage pattern and identified waiver span, adjustments based on past history, holidays, day service site closings, weekends, and other anticipated changes to direct service hours. The result shall include total planned HPC costs based on ISPs for the site and a total projected number of service hours for the site. These projections include any individual’s prior authorization requests that have been approved pursuant to rule 5101:3-41-12 of the Administrative Code. The summary and detail information included in the cost projection instrument shall be shared with the individual’s provider. This information shall also be shared with others as designated by the individual at the request of the individual.

(5) For each site span, after the payment authorization for waiver services (PAWS) has been confirmed by ODMRDD, the county board shall enter the following information into the ODMRDD web-based calculation tool which shall be used in the calculations described in paragraph (D)(6) of this rule:

(a) Total planned HPC costs for the site based on ISPs for individuals who are sharing HPC services by the same provider within the site;

(b) Total estimated HPC hours for the site to be provided; and

(6) After HPC services are provided at the site, the provider shall enter into the ODMRDD web-based calculation tool, the number of direct service hours rendered for all individuals for a specific seven-day time span and the specific dates that each individual received HPC services at the site. Using the total planned HPC costs based on ISPs for the site and total planned HPC hours for the site, the web-based calculation tool determines the provider’s direct service hourly rate for that site. The web-based calculation tool will then calculate the maximum HPC payment to the provider for that seven-day period. The web-based calculation tool then determines how the total payment to that provider for that seven-day period shall be apportioned to each individual’s authorized budget, resulting in a daily billing unit for each individual for each day that services were provided. The provider then uses that information to prepare a claim for reimbursement.

(7) When changes occur within the site that affect the total estimated direct service hours, total planned HPC costs based on ISPs, or an individual’s predicted ongoing participation at the site, the county board shall enter changes into the cost projection instrument and then the web-based calculation tool for a new, prospective site span. These changes shall be made in concert with any necessary changes to the ISP process and PAWS for the individual(s) living in the household who will be affected by these changes.

(a) If, during a site span, there is a significant change of service needs for an individual that may impact the total estimated direct service hours, total planned HPC costs based on ISPs, or an individual’s predicted ongoing participation at the site, the provider shall notify the county board.

(b) If the individual/guardian, county board, or provider wishes to convene a meeting to discuss a significant change of service needs for an individual during a site span, that meeting shall occur within ten working days of the day the request was made. Discussion shall occur in accordance with paragraph (E)(7) of rule 5123:2-9-06 of the Administrative Code.

(E) Agency providers of HPC may subcontract the provision of HPC services in accordance with paragraph (I) of rule 5123:2-13-04 of the Administrative Code. The subcontracted services shall be provided in accordance with this rule and rule 5123:2-9-06 of the Administrative Code.

(F) Transition to the daily billing unit

(1) Individuals who share the HPC services of the same residential provider in the same setting and who have not yet transitioned to the fifteen-minute unit reimbursement system shall transition directly to the approach outlined in this rule in accordance with timelines agreed to by ODMRDD, the Ohio department of job and family services (ODJFS), and the federal centers for medicare and medicaid services (CMS).

(2) Individuals who share the HPC services of the same residential provider in the same setting and whose service reimbursement has already been converted to the statewide fifteen-minute unit reimbursement system shall convert to the daily billing unit reimbursement approach described in this rule within one year of the effective date of this rule.

(3) The director of ODMRDD reserves the right to allow a provider of HPC residential services to continue to use the fifteen-minute reimbursement system in the event of a unique and/or extenuating circumstance. This right shall be exercised in consultation with ODJFS as the single state medicaid agency.

(4) In no circumstance shall negotiated reimbursement be permitted beyond the timelines agreed to by ODMRDD, ODJFS, and CMS.

(G) Service documentation requirements

(1) Notwithstanding paragraphs (B) and (E) of rule 5123:2-9-05 of the Administrative Code, service documentation for HPC shall include each of the following to validate medicaid reimbursement:

(a) Date of service.

(b) Place of service.

(d) Description and details of the services delivered that directly relate to the services specified on the individual’s approved ISP as the services to be provided.

(e) Medicaid identification number of the recipient(s).

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider, or an electronic process approved by ODMRDD.

(2) Reimbursements made to the provider for services delivered that are not supported by service documentation or are supported by service documentation that does not include all of the required items listed in paragraph (G)(1) of this rule may be recoverable under paragraph (P) of rule 5123:1-2-08 of the Administrative Code, paragraph (N) of rule 5123:1-2-11 of the Administrative Code, or paragraph (I) of rule 5123:2-9-06 of the Administrative Code

(H) Payment standards

(1) Notwithstanding the requirements of paragraphs (D)(1), (D)(11), and (D)(12) of rule 5123:2-9-06 of the Administrative Code, the billing process and payment for HPC services when individuals share the services of the same provider in the same setting shall be at a daily billing unit for each individual based on that individual’s apportioned share of the services rendered at the site and the number of days each person receives services pursuant to the web-based calculation tool. The service codes for the HPC daily billing unit are contained in the appendix to this rule.

(2) The ODMRDD-validated cost projection instrument shall utilize the lower of the provider’s usual and customary rate or the statewide HPC rates established in appendix A to rule 5123:2-9-06 of the Administrative Code, including the projected staff to individual ratios to determine daily billing units.

(3) Agency providers of HPC may bill for each day the individual receives HPC through the agency.

(4) Individual providers of HPC may bill for each day the HPC service is delivered by the provider. Individual providers shall work with the individual’s SSA to arrange for substitute coverage, when needed.

(5) Payment for HPC does not include room and board, items of comfort or convenience, or costs for the maintenance, upkeep, and improvement of the home.

(6) ODJFS retains the final authority, based on the recommendation of ODMRDD, to establish payment rates for all waiver services included in HCBS waivers administered by ODMRDD.

(I) Monitoring

(1) Providers, county boards, and ODMRDD shall have access to both PAWS utilization reports and reports generated by the web-based calculation tool in order to monitor estimated services and actual services provided at each specific site. This information shall be made available to ODJFS upon request.

(2) ODMRDD shall monitor the ongoing progress of the daily billing unit reimbursement approach through a series of fiscal control and quality assurance procedures including: validation of existing cost projection instruments; validation of total expenditures and total hours that are entered by the county board into the web-based calculation tool; verification that daily billing units are supported by appropriate documentation; and verification that provider service hours rendered are reported appropriately. Each type of procedural monitoring shall take place in each region of the state and shall be summarized in a report to ODJFS every six months.

(3) ODJFS reserves the right to perform independent oversight reviews as part of its general oversight functions, in addition to the ODMRDD monitoring activities described in paragraph (I)(2) of this rule.

(J) Due process rights and responsibilities

(1) Any recipient or applicant for waiver services administered by ODMRDD may utilize the process set forth in section 5101.35 of the Revised Code, in accordance with division 5101:6 of the Administrative Code for any purpose authorized by that statute and the rules implementing the statute. The process set forth in section 5101.35 of the Revised Code is available only to applicants, recipients, and their lawfully appointed authorized representatives. Providers shall have no standing in an appeal under this section.

(2) Applicants for and recipients of waiver services administered by ODMRDD shall use the process set forth in section 5101.35 of the Revised Code for any challenge related to the administration and/or scoring of the ODDP or to the type, amount/level, scope, or duration of services included or excluded from an ISP or individual behavior plan addendum. For purposes of clarity, a change in staff to waiver recipient service ratios does not automatically result in a change in the level of services received by an individual.

APPENDIX

SERVICE CODES FOR DAILY BILLING UNIT FOR

HOMEMAKER/PERSONAL CARE SERVICES

PROVIDED UNDER THE INDIVIDUAL OPTIONS WAIVER

Billing Unit: Daily

Service Codes: Homemaker/Personal Care – Agency Provider: ADL

Homemaker/Personal Care – Individual Provider: ADP

Replaces: 5123:2-13-07

Effective: 03/20/2008

R.C. 119.032 review dates: 03/20/2013

Promulgated Under: 119.03

Statutory Authority: 5123.04, 5111.871, 5111.873

Rule Amplifies: 5123.04, 5111.871, 5111.873

Prior Effective Dates: 12/21/2007 (Emer.)