5123:2-9-51 Home and community-based services waivers - adult day health center services under the transitions developmental disabilities waiver.

(A) Purpose

The purpose of this rule is to define adult day health center services under the transitions developmental disabilities waiver and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Adult day health center" means a freestanding building or space within another building that shall not be used for any other purpose during the provision of adult day health center services. An adult day health center shall not be located in an intermediate care facility.

(2) "Adult day health center services" means regularly scheduled services delivered at an adult day health center to individuals age eighteen and older who have a need for the services as identified in their individual service plans.

(a) Adult day health center services shall include:

(i) Personal care aide services as set forth in rule 5123:2-9-56 of the Administrative Code or waiver nursing services as set forth in rule 5123:2-9-59 of the Administrative Code;

(ii) Recreational and educational activities; and

(iii) At least one but no more than two meals per day that meet the individual's dietary requirements.

(b) Adult day health center services may include:

(i) Skilled therapy services as set forth in rule 5101:3-12-01 of the Administrative Code; and

(ii) Transportation of the individual to and from adult day health center services.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be approved by the Ohio office of medical assistance.

(4) "County board" means a county board of developmental disabilities.

(5) "Department" means the Ohio department of developmental disabilities.

(6) "Independent provider" means a non-agency, self-employed person approved by the Ohio office of medical assistance to provide services who does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for the purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Intermediate care facility for individuals with intellectual disabilities" (or "intermediate care facility") means an intermediate care facility for the mentally retarded certified as in compliance with applicable standards for the medicaid program by the director of health in accordance with Title XIX of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1396 .

(10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E)(2) of this rule to validate payment for medicaid services.

(C) Provider qualifications

(1) Adult day health center services shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio office of medical assistance.

(2) Adult day health center services shall not be provided by an independent provider.

(3) No later than thirty days after the effective date of this rule, and at least annually thereafter, each employee of a provider of adult day health center services who is engaged in the direct provision of adult day health center services shall complete training, in accordance with standards established by the department, in:

(a) The provisions governing rights of individuals as set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(b) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department.

(4) A provider of adult day health center services shall ensure that each employee hired on or after the effective date of this rule who is engaged in the direct provision of adult day health center services completes training, in accordance with standards established by the department, prior to initially providing adult day health center services and at least annually thereafter, in:

(a) The provisions governing rights of individuals as set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(b) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department.

(5) A provider of adult day health center services shall ensure that each non-licensed employee engaged in the direct provision of adult day health center services annually completes at least twelve hours of in-service training, excluding agency provider/program-specific orientation or training. Training completed pursuant to paragraph (C)(3) or (C)(4) of this rule may be counted toward the twelve hours.

(D) Requirements for service delivery

(1) Adult day health center services shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (F) of rule 5123:2-9-50 of the Administrative Code.

(2) Providers of adult day health center services shall:

(a) Be identified as the provider and have specified in the individual service plan the number of hours for which the provider is authorized to furnish adult day health center services to the individual;

(b) Operate the adult day health center in compliance with all federal, state, and local laws, rules, and regulations;

(c) Comply with applicable rules in Chapters 5101:3-45 and 5123:2-9 of the Administrative Code;

(d) Provide for replacement coverage of an individual's loss due to theft and/or property damage, upon request provide documentation to the department or the Ohio office of medical assistance or their designees verifying coverage, and maintain a written procedure identifying the steps an individual must take to file a liability claim;

(e) Ensure that any waiver nursing services are provided by a nurse who possesses a current, valid, and unrestricted license issued by the Ohio board of nursing as a registered nurse or a licensed practical nurse and who is providing nursing services within his or her scope of practice. A licensed practical nurse may provide waiver nursing services at the direction of a registered nurse;

(f) Provide task-based instruction to direct care staff providing adult day health center services as set forth in paragraph (B)(2) of this rule; and

(g) Maintain at all times a paid-direct-care-staff-to-individuals-served ratio of no less than one to six.

(E) Documentation of services

(1) Providers of adult day health center services shall maintain service documentation for each individual served in a manner that protects the confidentiality of the individual's records.

(2) Service documentation for adult day health center services shall include each of the following to validate payment for medicaid services:

(a) Individual-identifying information including, but not limited to, name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health insurance identification numbers;

(b) Individual's medical history;

(c) Name of individual's treating physician;

(d) A copy of all individual service plans in effect when the provider provides services;

(e) A copy of any advance directives including, but not limited to, a "do not resuscitate" order or medical power of attorney, if they exist;

(f) Documentation of drug and food interactions, allergies, and dietary restrictions;

(g) Documentation that clearly shows the date of adult day health center services delivery, including tasks performed or not performed, and the individual's arrival and departure times for each date;

(h) A discharge summary that includes information regarding progress made toward goal achievement and indicates any recommended follow-ups or referrals that is signed and dated by the adult day health center services provider, at the point the adult day health center services provider is no longer going to provide services to the individual or when the individual no longer needs adult day health center services; and

(i) Information specified in paragraph (E)(2) of rule 5123:2-9-59 of the Administrative Code when waiver nursing services or skilled therapy services are provided to the individual.

(F) Payment standards

(1) The billing units, service codes, and payment rates for adult day health center services are contained in the appendix to this rule.

(2) Providers shall submit claims for payment for adult day health center services to the Ohio office of medical assistance in accordance with rule 5101:3-41-22 of the Administrative Code.

(3) The adult day health center services full day billing unit shall apply when adult day health center services are provided to an individual for five or more hours in one calendar day.

(4) The adult day health center services half day billing unit shall apply when adult day health center services are provided to an individual for less than five hours in one calendar day.

(5) The services set forth in paragraphs (B)(2)(a) and (B)(2)(b) of this rule and delivered by an adult day health center shall not be reimbursed as separate services.

Replaces: Part of 5101:3-47-04

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Effective: 01/01/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04
Rule Amplifies: 5111.871 , 5123.04
Prior Effective Dates: 03/30/1990 (Emer.), 06/29/1990, 07/01/1990, 03/12/1992 (Emer.), 06/01/1992, 07/31/1992 (Emer.), 10/30/1992, 07/01/1993 (Emer.), 07/30/1993, 09/01/1993, 01/01/1996, 07/01/1998, 07/01/2006, 07/01/2010