5123:2-2-04 Compliance reviews of certified providers.

(A) Purpose and scope

This rule governs compliance reviews conducted by the department and county boards to ensure compliance by certified providers with applicable requirements. This rule applies to all certified providers, including certified providers licensed in accordance with section 5123.19 of the Revised Code.

(B) Definitions

(1) "Applicable requirements" means:

(a) Federal and state laws and regulations which govern the conduct of the certified provider, including but not limited to, Chapters 4723., 5111., 5123., and 5126. of the Revised Code and all administrative rules promulgated under the authority of these statutes.

(b) Requirements set forth in any waiver, approved under the authority of section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C.A. 1396n , 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 between the department and the Ohio office of medical assistance.

(2) "Certification revocation" means the revocation of a certified provider's certification to serve one or more individuals in one or more counties.

(3) "Certification suspension" means either of the following:

(a) Suspension of a certified provider's certification to serve one or more individuals in one or more counties for a specified time period; or

(b) Suspension of a certified provider's certification to serve additional individuals in one or more counties.

(4) "Certified provider" means an agency provider or independent provider certified by the department pursuant to section 5123.161 of the Revised Code to provide supported living or home and community-based services.

(5) "Compliance review" means a review of a certified provider conducted by the department or a county board for the purpose of determining provider compliance with applicable requirements in order to ensure the health, safety, and welfare of individuals served.

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

(7) "Home and community-based services" has the same meaning as in section 5126.01 of the Revised Code.

(8) "Individual" means a person with developmental disabilities.

(9) "Major unusual incident" has the same meaning as in rule 5123:2-17-02 of the Administrative Code.

(10) "Protocol" means the forms, instructions for the completion of written documentation, and process developed by the department and used by the department and county boards to conduct compliance monitoring in accordance with this rule. A protocol does not create provider standards or qualifications.

(C) Compliance reviews

(1) There are three types of compliance reviews:

(a) Routine compliance reviews

In accordance with priorities established by the department in the protocol for compliance reviews, the department shall coordinate with county boards to ensure that each certified provider receives a routine compliance review within one year of the certified provider's initial billing for provision of services. Thereafter, routine compliance reviews of certified providers shall be conducted so that each certified provider is reviewed once during the term of certification.

(b) Special compliance reviews

The department or a county board may conduct special compliance reviews as necessary:

(i) Pertaining to the health, safety, or welfare of an individual;

(ii) Based on a complaint or allegation; or

(iii) Based on a major unusual incident that may indicate the certified provider's failure to comply with applicable requirements.

(c) Abbreviated compliance reviews

(i) The department may accept a certified provider's accreditation by a national accrediting entity as demonstration that the certified provider is meeting applicable requirements. A certified provider that is accredited by a national accrediting entity is eligible for an abbreviated compliance review when the standards of the national accrediting entity:

(a) Meet or exceed the department's standards;

(b) Are compatible with the centers for medicare and medicaid services home and community-based services quality framework;

(c) Focus on achievement of desired outcomes for individuals served; and

(d)Ensure the health and safety of individuals served.

(ii) An abbreviated compliance review shall examine the certified provider's compliance with applicable requirements regarding:

(a) Background investigations of the certified provider's chief executive officer and employees;

(b) The behavior support portion of individual service plans;

(c) Medication administration; and

(d)Major unusual incidents.

(iii) To be eligible for abbreviated compliance review, the certified provider shall submit a written request to the department that includes a copy of the most recent survey/review of the certified provider by the national accrediting entity.

(iv) The certified provider shall notify the department in writing within ten days if the certified provider's accreditation by the national accrediting entity is amended, suspended, terminated, or not renewed and provide a copy of related correspondence from the national accrediting entity.

(v) Abbreviated compliance reviews may not be available when:

(a) The certified provider has not received an initial routine compliance review by the department or county board.

(b) The certified provider has had multiple or significant substantiated major unusual incidents since the most recent compliance review by the department or county board or survey/review by the national accrediting entity.

(c) The certified provider's chief executive officer and/or key members of the certified provider's management team have changed since the most recent compliance review by the department or county board or survey/review by the national accrediting entity.

(d) The certified provider's accreditation by the national accrediting entity has been amended or suspended.

(2) Only the department may conduct compliance reviews of residential facilities licensed in accordance with section 5123.19 of the Revised Code and administrative rules promulgated under its authority.

(3) The department shall develop a protocol for compliance reviews. A county board may not change or augment the protocol.

(a) The protocol shall include, but is not limited to, the following components:

(i) The method for selecting certified providers to be reviewed;

(ii) The types and scope of reviews that may be conducted;

(iii) The process and procedures for notifying certified providers of upcoming reviews;

(iv) The elements of provider compliance which shall be based on the applicable requirements;

(v) The elements of a written compliance review summary to a certified provider that shall include the explanation of any citations, the process to develop and implement a plan of correction, and an explanation of the due process afforded to a certified provider;

(vi) The criteria for conducting announced and unannounced reviews; and

(vii) Any forms or methods of documentation approved by the department.

(b) The department shall make the protocol available at its website (http://dodd.ohio.gov) and shall include the protocol in any training outlined in paragraph (E) of this rule.

(D) Compliance review summary and plan of correction

(1) The department or county board, as applicable, shall issue a written compliance review summary to the certified provider within seven days of conclusion of the compliance review in accordance with the format described in the protocol for compliance reviews. The compliance review summary shall be objective in terms of observations and citations, relying upon documentation that clearly addresses the standards reviewed.

(2) Within fourteen days of receipt of a compliance review summary that includes one or more citations, the certified provider shall submit to the department or county board, as applicable, a written appeal or a written plan of correction for each citation. If the certified provider does not submit a written appeal within fourteen days, the compliance review summary shall be final and not subject to appeal by the certified provider.

(a) The appeal for a citation shall include the certified provider's basis with supporting documentation for challenging the citation. The department or county board, as applicable, shall allow or disallow the appeal within ten days of receipt.

(i) If the compliance review was conducted by the department and the appeal is disallowed, the certified provider shall submit a written plan of correction for the citation to the department within fourteen days.

(ii) If the compliance review was conducted by a county board and the appeal is disallowed, the certified provider shall either:

(a) Submit a written plan of correction for the citation to the county board within fourteen days; or

(b)If the certified provider objects to the county board's decision to disallow the appeal, submit to the department a written appeal within seven days of the county board's decision. The department shall notify the certified provider and the county board of its decision to allow or disallow the appeal within fourteen days of receipt. If the department disallows the appeal, the certified provider shall submit a written plan of correction for the citation to the county board within fourteen days.

(b) The written plan of correction for a citation shall include action steps and timelines for remediation. The department or county board, as applicable, shall approve or disapprove the plan of correction within twenty days of receipt. When the department or county board disapproves a plan of correction, the certified provider shall work with the department or county board, as applicable, to develop an acceptable plan of correction.

(E) Training

(1) The department shall provide or arrange for initial training to county boards and certified providers regarding the requirements and procedures outlined in this rule and in the protocol for compliance reviews.

(2) Any employees or agents of the department or the county board whose responsibilities include conducting compliance reviews in accordance with this rule shall complete the initial training in the requirements and procedures outlined in this rule prior to conducting compliance reviews.

(3) The department shall provide documentation of a person's completion of this training to the county board. The county board shall maintain a list of the persons in its county that have completed this training and are able to conduct compliance reviews in accordance with this rule.

(4) The department may require persons who have received the initial training to receive continuing training in the implementation of this rule in a manner prescribed by the department.

(F) Certification suspension and certification revocation

(1) The department may initiate certification suspension or certification revocation proceedings if the department finds one or more of the following:

(a) Substantial violation of applicable requirements which present a risk to an individual's health and welfare; or

(b) A pattern of non-compliance with plans of correction approved in accordance with this rule; or

(c) A pattern of continuing non-compliance with applicable requirements; or

(d) A licensed provider has had its license revoked by the licensing authority; or

(e) Failure to cooperate with the compliance review process set forth in this rule; or

(f) Other good cause, including misfeasance, malfeasance, nonfeasance, substantiated abuse or neglect, financial irresponsibility, or other conduct the department determines is injurious to individuals being served. The department may gather and evaluate information from a variety of sources, including the county board and provider, in making such a determination.

(2) Certification suspension and certification revocation proceedings shall be conducted in accordance with Chapter 119. of the Revised Code.

(3) When the department issues a notice of its intent to suspend or revoke a certified provider's certification, the department shall give written notice to the Ohio office of medical assistance and to the county board of each county in which the proposed suspension or revocation is proposed to be effective.

(4) Each county board that is notified in writing by the department of the department's intent to suspend or revoke a certified provider's certification shall so notify in writing each individual in the county who is receiving services for which the provider's certification is proposed to be suspended or revoked, the individual's guardian if the individual is an adult for whom a guardian has been appointed, and the individual's parent or guardian if the individual is a minor.

(5) The department may suspend or revoke a certified provider's certification regardless of whether some or all of the deficiencies enumerated in accordance with this rule that prompted the department's intent to suspend or revoke the certification have been corrected at the time of the hearing.

(6) When the department suspends or revokes a certified provider's certification, the certified provider shall comply with the department's adjudication order within thirty days of the date of the mailing of the order.

(7) The department shall give written notice of the certified provider's suspension or revocation to the Ohio office of medical assistance and to the county board of each county in which the suspension or revocation is effective.

(8) Each county board that is notified in writing by the department of suspension or revocation of a certified provider's certification shall so notify in writing each individual in the county who is receiving services for which the provider's certification is suspended or revoked, the individual's guardian if the individual is an adult for whom a guardian has been appointed, and the individual's parent or guardian if the individual is a minor.

Replaces: 5123:2-9-08

Effective: 03/14/2013
R.C. 119.032 review dates: 03/14/2018
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04 , 5123.045 , 5123.162 , 5123.169 , 5123.19 , 5126.05 , 5126.08
Rule Amplifies: 5111.871 , 5123.04 , 5123.045 , 5123.162 , 5123.169 , 5123.19 , 5126.05 , 5126.08
Prior Effective Dates: 10/16/2003, 07/08/2004, 07/01/2005