173.391 Requirements for provider certification - disciplinary action.

(A) The department of aging or its designee shall do all of the following in accordance with Chapter 119. of the Revised Code:

(1) Certify a provider to provide community-based long-term care services under a program the department administers if the provider satisfies the requirements for certification established by rules adopted under division (B) of this section and pays the fee, if any, established by rules adopted under division (G) of this section;

(2) When required to do so by rules adopted under division (B) of this section, take one or more of the following disciplinary actions against a provider certified under division (A)(1) of this section:

(a) Issue a written warning;

(b) Require the submission of a plan of correction or evidence of compliance with requirements identified by the department;

(c) Suspend referrals;

(d) Remove clients;

(e) Impose a fiscal sanction such as a civil monetary penalty or an order that unearned funds be repaid;

(f) Suspend the certification;

(g) Revoke the certification;

(h) Impose another sanction.

(3) Except as provided in division (E) of this section, hold hearings when there is a dispute between the department or its designee and a provider concerning actions the department or its designee takes regarding a decision not to certify the provider under division (A)(1) of this section or a disciplinary action under divisions (A)(2)(e) to (h) of this section.

(B) The director of aging shall adopt rules in accordance with Chapter 119. of the Revised Code establishing certification requirements and standards for determining which type of disciplinary action to take under division (A)(2) of this section in individual situations. The rules shall establish procedures for all of the following:

(1) Ensuring that providers comply with section 173.38 of the Revised Code;

(2) Evaluating the services provided by the providers to ensure that the services are provided in a quality manner advantageous to the individual receiving the services;

(3) Determining when to take disciplinary action under division (A)(2) of this section and which disciplinary action to take;

(4) Determining what constitutes another sanction for purposes of division (A)(2)(h) of this section.

(C) The procedures established in rules adopted under division (B)(2) of this section shall require that all of the following be considered as part of an evaluation described in division (B)(2) of this section:

(1) The provider's experience and financial responsibility;

(2) The provider's ability to comply with standards for the community-based long-term care services that the provider provides under a program the department administers;

(3) The provider's ability to meet the needs of the individuals served;

(4) Any other factor the director considers relevant.

(D) The rules adopted under division (B)(3) of this section shall specify that the reasons disciplinary action may be taken under division (A)(2) of this section include good cause, including misfeasance, malfeasance, nonfeasance, confirmed abuse or neglect, financial irresponsibility, or other conduct the director determines is injurious, or poses a threat, to the health or safety of individuals being served.

(E) Subject to division (F) of this section, the department is not required to hold hearings under division (A)(3) of this section if any of the following conditions apply:

(1) Rules adopted by the director of aging pursuant to this chapter require the provider to be a party to a provider agreement; hold a license, certificate, or permit; or maintain a certification, any of which is required or issued by a state or federal government entity other than the department of aging, and either of the following is the case:

(a) The provider agreement has not been entered into or the license, certificate, permit, or certification has not been obtained or maintained.

(b) The provider agreement, license, certificate, permit, or certification has been denied, revoked, not renewed, or suspended or has been otherwise restricted.

(2) The provider's certification under this section has been denied, suspended, or revoked for any of the following reasons:

(a) A government entity of this state, other than the department of aging, has terminated or refused to renew any of the following held by, or has denied any of the following sought by, a provider: a provider agreement, license, certificate, permit, or certification. Division (E)(2)(a) of this section applies regardless of whether the provider has entered into a provider agreement in, or holds a license, certificate, permit, or certification issued by, another state.

(b) The provider or a principal owner or manager of the provider who provides direct care has entered a guilty plea for, or has been convicted of, an offense materially related to the medicaid program.

(c) The provider or a principal owner or manager of the provider who provides direct care has entered a guilty plea for, been convicted of, or been found eligible for intervention in lieu of conviction for an offense listed or described in divisions (A)(3)(a) to (e) of section 109.572 of the Revised Code, but only if the provider, principal owner, or manager does not meet standards specified by the director in rules adopted under section 173.38 of the Revised Code .

(d) The United States department of health and human services has taken adverse action against the provider and that action impacts the provider's participation in the medicaid program.

(e) The provider has failed to enter into or renew a provider agreement with the PASSPORT administrative agency, as that term is defined in section 173.42 of the Revised Code, that administers programs on behalf of the department of aging in the region of the state in which the provider is certified to provide services.

(f) The provider has not billed or otherwise submitted a claim to the department for payment under the medicaid program in at least two years.

(g) The provider denied or failed to provide the department or its designee access to the provider's facilities during the provider's normal business hours for purposes of conducting an audit or structural compliance review.

(h) The provider has ceased doing business.

(i) The provider has voluntarily relinquished its certification for any reason.

(3) The provider's provider agreement with the department of medicaid has been suspended under division (C) of section 5164.37 of the Revised Code.

(4) The provider's provider agreement with the department of medicaid is denied or revoked because the provider or its owner, officer, authorized agent, associate, manager, or employee has been convicted of an offense that caused the provider agreement to be suspended under section 5164.37 of the Revised Code.

(F) If the department does not hold hearings when any condition described in division (E) of this section applies, the department may send a notice to the provider describing a decision not to certify the provider under division (A)(1) of this section or the disciplinary action the department proposes to take under division (A)(2)(e) to (h) of this section. The notice shall be sent to the provider's address that is on record with the department and may be sent by regular mail.

(G) The director of aging may adopt rules in accordance with Chapter 119. of the Revised Code establishing a fee to be charged by the department of aging or its designee for certification issued under this section.

All fees collected by the department or its designee under this section shall be deposited in the state treasury to the credit of the provider certification fund, which is hereby created. Money credited to the fund shall be used to pay for community-based long-term care services, administrative costs associated with provider certification under this section, and administrative costs related to the publication of the Ohio long-term care consumer guide.

Amended by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 1/1/2013.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

Effective Date: 09-29-2005; 06-30-2006