Alaska Administrative Code, Article 2, 7 AAC 130.220 - Provider certification | Alaska Administrative Code

(a) Unless the department grants an exception under (j) of this section, the department will certify a provider agency as either a provider of one or more home and community-based waiver services under (1) or (3) of this subsection or a provider of care coordination services under (2) of this subsection, as follows:

(1) the department will certify a provider agency as a home and community-based waiver services provider, for

(A) nursing oversight and care management services provided under 7 AAC 130.235;

(B) chore services provided under 7 AAC 127.087;

(C) adult day services provided under 7 AAC 130.250;

(D) day habilitation services provided under 7 AAC 130.260;

(E) residential habilitation services provided under 7 AAC 130.265;

(F) employment services under 7 AAC 130.270;

(G) intensive active treatment services provided under 7 AAC 130.275;

(H) respite care services provided under 7 AAC 130.280;

(I) transportation services provided under 7 AAC 130.290;

(J) meal services provided under 7 AAC 130.295;

(K) environmental modification services provided under 7 AAC 130.300;

(2) the department will certify a provider agency as a care coordination agency provider for care coordination services provided under 7 AAC 130.240; notwithstanding agency certification, each individual employed by that agency to provide care coordination services must be certified separately and individually in accordance with 7 AAC 130.238;

(3) the department will certify a provider agency as a residential supported-living services provider for residential supported living services provided under 7 AAC 130.255.

(b) To receive payment for home and community-based waiver services, a provider must enroll in the Medicaid program under 7 AAC 105.210 and must be certified under this section. To be certified by the department, a provider must submit, in a format provided by the department, a complete application, and

(1) to provide services at an in-state location, the provider must meet and comply with the applicable standards of certification criteria, including

(A) the provider qualifications and program standards, set out in the department's Provider Conditions of Participation for Home and Community-Based Waiver Services and Community First Choice Chore Services, adopted by reference in 7 AAC 160.900; and

(B) for each service the provider plans to offer to recipients of home and community-based waiver services, 7 AAC 127.087(choreservices) or the provisions of this chapter applicable to each service and the conditions of participation adopted by reference in 7 AAC 160.900 and applicable to that service; or

(2) to provide services at an out-of-state location,

(A) must meet all applicable Medicaid home and community-based waiver services certification and licensing requirements of the jurisdiction in which the provider is located;

(B) must meet all applicable Medicaid home and community-based waiver services provider qualification and program standards of that jurisdiction;

(C) may provide to a recipient only the services that the provider is certified to offer at that out-of-state location; at the request of the department, for each service that the provider will render to a recipient, the provider must verify the provider's qualifications and capacity to provide the specified services to that recipient; and

(D) must submit critical incident reports to the department in accordance with 7 AAC 130.224.

(c) The department will certify a provider who meets and complies with the standards of certification for a

(1) probationary certification of one year, during which the department will not certify an additional service under 7 AAC 125.010 - 7 AAC 125.199, 7 AAC 127, and this chapter, or service location beyond those approved at the beginning of the probationary certification period, for

(A) a provider not previously certified by the department; or

(B) a renewing provider who does not meet the certification requirements to the department's satisfaction under (b)(1) of this section, or has committed an act or omission that is grounds for sanction under 7 AAC 105.400, regardless of whether a sanction was imposed; or

(2) standard certification of

(A) two years for each renewing provider that the department has determined met the probationary certification requirements under (1) of this subsection in the immediately preceding certification period; or

(B) a variable period of up to four years, to be determined by the department's review of the provider's compliance with the certification requirements under (b)(1) of this section in the preceding certification periods.

(d) Not later than 90 days before the expiration of a provider's certification, the department will send to the provider notice of the requirement to renew that certification. The provider must submit a new application for certification and all required documentation not later than 60 days before the expiration date of the current certification.

(e) A certified provider under this chapter shall comply with this chapter and the requirements of 7 AAC 105.200 - 7 AAC 105.280. The department will determine compliance through program monitoring, including audits, program reviews, and investigations, that may take place at the provider's place of business or at any site where services under this chapter are provided. To assure compliance, the department may

(1) request, in accordance with 7 AAC 105.240, records related to the services provided under this chapter; or

(2) take immediate custody of a provider's original records, maintained in accordance with 7 AAC 105.230, if the department has reason to believe, based on an audit, program review, or investigation, that those records are at risk of alteration; once records are in the custody of the department, the provider may make copies of those records only under the supervision of the department.

(f) In addition to the authority under 7 AAC 105.400 - 7 AAC 105.490 to take action in regard to certification, the department will deny an initial application or an application to renew certification or suspend certification of a provider if

(1) the provider fails to submit a complete application under (a) of this section so that it is received by the department not later than 30 days after the date of notice from the department that the application is incomplete;

(2) the provider's certification, license, or enrollment related to Medicaid or Medicare was denied, revoked, or rescinded;

(3) the provider's name appears on any state or federal exclusion list related to health care services;

(4) the department has documentation that indicates the provider is unable or unwilling to meet the certification requirements of this section or any other Medicaid requirement under 7 AAC 105 - 7 AAC 160;

(5) the department has evidence that the owner or administrator of a provider agency does not operate honestly, responsibly, and in accordance with applicable laws in order to maintain the integrity and fiscal viability of the medical assistance program;

(6) based upon evidence from an audit, provider review, or investigation, the department has probable cause to believe that a provider's noncompliance with the Medicaid program or this chapter causes immediate risk to the health, safety, or welfare of a recipient or would be considered to be fraud, abuse, or waste; or

(7) the provider has two consecutive probationary certification periods under (c)(1) of this section and is still not compliant to the department's satisfaction.

(g) If the department denies an initial application or an application to renew certification or suspends certification of a provider, the department will send, not later than 14 business days after the date of the decision, written notice of the action and information regarding the provider's right to appeal the decision under AS 44.64.

(h) Instead of decertification or suspension, the department may

(1) establish a corrective action plan that includes the method by which the provider will verify compliance and the date that compliance is required; and

(2) monitor the provider's progress toward meeting the requirements of the corrective action plan; if the department finds that the provider has not met the requirements of the corrective action plan on or before the date compliance is required, the department may decertify or suspend the provider as provided in (g) of this section.

(i) Notwithstanding the provisions of this section, if the department has reasonable cause to believe that the health, safety, or welfare of a recipient is at risk, the department may immediately suspend or revoke a provider's certification. If the department immediately suspends or revokes certification under this subsection, the department will

(1) give the provider initial notice, oral or written, of the suspension or revocation of certification, including information regarding the right to appeal; if no one is present to receive the notice, the department will post the notice on the main entrance to the building in which the provider agency is located; and

(2) not later than 14 business days after the date of the suspension or revocation of certification issue a formal report that includes information related to the action taken, the reason for the action, and the right to appeal.

(j) The department will grant an exception to a provider agency under (a) of this section if

(1) the availability of care coordination services in a non-urban geographic area of the state is insufficient to meet the needs of the recipients residing in that area, and an agency that is certified as a provider of home and community-based waiver services in that area is willing and qualified to provide care coordination services; in this paragraph, "non-urban geographic area" means a geographic area that, according to the Department of Labor and Workforce Development's Alaska Borough/Census Areas map, is located within the bounds of a borough or census area other than the

(A) Municipality of Anchorage;

(B) Fairbanks North Star Borough;

(C) City and Borough of Juneau;

(D) Kenai Peninsula Borough; and

(E) Matanuska-Susitna Borough; and

(2) the provider agency requests an exception in a format provided by the department.

(k) The department will certify a provider agency approved for an exception under (j) of this section for a period of three years. Every three years the department will evaluate under (j)(l) of this section whether the availability of care coordination services in a non-urban geographic area of the state is insufficient to meet the needs of the recipients residing in that area. If the department determines that the availability of care coordination services in that area is sufficient, the department will not certify an agency in that area as a provider of both home and community-based waiver services and care coordination services.

(l) An agency certified as a provider of both home and community-based waiver services and care coordination services in accordance with (j) of this section shall

(1) operate the care coordination services section as a distinct unit separate from the units that provide home and community-based waiver services under this chapter or personal care services under 7 AAC 125.010 - 7 AAC 125.199;

(2) appoint an individual to the position of program supervisor for care coordination services only; that individual may not serve as program supervisor for either home and community-based waiver services or personal care services during that individual's tenure as program supervisor for care coordination services;

(3) implement a process to resolve disputes that may arise among the service units; and

(4) provide an alternative dispute resolution process for recipients.

(m) A provider certified to offer the following home and community-based waiver services shall render those services in a setting that is integrated into the greater community and that allows the recipient to access that community to the same degree as an individual that does not receive home and community-based waiver services:

(1) adult day services under 7 AAC 130.250;

(2) residential supported-living services under 7 AAC 130.255;

(3) day habilitation services under 7 AAC 130.260;

(4) residential habilitation services under 7 AAC 130.260(b) and (g);

(5) employment services under 7 AAC 130.270;

(6) transportation services under 7 AAC 130.290 provided as agency-based services;

(7) meal services under 7 AAC 130.295 provided in a congregate setting.

(n) A provider shall render each service listed in (m) of this section in a setting that

(1) was selected by the recipient from among settings options that include nondisability specific settings;

(2) ensures the rights of the recipient to privacy, dignity, and respect, and to freedom from coercion and restraint;

(3) optimizes the recipient's initiative, autonomy, and independence in making life choices, including those for daily activities, physical environment, and interactions with others;

(4) implements the recipient's choices regarding services and supports, and the individuals that will provide them;

(5) assists a recipient that chooses to

(A) seek employment and work in competitive, integrated settings; or

(B) receive services in the community;

(6) encourages and facilitates the recipient's engagement in community life; and

(7) provides the opportunity for the recipient to control the recipient's personal resources.

(o) In addition to ensuring a setting meets the requirements specified in (n) of this section, a provider that owns or controls a residential setting

(1) shall provide for the recipient

(A) a legally enforceable, written agreement that complies with the requirements of AS 34.03.010-34.03.380;

(B) the option of a private unit, if available in the setting and appropriate for the recipient's needs, preferences, and resources for payment of room and board; and

(C) a setting that is physically accessible for the recipient; and

(2) except as provided under (p) of this section, shall provide for the recipient

(A) privacy in the recipient's living or sleeping unit;

(B) the freedom and support needed for a recipient to control the recipient's schedule and activities;

(C) access to food at all times; and

(D) visitors of the recipient's choosing at any time.

(p) A provider that owns or controls a residential setting may modify the setting requirements in (o)(2) of this section for a specific, assessed need of a recipient, only after the provider attempts positive interventions and other less intrusive methods of meeting the need, and these attempts prove unworkable. The modification must be approved in the support plan developed in accordance with 7 AAC 130.217 and 7 AAC 130.218, and must be supported by a written record that includes

(1) identification of the assessed need requiring modification;

(2) documentation, before any modification of the setting requirements, of positive interventions and other less intrusive methods that were used to address that need and that did not work;

(3) a description of the modification used; the modification must be directly proportional to the specific assessed need;

(4) an explanation of the method for collecting and reviewing data to measure the ongoing effectiveness of the modification;

(5) time limits for periodic reviews to determine if the modification continues to be necessary or should be terminated;

(6) documentation of the informed consent of the recipient for the modification; and

(7) a documented analysis concluding the modification will not cause harm to the recipient.

(q) Unless otherwise approved by the department, a provider may not render home and community-based waiver services in a setting that is

(1) in a building that is a publicly or privately operated facility that provides inpatient institutional treatment;

(2) in a building on the grounds of, or immediately adjacent to, a public institution; or

(3) in a location that isolates recipients from the broader community.

(r) A provider of home and community-based waiver services shall

(1) develop and implement written policies and procedures to ensure services are provided in accordance with 7 AAC 130.217, 7 AAC 130.218, and (m) - (q) of this section;

(2) train administrative staff and direct care workers to provide services as directed by those policies and procedures; and

(3) monitor and evaluate services to ensure compliance with settings requirements specified in this section.