Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule describes procedures to obtain
certification as a provider of individualized supported living (ISL), group
home, shared living, employment services, day habilitation, individualized
skills development, community networking, out of home respite, and intensive
therapeutic residential habilitation services through the home and
community-based waivers for individuals with intellectual and developmental
disabilities.
(1) Under
section 630.655, RSMo, the department is
mandated to develop certification standards and to certify providers to
operate, receive funds from the department, and be eligible for Medicaid
reimbursement. However, certification in itself does not constitute an
assurance or guarantee the department will fund designated services or
programs.
(A) A key goal of certification is
to enhance the quality of care and life for individuals with a focus on their
needs, preferences, and desired outcomes.
(B) The primary function of the certification
process is assessment of a provider's compliance with current standards of care
and state and federal requirements. A further function is to identify and
ensure corrective action is taken for deficiencies identified during the survey
process to ensure health and welfare of persons served by the
provider.
(C) This rule replaces
sections 9
CSR 45- 5.010(4) and (5) of the
Certification of Medicaid Agencies Serving Persons with Developmental
Disabilities.
(2) An
entity or individual who has received approval to contract with the department
and who has successfully enrolled with MO HealthNet as a provider may request
to become a provider of certified services by completing an application form as
required by the department for this purpose and submitting the application form
and other documentation as specified. The completed application is sent to
Department of Mental Health, Office of Licensure and Certification, PO Box 687,
Jefferson City, MO 65102, fax (573) 751-9207, or emailed to DMH-
OLC@dmh.mo.gov.
(A) The applicant must submit
a current written description of the programs and services for which it is
seeking certification by the department.
(B) Certification fees are not required.
(C) The department reviews a
completed application within thirty (30) calendar days of receipt to determine
whether the applicant would be appropriate for certification. The department
notifies the provider of its determination. A certificate is issued if-
1. The department has determined the
application is complete and all necessary documents have been filed with the
application; and
2. The department
has determined the provider, programs, and services are compliant with state
and federal laws and the corresponding rules.
(D) A site survey of the applicant will be
conducted to determine compliance with standards.
(E) Certified providers need to apply for
recertification at least sixty (60) calendar days prior to expiration of its
existing certificate. Recertification includes a new application and required
documentation.
(F) Ninety (90)
calendar days after its receipt, the department considers any application for
certification withdrawn if it is submitted without all the required information
and documents.
(G) An applicant can
withdraw its application at any time during the certification process, unless
otherwise required by law.
(3) The department conducts site surveys at a
provider for the purpose of determining compliance with certification
standards, program requirements, and other state and federal regulations.
(4) The department recognizes and
deems as certified a provider that maintains accreditation under standards for
services provided by the department from the Commission on Accreditation of
Rehabilitation Facilities (CARF), The Council on Quality and Leadership (The
Council), or Joint Commission on Accreditation of Healthcare Organizations
(Joint Commission). The deemed provider must-
(A) Submit to the department a copy of the
most recent accreditation survey report and verification of the accreditation
time period and dates within thirty (30) calendar days of receipt from the
accreditation agency;
(B) Notify the
department when the accreditation agency makes a complaint investigation visit
within seven (7) calendar days;
(C)
Notify the department of any changes in accreditation status during the time
period of accreditation and resurvey within seven (7) calendar days;
and
(D) Ensure compliance with all
certification rules and regulations pertaining to the service provided,
including fire safety regulations.
(E) The Division of Developmental
Disabilities may conduct a scheduled or unscheduled site survey of an
accredited provider at any time to monitor ongoing compliance with the
standards and requirements. If any survey finds conditions that are not in
compliance with applicable standards, the division may request corrective
action steps.
(5) Deemed
providers are not excluded from monitoring of service delivery by other quality
integrated functions within the department.
(6) The department provides advance notice
and coordinates with the provider to schedule routine, planned surveys.
(A) The department notifies the applicant and
the division's regional offices (ROs) regarding survey procedures and a copy of
any survey instrument that may be used. Survey procedures include but are not
limited to observation and inspection of service sites, interviews with
provider staff, individuals being served, and other interested parties, review
of provider administrative records necessary to verify compliance with
requirements, review of personnel records and service documentation, and
observation of program activities.
1. The
review of personnel records includes eligibility for employment, documentation
of training, and driver's license related to the billing of service.
(B) The applicant
agrees, by act of submitting an application, to allow and assist department
representatives in fully and freely conducting these survey procedures and to
provide department representatives reasonable and immediate access to premises,
individuals, and requested information.
(C) A provider shall cooperate with the
certification process. The provider shall provide information and documentation
that is accurate and complete. Actions of the provider, including but not
limited to falsification or fabrication of any information used to determine
compliance with requirements, may be grounds to deny issuance of or to revoke
certification.
(7)
Surveyor(s) will hold entrance and exit conferences with the provider to
discuss survey arrangements and survey findings, respectively. If a surveyor
identifies a deficiency that could result in actual jeopardy to the safety,
health, or welfare of persons served, the surveyor will not leave the program
until an acceptable plan of correction is presented which assures the surveyor
that there is no further risk of jeopardy to persons served. The RO will be
notified of the conditions that existed and the accepted plan of correction.
(8) Within thirty (30) calendar
days after the exit conference, the department will provide a written survey
report to the provider's chief executive officer and/or the provider contact on
the provider application and the division.
(A) The report details all deficiencies
identified during the survey.
(B)
Upon specific request, the provider shall make the report available to the
staff, individuals served, and to the public.
(9) If deficiences are identified, the
department will include in the survey report a request for the provider to
submit a plan of correction.
(A) The plan
must address each deficiency and specify the method of correction and the final
date of correction, including identification of other individuals having the
potential to be affected by the same deficient practice, how the provider will
monitor its corrective action including the job title of the individual
responsible for monitoring compliance on an ongoing basis, and what systemic
changes have been put into place to ensure the deficient practice doesn't occur
again. The provider is encouraged to work with the RO to develop a plan of
correction. No final date of correction will exceed one hundred eighty (180)
calendar days from the exit date of the survey.
(B) Within fifteen (15) calendar days after
receiving the plan of correction, the department notifies the provider and the
division of its decision to approve, deny, or require revisions of the proposed
plan.
(C) The surveyor assures the
plan of correction has been implemented and deficiencies corrected. The
department determines if it is necessary for the surveyor to make a return
visit to the provider based on the criteria of the plan of correction and will
notify the division and ROs of revisit.
(D) In the event the provider has not
submitted a plan of correction acceptable to the department within sixty (60)
calendar days of the original date that written notice of deficiencies was
presented by certified mail to the provider, it is subject to expiration of
certification.
(10) The
department sends copies of survey reports, notification about the status of
plans of correction, and any other communication relevant to survey to the
mailing address and electronic mail address on file in the provider's
application and/or the provider's chief executive officer.
(11) The department may grant certification
on a temporary, provisional, conditional, or regular status.
(A) Temporary status is granted to a provider
if the survey process has not been completed prior to the expiration of an
existing certificate and the applicant is not at fault for failure or delay in
completing the survey process.
(B)
Provisional status for a period not exceeding one (1) year is granted to a new
provider, a provider which has undergone a change of ownership, or a currently
certified provider adding a waivered service based on a review which finds the
program in compliance with requirements related to policy and procedure,
personnel qualifications and training, and physical plant and fire safety
compliance, when applicable, sufficient to begin providing services.
Provisional status is effective the date compliance is determined by the Office
of Licensure and Certification (OLC) and after the contract with the provider
has been executed by the RO.
1. The
department shall conduct a comprehensive site survey of the provisionally
certified provider and makes further determination of the provider's
certification status no sooner than ninety (90) calendar days after the
provider begins providing services to individuals nor later than the expiration
date of the provisional certificate.
2. If the provider has begun providing
services prior to the expiration of the provisional certificate but for less
than ninety (90) calendar days, the OLC director may extend the provisional
status for up to one hundred twenty (120) calendar days to allow time for a
comprehensive survey to occur.
3. If
the provider does not begin serving individuals prior to the expiration date of
the provisional certificate, the provisional certificate expires and the
provider is required to reapply.
4.
If an existing provider of employment services (prevocational services, career
planning, job development, and supported employment) wants to add an additional
employment service to their certification, the OLC director may waive the
provisional certification process and grant regular certification status to the
provider for the new service if-
A. The
provider submits an application for certification for the new service and the
department has determined the application is complete, and all necessary
documents have been filed with the application;
B. All required environmental and fire safety
surveys have been completed;
C. The
provider's certification survey was completed within the past twelve (12)
months;
D. The provider is currently
in compliance;
E. The RO agrees with
waiving the provisional process for the new service; and
F. The provider has not been on conditional
status during the past four (4) years.
5. If an existing provider of day
habilitation services wants to add community networking or individual skill
development, the OLC director may waive the provisional certification and grant
regular certification status to the provider for the new service if-
A. The provider submits an application for
certification for the new service and the department has determined the
application is complete, and all necessary documents have been filed with the
application;
B. The provider's
certification survey was completed within the past twelve (12)
months;
C. The provider is currently
in compliance;
D. The RO agrees with
waiving the provisional process for the new service; and E. The provider has
not been on conditional status during the past four (4) years.
6. If an existing
provider of community networking or individual skill development wants to add
community networking or individual skill development to their certification,
the OLC director may waive the provisional certification and grant regular
certification status to the provider for the new service if-
A. The provider submits an application for
certification for the new service and the department has determined the
application is complete, and all necessary documents have been filed with the
application;
B. The provider's
certification survey was completed within the past twelve (12)
months;
C. The provider is currently
in substantial compliance;
D. The
RO agrees with waiving the provisional process for the new service;
and
E. The provider has not been on
conditional status during the past four (4) years.
(C) Following
the period of provisional status, a regular certificate to provide Medicaid
waiver services is awarded to a provider following a comprehensive site survey
by the department that determines the provider is in compliance and meets all
standards relating to quality of care and the safety, health, rights, and
welfare of persons served. If deficiencies are cited during a survey, any and
all deficiencies must be corrected prior to the department issuing a
certificate. The effective date of the certificate is the date the agency was
determined to be in compliance as a result of the comprehensive survey and is
effective up to two (2) years.
(D)
Conditional status is granted to a provider following a site survey by the
department that determines there are pervasive and/or significant deficiencies
with standards that may affect quality of care to individuals and there is a
reasonable expectation the provider can achieve compliance within a stipulated
time period. The department considers patterns and trends of performance
identified during the site survey.
1. The
period of conditional status shall not exceed one hundred eighty (180) calendar
days. The department may directly monitor progress, may require the provider to
submit progress reports, or both.
2. The department will conduct an additional
site survey within the one hundred eighty (180) calendar day review period and
make an additional determination of the provider's compliance with all
standards.
3. During the period of
conditional status, the department may, at its discretion, take actions per
sections (17) and (19) of this rule. 4. At the expiration of conditional
status, if the provider is in compliance, the department will issue a
certificate with an effective date of the end of the conditional status and
expiring two (2) years from the expiration date of the previous certification
cycle.
(12) The
department may investigate any complaint regarding the operation of a certified
or deemed certified program or service. If conditions are found that are not in
compliance with applicable certification standards, the department may, at its
sole discretion, notify the accrediting organization of any concerns.
(13) The department may conduct a scheduled
or unscheduled site survey of a provider at any time to monitor ongoing
compliance with the certification standards. If any survey finds conditions
that are not in compliance with applicable certification standards, the
department may require corrective action steps and may change the provider's
certification status consistent with procedures set out in this rule.
(14) The department certifies only the
provider(s) named in the application. The provider(s) may not transfer
certification without the written approval of the department.
(A) A certificate is the property of the
department and is valid only as long as the provider meets standards of care
and other requirements.
(B) Within
seven (7) calendar days of the effective date that a certified provider has a
change in accreditation status or discontinues operation, the provider shall
provide written notice to the OLC and RO of any such change.
(C) Within seven (7) calendar days of the
effective date that a certified provider is sold or undergoes a change of
ownership, the provider shall submit a written notice to the OLC and the RO of
any such change. A change in ownership is considered to have occurred under the
following circumstances:
1. A new
corporation, partnership, limited partnership, limited liability company or
other entity assumes ownership of the operation;
2. An individual incorporates or forms a
partnership;
3. With respect to a
certificate holder which is a general partnership, a change occurs in the
majority interest of the partners;
4. With respect to a certificate holder which
is a limited partnership, a change occurs in the majority interest of the
general or limited partners;
5. With
respect to a certificate holder which is a corporation, a change occurs in the
persons who own, hold, or have the power to vote the majority of any class of
stock issued by the corporation; and 6. A certificate holder's change of
Federal Employer Identification Number (FEIN).
(D) Providers may not change the premises of
a group home, day habilitation program, or onsite employment service site
without prior notification to the OLC and RO and approval by DMH and the
Missouri Department of Public Safety.
(E) A provider must be certified to provide a
waivered service prior to providing the service. Any provider that establishes
a new program or type of program shall operate that program in accordance with
applicable standards. A provisional review, site survey, or comprehensive site
survey is conducted as determined by the department.
(15) The department may revoke or deny
issuance of certification based on a determination that-
(A) The nature of the deficiencies results in
substantial probability of or actual jeopardy to individuals being served;
(B) Serious or repeated incidents
of abuse or neglect of individuals being served or violations of rights have
occurred;
(C) Fraudulent fiscal
practices have transpired or significant and repeated errors in billings to the
department have occurred;
(D)
Failure to participate in the certification process in good faith, including
falsification or fabrication of any information used to determine compliance
with requirements;
(E) The nature
and extent of deficiencies results in the failure to conform to the
certification standards of the program or service being offered;
(F) Compliance with standards has not been
attained by a provider upon expiration of conditional certification;
(G) Failure to allow the surveyors entry into
service site areas or to access individuals receiving services;
(H) Contract for service delivery has ended
with the department;
(I) Any
provider, or member, partner, administrator, executive director, or program
director is found to have disqualifying offense under section
630.170, RSMo, unless an
exception has been granted through the DMH Exceptions Committee under sections
630.656 and
630.170, RSMo; or
(J) Any provider, or member, partner,
administrator, executive director, or program director of a certified agency is
found to have ever acted or omitted their duty in a manner which materially and
adversely affected the health, safety, welfare, or property of an individual
receiving services.
(16)
If a certified provider discontinues operation as evidenced by the fact that no
individual has received a certified service from the provider for the previous
twelve (12) months or any time the department is unable to freely gain entry to
conduct an inspection, the provider is considered no longer certified. The
department notifies the provider in writing that the certificate is void.
(17) The department director, at
its discretion, may-
(A) Place a monitor at a
program if there is substantial probability of or actual jeopardy to the
safety, health, rights, or welfare of individuals being served.
1. The cost of the monitor is charged to the
provider at a rate which will recoup all reasonable expenses incurred by the
department.
2. The department shall
remove the monitor when a determination is made that the safety, health,
rights, and welfare of individuals being served are no longer at risk.
(B) Take other action to
ensure and protect the safety, health, or welfare of individuals being served.
(C) Initiate additional service
delivery review through other quality integrated functions established within
the department.
(18) A
provider which has had certification denied or revoked may appeal in writing to
the director of the department within thirty (30) calendar days following
notice of the denial or revocation being presented by certified mail to the
provider. The director of the department shall conduct a hearing under
procedures set out in Chapter 536, RSMo, and issue findings of fact,
conclusions of law, and a decision which shall be final.
(19) The department has authority to impose
administrative sanctions.
(A) The department
may suspend the certification process pending completion of an investigation
when a provider that has applied for certification or the staff of that
provider is under investigation for fraud, financial abuse, abuse or neglect of
persons served, revocation of persons' rights without due process, or improper
clinical practices. This includes but is not limited to investigations by any
state authority for Medicaid audit and compliance, any state authority for
child or adult abuse, neglect or financial exploitation, the Health and Human
Services Office of Inspector General, or other local, state, or federal law
enforcement.
(B) The department may
administratively sanction a certified provider that has been found to have
committed fraud, financial abuse, abuse of persons served, or improper clinical
practices, or that had reason to know its staff were engaged in such practices.
(C) Administrative sanctions
include but are not limited to suspension of certification, clinical
utilization review requirements, clinical audit, suspension of new admissions
or referrals, implementation of a corrective action plan, denial or revocation
of certification, or other actions as determined by the department.
(D) The department has the authority to
refuse to accept an application for certification from a provider that has had
certification denied or revoked or that has been found to have committed fraud,
financial abuse, or improper clinical practices, or whose staff and clinicians
were engaged in improper practices.
(E) A provider which has certification denied
or revoked as an administrative sanction may appeal these sanctions pursuant to
section (18).
(20) A
provider may request the department's exceptions committee waive a requirement
for certification if the head of the provider organization provides evidence
that a waiver is in the best interests of the individuals it serves.
(A) A request for a waiver is in writing and
includes justification for the request.
(B) The request is submitted to Exceptions
Committee, Department of Mental Health, PO Box 687, Jefferson City, MO 65102.
(C) The exceptions committee holds
meetings in accordance with Chapter 610, RSMo, and responds with a written
decision within forty-five (45) calendar days of receiving a request.
(D) The exceptions committee may
issue a waiver on a time- limited or other basis.
(E) If a waiver request is denied, the
provider has forty-five (45) calendar days from date of denial to fully comply
with the standard unless a different time period is specified by the
committee.
*Original authority: 630.050, RSMo 1980, amended 1993, 1995
and 630.655, RSMo 1980.
