Current through all regulations passed and filed through September 16, 2024
(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
