Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-44 - Nursing Facility-Based Level of Care Home and Community-Based Services Programs
Section 5160-44-31 - Ohio department of medicaid (ODM)-administered waiver programs: provider conditions of participation
Universal Citation: OH Admin Code 5160-44-31
Current through all regulations passed and filed through September 16, 2024
(A) An ODM-administered waiver service provider will maintain a professional relationship with the individuals to whom they provide services. Providers will furnish services in a manner that is in accordance with the individual's approved person-centered services plan, is attentive to the individual's needs, and maximizes the individual's independence. A provider will refrain from any behavior that may detract from the goals, objectives and services outlined in the individual's approved person-centered services plan and/or that may jeopardize the individual's health and welfare.
(B) An ODM-administered waiver service provider will:
(1) Maintain an
active, valid medicaid provider agreement as set forth in rule
5160-1-17.2 of the
Administrative Code.
(2) Comply
with all provider requirements set forth in Chapters 5160-44 and 5160-45 of the
Administrative Code, and Chapter 5160-46 or 5160-58 of the Administrative Code,
depending upon the waiver(s) for which the provider is rendering services.
Provider requirements include:
(a) Provider
enrollment as set forth in rule
5160-45-04 of the Administrative
Code;
(b) Criminal record checks as
set forth in rule
5160-45-07 or 5160-45-08, as
applicable, and rule
5160-45-11 of the Administrative
Code;
(c) Incident reporting as set
forth in rule
5160-44-05 of the Administrative
Code; and
(d) Provider monitoring,
reviews and oversight as set forth in rules
5160-45-06 and
5160-45-09 of the Administrative
Code.
(3) Be at least
eighteen years of age, including the provider and its employees, if
applicable.
(4) Be able to read,
write, and understand English at a level that enables the provider to comply
with all applicable program requirements.
(5) Be able to effectively communicate with
the individual.
(6) Deliver
services professionally, respectfully and legally.
(7) Ensure that individuals to whom the
provider is rendering ODM-administered waiver services are protected from
abuse, neglect, exploitation and other threats to their health, safety and
well-being. Upon entering into a medicaid provider agreement, and annually
thereafter, all providers including all employees who have direct contact with
individuals enrolled on an ODM-administered waiver, must acknowledge in writing
they have reviewed rule
5160-44-05 of the Administrative
Code regarding incident management and related procedures.
(8) Work with the individual and case manager
to coordinate service delivery, including:
(a)
Agreeing to provide and providing services in the amount, scope, location and
duration they have capacity to provide, and as specified on the individual's
approved person-centered services plan.
(b) Participating in the development of a
back-up plan in the event that providers are unable to furnish services on the
appointed date and time.
(c)
Contacting the individual and the case manager in the event the provider is
unable to render services on the appointed date and time.
(i) In the case of an emergency or unplanned
absence, the provider
will immediately activate the back-up plan as set
forth in the individual's approved person-centered services plan, verify with
the individual and notify the case manager with information about the
absence.
(ii) In the event of a
planned absence, the provider
will verify with the individual and notify the
case manager no later than seventy-two hours prior to the absence with
information about the absence.
(9) Upon request and within the timeframe
prescribed in the request, provide information and documentation to ODM, its
designee and/or the centers for medicare and medicaid services (CMS).
(10) Successfully complete ODM-mandated new
provider training within ninety days after a new provider's medicaid enrollment
date.
(11) Participate in all
appropriate provider
trainings mandated or sponsored by ODM or its designees, including but not
limited to those set forth in Chapters 5160-44, 5160-45, 5160-46 and 5160-58 of
the Administrative Code.
(12) Be
knowledgeable about and comply with all applicable federal and state laws,
including the "Health Insurance Portability and Accountability Act of 1996"
(HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on
October 1, 2023), and the medicaid safeguarding information
requirements set forth in 42
C.F.R. 431.300 to
431.306 (as in effect on October
1, 2023),
along with sections 5160.45 to
5160.481 of the Revised
Code.
(13) Ensure that the
provider's contact information, including but not limited to address, telephone
number, fax number and email address, is current. In the event of a change in
contact information, the provider
will notify ODM via the
provider network management (PNM)
portal and its designee, no later than seven calendar days after such
changes have occurred.
(14)
Maintain and retain all required documentation related to the services
delivered during
each visit, including but not limited to: an
individual-specific description and details of the tasks performed or not
performed in accordance with the approved person-centered services plan and
when required, the individual's plan of care.
(a) Verification of service delivery
will
include, but not be limited to, the date and
location of service delivery, service start and end times, and the signatures
of the provider and the individual or authorized representative.
(b) Acceptable signatures include, but are
not limited to a handwritten signature, initials, a stamp or mark, or an
electronic signature. Any accommodations to the individual's or authorized
representative's signature
will be documented on the person-centered
services plan.
(c) If the
individual is unable to provide the signature required by this paragraph at the
time of the service, the individual is to submit an electronic signature or
standard signature via regular mail, or otherwise provide a signature in no
instance any later than within three business days of
the completion of the service delivery that requires signature.
(15)
Retain all records of service delivery and billing for a period of six years
after the date of receipt of the payment based upon those records, or until any
initiated audit is completed, whichever is longer.
(16) Cooperate with ODM and its designee
during all provider monitoring and oversight activities by being available to
answer questions during reviews, and by assuring the availability and
confidentiality of individual information and other documents that may be
requested as part of provider monitoring activities.
(17) To the extent not otherwise required by
rule 5160-44-05 of the Administrative
Code, notify ODM or its designee within twenty-four hours when the provider is
aware of issues that may affect the individual and/or provider's ability to
render services as directed in the individual's person-centered services plan,
including when:
(a) The individual
consistently declines services;
(b)
The individual plans to or has moved to another residential address;
(c) There are changes in the physical, mental
and/or emotional status of the individual;
(d) There are changes in the individual's
environmental conditions;
(e) The
individual's caregiver status has changed;
(f) The individual no longer requires
medically necessary services as defined in rule
5160-1-01 of the Administrative
Code;
(g) The individual's actions
toward the provider are threatening or the provider feels unsafe or threatened
in the individual's environment;
(h) The individual is consistently
noncompliant with physician orders, or is noncompliant with physician orders in
a manner that may jeopardize his or her health and welfare;
(i) The individual's requests conflict with
his or her person-centered services plan and/or may jeopardize his or her
health and welfare; or
(j) Any
other situation that affects the individual's health and welfare.
(18) Make arrangements to accept
all correspondence sent by ODM or its designee, including but not limited to,
certified mail.
(19) Maintain a
current e-mail address with ODM and its designee in order to receive electronic
notification of any rule adoption, amendment or rescission, and any other
communications from ODM or its designee
(20) Submit written notification to the
individual and ODM or its designee at least thirty calendar days before the
anticipated last date of service if the provider is terminating the provision
of ODM-administered waiver services to the individual. Exceptions include:
(a) The provider
will submit
verbal and written notification to the individual and ODM or its designee at
least ten days before the anticipated last date of service if the individual
has been:
(i) Admitted to a
hospital;
(ii) Placed in an
institutional setting; or
(iii)
Incarcerated.
(b) ODM
may waive advance notification for a provider upon request and on a
case-by-case basis.
(21)
Be identified as the provider, and have specified on the individual's
person-centered service plan that is prior approved by ODM or its designee, the
amount of services the provider is authorized to furnish to the
individual.
(22) Have a valid
social security number and at least one of the following current,
government-issued photographic identification cards:
(a) Driver license;
(b) State of Ohio identification card;
or
(c) United States of America
permanent residence card.
(C) A provider of nursing, personal care and home care attendant services under an ODM-administered waiver program will verify service delivery using an ODM-approved electronic visit verification (EVV) system in accordance with rule 5160-1-40 of the Administrative Code.
(D) At no time, will an ODM-administered waiver service provider:
(1)
Engage in any behavior that causes or may cause physical, verbal, mental or
emotional abuse or distress to the individual.
(2) Engage in any other behavior that may
compromise the health and welfare of the individual.
(3) Engage in any activity or behavior that
may take advantage of or manipulate the individual or his or her authorized
representative, family or household members or which may result in a conflict of interest,
exploitation, or any other advantage for personal gain, including:
(a) Misrepresentation;
(b) Accepting, obtaining, attempting to
obtain, borrowing, or receiving money or anything of value including, but not
limited to gifts, tips, credit cards or other items;
(c) Being designated on any financial account
including, but not limited to bank accounts and credit cards;
(d) Using real or personal property of
another;
(e) Using information of
another;
(f) Lending or giving
money or anything of value;
(g)
Engaging in the sale or purchase of products, services or personal items;
and
(h) Engaging in any activity
that takes advantage of or manipulates ODM-administered waiver program
rules.
(4) Falsify the
individual's signature, including using copies of the signature.
(5) Make fraudulent, deceptive or misleading
statements in the advertising, solicitation, administration or billing of
services.
(6) Submit a claim for
waiver services rendered while the individual is hospitalized,
institutionalized or incarcerated. The only exception is when the individual is
receiving out-of-home respite as set forth on his or her person-centered
services plan.
(E) While rendering services, an ODM-administered waiver service provider will not:
(1) Take the individual to the provider's
place of residence.
(2) Bring
children, animals, friends, relatives, other individuals or anyone else to the
individual's place of residence.
(3) Provide care to persons other than the
individual.
(4) Smoke without the
consent of the individual.
(5)
Sleep.
(6) Engage in any activity
that is not related to the provision of services to the extent the activity
distracts from, or interferes with, service delivery. Such activities include,
but are not limited to the following:
(a)
Using electronic devices for personal or entertainment purposes including, but
not limited to watching television, using the computer or playing
games.
(b) Making or receiving
personal communications.
(c)
Engaging in socialization with persons other than the individual.
(7) Deliver services when the
provider is medically, physically or emotionally unfit.
(8) Use or be under the influence of the
following while providing services:
(a)
Alcohol.
(b) Illegal
drugs.
(c) Chemical
substances.
(d) Controlled
substances that may adversely affect the provider's ability to furnish
services.
(9) Engage in
any activity or conduct that may reasonably be interpreted as sexual in nature,
regardless of whether or not it is consensual.
(10) Engage in any behavior that may
reasonably be interpreted as inappropriate involvement in the individual's
personal beliefs or relationships including, but not limited to discussing
religion, politics or personal issues.
(11) Consume the individual's food and/or
drink without his or her offer and consent.
(F) Parents of minor children, spouse, and other individual's designated legal decision-making authority:
(1)
Unless otherwise permitted by rule
5160-44-32 of the Administrative
Code, an ODM-administered waiver service provider will not be designated to
serve or make decisions for the individual in any capacity involving a
declaration for mental health treatment, general power of attorney, health care
(medical) power of attorney, financial power of attorney, legal custody of a
minor child, guardianship pursuant to court order, as an authorized
representative, or as a representative payee.
(2) A
provider may be designated as an authorized representative or pursuant to a
declaration for mental health treatment, general power of attorney, health care
(medical) power of attorney, financial power of
attorney or guardianship for the individual if:
(a) The provider was serving in that capacity
prior to September 1, 2005; and
(b)
The provider was the individual's paid medical provider prior to September 1,
2005; and
(c) The designation is
not otherwise prohibited by law.
(G) An agency provider will pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. Federal employment taxes include medicare and social security.
(H) Non-agency providers will pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. Federal employment taxes include medicare and social security. On an annual basis, non-agency providers will submit an ODM-approved affidavit stating that they paid their applicable federal, state and local income and employment taxes.
(I) Failure to meet the requirements set forth in this rule may result in any of the actions set forth in rules 5160-44-05, 5160-45-06 and 5160-45-09 of the Administrative Code including termination of the medicaid provider agreement in accordance with rule 5160-1-17.6 of the Administrative Code. In the event ODM proposes termination of the medicaid provider agreement, the provider may be entitled to a hearing or review in accordance with Chapter 5160-70 of the Administrative Code.
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