Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-45 - Administered Waiver Service Providers
Section 5160-45-06 - Ohio department of medicaid (ODM) -administered waiver program: structural reviews of providers and investigation of provider occurrences
Universal Citation: OH Admin Code 5160-45-06
Current through all regulations passed and filed through September 16, 2024
(A) The Ohio department of medicaid (ODM) or its designee shall continuously monitor every ODM-administered waiver provider. Monitoring activities shall include, but not be limited to:
(1) A structural review of
compliance with all ODM-administered waiver provider requirements in accordance
with paragraph (B) of this rule.
(2) Investigation of provider occurrences in
accordance with paragraph (C) of this rule.
(B) Structural reviews.
(1) Medicare-certified and otherwise
accredited agency providers as defined in rule
5160-45-01 of the Administrative
Code are subject to reviews in accordance with their certification and
accreditation bodies and may be exempt from a regularly scheduled structural
review as determined by ODM. Upon request by ODM or its designee,
medicare-certified and otherwise-accredited agency providers, shall make
available within ten business days, all review reports and accepted plans of
correction from the certification and/or accreditation bodies.
(2) All other agency providers are subject to
structural reviews by ODM or its designee every two years after the provider
begins furnishing billable services.
(3) All non-agency ODM-administered waiver
providers are subject to structural reviews by ODM or its designee during each
of the first three years after a provider begins furnishing billable services.
Thereafter, and unless otherwise prescribed by either paragraph (B)(4) or
(B)(5) of this rule, structural reviews shall be conducted annually.
(4) ODM or its designee may conduct biennial
structural reviews of a non-agency ODM-administered waiver provider, when all
the following apply:
(a) There were no
findings against the provider during the provider's most recent structural
review;
(b) The provider was not
substantiated to be the violator in an incident described in rule
5160-44-05 of the Administrative
Code;
(c) The provider was not the
subject of more than one provider occurrence during the previous twelve months;
and
(d) The provider does not live
with an individual receiving ODM-administered waiver services.
(5) All ODM-administered waiver
providers may be subject to an announced or unannounced structural review at
any time as determined by ODM or its designee.
(6) Structural reviews may be conducted in
person between the provider and ODM or its designee or via desk review, and in
a manner consistent with paragraph (B)(3) of rule
5160-45-09 of the Administrative
Code.
(7) All structural reviews
use an ODM-approved structural review tool.
(8) Structural reviews shall not occur while
the provider is furnishing services to an individual.
(9) The structural review process consists of
the following activities:
(a) Except for
unannounced structural reviews, the provider shall be notified in advance of
the review to arrange a mutually acceptable time, date and location for the
review. Advance notification shall also include identification of the time
period for which the review is being conducted and a list of the type of
documents required for the review.
(b) The provider shall ensure the
availability of required documents and maintain the confidentiality of
information about individuals enrolled on the ODM-administered
waiver.
(c) ODM or its designee
shall examine all substantiated incident reports or provider occurrences
related to the provider. Documented findings of noncompliance shall be
addressed during the review.
(d)
The structural review shall include an evaluation of compliance with Chapter
5160-45 of the Administrative Code and Chapter(s) 5160-44, 5160-46, and/or
5160-58 of the Administrative Code, depending upon the waiver(s) under which
the provider is furnishing services.
(e) A unit of service verification shall be
conducted by ODM or its designee to ensure all waiver services are authorized,
delivered and reimbursed in accordance with the approved person-centered
services plan for the individual receiving waiver services.
(f) The provider's compliance with the home
and community-based settings requirements set forth in rule
5160-44-01 of the Administrative
Code will be evaluated, which will include interviews with individuals served
in the setting.
(g) An evaluation
shall be conducted to determine whether the provider has implemented all plans
of correction approved since the last review. Failure to successfully complete
all plans of correction and/or the existence of repeat violations may lead to
additional sanctions including, but not limited to termination of their
provider agreement.
(h) A final
exit interview summarizing the overall outcome of the review will occur between
the non-agency provider, or in the case of an agency provider, the agency
administrator or his or her designee, and ODM or its designee at the conclusion
of the review.
(10) The
exit interview will be followed up with a written report to the provider from
ODM or its designee. The report shall summarize the overall outcome of the
structural review, specify the Administrative Code rules that are the basis for
which noncompliance has been determined, and outline the specific findings of
noncompliance. When findings are indicated, the provider shall respond in
writing to the report in a plan of correction, including any individual
remediation.
(11)
ODM, at its sole discretion, may choose to suspend a
provider's structural review.
(C) Provider occurrences.
(1) "Provider occurrence" means any alleged,
suspected or actual performance or operational issue by a provider furnishing
ODM-administered waiver services that does not meet the definition of an
incident as set forth in rule
5160-44-05 of the Administrative
Code. Provider occurrences include, but are not limited to alleged violations
of provider eligibility and/or service specification requirements, provider
conditions of participation, billing issues including overpayments, and
medicaid fraud.
(2) Upon discovery,
ODM or its designee shall investigate provider occurrences including requesting
any documentation required for the investigation.
(3) If ODM or its designee substantiates the
provider occurrence, it shall notify the provider. The notification shall
specify:
(a) The provider's action or
inaction that constituted the provider occurrence;
(b) The Administrative Code rule(s) that
support the finding(s) of noncompliance;
(c) What the provider must do to correct the
finding(s) of noncompliance, including acknowledgement of technical assistance,
required training, and any individual remediation;
(D) Plans of correction for structural reviews and provider occurrences.
(1) The provider must submit to ODM or its
designee a plan of correction for all identified findings of noncompliance,
including any individual remediation, within forty-five calendar days after the
date on the written report.
(2) If
ODM or its designee finds the provider's plan of correction acceptable, it
shall acknowledge, in writing, to the provider that the plan addresses the
findings outlined in the written report. If ODM or its designee determines that
it cannot approve the provider's plan of correction, it shall inform the
provider of this determination, in writing, require that the provider submit a
new plan of correction and specify the required actions that must be included
in the plan of correction. The provider must submit the new plan of correction
within the prescribed timframes, not to exceed forty-five calendar
days.
(3) ODM permits flexibility
with the required timeframes for submission of plans of correction required in
this paragraph, so long as it is documented in the provider's file.
(E) If the possibility of an overpayment is identified through the structural review and/or provider occurrence processes, ODM will conduct a final review, and as appropriate, issue all payment adjustments in accordance with rule 5160-1-19 of the Administrative Code.
(F) ODM may take action against the provider in accordance with rule 5160-45-09 of the Administrative Code for failure to comply with any of the requirements set forth in this rule.
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