Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-45 - Administered Waiver Service Providers
Section 5160-45-09 - ODM-administered waiver program: program compliance, monitoring and oversight of ODM-administered waiver service providers and ODM-administered waiver program contractors
Universal Citation: OH Admin Code 5160-45-09
Current through all regulations passed and filed through September 16, 2024
(A) The Ohio department of medicaid (ODM) is responsible for the ongoing monitoring and oversight of all ODM-administered waiver service providers and all ODM-administered waiver contractors in order to assure providers' and contractors' compliance with ODM-administered waiver program requirements.
(B) Monitoring and oversight of ODM-administered waiver service providers.
(1) ODM and its designee shall conduct
ongoing monitoring and oversight of ODM-administered waiver service providers
to verify that each provider is:
(a)
Complying with the terms and conditions of its medicaid provider agreement, the
ODM-administered waiver program and all applicable federal, state and local
laws and regulations.
(b) Ensuring
the health and welfare of individuals to whom they are providing
services.
(c) Ensuring the
provision of quality services as part of the ODM-administered waiver
program.
(2) Monitoring
and oversight includes, but is not limited to the following:
(a) Interviews with individuals enrolled on
the ODM-administered waivers and/or their authorized representative or legal
guardian, providers and contractor staff.
(b) Visits to the provider's place of
business or another agreed upon location for the purpose of examining or
collecting records, reviewing documentation, and conducting structural
reviews.
(c) Reviews of electronic
and/or hard copy records and billing documentation, etc.
(3) Providers shall fully cooperate with all
requests made by ODM, and/or its designee as part of the monitoring and
oversight process. This includes, but is not limited to the following:
(a) Upon request, arranging for or otherwise
furnishing an adequate workspace for ODM and/or its designee to conduct visits
as described in paragraph (B)(2)(b) of this rule. This workspace must be in a
secure location which protects sensitive and confidential information from
being disclosed contrary to relevant confidentiality and information disclosure
laws.
(b) Making all requested
information available at the time of review.
(c) Ensuring the availability of supervisors
and/or other staff who may possess relevant information to answer
questions.
(4) At the
conclusion of a provider's monitoring and oversight review:
(a) ODM or its designee shall notify the
provider in writing of its findings. ODM or its designee may do any of the
following:
(i) Request that the provider
prepare and submit to ODM or its designee a plan of correction within the
prescribed time frame. The plan of correction shall set forth the action(s)
that must be taken by the provider to correct each finding, and establish a
target date by which the corrective action must be completed. If ODM or its
designee does not approve the submitted plan of correction, ODM or its designee
may request a new plan of correction or take other appropriate
action.
(ii) Provide technical
assistance to the provider.
(iii)
Refer the provider to other entities for further investigation. Such entities
include, but are not limited to:
(a) The
surveillance and utilization review section (SURS) or other program area(s)
within ODM;
(b) The Ohio attorney
general;
(c) The Ohio department of
health (ODH);
(d) The Ohio board of
nursing (OBN);
(e) Other licensing,
certification or credentialing bodies, as appropriate; and
(f) Law enforcement.
(b) ODM may:
(i) Issue the provider a notice of
operational deficiency (NOD) based upon its or its designee's review
findings.
(ii) Propose suspension
or termination of the provider's medicaid provider agreement pursuant to
section 5164.38 of the Revised Code and
rules 5160-1-17.5 and 5160-1- 17.6 of
the Administrative Code.
(C) Monitoring and oversight of ODM-administered waiver contractors.
(1) ODM
shall conduct ongoing monitoring and oversight of the ODM-administered waiver
contractors to verify that each contractor is:
(a) Complying with the terms and conditions
of its contract and all applicable federal, state and local laws and
regulations.
(b) Ensuring the
health and welfare of individuals to whom they are providing
services.
(c) Ensuring the
provision of quality services as part of the ODM-administered waiver
program.
(2) Monitoring
and oversight may include, but are not limited to the following:
(a) Interviews with individuals enrolled on
the ODM-administered waivers and/or their authorized representative or legal
guardian, providers and contractor staff.
(b) Visits to the contractor's place of
business or another agreed upon location for the purpose of examining or
collecting records, reviews of documentation, structural reviews.
(c) Reviews of electronic and/or hard copy
records and billing documentation, etc.
(3) Contractors shall fully cooperate with
all requests made by ODM as part of the monitoring and oversight process. This
includes, but is not limited to the following:
(a) Upon request, arranging for or otherwise
furnishing an adequate workspace for ODM to conduct visits as described in
paragraph (C)(2)(b) of this rule. This workspace must be in a secure location
which protects sensitive and confidential information from being disclosed
contrary to relevant confidentiality and information disclosure laws.
(b) Making all requested information
available at the time of review, and in accordance with the terms of compliance
with contracts.
(c) Ensuring the
availability of supervisors and/or other staff who may possess relevant
information to answer questions.
(4) At the conclusion of a contractor's
monitoring and oversight review, ODM shall notify the contractor of its
findings. Additionally, if determined appropriate, ODM may do any of the
following:
(a) Request that the contractor
prepare and submit to ODM a plan of correction within the prescribed time
frame. The plan of correction shall set forth the action(s) that must be taken
to correct each finding, and establish a target date by which the corrective
action must be completed. If ODM does not approve the submitted plan of
correction, ODM may request a new plan of correction or take other appropriate
action.
(b) Provide technical
assistance to the contractor.
(c)
Refer the contractor to other entities for further investigation. Such entities
include, but are not limited to:
(i)
SURS;
(ii) The Ohio attorney
general;
(iii) ODH;
(iv) OBN;
(v) Other licensing, certification or
credentialing bodies, as appropriate; and
(vi) Law enforcement.
(d) Issue the contractor a NOD based upon
review findings.
(e) Terminate the
contractor's contract pursuant to its terms.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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