Current through Reg. 49, No. 38; September 20, 2024
(a) DADS
may terminate a provider agreement:
(1) for
reasons set forth in federal or state laws, rules or regulations, including
this chapter and 1 TAC Chapter 355 (relating to Reimbursement Rates);
(2) if the program provider fails to comply
with the terms of the provider agreement, including failure of the program
provider's facility to maintain ICF/IID Program certification;
(3) if federal or state laws, rules or
regulations are enacted, amended, repealed or judicially interpreted so as to
render the fulfillment of the provider agreement by either the program provider
or DADS unfeasible or impossible, and DADS and program provider cannot agree
upon amendments to the provider agreement necessary to comply with such changes
to laws, rules or regulation;
(4)
if a certification made by the program provider in the provider agreement is
false or becomes inaccurate;
(5) if
DADS determines that a program provider has failed to implement a DPoC in
accordance with § 261.267 of this chapter (relating to Directed Plan of
Correction and Vendor Hold Based on State Survey Agency Findings); or
(6) if, during an 18-month period, three
vendor holds are imposed on payments due under that provider agreement in
accordance with § 261.267 of this chapter.
(A) A vendor hold may be used to terminate a
provider agreement in accordance with this paragraph regardless of whether
there was an actual interruption of payment to the program provider.
(B) A vendor hold may be used no more than
once to terminate a provider agreement in accordance with this
paragraph.
(b) If DADS proposes to terminate a provider
agreement, DADS may place a vendor hold on payments due to the program provider
under the provider agreement until:
(1) an
audit of the program provider's financial records, conducted in accordance with
§ 261.269 of this chapter (relating to Audits) is completed;
(2) a review of the program provider's fiscal
accountability cost report, conducted in accordance with 1 TAC §355.452(relating to
Cost Reporting Procedures) and 1 TAC §
355.457(relating
to Cost Finding Methodology) is completed; and
(3) any amounts owed to DADS as a result of
the audit and review are resolved.
(c) If DADS proposes to terminate a provider
agreement, DADS sends a written notice of the proposed termination to the
program provider. The program provider may submit a written request for an
informal reconsideration (IR) in accordance with paragraph (1) of this
subsection.
(1) DADS considers a request for
an IR only if the program provider submits the request and any supporting
documentation the program provider wants DADS to consider to DADS, within seven
days after receiving DADS notice of proposed termination.
(2) If the program provider submits a timely
request for an IR, DADS provides a written response to the program provider
affirming or reversing the proposed termination.
(3) If the program provider does not submit a
timely request for an IR, or DADS affirms the proposed termination, DADS
proceeds with the proposed termination in accordance with subsection (d) of
this section.
(d) If
DADS proposes to terminate a provider agreement after the process described in
subsection (c) of this section, DADS sends a second written notice of the
proposed termination to the program provider. The program provider may submit a
written request for an administrative hearing in accordance with 1 TAC §
357.484(relating
to Request for a Hearing).
(e) If
DADS proposes to terminate a provider agreement and the program provider
requests an administrative hearing in accordance with 1 TAC §
357.484,
DADS does not terminate the provider agreement before the completion of the
administrative hearing, but payments to the program provider may be withheld by
DADS.
(1) If the final decision of the
administrative hearing is favorable to DADS or the program provider does not
make a timely request for an administrative hearing, then payments withheld
will not be made by DADS to the program provider.
(2) If the final decision is favorable to the
program provider, then DADS pays amounts withheld and resumes payment under the
provider agreement.
(f)
If DADS terminates a provider agreement, DADS does not enter into a new
provider agreement with the program provider until at least two days have
elapsed from the effective date of the termination.
(g) DADS may enter into a new provider
agreement with a program provider that has had its provider agreement
terminated if:
(1) within 30 days after
termination, the program provider requests a new provider agreement;
and
(2) within 90 days after
termination, DADS determines that all deficiencies or actions that led to
termination of the provider agreement have been corrected and the program
provider is otherwise qualified to enter into a provider agreement.
(h) In determining whether to
enter into a new provider agreement with a program provider that has had its
provider agreement terminated, DADS considers:
(1) the nature, severity, and pervasiveness
of the deficiencies or actions that led to termination of the provider
agreement; and
(2) the facility's
or the program provider's history of compliance with ICF/IID Program
requirements.
(i) The
term and effective date of a new provider agreement entered into in accordance
with subsection (f) of this section will be determined by DADS.
(j) If DADS determines not to enter into a
new provider agreement:
(1) a local authority
must assist DADS in relocating individuals who choose to move from the
facility; and
(2) the program
provider must assist DADS or the local authority in relocating individuals who
choose to move from the facility.
