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 5160-44-05 - Nursing facility-based level of care home and community-based services (HCBS) programs, medicaid managed care organizations, the OhioRISE program, and specialized recovery services (SRS) program: incident management

Current through all regulations passed and filed through July 1, 2024
This rule sets the standards and
				procedures for managing incidents that may have a negative impact on
				individuals. The purpose is to establish the procedures for reporting and
				addressing critical incidents and reportable incidents, and to implement a
				continuous quality improvement process to prevent and reduce the risk of harm
				to individuals. This rule applies to the Ohio department of aging (ODA), the
				Ohio department of medicaid (ODM), their designees, and to individuals as
				defined in this rule. This rule also applies to providers of waiver services,
				providers of OhioRISE services, providers of services provided through a
				medicaid managed care organization (MCO), and providers of services under the
				specialized recovery services (SRS) program. ODA and ODM may designate other
				entities to perform one or more of the incident management functions set forth
				in this rule.
(A)
								For the purpose of this rule, the following definitions
			 apply:
(1)
									"Care
			 management entity" means an entity delegated or contracted by ODA or ODM to
			 perform care management activities and related functions for individuals
			 enrolled on a waiver, or enrolled concurrently on the MyCare Ohio managed care
			 program and the SRS program.
(2)
									"Critical
			 incident" means incidents identified in paragraph (C) of this
			 rule.
(3)
									"Health and safety action plan" means a document
			 developed by the care management entity or recovery management entity that
			 identifies situations, circumstances, and behaviors that without intervention
			 may jeopardize the individual's health and welfare and potentially risk his or
			 her program enrollment. It sets forth the interventions to remedy risks to the
			 health and welfare of an individual and to ensure the individual's needs are
			 met.
(4)
									"Incident" means an alleged, suspected or actual event
			 that is not consistent with the routine care of, or service delivery to an
			 individual that may have a negative impact on the health and welfare of the
			 individual.
(5)
									"Incident management system" means the system in which
			 reported incidents are entered, including, as applicable, investigative and
			 review notes, findings and results, prevention plans, and any other applicable
			 information. For the pre-admission screening system providing options and
			 resources today (PASSPORT) waiver, and assisted living waiver, the incident
			 management system is the system established by ODA. For the Ohio home care
			 waiver, My Care Ohio waiver, SRS program, OhioRISE program, and individuals
			 enrolled in a MCO, the incident management system is the system established by
			 ODM.
(6)
									"Individual" means a person enrolled as a waiver
			 recipient, or in the specialized recovery services (SRS) program, or in the
			 OhioRISE program, or in a MCO.
(7)
									"Investigative
			 entity" means ODM, ODA, and their designee.
(8)
									"Managed Care
			 Organization" means a health insuring corporation (HIC) licensed in the state
			 of Ohio that enters into a managed care provider agreement with the state of
			 Ohio. As used in this rule, managed care organizations do not include managed
			 care plans defined in rule
			 5160-58-01
			 of the Administrative Code which administer the MyCare Ohio managed care
			 program.
(9)
									"MyCare Ohio managed care program" means the integrated
			 care delivery system program described in Chapter 5160-58 of the Administrative
			 Code.
(10)
									"OhioRISE Plan" means the prepaid inpatient health plan
			 as defined in Chapter 5160-59 of the Administrative Code that is under contract
			 with ODM to manage the OhioRISE program benefits. The OhioRISE plan contracts
			 with local entities to provide care management functions for those individuals
			 enrolled in the OhioRISE program.
(11)
									"OhioRISE
			 program" means the Ohio resilience through integrated system and excellence
			 program as described in Chapter 5160-59 of the Administrative
			 Code.
(12)
									"Recovery management entity" means an entity delegated
			 or contracted by ODM to perform case management activities via the recovery
			 manager and related functions for individuals enrolled in the SRS
			 program.
(13)
									"Reportable incident" means an incident identified in
			 paragraph (D) of this rule.
(14)
									"Specialized
			 recovery services program" means Ohio's home and community based services
			 (HCBS) state plan program set forth in Chapter 5160-43 of the Administrative
			 Code.
(15)
									"Substantiated" means, there is a preponderance of
			 evidence to indicate the reported incident is more likely to have occurred than
			 not to have occurred.
(16)
									"Waiver" means an Ohio medicaid nursing facility-based
			 level of care HCBS waiver program which includes the assisted living waiver set
			 forth in Chapter 173-38 of the Administrative Code, the PASSPORT waiver set
			 forth in Chapter 173-42 of the Administrative Code, the Ohio home care waiver
			 set forth in Chapter 5160-46 of the Administrative Code, and the MyCare Ohio
			 waiver set forth in Chapter 5160-58 of the Administrative Code. This rule does
			 not apply to developmental disabilities level of care waivers set forth in
			 Chapter 5123-9 of the Administrative Code, the state-funded PASSPORT program
			 set forth in Chapter 173-40 of the Administrative Code, or the state-funded
			 assisted living program set forth in rule 173-51 of the Administrative
			 Code.