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

Current through all regulations passed and filed through July 1, 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.