Ohio Admin. Code 173-39-04 - [Effective 1/1/2025] ODA provider certification: structural compliance reviews
(A) Deadline for ODA's
designee to conduct the first review: The one-year anniversary of the
provider's certification date.
(B)
Deadlines for ODA's designee to conduct subsequent reviews:
(1) The one-year anniversary of the previous
review if the provider is one of the following:
(a) A provider of an adult day
service.
(b) A provider of an
assisted living service.
(c) A
provider of personal care, enhanced community living,
or waiver nursing,
or structured family caregiving that is neither certified by medicare nor
accredited by the accreditation commission for health care, the community
health accreditation partner, the joint commission, or another national
accreditation organization that is approved by CMS and ODH.
(d) A provider of the choices home care
attendant service.
(e) A provider
of the home care attendant service.
(2) The three-year anniversary of the
previous review if the provider is not listed under paragraph (B)(1) of this
rule.
(C) Deadline
extensions: ODA may extend a deadline for ODA's designee under paragraph (A) or
(B) of this rule if ODA's designee provides ODA with a request for an extension
that includes the rationale for a delay and a forecast on the time needed to
complete the review.
(D) ODA or its
designee may conduct an unannounced review of a provider at any time to review
compliance with this chapter.
(E)
ODA's designee may review a provider at any time without waiting for a deadline
in paragraph (A), (B), or (C) of this rule to near.
(F) Responsible designees, type of reviews to
conduct, and scope of reviews:
(1) Based on
the provider type and situation, Appendix A to this rule establishes when a
designee is responsible for conducting a review, the type of review it is
responsible to conduct, and the scope of that review.
(2) ODA may authorize a designee to conduct a
desk review even if Appendix A to this rule establishes a requirement for an
on-site review.
(G)
Review components: For each review, ODA's designee shall do the following:
(1) Inform the provider of the review in
writing before beginning the review and before conducting an introductory
conference with the provider, unless the review is an unannounced review under
paragraph (D) of this rule.
(2)
Conduct an introductory conference with the provider to explain the purpose and
scope of the review.
(3) Review
compliance with each applicable requirement in rule
173-39-02 of the Administrative
Code other than the records and monitoring requirements in that rule, unless
Appendix A to this rule determines that this paragraph is not a component of
the review.
(4) Review compliance
with each applicable requirement in rules
173-39-02.1 to
173-39-02.24 of the
Administrative Code and the records and monitoring requirements in rule
173-39-02 of the Administrative
Code.
(5) Verify that a sample of
paid service units were provided according to the applicable requirements in
rules 173-39-02.1 to
173-39-02.24 of the
Administrative Code and the records and monitoring requirements in rule
173-39-02 of the Administrative
Code.
(6) Review a sample of paid
service units for ten per cent of the individuals that the provider served
during the previous three months (if a subsequent review of a provider listed
under paragraph (B)(1) of this rule) or the previous six months (if a
subsequent review of a provider listed under paragraph (B)(2) of this rule), so
long as the ten-per-cent sample contains no fewer than three individuals and no
more than thirty individuals, with the following exceptions:
(a) If non-compliance is identified, ODA or
its designee may review a larger sample size or order an independent audit at
the provider's expense.
(b) If the
provider operates from multiple business sites, ODA's designee shall review a
sample of paid service units for ten per cent of the individuals that the
provider served from each business site.
(c) If the provider did not bill ODA for
providing a service to any individual during the period in paragraph (G)(6) of
this rule, ODA or its designee shall indicate in the review record that ODA did
not pay the provider for providing a service to any individual during the
review period, then complete the remaining elements of the review under this
rule.
(d) If the provider is a
participant-directed provider, ODA or its designee shall review records for
each individual served during the review period in paragraph (G)(6) of this
rule. If the provider did not bill ODA for providing any units of service
during the review period in paragraph (G)(6) of this rule, ODA or its designee
shall indicate in the review record that ODA did not pay the provider to
provide any units of service during the review period, then complete the
remaining elements of the review under this rule.
(e) If the provider is certified to provide
both personal care and homemaker, ODA or its designee shall combine the review
for each service so that the aggregate sample size for the combined services
equals the sample size in paragraph (G)(6) of this rule.
(f) During a state of emergency declared by
the governor or a federal public health emergency, ODA may determine a lesser
review sample and issue this determination by notice.
(7) Review the qualifications of the
employees who provided services to individuals in the sample in paragraph
(G)(6) of this rule according to the following standards:
(a) The sample size of employees corresponds
to the sample size of individuals in Appendix B to this rule.
(b) If the provider hired or subcontracted
with RNs or LPNs under the direction of RNs, the number of RNs or LPNs in the
sample corresponds to the sample size of individuals in Appendix B to this
rule.
(c) The sample of employees
includes any employees providing services to individuals in the sample in
paragraph (G)(6) of this rule that the provider hired since the previous
review.
(d) The sample of employees
does not need to include an employee providing services to individuals in the
sample in paragraph (G)(6) of this rule if one or more of ODA's designees
already reviewed the employee's qualifications when conducting a review of the
same provider at a different business site within the past three hundred
sixty-five days.
(e) For a provider
that provides only home-delivered meals or a personal emergency response
system, the maximum sample size is ten employees.
(H) At the conclusion of the
review:
(1) If ODA's designee determines a
provider is out of compliance, then ODA's designee shall ensure all of the
following occur:
(a) ODA's designee notifies
the provider at the exit interview or, if the provider is unavailable for the
exit interview, with a detailed communication within one business day after the
review.
(b) ODA's designee records
the method of notification in paragraph (H)(1)(a) of this rule in
PIMS.
(c) ODA or its designee
determine whether to impose an immediate disciplinary action under rule
173-39-05 of the Administrative
Code.
(2) Within ten
business days after the review, ODA's designee shall issue a summary letter to
the provider, including a summary of all areas of non-compliance, request for a
plan of correction or evidence of compliance, and disciplinary action if
imposed by ODA or its designee.
(3)
Within ten business days after the date ODA's designee issues the summary
letter to the provider, the provider shall provide a plan of correction or
evidence of compliance with the laws, rules, or regulations determined to have
been violated during the review which were not subject to disciplinary action
under rule
173-39-05 of the Administrative
Code.
(4) ODA or its designee may
impose a disciplinary action under rule
173-39-05 of the Administrative
Code if either of the following occur:
(a) The
provider did not provide ODA or its designee with a plan of correction or
evidence of compliance.
(b) The
provider remains out of compliance after ODA or its designee receives a plan of
correction or evidence of compliance from the provider.
(5) If a unit-of-service error is detected
during unit-of-service verification, the provider shall return the overpayment
of funds to ODA or its designee using appropriate auditing
procedures.
(I) ODA may
suspend any review during a state of emergency declared by the governor or a
federal public health emergency.
(J) ODA's designee or the provider may email
any plan of correction, evidence of compliance, notice, communication, or
summary letter required in this rule.
Notes
Promulgated Under: 119.03
Statutory Authority: 121.07, 173.01, 173.02, 173.391, 173.52, 173.522, 173.54, 173.543
Rule Amplifies: 173.39, 173.391, 173.52, 173.522, 173.54, 173.543; 42 CFR 441.352
Prior Effective Dates: 03/31/2006, 08/30/2010, 03/17/2011, 01/01/2020, 06/11/2020 (Emer.), 10/23/2020, 04/04/2022, 07/01/2023, 07/01/2024
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