Ohio Admin. Code 5160-3-02.2 - Nursing facilities (NFs): termination, denial, and non-revalidation of provider agreements
(A) Written notice.
(1) The Ohio department of
job and family services (ODJFS)
medicaid (ODM) may terminate, deny, or not
renew
revalidate a NF provider
agreement upon thirty days written notice to the
nursing facility (NF)
NF.
(2)
Notices and termination orders must comply with provisions set forth in
sections 5111.06
5164.38
and
5111.51
5165.77
of the Revised
Code.
(B) Reasons for
which ODJFS
ODM may terminate, deny, or not
renew
revalidate a NF provider
agreement.
(1)
According to
In accordance
with section 5111.22
5164.33
of the Revised
Code, ODJFS
ODM may terminate, deny, or not
renew
revalidate a NF provider
agreement if ODJFS
ODM determines such an agreement is not in the best
interests of the state or the medicaid residents
of long term care facilities
the NF.
(2)
ODJFS
ODM may terminate, deny, or not
renew
revalidate a NF provider
agreement on the basis of best interest including, but not limited to, the
following reasons: (l)
(k) The provider fails
to pay the full amount of a franchise permit fee (FPF) installment when due pursuant to section
3721.541
5168.52
of the Revised
Code.
(a) The provider has not
fully and accurately disclosed information to
ODJFS
ODM
information as required by the provider
agreement or any rule contained in division
5101:3
Chapter 5160-3 of the
Administrative Code;
.
(b) The
provider has failed to abide by or to have the capacity to comply with the
terms and conditions of the provider agreement and/or rules and regulations
promulgated by ODJFS
ODM;
(c) The provider has been found liable by a
court for negligent performance of professional duties;
.
(d) The provider has failed to file cost
reports as required according to
in rule 5101:3-3-20
5160-3-20
of the Administrative Code;
.
(e) The provider has made false statements or
has altered records, documents, or charts. Alteration does not include properly
documented correction of records;
.
(f) The
provider has failed to cooperate or provide requested records or documentation
for purposes of an audit or review of any provider activity by any federal,
state, or local agency;
.
(g) The
provider has been found in violation of section 504 of the Rehabilitation Act
of 1973,
29 U.S.C
794 (March 24, 2014),
as amended; the Civil Rights Act of 1964,
42
U.S.C. 1971 (July 27, 2006) as amended; or
Public
Law 101-336 (the Americans with
Disabilities Act of 1990)
,
42 U.S.C.
12101 et seq (March 15, 2011) in
relation to the employment of individuals, the provision of services, or the
purchase of goods and services;
.
(h) The
attorney general, auditor of state, or any board, bureau, commission, or
department has recommended ODJFS
ODM terminate the provider agreement where the
reason for the request bears a reasonable relationship to the administration of
the medicaid program or the integrity of state and/or federal funds;
.
(i)
The
In accordance with rule
5160-1-13.1 of the
Administrative Code, the provider has violated the prohibition against
billing medicaid residents for covered services, or has
requested the resident to share in the cost of covered services through
deductibles, coinsurance, co-payments, or other similar charges, other than
medicaid co-payments as defined in rule
5160-1-09 of the Administrative
Code.
or factoring as found in rule
5101:3-1-13.1 or 5101:3-1-23 of the Administrative Code;
(j) The facility has been found by the Ohio
department of health (ODH) during a survey of the facility to have an emergency
that is the result of a deficiency or cluster of deficiencies, and that
constitutes immediate jeopardy;
.
(k) The provider does not comply
with the requirements of section 5111.30 of the Revised Code for the
installation of fire extinguishing and fire alarm systems, and with the
requirements of section 3721.071 of the Revised Code for the submission of a
written fire safety code; and
(C)
Reasons for which ODJFS
ODM shall terminate, deny, or not
renew
revalidate a NF provider
agreement. (1)
(2)
ODJFS
ODM
shall terminate, deny, or not renew
revalidate a NF
provider agreement when any of the situations set
forth in division (D) of section 5111.06 of the Revised Code occur
for,
including,
but not limited to, the following reasons set forth in
Chapters 5164. and 5165. of the Revised Code, and Chapters 5160-1 and 5160-3 of
the Administrative Code:
(c)
(a)
The provider, or its owner, officer, authorized
agent, associate, manager, or employee has pled guilty to or been convicted of
a criminal offense, found liable in a civil action, or voluntarily settled a
civil suit brought pursuant to section 109.85 of the Revised Code;
In accordance with division (D) of section
5164.35 of the Revised Code,
there has been a conviction of, or the entry of a judgment in either a criminal
or civil action against the provider or its owner, officer, authorized agent,
associate, manager, or employee in an action brought pursuant to section
109.85 of the Revised
Code.
(d)
(b) The provider has committed medicaid fraud as
defined in rule 5101:3-1-29
5160-1-29
of the Administrative Code;
.
(g)
(f)
The provider has failed to ensure a nursing facility 's full participation in
the medicare program as a skilled nursing facility (SNF) pursuant to section
5111.21
5165.082
of the Revised
Code and rule 5101:3-3- 02.4
5160-3- 02.4 of the Administrative Code.
(2)
(3) If ODH terminates
certification of a nursing facility,
ODJFS
ODM
shall terminate the facility's provider agreement pursuant to
division (D) of section
5111.06
5164.38
and
division (B) of section
5111.52
5165.79
of the Revised
Code.
(1)
ODM
shall terminate, deny, or not revalidate a NF provider agreement for, but not
limited to, the following reasons:
(a)
The provider has been terminated, suspended, or
excluded by the medicare program and/or by the United States centers for
medicare and medicaid services (CMS) and that action is binding on
participation in the medicaid program or renders federal financial
participation unavailable for participation in the medicaid program. Under
these conditions, medicaid termination and payment sanction dates shall be the
same as medicare termination and payment sanction dates.
(b)
The facility has
been decertified by ODH and/or the United States department of health and human
services.
(c)
The provider has pled guilty to or been convicted of a
criminal activity materially related to either the medicare or medicaid
program.
(d)
Any license, permit, or certificate that is required by
ODM or the terms of the provider agreement has been denied, suspended, revoked,
or not renewed.
(a) The provider has been
terminated, suspended, or excluded by the medicare program and/or by the United
States centers for medicare and medicaid services (CMS) and that action is
binding on participation in the medicaid program or renders federal financial
participation unavailable for participation in the medicaid program. Under
these conditions, medicaid termination and payment sanction dates shall be the
same as medicare termination and payment sanction dates;
(b) The facility has been
decertified by the Ohio department of health (ODH) and/or the United States
department of health and human services;
(c)
In accordance
with section 5165.073 of the Revised Code,
the provider does not comply with the requirements of section
3721.071 of the Revised Code for
the installation of fire extinguishing and fire alarm systems.
(d)
Any of the
scenarios specified under division (B) of section
5165.771 of the Revised Code
regarding the special focus facility program apply to the
provider.
(e)
In accordance with section
5165.106 of the Revised Code,
the provider fails to file a cost report required by section
5165.10 of the Revised Code by
the date it is due or by the date, if any, to which the due date is extended
pursuant to division (D) of section
5165.10 of the Revised Code,
unless the provider submits a complete and adequate cost report within thirty
days after notice of termination by ODM.
(e) The provider has pled guilty to
or been convicted of a criminal activity materially related to either the
medicare or medicaid program; or
(f) Any license, permit, or
certificate that is required by ODJFS or the terms of the provider agreement
has been denied, suspended, revoked, or not renewed.
(g)
In accordance
with section 5165.072 of the Revised Code,
the provider fails to maintain eligibility for the provider agreement as set
forth in section 5165.06 of the Revised
Code.
(h)
In accordance with division (B)(1) of section
5164.32 of the Revised Code, the
provider fails to file a complete application for revalidation within the time
and in the manner required by the revalidation process as specified by
ODM.
(D) Adjudication
order.
(1)
According to
In accordance
with section 5111.06
5164.38
of the Revised
Code, ODJFS
the
director of ODM shall terminate, deny, or not renew
revalidate an
existing NF provider agreement by issuing an
order pursuant to an adjudication conducted in accordance with Chapter 119. of
the Revised Code, unless such action occurred as the result of events described
in paragraph (C) of this rule
division (E) of section
5164.38 of the Revised
Code.
(2)
According to
In
accordance with division (E) of section 5111.51
5165.77
of the Revised
Code, if ODJFS
ODM issues a termination order as the result of events
set forth in paragraph (B)(2)(j) of this rule, the termination may take effect
prior to or during the pendency of the proceeding under Chapter 119. of the
Revised Code.
(E)
Impact of provider actions on CMS-imposed reasonable assurance periods.
(1) When seeking reentry to the medicaid
program, providers are subject to procedures set forth in CMS publication
100-07 entitled "State Operations Manual" at Chapter 7
sections 7321B to 7321D (09/10/10)
section 7321 (6/12/14) for SNFs and NFs, to comply
with the provisions at
42 CFR
489.57
(October 1,
2015) that govern reinstatement after termination, and require that the
reason for termination of the previous agreement has been removed and there is
reasonable assurance that it will not recur.
(2) After CMS has initiated involuntary
termination action for a dually certified SNF/NF, or after ODH has initiated
involuntary termination action for a medicaid-certified NF, a provider of a NF
who is permitted to voluntarily terminate, voluntarily withdraw, or undergoes a
change of operator, or the subsequent operator of the same facility, shall be
subject to reasonable assurance requirements set by CMS when seeking reentry to
the medicaid program.
(3) CMS or
ODH initiates a termination action when it sends a provider the initial notice
certifying noncompliance and proposing termination.
(4) Certification of noncompliance
is a citation of noncompliance with a condition, or a
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5165.02
Rule Amplifies: 109.85, 3721.071, 5164.32, 5164.33, 5164.35, 5164.38, 5165.072, 5165.073, 5165.106, 5165.77, 5165.771, 5165.79, 5165.85, 5165.87, 5168.52
Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 1/1/95, 5/16/02, 9/29/05, 2/15/11, 1/10/13
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