Or. Admin. Code § 411-066-0015 - Certification
ADS programs that enroll with APD to provide services must be certified.
(1) INITIAL CERTIFICATION.
(a) To receive APD Adult Day Service
certification, which is required to become a DHS Medicaid-enrolled provider, an
ADS program must complete all of the following certification process steps:
(A) Contact APD to schedule an initial
on-site visit.
(B) Provide a cover
letter detailing qualifications as an ADS.
(C) In preparation for the on-site
inspection, the ADS will Complete the ADS certification self-assessment which
demonstrates the program meets the standards for adult day services in OAR
411-066-0020.
(D) Participate in a follow-up on-site
inspection by APD.
(b)
APD must complete an on-site certification assessment visit, citing standards
(OAR 411-066-0020) as "met" or
"unmet".
(A) If all standards are met, APD
shall certify the ADS program.
(B)
If any of the standards are unmet, the application for certification shall be
denied.
(i) The ADS program may bring the
unmet standards into compliance and request APD complete a follow-up site
certification assessment.
(ii) A
request for a site certification reassessment must be made within 30 calendar
days after denial. If the request for the site certification reassessment is
more than 30 calendar days, the ADS program shall be required to resubmit the
information in (1)(a)(B) - (D) of this rule.
(C) If the denial is upheld after a site
certification reassessment, the ADS program may request an informal conference
in writing within 10 business days of receipt of the denial notice. Within 10
business days of receipt of the request for an informal conference, the Deputy
Director shall review all material relating to the denial of the certification.
(i) The Deputy Director shall determine,
based on a review of the material, whether to uphold the denial.
(ii) If the Deputy Director does not sustain
the decision, certification shall be granted immediately.
(iii) The decision of the Deputy Director is
subject to a contested case hearing under ORS
183.413 to
183.470, if requested within 90
days.
(c) APD
may perform an unannounced on-site certification review any time during the
certification period to ensure quality and safety standards continue to be
met.
(2) MEDICAID
PROVIDER ENROLLMENT. The ADS program must be an enrolled Medicaid provider in
order to be eligible to receive payment from the Department for claims in
connection with services provided by the ADS. The criteria for Medicaid
provider enrollment and issuance of a provider number include, but are not
limited to:
(a) Meeting all program-specific
requirements.
(b) Providing a copy
of the ADS program's current certification.
(c) Current business registration and assumed
business name (ABN), if applicable, with the Oregon Secretary of State's
Corporation Division.
(d)
Completing an Adult Day Services Medicaid Provider Enrollment Application and
Agreement (PEA) upon enrollment and renewal and meeting all Medicaid provider
enrollment requirements.
(e)
Maintaining the insurance requirements as defined in the PEA.
(3) MAINTAINING CERTIFICATION.
Certification for an ADS program may continue for up to two years, or longer as
defined below, from the effective date, if the ADS program complies with the
standards for certification as established in OAR
411-066-0020.
(a) ADS programs wanting to renew
certification and Medicaid provider enrollment must:
(A) Complete an ADS certification
self-assessment demonstrating the program meets these rules. ADS certification
self-assessments received by DHS APD prior to the ADS certification expiration
date may allow the ADS certification to remain in effect at the discretion of
APD until a final recertification decision is issued.
(B) Participate in a follow-up on-site
inspection by APD.
(b)
APD must complete an on-site certification assessment form after the visit,
citing standards (OAR
411-066-0020) as "met" or
"unmet".
(A) If all standards are met, APD
shall notify the ADS program that certification shall be renewed.
(B) If any of the standards are unmet, the
application for certification shall be denied.
(i) The ADS program may bring the unmet
standards into compliance and request APD complete a follow-up site
certification assessment.
(ii) A
request for a site certification reassessment must be made within 30 calendar
days after denial. If the request for the site certification reassessment is
more than 30 calendar days, the ADS program shall be required to resubmit the
information in (1)(a)(B) - (D) of this rule.
(iii) Depending upon the nature of the
inadequacy, APD may perform a follow-up inspection to confirm
compliance.
(iv) APD may
immediately suspend certification for threat to the participant's health,
safety, welfare, or failure to comply with the standards.
(C) If the site reassessment result is not
accepted in full, or the follow-up inspection reveals non-compliance, APD may
deny, revoke or refuse to renew the certification and provider enrollment. The
ADS program shall be notified in writing of the decision.
(D) If the denial or revocation is upheld
after reviewing the site reassessment results, or follow-up inspection, the ADS
program may, submit a written request for an informal conference within 10
business days of receipt of the notice. Within 10 business days of receipt of
the request for the informal conference, the Deputy Director shall review all
material regarding the denial or revocation.
(i) The Deputy Director shall determine,
based on a review of the material, whether to uphold the denial or
revocation.
(ii) If the Deputy
Director does not sustain the decision, certification shall be granted
immediately.
(iii) The decision of
the Deputy Director is subject to a contested case hearing under ORS
183.413 to
183.470 if requested within 90
days.
(c) APD
may perform an unannounced on-site certification review any time during the
certification period to ensure quality and safety standards continue to be
met.
(4) Termination of
Medicaid provider enrollment.
(a) Enrolled
Medicaid providers of ADS may be denied enrollment, terminated, or prohibited
from providing ADS for any of the following:
(A) Violation of any part of these
rules.
(B) Violation of the
protective service and abuse rules in OAR chapter 411, division 020 and OAR
chapter 407, division 045.
(C)
Failure to keep required certifications current.
(D) Failure to maintain Medicaid provider
enrollment.
(E) Failure to provide
copies of the records described in these rules to designated Department or
Oregon Health Authority entities.
(b) Enrolled Medicaid providers
may appeal a termination of their Medicaid provider number based on OAR
407-120-0360(8)(g)
and OAR chapter 410, division 120, as
applicable.
(c) Enrolled Medicaid
providers of ADS must provide advance written notice to the Department at least
30 days prior to no longer providing ADS.
Notes
Statutory/Other Authority:ORS 409.050, 410.070, 410.490, 410.495, 413.085
Statutes/Other Implemented:ORS 410.485 - 410.495
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