173-39-01. ODA provider certification: introduction and definitions

(A) Introduction:

(1) This chapter establishes the certification requirements for providers who provide services to individuals through an ODA-administered medicaid waiver program or the state-funded components of the assisted living or PASSPORT programs; the requirements for providing services through those programs; and disciplinary actions that may be imposed.

(2) Rule 5160-58-04 of the Administrative Code requires providers to comply with many of the requirements for providing services in this chapter when the provider provides those services to individuals in the mycare Ohio program.

(B) Definitions for this chapter:

"Activity of daily living" (ADL) has the same meaning as in rule 5160-3-05 of the Administrative Code.

"Activity plan" means a description of interventions and the dates and times the provider shall provide the interventions.

"ADS" has the same meaning as in rule 173-39-02.1 of the Administrative Code.

"Assistance with self-administration of medication" has the same meaning as in paragraph (C) of rule 4723-13-02 of the Administrative Code when an unlicensed person provides the assistance.

"Business site" includes any location at which the provider retains records or provides services. "Business site" does not include the home of an individual receiving services unless the individual employs a participant-directed provider.

"Caregiver" means a relative, friend, or significant other who voluntarily provides assistance to the individual and is responsible for the individual's care on a continuing basis.

"Case manager" means the registered nurse, licensed social worker, or licensed independent social worker that ODA's designee employs to plan, coordinate, monitor, evaluate, and authorize services for ODA-administered programs that require provider certification under this chapter.

"CDJFS" means county department of job and family services.

"Certification" means ODA's approval of a provider to provide one or more of the services that this chapter regulates.

"CMS" means centers for medicare and medicaid services.

"Complete application" means the application and all documentation and information required by rule 173-39-03, 173-39-03.1, 173-39- 03.2, 173-39- 03.3, or 173-39- 03.4 of the Administrative Code. An application to become an ODA-certified assisted living provider is a complete application if the provider indicates in its application that it applied for a RCF license and the provider submits the required RCF licensure information to ODA as soon as it is available. An application to become an ODA-certified assisted living provider shall not be approved until an RCF license is issued by ODH.

"Continuing care retirement communities" has the same meaning as in rule 5160:1-6-02.3 of the Administrative Code.

"Consumer" has the same meaning as "individual."

"Current owner" means a person with an ownership interest in an ODA-certified provider whose interest in the provider is being sold or transferred.

"Electronic visit verification" (EVV) means using the ODM-approved EVV system to verify the provision of any service required by ODM, pursuant to rule 5160-1-40 of the Administrative Code.

"Emergency contact person" means a person the individual or caregiver wants the provider to contact in the event of an emergency to inform the person about the nature of the emergency.

"Governing body or managing employee" means chief executive officer(s) or other individuals who are responsible to establish and implement policies regarding the management and/or operations of a provider.

"HCBS" means home and community-based services.

"HHS" means the United States department of health and human services.

"Incident" means any event that is not consistent with providing routine care of a service to an individual. Examples of an incident are abuse, neglect, abandonment, accidents, or unusual events or situations that may result in injury to a person or damage to property or equipment. An incident may involve an individual, a caregiver (to the extent the event impacts the individual), a provider, a facility, or a staff member of a provider, facility, ODA, ODA's designee, or other administrative authority.

"Individual" has the same meaning in rule 5160-31-02 of the Administrative Code.

"Individual's signature" means the individual's signature or that of the individual's caregiver, which may include a handwritten signature; initials; stamp or mark; or electronic signature that represents the individual's acknowledgment that he or she received a service. ODA's designee documents the individual's signature of choice (i.e., handwritten, initials, stamp or mark, or electronic) in the individual's record and communicates it to the provider.

"Instrumental activity of daily living" (IADL) has the same meaning as in rule 5160-3-05 of the Administrative Code.

"Licensed practical nurse" (LPN) has the same meaning as in section 4723.01 of the Revised Code.

"Medicaid-provider agreement" means an agreement between ODM and the provider.

"Medicaid provider number" means a number ODM issued to a provider with whom ODM has entered into a medicaid-provider agreement.

"National provider identifier" (NPI) means a number issued to a provider by HHS.

"Nursing facility" has the same meaning as in section 5165.01 of the Revised Code.

"ODA" means the Ohio department of aging.

"ODA-certified provider" means a provider certified by ODA according to this chapter.

"ODA's designee" means an entity to which ODA delegates one or more of its administrative duties. ODA's current designees include the area agencies on aging that ODA lists in rule 173-2-04 of the Administrative Code and "Catholic Social Services of the Miami Valley." When "its designee" occurs after "ODA," it means "ODA's designee."

"ODH" means the Ohio department of health.

"ODM" means the Ohio department of medicaid.

"Ownership interest" means interest totaling five per cent or more in the provider, indirect ownership interest equal to five percent or more in the provider, a combination of direct and indirect ownership interest equal to five per cent or more in the provider; or an interest of five per cent or more in any mortgage, deed of trust, note, or other obligation if that interest equals at least five per cent of the value of the property or assets of the provider.

"Plan of treatment" means the orders of a licensed healthcare professional whose scope of practice includes making plans of treatment.

"Provider" has the same meaning as in section 173.39 of the Revised Code. ODA certifies the following categories of providers: agency providers, assisted living providers, non-agency providers, and participant-directed providers. "Agency provider" means a legally-organized entity that employs staff. "Assisted living provider" means a licensed residential care facility. "Non-agency provider" (i.e., "self-employed provider") means a legally-organized entity that is owned and controlled by one self-employed person who does not employ, either directly or through a contract, anyone else to provide services, and who is unsupervised. "Participant-directed provider" means a person that an individual (participant) directly employs and supervises to provide a service.

"Provider agreement" means an agreement between ODA's designee and the provider.

"Region" means a distinct geographic area in which ODA's designee administers the PASSPORT and assisted living programs. Each region consists of the counties assigned to similarly-numbered planning and service areas (PSAs) in rule 173-2-02 of the Administrative Code, except for "PSA2." In that PSA, Clark, Greene, and Montgomery counties comprise "Region 2" and Champaign, Darke, Logan, Miami, Preble, and Shelby counties comprise "Region CSS."

"Registered nurse" (RN) has the same meaning as in section 4723.01 of the Revised Code.

"Residential care facility" (RCF) has the same meaning as in section 3721.01 of the Revised Code.

"Service plan" means the written outline of the services that a case manager authorizes a provider to provide to an individual, regardless of the funding source for those services. "Service plan" includes the person-centered planning in rule 5160-44-02 of the Administrative Code.

"Services" has the same meaning as "community-based long-term care services" in section 173.39 of the Revised Code.

"Significant change" means a variation in the health, care, or needs of an individual that warrants further evaluation to determine if changes to the type, amount, or scope of services are needed. Significant changes include differences in health status, caregiver status, residence, service location, service delivery, hospitalization, and emergency department visits that result in the individual not receiving services for thirty days.

"Vocational program" means a planned series, or a sequence of courses or modules, that incorporate challenging, academic education and rigorous, performance-based training to prepare participants for success in a particular health care career or occupation.

Replaces: 173-39-01

Effective: 7/1/2019
Five Year Review (FYR) Dates: 07/01/2024
Promulgated Under: 119.03
Statutory Authority: 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 C.F.R. 441.352
Prior Effective Dates: 03/31/2006, 05/07/2009, 10/16/2009, 08/30/2010, 03/17/2011, 07/01/2014, 11/01/2015, 07/01/2016, 03/01/2017