173-39-02 Conditions of participation.

 

 

 

173-39-02                    Conditions of participation.

 

 

 

(A)   Introduction: This rule presents the conditions of participation for each of the four types of ODA-certified long-term care providers: agency providers, non-agency providers, consumer-directed individual providers, and assisted living providers.

 

(B)   Agency providers: These are the conditions for any provider who seeks to become, or to remain, an ODA-certified long-term care agency provider:

 

(1)  Service provision:

 

(a)    The provider shall comply with rule 173-39-02.1 of the Administrative Code, if providing an adult day service; rule 173-39-02.3 of the Administrative Code, if providing a pest-control service; rule 173-39-02.4 of the Administrative Code, if providing a home-care attendant service; rule 173-39-02.5 of the Administrative Code, if providing a chore service; rule 173-39-02.6 of the Administrative Code, if providing an emergency response system service; rule 173-39-02.7 of the Administrative Code, if providing home medical equipment and supplies; rule 173-39-02.8 of the Administrative Code, if providing a homemaker service; rule 173-39-02.9 of the Administrative Code, if providing a minor home modification, maintenance, or repair service; rule 173-39-02.10 of the Administrative Code, if providing a nutritional consultation service; rule 173-39-02.11 of the Administrative Code, if providing a personal care service; rule 173-39-02.12 of the Administrative Code, if providing a social work counseling service; rule 173-39-02.13 of the Administrative Code, if providing a non-emergency medical transportation service; rule 173-39-02.14 of the Administrative Code, if providing a home-delivered meal service; rule 173-39-02.15 of the Administrative Code, if providing an independent living assistance service; rule 173-39-02.17 of the Administrative Code, if providing a community transition service; rule 173-39-02.18 of the Administrative Code, if providing a non-medical transportation service; and rule 173-39-02.19 of the Administrative Code, if providing a home-delivered meal service with a kosher diet; and rule 173-39-02.20, if providing an enhanced community living service.

 

(b)      The provider may provide a service that is not authorized by the consumer's service plan, but ODA (or ODA's designee the PAA) only reimburses the provider for providing a service that is authorized by the consumer's service plan.

 

(c)   The provider shall notify ODA (or its designee the PAA) no later than one business day after the provider is aware of any significant consumer behavior  that  may  affect  a  consumer's  service  needs,  including  a

 

 

consumer's repeated refusal of services.

(d)  The provider shall notify ODA (or its designee the PAA) no later than one business day after the provider is aware of any significant change that may affect a consumer's service needs, including:

(i)   The provider does not provide an authorized service at the time (or, for the period of time) authorized by the case manager;

(ii)   The consumer moves to another address; or,

(iii)    The consumer's physical, mental, or emotional status changes, or the provider can document changes in the environmental conditions or other health and safety issues.

(e)    The provider shall notify the consumer and ODA's designee the PAA in writing at least thirty days before the last date of service if the provider is terminating the provision of ODA-certified services to the consumer, unless:

(i)     The consumer has been hospitalized, placed in a long-term care facility, or has expired;

(ii)     The health or safety of the consumer or provider is at serious, imminent risk; and,

(iii)   The consumer is terminating services with the provider.

(f)     The provider shall adopt and implement ethical standards to require workers to provide services in a professional, respectful, and legal manner and not engage in any unprofessional, disrespectful, or illegal behavior including the following unprofessional, disrespectful, or illegal behavior:

(i)    Consuming the consumer's food or drink, or using the consumer's personal property without his/her consent.

(ii)    Bringing a child, friend, relative, or anyone else, or a pet, to the consumer's place of residence.

(iii)   Taking the consumer to the provider's place of business.

(iv)   Consuming alcohol during the delivery of services to the consumer.

(v)    Consuming medicine, drugs, or other chemical substances not in accordance with the legal, valid, prescribed use, or in any way that impairs the provider in the delivery of services to the consumer.

(vi)   Discussing religion or politics with the consumer and others in the care setting.

(vii)    Discussing personal issues with the consumer or any other person in the care setting.

(viii)    Accepting, obtaining, or attempting to obtain money, or anything of value, including gifts or tips, from the consumer or his/her household members or family members.

(ix)     Engaging the consumer in sexual conduct, or in conduct that a reasonable person would interpret as sexual in nature, even if the conduct is consensual.

(x)     Leaving the consumer's home for a purpose not related to the provision of services without notifying the agency supervisor, the consumer's emergency contact person, any identified caregiver, or the consumer's case manager. "Emergency contact person" means a person the consumer or caregiver wants the provider to contact in the event of an emergency to inform the person about the nature of the emergency.

(xi)   Engaging in any activity that may distract the provider from service delivery, including:

(a)   Watching television or playing computer or video games.

(b)   Engaging in non-care-related socialization with a person other than the consumer (e.g., a visit from a person who is not providing care to the consumer; making or receiving a personal telephone call; or, sending or receiving a personal text message or email).

(c)   Providing care to a person other than the consumer.

(d)   Smoking without the consumer's consent.

(e)   Sleeping.

(xii)    Engaging in behavior that causes, or may cause, physical, verbal, mental or emotional distress or abuse to the consumer.

(xiii)    Engaging in behavior that a reasonable person would interpret as inappropriate involvement in the consumer's personal relationships.

(xiv)    Being designated to make decisions for the consumer in any capacity involving a declaration for mental health treatment, power of attorney, durable power of attorney, or guardianship.

(xv)     Selling or purchasing from the consumer products or personal items, unless the provider is the consumer's family member who does so only when not providing a service.

(xvi)   Engaging in behavior that constitutes a conflict of interest or takes advantage of or manipulates ODA-certified services resulting in an unintended advantage for personal gain that has detrimental results to the consumer, the consumer's family or caregivers, or another provider.

(2)   Consumer safety:

(a)    The provider shall have a written procedure for documenting consumer incidents. The procedure shall include notifying ODA (or its designee the PAA) of the incident.

(b)   The provider shall report any reasonable cause to believe that a consumer has suffered abuse, neglect, or exploitation to the CDJFS (or its designee), in accordance with section 5101.61 of the Revised Code, and also notify ODA (or its designee the PAA) of the reasonable cause.

(c)      The provider shall maintain a minimum of one million dollars in commercial liability insurance.

(d)   The provider shall maintain insurance coverage for consumer loss due to

theft or property damage and provide written instructions that any consumer may use to obtain reimbursement for a loss due to employee theft or property damage.

(3)    Confidentiality: The provider shall comply with all state and federal laws and regulations governing consumer confidentiality including, but not limited to, 42 C.F.R. 431.300 to 431.307, and 45 C.F.R. parts 160, 162, and 164.

(4)   Provider qualifications:

(a)   The provider shall be a formally-organized business or service agency that is registered with the Ohio secretary of state that has been operating, providing, and being paid for the same services for which certification is being applied for at least two adults in the community for a minimum of three months at the point of application.

(b)   The provider shall disclose all entities that own at least five per cent of the business.

(c)    The provider shall have a written statement defining the purpose of the business or service agency.

(d)   The provider shall have written policies. Additionally, if the provider has a governing board, the provider shall have written bylaws; and, if the provider is incorporated, the provider shall have written articles of incorporation.

(e)     The provider shall have a written table of organization that clearly identifies lines of administrative, advisory, contractual, and supervisory authority.

(f)    The provider shall not allow a staff person to provide a service to a consumer if the person is a spouse, parent, step-parent, legal guardian, or authorized representative of the consumer.

(g)     The provider shall not allow a volunteer to provide any aspect of a certified long-term care service for a consumer without supervision by the provider's supervisory staff.

(h)    The provider shall maintain a physical facility from which to conduct business that has all of the following:

(i)    A primary business telephone number that is locally listed (e.g., in the telephone book in the provider's area of business) under the name of the business or a toll-free telephone number that is available through directory assistance that allows for reliable, dependable, and accessible communication.

(ii)   A designated, locked storage space for consumer records.

(i)   The provider shall comply with all applicable federal, state, and local laws.

(j)   The provider shall disclose the identity of any person who is an owner or has control over the agency if that person has been convicted of a felony under state or federal law.

(k)   The provider shall comply with the criminal records check requirements under rule 173-9-01 of the Administrative Code.

(l)    The provider shall have a written statement supporting compliance with Title VI of the "Civil Rights Act of 1946 1964," as amended, 42 USC 2000, et seq. regarding the provision of services.

(m)    The provider shall have a written statement supporting compliance with the "Equal Employment Opportunity Act of 1972," as amended, federal wage-and-hour laws, and workers' compensation laws regarding the recruitment and employment of persons.

(n)   The provider shall annually provide to ODA (or its designee the PAA) a written statement that certifies that the provider has paid all applicable federal, state, and local income and employment taxes.

(5)   Monitoring:

(a)     Records  retention:  The  provider  shall

maintain  and  retain  all  records

relating to costs, work performed, and supporting documentation records for payment of work performed, along with copies of all deliverables for until the latter of:audit by the state of Ohio (including, but not limited to, ODJFS, ODA, the auditor of the state of Ohio, the inspector general, and duly authorized law enforcement officials) and agencies of the United States government for three years, or until an audit is concluded and all issues are resolved, whichever occurs later.

(i) Three years after the date the provider receives payment for the service;

(ii) The date on which ODA, ODJFS, the PAA, or a duly-authorized law enforcement official concludes a review of the records and any findings are finally settled; or,

(iii) The date on which the auditor of the state of Ohio, the inspector general, or a duly-authorized law enforcement official concludes an audit of the records and any findings are finally settled.

(b)       Access: The provider shall, upon request, immediately provide representatives of ODA (or its designee the PAA) with access to its facility, a place to work in its facility, and access to policies, procedures, records, and documentation for each unit of service billed.

(6)   Reimbursement:

(a)   The provider shall bill only for a service if the provider complies with the requirements under this rule and the requirements, including documentation service-verification requirements, under rules 173-39-02.1, 173-39-02.3, 173-39-02.4, 173-39-02.5, 173-39-02.6, 173-39-02.7, 173-39-02.8, 173-39-02.9, 173-39-02.10, 173-39-02.11, 173-39-02.12, 173-39-02.13, 173-39-02.14, 173-39-02.15, 173-39-02.17, or 173-39-02.18, 173-39-02.19, or 173-39-03.20 of the Administrative Code for any service the provider provides that is regulated by one of those rules.

(b)     ODA's obligation to reimburse the provider for the costs of services provided as a certified long-term care provider is subject to the hold and review process described in rule 5101:3-1-27.2 of the Administrative Code.

(c)    The provider shall accept the reimbursement levels negotiated for each service by the provider and ODA's designee the PAA as payment in full, and not seek any additional payment for those services from the consumer or any other person.

(C)     Non-agency  providers:  These  are  the  conditions  for  any  provider  who  seeks  to become, or to remain, an ODA-certified long-term care non-agency provider:

(1)   Service provision:

(a)    The provider shall comply with rule 173-39-02.5 of the Administrative Code, if providing a chore service; rule 173-39-02.7 of the Administrative Code, if providing home medical equipment and supplies; rule 173-39-02.9 of the Administrative Code, if providing a minor home modification, maintenance, or repair service; rule 173-39-02.10 of the Administrative Code, if providing a nutritional consultation service; rule 173-39-02.12 of the Administrative Code, if providing a social work counseling service; rule 173-39-02.13 of the Administrative Code, if providing a non-emergency medical transportation service; rule 173-39-02.17 of the Administrative Code, if providing a community transition service; and rule 173-39-02.18 of the Administrative Code, if providing a non-medical transportation service.

(b)      The provider may provide a service that is not authorized by the consumer's service plan, but ODA (or ODA's designee the PAA) only reimburses the provider for providing a service that is authorized by the consumer's service plan.

(c)   The provider shall notify ODA (or its designee the PAA) no later than one business day after the provider is aware of any significant consumer behavior that may affect a consumer's service needs, including a consumer's repeated refusal of services.

(d)  The provider shall notify ODA (or its designee the PAA) no later than one business day after the provider is aware of any significant change that may affect the consumer's service needs, including:

(i)   The provider does not provide an authorized service at the time (or, for the period of time) authorized by the case manager;

(ii)   The consumer moves to another address; or,

(iii)    The consumer's physical, mental, or emotional status changes, or the provider can document changes in the environmental conditions or other health and safety issues.

(e)    The provider shall notify the consumer and ODA's designee the PAA in writing at least thirty days before the last date of service if the provider is terminating the provision of ODA-certified services to the consumer, unless:

(i)     The consumer has been hospitalized, placed in a long-term care

facility, or has expired;

(ii)     The health or safety of the consumer or provider is at serious, imminent risk; and,

(iii)   The consumer is terminating services with the provider.

(f)   The provider shall provide services in a professional, respectful, and legal manner and shall not engage in any unprofessional, disrespectful, or illegal behavior including the following unprofessional, disrespectful, or illegal behavior:

(i)    Consuming the consumer's food or drink, or using the consumer's personal property without his/her consent.

(ii)    Bringing a child, friend, relative, or anyone else, or a pet, to the consumer's place of residence.

(iii)   Taking the consumer to his/her place of business.

(iv)   Consuming alcohol during the delivery of services to the consumer.

(v)    Consuming medicine, drugs, or other chemical substances not in accordance with the legal, valid, prescribed use, or in any way that impairs the provider in the delivery of services to the consumer.

(vi)   Discussing religion or politics with the consumer and others in the care setting.

(vii)    Discussing personal issues with the consumer or any other person in the care setting.

(viii)    Accepting, obtaining, or attempting to obtain money, or anything of value, including gifts or tips, from the consumer or his/her household members or family members.

(ix)     Engaging the consumer in sexual conduct, or in conduct that a reasonable person would interpret as sexual in nature, even if the conduct is consensual.

(x)     Leaving the consumer's home for a purpose not related to the provision of services, the consumer's emergency contact person, any identified caregiver, or the consumer's case manager. "Emergency contact person" means a person the consumer or caregiver wants the provider to contact in the event of an emergency to inform the person about the nature of the emergency.

(xi)   Engaging in any activity that may distract the provider from service delivery, including:

(a)   Watching television or playing computer or video games.

(b)   Engaging in non-care-related socialization with a person other than the consumer (e.g., a visit from a person who is not providing care to the consumer; making or receiving a personal telephone call; or, sending or receiving a personal text message or email).

(c)   Providing care to a person other than the consumer.

(d)   Smoking without the consumer's consent.

(e)   Sleeping.

(xii)    Engaging in behavior that causes, or may cause, physical, verbal, mental or emotional distress or abuse to the consumer.

(xiii)    Engaging in behavior that a reasonable person would interpret as inappropriate involvement in the consumer's personal relationships.

(xiv)    Being designated to make decisions for the consumer in any capacity involving a declaration for mental health treatment, power of attorney, durable power of attorney, or guardianship.

(xv)     Selling or purchasing from the consumer products or personal items, unless the provider is the consumer's family member who does so only when not providing a service.

(xvi)   Engaging in behavior that constitutes a conflict of interest or takes advantage of or manipulates ODA-certified services resulting in an unintended advantage for personal gain that has detrimental results to the consumer, the consumer's family or caregivers, or another provider.

(2)   Consumer safety:

(a)    The provider shall have a written procedure for documenting consumer incidents. The procedure shall include notifying ODA (or its designee the PAA) of the incident.

(b)   The provider shall report any reasonable cause to believe that a consumer has suffered abuse, neglect, or exploitation to the CDJFS (or its designee), in accordance with section 5101.61 of the Revised Code, and also notify ODA (or its designee the PAA) of the reasonable cause.

(c)      The provider shall maintain a minimum of one million dollars in commercial liability insurance or professional liability insurance.

(d)   The provider shall maintain insurance coverage for consumer loss due to the theft or property damage caused by the provider and provide written instructions that any consumer may use to obtain reimbursement for a loss due to theft or property damage caused by the provider.

(3)    Confidentiality: The provider shall comply with all state and federal laws and regulations governing consumer confidentiality including, but not limited to, 42 C.F.R. 431.300 to 431.307, and 45 C.F.R. parts 160, 162, and 164.

(4)   Provider qualifications:

(a)    The provider shall not provide a service to a consumer if he/she is a spouse, parent, step-parent, legal guardian, or authorized representative of the consumer.

(b)     The provider shall not allow a volunteer to provide any aspect of a certified long-term care service for a consumer without supervision by the provider's supervisory staff.

(c)   The provider shall disclose whether he/she has been convicted of a felony under state or federal law.

(d)   The provider shall comply with the criminal records check requirements under rule 173-9-01 of the Administrative Code.

(e)    The provider shall have a written statement supporting compliance with Title VI of the "Civil Rights Act of 1946 1964," as amended, 42 USC 2000, et seq. regarding the provision of services.

(f)  The provider shall annually provide to ODA (or its designee or the PAA) a written statement that certifies that he/she has paid all applicable federal, state, and local income and employment taxes.

(5)   Monitoring:

(a)     Records  retention:  The  provider  shall

maintain  and  retain  all  records

relating to costs, work performed, and supporting documentation records for payment of work performed, along with copies of all deliverables for until the latter of:audit by the state of Ohio (including, but not limited to, ODJFS, ODA, the auditor of the state of Ohio, the inspector general, and duly authorized law enforcement officials) and agencies of the United States government for three years, or until an audit is concluded and all issues are resolved, whichever occurs later.

(i) Three years after the date the provider receives payment for the service;

(ii) The date on which ODA, ODJFS, the PAA, or a duly-authorized law enforcement official concludes a review of the records and any findings are finally settled; or,

(iii) The date on which the auditor of the state of Ohio, the inspector general, or a duly-authorized law enforcement official concludes an audit of the records and any findings are finally settled.

(b)       Access: The provider shall, upon request, immediately provide representatives of ODA (or its designee the PAA) with access to his/her place of work, a place to work in his/her place of work, and access to policies, procedures, records, and documentation for each unit of service billed.

(6)   Reimbursement:

(a)   The provider shall bill only for a service if the provider complies with the

requirements under this rule and the requirements, including documentation service-verification requirements, under rules 173-39-02.5,  173-39-02.7,  173-39-02.9,  173-39-02.10,  173-39-02.12,

173-39-02.13, 173-39-02.17, or 173-39-02.18 for any service the provider provides that is regulated by one of those rules.

(b)     ODA's obligation to reimburse the provider for the costs of services provided as a certified long-term care provider is subject to the hold and review process described in rule 5101:3-1-27.2 of the Administrative Code.

(c)    The provider shall accept the reimbursement levels negotiated for each service by the provider and ODA's designee the PAA as payment in full, and not seek any additional payment for those services from the consumer or any other person.

(D)   Consumer-directed individual providers: These are the conditions for any person who seeks to become, or to remain, an ODA-certified long-term care consumer-directed individual provider:

(1)   Service provision:

(a)    At the consumer's request, the provider shall participate in an interview with the consumer before initiating any service.

(b)    The provider shall comply with rule 173-39-02.2 of the Administrative Code, if providing an alternative meal service; rule 173-39-02.3 of the Administrative Code, if providing a pest-control service; and rule 173-39-02.4 of the Administrative Code, if providing a home-care attendant service.

(c)    The provider shall enter into and abide by a written agreement with the consumer specifying the agreed-upon arrangements for service provision.

(d)   The provider shall notify ODA (or its designee or the PAA) no later than one business day after the provider is aware of any significant consumer behavior that may affect a consumer's service needs, including a consumer's repeated refusal of services.

(e)   The provider shall notify ODA (or its designee or the PAA) no later than one business day after the provider is aware of any significant change

that may affect the consumer's service needs, including:

(i)   The consumer moves to another address; or,

(ii)   The consumer's physical, mental or emotional status changes, or the provider can document changes in the environmental conditions or other health and safety issues.

(f)   The provider shall notify the consumer and ODA's designee the PAA in writing at least thirty days before the last date of service if the provider is terminating the provision of ODA-certified services to the consumer, unless the health or safety of the consumer or provider is at serious, imminent risk.

(g)   The provider shall provide services in a professional, respectful, and legal manner and shall not engage in any unprofessional, disrespectful, or illegal behavior including the following unprofessional, disrespectful, or illegal behavior:

(i)   Consuming alcohol during the delivery of services to the consumer.

(ii)      Consume medicine, drugs, or other chemical substance not in accordance with the legal, valid, prescribed use, or in any way that impairs the provider in the delivery of services to the consumer.

(iii)   Accepting, obtaining, or attempting to obtain money or anything of value from the consumer or his/her household members or family members. However, if the provider is the consumer's family member, he/she may accept gifts for birthdays and holidays.

(iv)     Engaging the consumer in sexual conduct, or in conduct that a reasonable person would interpret as sexual in nature, even if the conduct is consensual.

(v)    Leaving the home for a purpose not related to the provision of services without the consent or knowledge of the consumer.

(vi)   Engaging in any activity that may distract the provider from service delivery, including:

(a)   Watching television or playing computer or video games.

(b)   Engaging in non-care-related socialization with a person other than the consumer (e.g., a visit from a person who is not providing care to the consumer; making or receiving a personal telephone call; or, sending or receiving a personal text message or email).

(c)   Providing care to a person other than the consumer.

(d)   Smoking without the consumer's consent.

(e)   Sleeping.

(vii)    Engaging in behavior that a reasonable person would interpret as inappropriate involvement in the consumer's personal relationships.

(viii)    Serving as the authorized representative for the ODA-certified consumer-directed long-term care program.

(ix)    Being designated or serve to make decisions for the consumer in any capacity involving a declaration for mental health treatment, durable power of attorney, or guardianship pursuant to court order.

(x)    Selling to or purchasing from the consumer products or personal items, unless the provider is the consumer's family member who does so only when not providing a service.

(2)   Consumer safety:

(a)     The provider shall notify ODA (or its designee or the PAA) of any "incident" involving a consumer, as defined in rule 173-39-01 of the Administrative Code.

(b)   The provider shall report any reasonable cause to believe that a consumer has suffered abuse, neglect, or exploitation to the CDJFS (or its designee), in accordance with section 5101.61 of the Revised Code, and also notify ODA (or its designee the PAA) of the reasonable cause.

(c)    The provider shall have proof of automobile liability insurance, if the provider uses a motor vehicle to transport the consumer.

(3)    Confidentiality: The provider shall comply with all state and federal laws and regulations governing consumer confidentiality including, but not limited to, 42 C.F.R. 431.300 to 431.307, and 45 C.F.R. parts 160, 162, and 164.

(4)   Provider qualifications:

(a)    The provider shall complete an application to become an ODA-certified long-term care consumer-directed individual provider.

(b)   The provider is at least eighteen years of age.

(c)   The provider shall possess a valid social security number.

(d)    The provider shall not provide a service to a consumer if he/she is a spouse, parent, parent, or step-parent.

(e)    The provider shall comply with the criminal records check requirements under rule 173-9-01 of the Administrative Code.

(5)   Monitoring: The provider shall provide representatives of ODA (or its designee) or the PAA with access to his/her place of work and to any records and other documents related to the provision of services. The provider shall cooperate in ODA's (and ODA's designee's the PAA's) quality-assurance activities, including:

(a)   Providing space for on-site reviews of consumer records;

(b)    Making all requested information available to ODA (or its designee the PAA) at the time quality-assurance reviews are conducted; and,

(c)   Being available to answer questions.

(6)   Reimbursement: The provider shall accept the reimbursement levels negotiated for each service by the provider, consumer, and ODA's designee the PAA as payment in full and not seek any additional payment for those services from the consumer or any other person.

(E)    Assisted living providers: These are the conditions for any provider who seeks to become, or to remain, an ODA-certified long-term care assisted living provider:

(1)   Service provision:

(a)     The provider shall not provide any services under the assisted living program to a person who is not enrolled in the program.

(b)   The provider shall comply with any regulation under rules 173-39-02.16 and 173-39-02.17 of the Administrative Code.

(c)      The provider may provide a service that is not authorized by the consumer's service plan, but ODA (or ODA's designee the PAA) only reimburses the provider for providing a service that is authorized by the consumer's service plan.

(d)   The provider shall acknowledge that any statute or rule that regulates the assisted living program supersedes any clause in the facility's resident agreement.

(e)   The provider shall notify ODA (or its designee the PAA) no later than one business day after the provider is aware of any significant consumer behavior that may affect a consumer's service needs, including a consumer's repeated refusal of services.

(f)   The provider shall notify ODA (or its designee the PAA) no later than one business day after the provider is aware of any significant change that may affect the consumer's service needs, including significant changes in the consumer's physical, mental, or emotional status; or significant changes that the provider documents in the environmental condition or in other significant health and safety issues.

(g)    The provider shall transfer or discharge a consumer under the terms of section 3721.16 of the Revised Code.

(h)    If the provider terminates its medicaid provider agreement with ODJFS, pursuant to section 3721.19 of the Revised Code, it shall provide written notification to the consumer and ODA's designee the PAA at least ninety days before terminating services to the consumer.

(i)    The provider shall adopt and implement ethical standards of practice by

requiring facility staff to deliver services in accordance with the residents' rights policies and procedures described in section 3721.12 of the Revised Code, and in accordance with the provider's policies and procedures.

(2)   Consumer safety:

(a)    The provider shall have a written procedure for documenting consumer incidents, in accordance with paragraph (B) of rule 3701-17-62 of the Administrative Code. The procedure shall include notifying ODA (or its designee the PAA) of the incident.

(b)   The provider shall report any reasonable cause to believe that a consumer has suffered abuse, neglect, or exploitation, in accordance with rule 3701-64-02 of the Administrative Code, and also notify ODA (or its designee the PAA) of the reasonable cause.

(c)      The provider shall maintain a minimum of one million dollars in commercial liability insurance.

(d)   The provider shall maintain insurance coverage for consumer loss due to theft or property damage and provide written instructions that any consumer may use to obtain reimbursement for a loss due to employee theft or property damage.

(3)    Confidentiality: The provider shall comply with all state and federal laws and regulations governing consumer confidentiality including, but not limited to, 42 C.F.R. 431.300 to 431.307, and 45 C.F.R. parts 160, 162, and 164.

(4)   Provider qualifications:

(a)    The provider shall be licensed as a residential care facility by the Ohio department of health under rules 3701-17-50 to 3701-17-68 of the Administrative Code.

(b)   The provider shall have a written statement of policies and directives, and bylaws or articles of incorporation.

(c)     The provider shall have a written table of organization that clearly identifies lines of administrative, advisory, contractual, and supervisory authority, unless the business consists of a self-employed person.

(d)    The provider shall not allow a staff person to provide a service to a consumer if the person is a spouse, parent, parent, step-parent, legal guardian, or authorized representative of the consumer.

(e)    The provider shall not allow a volunteer to provide any aspect of the services regulated under rule 173-39-02.16 or 173-39-02.17 of the Administrative Code for consumers without supervision by the provider's supervisory staff.

(f)    The provider shall comply with all applicable federal, state, and local laws.

(g)   The provider shall comply with the criminal records check requirements under rule 173-9-01 of the Administrative Code.

(h)    The provider shall have a written statement supporting compliance with Title VI of the "Civil Rights Act of 1946 1964," as amended, 42 USC 2000, et seq. regarding the provision of services.

(i)    The provider shall have a written statement supporting compliance with the "Equal Employment Opportunity Act of 1972," as amended, federal wage-and-hour laws, and workers' compensation laws regarding the recruitment and employment of persons.

(5)   Monitoring:

(a)     Records  retention:  The  provider  shall

maintain  and  retain  all  records

relating to costs, work performed, and supporting documentation records for payment of work performed, along with copies of all deliverables for until the latter of:audit by the state of Ohio (including, but not limited to, ODJFS, ODA, the auditor of the state of Ohio, the inspector general, and duly authorized law enforcement officials) and agencies of the United States government for three years, or until an audit is concluded and all issues are resolved, whichever occurs later.

(i) Three years after the date the provider receives payment for the service;

(ii) The date on which ODA, ODJFS, the PAA, or a duly-authorized law enforcement official concludes a review of the records and any findings are finally settled; or,

(iii) The date on which the auditor of the state of Ohio, the inspector general, or a duly-authorized law enforcement official concludes an audit of the records and any findings are finally settled.

(b)       Access: The provider shall, upon request, immediately provide representatives of ODA (or its designee the PAA) with access to its facility, a place to work in its facility, and access to policies, procedures, records, and documentation for each unit of service billed.

(6)   Reimbursement:

(a)   The provider shall bill only for a service if the provider complies with the requirements under this rule and the requirements, including documentation service-verification requirements, under rule 173-39-02.16 or 173-39-02.17 of the Administrative Code.

(b)     ODA's obligation to reimburse the provider for the costs of services provided as a certified long-term care provider is subject to the hold and review process described in rule 5101:3-1-27.2 of the Administrative Code.

(c)    The provider shall accept the reimbursement levels negotiated for each service by the provider and ODA's designee the PAA as payment in full, and not seek any additional payment for those services from the consumer or any other person.

(d)   The assisted living program shall not pay for any service provided to an applicant before the PAA enrolls the applicant into the program and before case manager authorizes the service in the consumer's service plan.

(e)    If a consumer is absent from the facility, the provider shall not accept a payment for the service under rule 173-39-02.16 of the Administrative Code or charge the consumer an additional fee for the service or charge the consumer an additional fee to hold the unit during the consumer's absence.

(F)   If a provider fails to meet or maintain any of the required conditions of participation under this rule, ODA (or ODA's designee the PAA) may sanction the provider under the terms of rule 173-39-06 of the Administrative Code, which include the denial or revocation of the provider's certification.

Effective:   R.C. 119.032 review dates:	08/30/2010   06/15/2010 and 08/30/2015
CERTIFIED ELECTRONICALLY
Certification
08/20/2010
Date
Promulgated Under:	119.03
Statutory Authority:	173.02, 173.391, 5111.89
Rule Amplifies:	173.39, 173.391, 173.402, 173.403, 173.431, 5111.89
Prior Effective Dates:	03/31/2006, 04/26/2009, 10/19/2009