Ohio Home Care

5101:3-51-03 HOME Choice ("Helping Ohioans Move, Expanding Choice") Demonstration Program: Conditions of Participation for Providers

CSTL 08-02

Effective Date: July 1, 2008

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or on the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.This rule sets forth the conditions of participation for providers furnishing demonstration, supplemental and qualified services to HOME choice demonstration program participants.

(A) Demonstration and supplemental services.

(1) All providers of demonstration and supplemental services to participants enrolled on the HOME choice demonstration program shall:

(a) Meet all requirements in the applicable provider service specifications set forth in rule 5101:3-51-04 of the Administrative Code, and provider enrollment criteria set forth in rule 5101:3-51-05 of the Administrative Code.

(b) As applicable, comply with the criminal records check requirements set forth in:

(i) Rules 5101:3-45-07 and 5101:3-45-08 of the Administrative Code if the provider is approved by ODJFS;

(ii) Rule 173-41-01 of the Administrative Code if the provider is certified by the Ohio department of aging (ODA);

(iii) Rule 5123:2-1-05 or 5123:2-1-05.1 of the Administrative Code, as applicable, if the provider is certified by the Ohio department of mental retardation and developmental disabilities (ODMR/DD); or

(iv) Rules 5122-30-03 and 5122-30-04 of the Administrative Code, or rule 5122-26-06 of the Administrative Code, as applicable, if the provider is certified by the Ohio department of mental health (ODMH).

(d) Assure participants receive HOME choice demonstration program services in accordance with their all service plan, service plan, individual service plan (ISP) or non-waiver HOME choice demonstration service plan, as appropriate.

(e) Upon request and within the timeframe prescribed in the request, provide all information to the state agency administering the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or ODJFS if the HOME choice demonstration program participant is not enrolled on an HCBS waiver, and to CMS and the entity under contract with ODJFS to provide HOME choice financial management services (FMS).

(f) Comply with all federal and state privacy laws, including the health insurance portability and accountability act (HIPAA) regulations set forth in 45 C.F.R. parts 160, 162 and 164 (as in effect on the effective date of this rule), and the medicaid confidentiality regulations as set forth in 42 C.F.R. 421.300 to 306 (as in effect on the effective date of this rule), and sections 5101.26 to 5101.28 of the Revised Code.

(g) Maintain and retain all required documentation. For each unit of service furnished, the provider shall clearly document what service was provided and obtain the signature of the participant on the dated document.

(h) Retain all records of service delivery and billing for a period of six years after the date of receipt of the payment based upon those records or until any initiated audit is completed, whichever is longer.

(i) Cooperate with ODJFS and the FMS provider under contract with ODJFS during any quality assurance activities to monitor the provider's performance, including providing space for and being able to answer questions during onsite reviews, and making all requested information available promptly.

(j) Notify the case manager (CM), the service and support administrator (SSA) or ODJFS HOME choice demonstration program care coordinator, as appropriate, within twenty-four hours and provide written documentation within five calendar days when the provider is aware of significant changes that may affect the service needs of the participant. Significant changes that may affect the service needs of the participant include, but are not limited to:

(i) The participant consistently declines services.

(ii) The participant moves to another residential setting.

(iii) Changes in the physical, mental and/or emotional status of the participant, changes in environmental conditions, and/or other health and welfare issues.

(iv) Abuse or neglect of the participant is suspected.

(k) Submit written notification to the participant and the FMS provider under contract with ODJFS, and the CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, at least fourteen calendar days prior to the anticipated last date of the service if the provider is terminating the provision of HOME choice demonstration program services to the participant. Exceptions to this requirement include:

(i) Fourteen-day advanced notification is not required when the participant has been hospitalized, placed in a long term care facility, or has expired.

(ii) The fourteen-day advanced notification may be waived for the provider by the CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, on a case-by-case basis.

(iii) Advanced notification of service termination is not required if the participant is terminating the services of the provider.

(2) Providers furnishing HOME choice demonstration program services to participants enrolled on an ODA-administered waiver, providers shall comply with the consumer incident reporting requirements set forth in rule 173-39-02 of the Administrative Code.

(3) Providers furnishing HOME choice demonstration program services to participants enrolled on an ODMR/DD-administered waiver, or who are not enrolled on an HCBS waiver but are eligible for services through a county board of mental retardation and developmental disabilities (CBMR/DD), providers shall comply with the major unusual incident requirements set forth in rule 5123:2-17-02 of the Administrative Code.

(4) Providers furnishing HOME choice demonstration program services to participants enrolled on an ODJFS-administered waiver, providers shall comply with the consumer incident reporting requirements set forth in rule 5101:3-12-29 of the Administrative Code.

(5) Providers furnishing HOME choice demonstration program services to participants who are not enrolled on an HCBS waiver, or who are not eligible for services through a CBMR/DD, providers shall comply with the consumer incident reporting requirements set forth in rule 5101:3-12-29 of the Administrative Code

(6) Agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements.

(7) Non-agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. On an annual basis, non-agency providers must also submit an ODJFS-approved affidavit stating that they paid the applicable federal, state and local income and employment taxes.

(8) All providers shall deliver services professionally, respectfully, and legally, and during the provision of authorized services, shall not engage in unprofessional, disrespectful or illegal behavior that includes, but is not limited to, the following:

(a) Consuming the participant's food and/or drink, or using the participant's personal property without the participant's offer and consent.

(b) Bringing children, pets, friends, relatives or anyone else to the participant's place of residence.

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

(e) Discussing religion or politics with the participant and others present in the care setting.

(f) Discussing providers' personal issues with the participant and others in the care setting.

(g) Accepting, obtaining or attempting to obtain money or anything of value, including gifts or tips from the participant, household members and family members of the participant.

(h) Engaging with the participant in sexual conduct, or in conduct that may reasonably be interpreted as sexual in nature, regardless of whether or not the contact is consensual.

(i) Leaving the home for a purpose not related to the provision of services without notifying the agency supervisor, the participant's emergency contact person, identified caregiver and/or CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate.

(j) Using the participant's motor vehicle, unless used solely for the benefit of the participant.

(k) Engaging in activities that may distract from service delivery including, but not limited to:

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

(ii) Making or receiving personal calls.

(iii) Engaging in non-care-related socialization with individuals other than the participant.

(iv) Providing care to individuals other than the participant.

(v) Smoking without the consent of the participant.

(vi) Sleeping.

(9) HOME choice demonstration program providers shall not:

(a) Engage in behavior that causes or may cause physical, verbal, mental or emotional distress or abuse to the participant.

(b) Engage in behavior that may reasonably be interpreted as inappropriate involvement in the participant's personal relationships.

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

(d) Sell to or purchase from the participant products or personal items. The only exception to this would be family members when not delivering services.

(e) Engage in behavior that constitutes a conflict of interest or takes advantage of or manipulates the HOME choice demonstration program rules set forth in Chapter 5101:3-51 of the Administrative Code, resulting in an unintended advantage for personal gain; or that has detrimental results for the participant, the family, caregiver and/or another provider.

(B) Qualified services.

(1) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODMR/DD shall meet the assurances set forth in rules 5123:2-9-08 and 5123:2-9-09 of the Administrative Code.

(2) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODA shall meet the conditions of participation established for ODA-administered waivers set forth in rule 173-39-02 of the Administrative Code.

(3) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODJFS shall meet the conditions of participation established for ODJFS-administered waivers as set forth in rule 5101:3-45-10 of the Administrative Code.

(4) Providers furnishing qualified services to HOME choice demonstration program participants who are not enrolled on an HCBS waiver shall meet the same conditions of participation set forth for

ODJFS-administered waiver service providers as described in rule 5101:3-45-10 of the Administrative Code.

(C) Failure to meet the requirements set forth in this rule may result in termination of the HOME choice demonstration program provider's provider agreement in accordance with rule 5101:3-1-17.6 of the Administrative Code. The provider shall be entitled to a hearing under Chapter 119. of the Revised Code in accordance with Chapter 5101:6-50 of the Administrative Code.

Effective:

R.C. 119.032 review dates:

Certification

Date

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am. Sub. H.B. 119, 127th G.A.