Ohio Admin. Code 173-39-02 - ODA provider certification: requirements for providers to become, and to remain, certified
Introduction: This rule presents requirements for every type of provider to become, and to remain, certified. For agency and assisted living providers, the requirements in this rule include requirements for each provider's employees.
(A) Requirements
for every type of provider to become certified:
(1) Qualifications: The provider shall meet
all of the following:
(a) Any qualification
(e.g., licensure, training requirements, staffing levels) required by this
chapter.
(b) Any qualification
(e.g., licensure, certification, registration) required by applicable federal,
state, and local laws, including the requirement under 45 C.F.R. Part 162 to
have a national provider identifier (NPI), if applicable.
(2) Criminal records checks and database
reviews: Sections 173.38 and
173.381 of the Revised Code and
Chapter 173-9 of the Administrative Code establish the requirements for
criminal records checks and database reviews. Rule
173-9-02 of the Administrative
Code lists exceptions to the applicability of those requirements. Rule
5160-1-17.8 of the
Administrative Code establishes additional provider screening requirements for
participation in a medicaid-funded program.
(3) Business site:
(a) The provider shall maintain a business
site(s) from which to conduct business, unless the provider is a
participant-directed provider.
(b)
The provider's business site(s) for providing services are subject to the HCBS
setting requirements in rule
5160-44-01 of the Administrative
Code. Additionally, any such business site used for providing ADS or assisted
living services may be subject to federal heightened scrutiny under
42 C.F.R.
441.301(c)(5)(v) and rules
173-39-03 and
173-39-03.1 of the Administrative
Code.
(c) Each business site in
which the provider retains records (e.g., headquarters, regional offices) shall
have a designated, locked storage space for retaining records that is
accessible to ODA and its designee, HHS, the state auditor's office, and
ODM.
(4) Contact
information: The provider shall have a valid email address and telephone
number.
(5) Insurance: The provider
shall have the following, unless the provider is a participant-directed
provider:
(a) A minimum of one million dollars
in commercial liability insurance, which includes coverage for individuals'
losses due to theft or property damage. In lieu of commercial liability
insurance, a non-agency provider may have a minimum of one million dollars in
professional liability insurance, which includes coverage for individuals'
losses due to theft or property damage.
(b) Written instructions any individual may
use to obtain payment for loss due to theft or property damage caused by the
provider, or if applicable, the provider's employee.
(6) Provider agreements: The provider shall
enter into, comply with, and maintain an active status with the following:
(a) A medicaid provider agreement under rules
5160-1-17.2 and
5160-1-17.4 of the
Administrative Code.
(b) A provider
agreement, with ODA's designee for the region in
which the provider seeks certification to provide services pursuant to rule
173-39-03 of the Administrative
Code.
(7) Incident reporting: The provider shall
have a written or electronic policy on documenting incidents which complies
with paragraph (B)(3)(b) of this rule.
(8) Electronic visit verification (EVV): Rule
5160-1-40 of the Administrative
Code (until July 1, 2024) or Chapter 5160-32 of the
Administrative Code (on or after July 1, 2024) establishes the
requirements for certain providers to have an ODM-approved EVV system in
place.
(B) Requirements
for every type of provider to remain certified:
(1) Continuation: The provider shall remain
in compliance with all requirements under paragraph (A) of this rule.
(2) Service-related: For any service ODA
certified the provider to furnish, the provider shall report all mandatory
reporting items to verify the service to ODA or its designee and comply with
any rule in this chapter regulating the provision of the service.
(3) Reporting:
(a) APS: Section
5101.63 of the Revised Code, as
applicable, establishes a requirement for the provider to report any reasonable
cause to believe an individual suffered abuse, neglect, or exploitation to the
local adult protective services program. The provider shall also notify ODA or
its designee within one business day after becoming aware of the reasonable
cause.
(b) Significant changes: The
provider shall notify ODA or its designee no later than one business day after
the provider is aware of any significant change that may affect the
individual's service needs or safety, including one or more of the following:
(i) The provider does not provide an
authorized service at the time, or for the period of time, authorized by ODA's
designee.
(ii) The individual moves
to another address.
(iii) The
individual's repeated refusal of services.
(iv) Any incident that is subject to the
incident-reporting requirements in rule
5160-44-05 of the Administrative
Code.
(v) Any other significant
change in the individual's physical, mental, or emotional status or the
individual's environment that affects the individual's service needs or
safety.
(c) Contact
information: The provider shall notify ODA or its designee of any change in the
provider's telephone number, mailing address, or email address within seven
days after the change.
(d) Last day
of service: Unless the provider is an assisted
living provider, the
The provider shall
notify the individual and ODA's designee in writing at least thirty days before
the last day the provider provides services to the individual, unless one or
more of the following occurs:
(i) The
individual has been hospitalized, placed in a long-term care facility, or is
deceased.
(ii) The health or safety
of the individual or provider is at serious, imminent risk.
(iii) The individual chooses to no longer
receive services from the provider.
(iv)
The provider is
an assisted living provider, in which case paragraph (D)(4)(d) of this rule
applies.
(4) Confidentiality: The provider is subject
to all state and federal laws and regulations governing individual
confidentiality including sections
5160.45 to
5160.481 of the Revised Code,
42 C.F.R.
431.300 to
431.307, and 45 C.F.R. parts 160,
162, and 164.
(5) Legally-responsible family
members: The provider shall not provide a service to an individual if the
provider is the individual's spouse, parent, step-parent, legal guardian, power
of attorney, or authorized representative. During a state of emergency declared
by the governor or a federal public health emergency, a provider may provide a
service to an individual if the provider is the individual's spouse, parent, or
step-parent. The period in which a spouse, parent, or step-parent is qualified
to provide a service to an individual during a state of emergency declared by
the governor or a federal public health emergency ends when the provider's
medicaid provider agreement is terminated.
(5)
Direct-care
worker relationships: Rule
5160-44-32 of the Administrative
Code establishes standards for which relationships are eligible for payment for
providing services.
(6)
Volunteers: The provider shall supervise the provider's volunteers.
(7) Person-centered planning: The provider is
subject to the person-centered planning requirements in rule
5160-44-02 of the Administrative
Code.
(8) Ethical, professional,
respectful, and legal service standards: The provider shall not engage in any
unethical, unprofessional, disrespectful, or illegal behavior including the
following:
(a) Consuming alcohol while
providing services to the individual.
(b) Consuming medicine, drugs, or other
chemical substances in a way that is illegal, unprescribed, or impairs the
provider from providing services to the individual.
(c) Accepting, obtaining, or attempting to
obtain money, or anything of value, including gifts or tips, from the
individual or his or her household or family members.
(d) Engaging the individual in sexual
conduct, or in conduct a reasonable person would interpret as sexual in nature,
even if the conduct is consensual.
(e) Leaving the individual's home when
scheduled to provide a service for a purpose not related to providing the
service without notifying the agency supervisor, the individual's emergency
contact person, any identified caregiver, or ODA's designee.
(f) Failing to cooperate with or treating ODA
or its designee respectfully.
(g)
Engaging in any activity while providing a service that may distract the
provider from providing the service as authorized, including the following:
(i) Watching television, movies, videos, or
playing games on computers, personal phones, or other electronic devices
whether owned by the individual, provider, or the provider's staff.
(ii) Non-care-related socialization with a
person other than the individual (e.g., a visit from a person who is not
providing care to the individual; making or receiving a personal telephone
call; or, sending or receiving a personal text message, email, or
video).
(iii) Providing care to a
person other than the individual.
(iv) Smoking tobacco or any other material in
any type of smoking equipment, including cigarettes, electronic cigarettes,
vaporizers, hookahs, cigars, or pipes.
(v) Sleeping.
(vi) Bringing a child, friend, relative, or
anyone else, or a pet, to the individual's place of residence.
(vii) Discussing religion or politics with
the individual and others.
(viii)
Discussing personal issues with the individual or any other person.
(h) Engaging in behavior that
causes, or may cause, physical, verbal, mental, or emotional distress or abuse
to the individual including publishing photos of the individual on social media
without the individual's written or electronic consent.
(i) Engaging in behavior a reasonable person
would interpret as inappropriate involvement in the individual's personal
relationships.
(j) Making
decisions, or being designated to make decisions, for the individual in any
capacity involving a declaration for mental health treatment, power of
attorney, durable power of attorney, guardianship, or authorized
representative.
(k) Selling to, or
purchasing from, the individual products or personal items, unless the provider
is the individual's family member who does so only when not providing
services.
(l) Consuming the
individual's food or drink, or using the individual's personal property without
his or her consent.
(m) Taking the
individual to the provider's business site, unless the business site is an ADS
center, RCF, or (if the provider is a participant-directed provider) the
individual's home.
(n) Engaging in
behavior constituting a conflict of interest, or taking advantage of, or
manipulating services resulting in an unintended advantage for personal gain
that has detrimental results to the individual, the individual's family or
caregivers, or another provider.
(9) Training: The provider shall participate
in ODA's or its designee's mandatory free provider training sessions.
(10) Records and monitoring:
(a) Records retention:
(i) Service records: The provider shall
retain all records necessary (including activity plans, assessments (if
required), permits (if required), and all mandatory reporting items to verify
an episode of service), and in such form, so as to fully disclose the extent of
the services the provider provided, and significant business transactions,
until all of the following periods of time have passed:
(a) Six years after the date the provider
receives payment for the service.
(b) The date on which ODA, its designee, ODM,
or a duly-authorized law enforcement official concludes a review of the records
and any findings are resolved.
(c)
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 resolved.
(ii) Qualification records: Each provider
shall retain all records regarding the provider's or an employee's
qualifications to provide a service for the duration of the provider's
certification or the duration of the employee's employment and for six years
after the provider is no longer certified or no longer retains the employee.
Qualification records include records on background checks, initial
qualifications, orientation, and training.
(iii) Electronic records: The provider may
use an electronic system to collect or retain records.
(b) Compliance reviews: The provider shall
participate in good faith in any compliance reviews under rule
173-39-04 of the Administrative
Code and assist ODA and its designee with scheduling those reviews.
(c) Access: The provider shall, upon request,
immediately provide representatives of ODA, its designee, HHS, the state
auditor's office, and ODM with access to its business site(s) during the
provider's normal business hours, a place to work in its business site(s), and
access to policies, procedures, and records for each unit of service
billed.
(11) Payment:
(a) The provider may bill for a service only
if the provider complies with the requirements under all applicable laws,
rules, and regulations, including service-verification requirements.
(b) ODA's obligation to pay the provider for
the costs of services provided as a certified provider is subject to the hold
and review process described in rule
5160-1-27.2 of the
Administrative Code.
(c) The
provider shall accept the payment rates established in its provider agreement
with ODA's designee as payment in full for the services it provides, and not
seek any additional payment for services from the individual or any other
person.
(d) The provider may
provide a service not authorized by the individual's person-centered services
plan, but ODA (or its designee) pays a provider only for providing services
authorized by the individual's person-centered services plan.
(12) Other laws: The provider is
subject to all applicable federal, state, and local laws, rules, and
regulations and is responsible for ensuring all subcontractors comply with all
applicable federal, state, and local laws, rules, and regulations.
(13) Rules updates: The provider shall
subscribe to receive email updates on ODA's rules on
through
https://aging.ohio.gov.
(C) Requirements for specific
types of providers to become certified:
(1)
Agency providers:
(a) Disclosures: The
provider shall disclose the following:
(i) The
name of any person with an ownership interest in the provider.
(ii) The name of any person with an ownership
interest in the provider who was convicted of a felony under a state or federal
law.
(iii) A table of organization
clearly identifying lines of administrative, advisory, contractual, and
supervisory responsibilities.
(iv)
The active registration as a business entity with the Ohio secretary of
state.
(b)
Statements:
Attestations: The provider shall provide ODA or its
designee with statements
written or electronic attestations on the
following:
(iii)(ii) The provider's
compliance with the Equal Employment Opportunity Act of 1972, federal
wage-and-hour laws, and workers' compensation laws regarding the recruitment
and employment of persons.
(iv)(iii) The provider's
payment of all applicable federal, state, and local income and employment taxes
for the most recent year.
(i) The purpose of the provider's
business.
(c) Policies: The provider shall have written
policies, bylaws, or articles of incorporation (or an electronic record of
policies, bylaws, or articles of incorporation) that include requirements for
its employees to provide services in a manner compliant with paragraph (B)(8)
of this rule.
(2)
Non-agency providers: The provider shall provide a statement
written or
electronic attestation to ODA or its designee certifying that he or
she
the provider paid all applicable
federal, state, and local income and employment taxes.
(3) Participant-directed providers: A person
may qualify to become a participant-directed provider only if the person meets
the requirements in rule
173-39-02.4 of the Administrative
Code.
(4) Assisted living
providers:
(a) Preemption: The provider shall
acknowledge that any statute governing, or rule regulating, the assisted living
program supersedes any clause in the RCF's resident agreement.
(b) License: The provider shall have an RCF
license issued under Chapter 3701-16 of the Administrative Code and comply with
section 3721.121 of the Revised
Code.
(c) Identifying key persons:
The provider shall disclose the following:
(i)
The name of any person with an ownership interest in the provider.
(ii) The name of any person with an ownership
interest in the provider who was convicted of a felony under a state or federal
law.
(iii) A table of organization
clearly identifying lines of administrative, advisory, contractual, and
supervisory responsibilities.
(d)
Statements:
Attestations: The provider shall provide ODA or its
designee with statements
written or electronic attestations on the
following:
(i) The provider's compliance with
45 C.F.R.
80.4 regarding the provision of
services.
(ii) The provider's
compliance with the Equal Employment Opportunity Act of 1972, federal
wage-and-hour laws, and workers' compensation laws regarding the recruitment
and employment of persons.
(e) Policies: The provider shall have written
policies, bylaws, or articles of incorporation (or an electronic record of
policies, bylaws, or articles of incorporation) that include the following:
(i) A requirement for the residents' rights
policy that the provider adopts under section
3721.12 of the Revised Code to
apply the prohibition against unethical, unprofessional, disrespectful, or
illegal behavior under paragraph (B)(8) of this rule to its
employees.
(ii) A requirement for
the policy that the provider adopts under rule
3701-64-02 of the Administrative
Code on reporting abuse, neglect, or exploitation to ODH to apply the
requirement under paragraph (B)(3)(a) of this rule to report abuse, neglect, or
exploitation to ODA or its designee to its employees.
(iii) A requirement for the policy that the
provider adopts under paragraph (B) of rule
3701-16-12 of the Administrative
Code to apply the requirement under paragraph (B)(3)(b) of this rule to report
incidents to ODA or its designee to its employees.
(D) Requirements for
specific types of providers to remain an ODA-certified provider:
(1) Agency providers: The provider shall
remain in compliance with all requirements under paragraphs (B) and (C)(1) of
this rule.
(2) Non-agency
providers: The provider shall remain in compliance with all requirements under
paragraphs (B) and (C)(2) of this rule.
(3) Participant-directed providers:
(a) Continuation: The provider shall remain
in compliance with all requirements under paragraphs (B) and (C)(3) of this
rule.
(b) Records retention: In
addition to the records-retention requirements under paragraph (B)(10)(a) of
this rule, the provider shall store the individual's records in the home of the
individual in a physical location or an electronic device that is accessible to
the provider, individual, and ODA or its designee.
(4) Assisted living providers:
(a) Continuation: The provider shall remain
in compliance with all requirements under paragraphs (B) and (C)(4) of this
rule.
(b) Payment:
(i) The assisted living program does not pay
for any service the provider provides to an individual before ODA's designee
enrolls the individual into the program and before ODA's designee authorizes
the service in the individual's person-centered services plan.
(ii) If an individual is absent from the RCF,
the provider shall not accept a payment for the service under rules
173-39-02.16 and
5160-33-07 of the Administrative
Code or charge the individual an additional fee for the service or to hold the
unit during the individual's absence.
(c) Transfers/discharges: Section
3721.16 of the Revised Code
establishes the terms for transferring or discharging an individual.
(d) Last day of service: If the provider
terminates its medicaid-provider
medicaid provider agreement, pursuant to section
3721.19 of the Revised Code,
or if the provider plans to stop providing services to
an individual, then it shall provide written notification to the
individual and to ODA's designee at least ninety days before terminating the
medicaid provider agreement or provision of
services to the individual.
Notes
Promulgated Under: 119.03
Statutory Authority: 121.07, 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, 04/26/2009, 10/19/2009, 08/30/2010, 03/17/2011, 01/01/2013, 07/01/2014, 07/01/2016,07/01/2019, 06/11/2020 (Emer.), 11/08/2020,04/04/2022, 07/01/2023
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
Introduction: This rule presents requirements for every type of provider to become, and to remain, certified. For agency and assisted living providers, the requirements in this rule include requirements for each provider's employees.
(A) Requirements for every type of provider to become certified:
(1) Qualifications: The provider shall meet all of the following:
(a) Any qualification (e.g., licensure, training requirements, staffing levels) required by this chapter.
(b) Any qualification (e.g., licensure, certification, registration) required by applicable federal, state, and local laws, including the requirement under 45 C.F.R. Part 162 to have a national provider identifier (NPI), if applicable.
(2) Criminal records checks and database reviews: Sections 173.38 and 173.381 of the Revised Code and Chapter 173-9 of the Administrative Code establish the requirements for criminal records checks and database reviews. Rule 173-9-02 of the Administrative Code lists exceptions to the applicability of those requirements. Rule 5160-1-17.8 of the Administrative Code establishes additional provider screening requirements for participation in a medicaid-funded program.
(3) Business site:
(a) The provider shall maintain a business site(s) from which to conduct business, unless the provider is a participant-directed provider.
(b) The provider's business site(s) for providing services are subject to the HCBS setting requirements in rule 5160-44-01 of the Administrative Code. Additionally, any such business site used for providing ADS or assisted living services may be subject to federal heightened scrutiny under 42 C.F.R. 441.301(c)(5)(v) and rules 173-39-03 and 173-39-03.1 of the Administrative Code.
(c) Each business site in which the provider retains records (e.g., headquarters, regional offices) shall have a designated, locked storage space for retaining records that is accessible to ODA and its designee, HHS, the state auditor's office, and ODM.
(4) Contact information: The provider shall have a valid email address and telephone number.
(5) Insurance: The provider shall have the following, unless the provider is a participant-directed provider:
(a) A minimum of one million dollars in commercial liability insurance, which includes coverage for individuals' losses due to theft or property damage. In lieu of commercial liability insurance, a non-agency provider may have a minimum of one million dollars in professional liability insurance, which includes coverage for individuals' losses due to theft or property damage.
(b) Written instructions any individual may use to obtain payment for loss due to theft or property damage caused by the provider, or if applicable, the provider's employee.
(6) Provider agreements: The provider shall enter into, comply with, and maintain an active status with the following:
(a) A medicaid provider agreement under rules 5160-1-17.2 and 5160-1-17.4 of the Administrative Code.
(b) A provider agreement, with ODA's designee for the region in which the provider seeks certification to provide services pursuant to rule 173-39-03 of the Administrative Code.
(7) Incident reporting: The provider shall have a written or electronic policy on documenting incidents which complies with paragraph (B)(3)(b) of this rule.
(8) Electronic visit verification (EVV): Rule 5160-1-40 of the Administrative Code (until July 1, 2024) or Chapter 5160-32 of the Administrative Code (on or after July 1, 2024) establishes the requirements for certain providers to have an ODM-approved EVV system in place.
(B) Requirements for every type of provider to remain certified:
(1) Continuation: The provider shall remain in compliance with all requirements under paragraph (A) of this rule.
(2) Service-related: For any service ODA certified the provider to furnish, the provider shall report all mandatory reporting items to verify the service to ODA or its designee and comply with any rule in this chapter regulating the provision of the service.
(3) Reporting:
(a) APS: Section 5101.63 of the Revised Code, as applicable, establishes a requirement for the provider to report any reasonable cause to believe an individual suffered abuse, neglect, or exploitation to the local adult protective services program. The provider shall also notify ODA or its designee within one business day after becoming aware of the reasonable cause.
(b) Significant changes: The provider shall notify ODA or its designee no later than one business day after the provider is aware of any significant change that may affect the individual's service needs or safety, including one or more of the following:
(i) The provider does not provide an authorized service at the time, or for the period of time, authorized by ODA's designee.
(ii) The individual moves to another address.
(iii) The individual's repeated refusal of services.
(iv) Any incident that is subject to the incident-reporting requirements in rule 5160-44-05 of the Administrative Code.
(v) Any other significant change in the individual's physical, mental, or emotional status or the individual's environment that affects the individual's service needs or safety.
(c) Contact information: The provider shall notify ODA or its designee of any change in the provider's telephone number, mailing address, or email address within seven days after the change.
(d) Last day of service: Unless the provider is an assisted living provider, the The provider shall notify the individual and ODA's designee in writing at least thirty days before the last day the provider provides services to the individual, unless one or more of the following occurs:
(i) The individual has been hospitalized, placed in a long-term care facility, or is deceased.
(ii) The health or safety of the individual or provider is at serious, imminent risk.
(iii) The individual chooses to no longer receive services from the provider.
(iv) The provider is an assisted living provider, in which case paragraph (D)(4)(d) of this rule applies.
(4) Confidentiality: The provider is subject to all state and federal laws and regulations governing individual confidentiality including sections 5160.45 to 5160.481 of the Revised Code, 42 C.F.R. 431.300 to 431.307, and 45 C.F.R. parts 160, 162, and 164.
(5) Legally-responsible family members: The provider shall not provide a service to an individual if the provider is the individual's spouse, parent, step-parent, legal guardian, power of attorney, or authorized representative. During a state of emergency declared by the governor or a federal public health emergency, a provider may provide a service to an individual if the provider is the individual's spouse, parent, or step-parent. The period in which a spouse, parent, or step-parent is qualified to provide a service to an individual during a state of emergency declared by the governor or a federal public health emergency ends when the provider's medicaid provider agreement is terminated.
(5) Direct-care worker relationships: Rule 5160-44-32 of the Administrative Code establishes standards for which relationships are eligible for payment for providing services.
(6) Volunteers: The provider shall supervise the provider's volunteers.
(7) Person-centered planning: The provider is subject to the person-centered planning requirements in rule 5160-44-02 of the Administrative Code.
(8) Ethical, professional, respectful, and legal service standards: The provider shall not engage in any unethical, unprofessional, disrespectful, or illegal behavior including the following:
(a) Consuming alcohol while providing services to the individual.
(b) Consuming medicine, drugs, or other chemical substances in a way that is illegal, unprescribed, or impairs the provider from providing services to the individual.
(c) Accepting, obtaining, or attempting to obtain money, or anything of value, including gifts or tips, from the individual or his or her household or family members.
(d) Engaging the individual in sexual conduct, or in conduct a reasonable person would interpret as sexual in nature, even if the conduct is consensual.
(e) Leaving the individual's home when scheduled to provide a service for a purpose not related to providing the service without notifying the agency supervisor, the individual's emergency contact person, any identified caregiver, or ODA's designee.
(f) Failing to cooperate with or treating ODA or its designee respectfully.
(g) Engaging in any activity while providing a service that may distract the provider from providing the service as authorized, including the following:
(i) Watching television, movies, videos, or playing games on computers, personal phones, or other electronic devices whether owned by the individual, provider, or the provider's staff.
(ii) Non-care-related socialization with a person other than the individual (e.g., a visit from a person who is not providing care to the individual; making or receiving a personal telephone call; or, sending or receiving a personal text message, email, or video).
(iii) Providing care to a person other than the individual.
(iv) Smoking tobacco or any other material in any type of smoking equipment, including cigarettes, electronic cigarettes, vaporizers, hookahs, cigars, or pipes.
(v) Sleeping.
(vi) Bringing a child, friend, relative, or anyone else, or a pet, to the individual's place of residence.
(vii) Discussing religion or politics with the individual and others.
(viii) Discussing personal issues with the individual or any other person.
(h) Engaging in behavior that causes, or may cause, physical, verbal, mental, or emotional distress or abuse to the individual including publishing photos of the individual on social media without the individual's written or electronic consent.
(i) Engaging in behavior a reasonable person would interpret as inappropriate involvement in the individual's personal relationships.
(j) Making decisions, or being designated to make decisions, for the individual in any capacity involving a declaration for mental health treatment, power of attorney, durable power of attorney, guardianship, or authorized representative.
(k) Selling to, or purchasing from, the individual products or personal items, unless the provider is the individual's family member who does so only when not providing services.
(l) Consuming the individual's food or drink, or using the individual's personal property without his or her consent.
(m) Taking the individual to the provider's business site, unless the business site is an ADS center, RCF, or (if the provider is a participant-directed provider) the individual's home.
(n) Engaging in behavior constituting a conflict of interest, or taking advantage of, or manipulating services resulting in an unintended advantage for personal gain that has detrimental results to the individual, the individual's family or caregivers, or another provider.
(9) Training: The provider shall participate in ODA's or its designee's mandatory free provider training sessions.
(10) Records and monitoring:
(a) Records retention:
(i) Service records: The provider shall retain all records necessary (including activity plans, assessments (if required), permits (if required), and all mandatory reporting items to verify an episode of service), and in such form, so as to fully disclose the extent of the services the provider provided, and significant business transactions, until all of the following periods of time have passed:
(a) Six years after the date the provider receives payment for the service.
(b) The date on which ODA, its designee, ODM, or a duly-authorized law enforcement official concludes a review of the records and any findings are resolved.
(c) 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 resolved.
(ii) Qualification records: Each provider shall retain all records regarding the provider's or an employee's qualifications to provide a service for the duration of the provider's certification or the duration of the employee's employment and for six years after the provider is no longer certified or no longer retains the employee. Qualification records include records on background checks, initial qualifications, orientation, and training.
(iii) Electronic records: The provider may use an electronic system to collect or retain records.
(b) Compliance reviews: The provider shall participate in good faith in any compliance reviews under rule 173-39-04 of the Administrative Code and assist ODA and its designee with scheduling those reviews.
(c) Access: The provider shall, upon request, immediately provide representatives of ODA, its designee, HHS, the state auditor's office, and ODM with access to its business site(s) during the provider's normal business hours, a place to work in its business site(s), and access to policies, procedures, and records for each unit of service billed.
(11) Payment:
(a) The provider may bill for a service only if the provider complies with the requirements under all applicable laws, rules, and regulations, including service-verification requirements.
(b) ODA's obligation to pay the provider for the costs of services provided as a certified provider is subject to the hold and review process described in rule 5160-1-27.2 of the Administrative Code.
(c) The provider shall accept the payment rates established in its provider agreement with ODA's designee as payment in full for the services it provides, and not seek any additional payment for services from the individual or any other person.
(d) The provider may provide a service not authorized by the individual's person-centered services plan, but ODA (or its designee) pays a provider only for providing services authorized by the individual's person-centered services plan.
(12) Other laws: The provider is subject to all applicable federal, state, and local laws, rules, and regulations and is responsible for ensuring all subcontractors comply with all applicable federal, state, and local laws, rules, and regulations.
(13) Rules updates: The provider shall subscribe to receive email updates on ODA's rules on through https://aging.ohio.gov.
(C) Requirements for specific types of providers to become certified:
(1) Agency providers:
(a) Disclosures: The provider shall disclose the following:
(i) The name of any person with an ownership interest in the provider.
(ii) The name of any person with an ownership interest in the provider who was convicted of a felony under a state or federal law.
(iii) A table of organization clearly identifying lines of administrative, advisory, contractual, and supervisory responsibilities.
(iv) The active registration as a business entity with the Ohio secretary of state.
(b) Statements: Attestations: The provider shall provide ODA or its designee with statements written or electronic attestations on the following: (iii)(ii) The provider's compliance with the Equal Employment Opportunity Act of 1972, federal wage-and-hour laws, and workers' compensation laws regarding the recruitment and employment of persons. (iv)(iii) The provider's payment of all applicable federal, state, and local income and employment taxes for the most recent year.
(i) The purpose of the provider's business.
(c) Policies: The provider shall have written policies, bylaws, or articles of incorporation (or an electronic record of policies, bylaws, or articles of incorporation) that include requirements for its employees to provide services in a manner compliant with paragraph (B)(8) of this rule.
(2) Non-agency providers: The provider shall provide a statement written or electronic attestation to ODA or its designee certifying that he or she the provider paid all applicable federal, state, and local income and employment taxes.
(3) Participant-directed providers: A person may qualify to become a participant-directed provider only if the person meets the requirements in rule 173-39-02.4 of the Administrative Code.
(4) Assisted living providers:
(a) Preemption: The provider shall acknowledge that any statute governing, or rule regulating, the assisted living program supersedes any clause in the RCF's resident agreement.
(b) License: The provider shall have an RCF license issued under Chapter 3701-16 of the Administrative Code and comply with section 3721.121 of the Revised Code.
(c) Identifying key persons: The provider shall disclose the following:
(i) The name of any person with an ownership interest in the provider.
(ii) The name of any person with an ownership interest in the provider who was convicted of a felony under a state or federal law.
(iii) A table of organization clearly identifying lines of administrative, advisory, contractual, and supervisory responsibilities.
(d) Statements: Attestations: The provider shall provide ODA or its designee with statements written or electronic attestations on the following:
(i) The provider's compliance with 45 C.F.R. 80.4 regarding the provision of services.
(ii) The provider's compliance with the Equal Employment Opportunity Act of 1972, federal wage-and-hour laws, and workers' compensation laws regarding the recruitment and employment of persons.
(e) Policies: The provider shall have written policies, bylaws, or articles of incorporation (or an electronic record of policies, bylaws, or articles of incorporation) that include the following:
(i) A requirement for the residents' rights policy that the provider adopts under section 3721.12 of the Revised Code to apply the prohibition against unethical, unprofessional, disrespectful, or illegal behavior under paragraph (B)(8) of this rule to its employees.
(ii) A requirement for the policy that the provider adopts under rule 3701-64-02 of the Administrative Code on reporting abuse, neglect, or exploitation to ODH to apply the requirement under paragraph (B)(3)(a) of this rule to report abuse, neglect, or exploitation to ODA or its designee to its employees.
(iii) A requirement for the policy that the provider adopts under paragraph (B) of rule 3701-16-12 of the Administrative Code to apply the requirement under paragraph (B)(3)(b) of this rule to report incidents to ODA or its designee to its employees.
(D) Requirements for specific types of providers to remain an ODA-certified provider:
(1) Agency providers: The provider shall remain in compliance with all requirements under paragraphs (B) and (C)(1) of this rule.
(2) Non-agency providers: The provider shall remain in compliance with all requirements under paragraphs (B) and (C)(2) of this rule.
(3) Participant-directed providers:
(a) Continuation: The provider shall remain in compliance with all requirements under paragraphs (B) and (C)(3) of this rule.
(b) Records retention: In addition to the records-retention requirements under paragraph (B)(10)(a) of this rule, the provider shall store the individual's records in the home of the individual in a physical location or an electronic device that is accessible to the provider, individual, and ODA or its designee.
(4) Assisted living providers:
(a) Continuation: The provider shall remain in compliance with all requirements under paragraphs (B) and (C)(4) of this rule.
(b) Payment:
(i) The assisted living program does not pay for any service the provider provides to an individual before ODA's designee enrolls the individual into the program and before ODA's designee authorizes the service in the individual's person-centered services plan.
(ii) If an individual is absent from the RCF, the provider shall not accept a payment for the service under rules 173-39-02.16 and 5160-33-07 of the Administrative Code or charge the individual an additional fee for the service or to hold the unit during the individual's absence.
(c) Transfers/discharges: Section 3721.16 of the Revised Code establishes the terms for transferring or discharging an individual.
(d) Last day of service: If the provider terminates its medicaid-provider medicaid provider agreement, pursuant to section 3721.19 of the Revised Code, or if the provider plans to stop providing services to an individual, then it shall provide written notification to the individual and to ODA's designee at least ninety days before terminating the medicaid provider agreement or provision of services to the individual.
Notes
Promulgated Under: 119.03
Statutory Authority: 121.07, 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, 04/26/2009, 10/19/2009, 08/30/2010, 03/17/2011, 01/01/2013, 07/01/2014, 07/01/2016,07/01/2019, 06/11/2020 (Emer.), 11/08/2020,04/04/2022, 07/01/2023