~are · 2012. 6. 13. · district of columbia vol. 59 -no. 9 march 2, 2012 i department ofi health...

DISTRICT OF COLUMBIA VOL. 59 - NO. 9 MARCH 2, 2012

I DEPARTMENT OFi HEALTH CARE FINANCE

NOTICE OF Jj-JNAL RULEMAKING

The Director of the Department of Health ~are Finance (DHCF), pursuant to the authority set forth in An Act to enable the pi strict of Columbia to receive federaJ financial assistance under Title XIX ofthd Social Security Act for a medical assistance program, and for other purposes approved cember 27, 1967 (81 Stat.774; D.C. Official Code § 1-307.02 (2006 Repl.)) and section 6(6) fthe Department of Health Care Finance Establishment Act of2007, effective Febr ry 27, 2008 (D.C. Law 17-1 09; D.C. Official Code § 7-771.05(6)(2008 Repl.)), hereby gives otice ofthe adoption of an amendment to chapter 50, Medicaid Reimbursement for Persona Care Services, of title 29, Public Welfare, of the

District of Columbia Municipal Regulatiors (DCMR).

Personal care aide (PCA) services are basf health-related services that are provided by unskilled health care professionals to indi iduals who require services that range from bathing to meal preparation. These final rules will amend the previously rules by requiring a preexisting relationship between benefici ·es and their primary care physicians or advanced practice registered nurses before a PCA p scription for services can be provided; expanding the opportunity of providing PCA service to individuals associated with Medicaid beneficiaries who are not family members! setting standards for staffing agencies that contract with home health agencies for the delive~ ofPCA services; expanding the requirements governing National Provider ldentificatio1 (NPl) numbers in conjunction with the new federal standards; and amending the notice requir ment for discharges to comply with federaJ and District law governing advance notice.

A notice of proposed rulemaking was pub ished in the D.C. Register on August 19, 201 I (58 OCR 7523). Numerous comments have en received and no substantive changes have been made. The proposed rules have been ended to clarify that each staffing agency contract shall contain the NPI of each PC providing services as ofthe date of the contract; to correct a clerical error by reinstating th requirement set forth in the previously published finaJ rules to require each provider's polic manual contain information including an up-to-date listing of professional staff lice sure and registration information; to correct a clerical error to require the review of the Jan of care every sixty-two (62) days consistent

I with the previously published final rules; ;dd clarifying language to ensure compliance with D.C. Language Access Act, effective June' 19, 2004 (D.C. Law 15-167; D.C. Official Code§§

2-1931, et seq. (2007 Rep!.)); add clarify~· g language to ensure that all notices issued by providers comply with due process requi ments set forth in District and federal law; clarify that each personal care aide be able to rea and write the English language at least at the fifth grade level; add language to clarify that~~ services provided by each licensed professional are consistent as defined in District law; t~ clarify that claims from staffing agency referrals shall not be reimbursed and to clarify the lfrrn staffing agency shall have the same definition set forth in District Jaw. A few minor tecrnical and grarrunatical changes were also made to the Notice of Proposed Rulemaking whic are not substantive in nature, and therefore, do not alter the intent and/or application of the es.

001760


I The Director adopted these finaJ rules on ebruary 13, 2012, and these rules shall become effective for services rendered beginning nor after July 2, 2012.

Chapter SO, MEDICAID REIMBURSE ENT FOR PERSONAL CARE SERVICES, of Title 29, PUBLIC WELFARE, of the D MR is deleted in its entirety and replaced to read as follow:

5000

5000.1

5000.2

5000.3

5000.4

5000.5

CHAPTER SO MEDIC REIMBURSEMENT FOR PERSONAL CARE SE VICES

GENERAL PROVISIONS

These rules establish the stan¥ards and conditions of participation for home health agencies providing perSonal care services (Provider) under the District of Columbia Medicaid Program kMedicaid Program).

The provisions shall be in suJport and furtherance ofthe following goals:

(a) To p~ov;de nec_ess•+ hands-on personal ca~ ass;stance w;ththe_ actiVIties of dally h · mg that ass1st a benefic1ary to safely res1de m the home; and

(b) To encourage home based care as a preferred and cost-effective aJternative to institu ional care.

A Provider receiving reimb rsement for personal care services shaH be a home

health agency and meet thelconditions of participation for home health agencies set forth in Sectio1s 1861 ( o) and 1891 (e) of the Social Security Act and 42 CFR 484; shall be e oiled as a Medicare Provider; and shall comply with the requirements set fi rth in the Health-Care and Community Residence

Facility Act, Hospice and orne-Care LicensureAct of I 983, effective Feb. 24, 1984 (D.C. Law 5-48; D.C. Official Code,§§ 44-501, et seq. (2005 Rep!. & 2011 Supp.)), and impleme ting rules.

An applicant seeking top icipate as a personal care services Provider under

the Medicaid Program shall submit a Medicaid Home Health Provider enrollment application to th Department of Health Care Finance (DHCF).

Each Provider application s all contain, but not be limited to, the following:

(a) Name and address ofth applicant's organization and location of the

applicant's place of bus ness. An applicant shall submit a separate application for each pia e of business from which the applicant intends to

offer District ofColum ia Medicaid program services;

. 2


5000.6

5000.7

5001

5001.1

Answers to meet rejirements as set forth in 42 C.F.R. § 455, subpart b: Disclosure oflnfo .. '(tion by Providers and Fiscal Agents;

(b)

(c) Names of all indivi~uals providing personal care services, license numbers and Nation~ Provider Identifier (NPI) numbers from the National Plan and Ptovider Enumeration System (NPPES) as of the date of the applicati~n to become a District of Columbia Medicaid Provider;

(d)

(e)

The applicant's U.S .. Department of Health and Human Services,

Centers for Medicart1

and Medicaid Services (CMS) Medicare Supplier Letter issued pursua t to 42 C.F.R. § 424.510 to evidence enrollment of the applicant in t e Medicare program;

A copy or copies of ll contracts held between the applicant and any staffing agency pert ining to the delivery of personal care services; A copy or copies of icense(s) held by the employees of any staffing agency or agencies sed by the Provider for the delivery of personal care services;

(t)

(g) The applicant's NPI umber as required by the Health Insurance Portability and A ceo ntability Act of 1996 (P. L. 104-191 );

(h) A copy of the applic nt's surety bond, pursuant to requirements set forth in § 5002.2 of his title; and

(i) A copy of a Certifi te of Registration or Certificate of Authority, if required by title 29 fthe D.C. Official Code.

A Provider shall submit an w Medicaid Provider enrollment application within thirty (30) days after any change in business ownership. Re-enrollment or continued enrollment in ~e Medicaid program after any change in business

ownership shall be conditiled upon the Provider's compliance with all applicable Federal and Dis 'ct requirements.

A Provider shall submit a n w Medicaid Provider enrollment application and successfully re-enroll in the D.C. Medicaid program at least every five (5) years from the date of its m st recent enrollment or reenrollment.

STAFFING AGENCIE

A Provider may contract wi a licensed staffing agency that will perform personal care services not t exceed a maximum often percent (10%) of the

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DISTRICT OF COLUMBIA VOL 59- NO.9 MARCH 2 1 2012

5001.2

units of service provided in lany given four (4) month period. Agreements I

between the Provider and ~ agency providing personal care staffing services

shall be in writing and inciTe at a minimum, the following:

(a) The staffing agency'~ NPI number obtained from the National Plan and Provider Enumeratiqn System (NPPES) and the NPI numbers of all

staff supplied to the lome health agency listed on all beneficiary documentation;

(b) A description of the ervices to be provided;

(c)

(d)

(e)

(f)

(g)

(h)

Business address of ach staffing agency location;

The procedures use for managing, supervising, and evaluating the services delivered b agency personnel;

Procedures for implqrnenting plans of care; submitting clinicaJ and progress notes; sche~uling of visits; preparing beneficiary assessments;

and other designat1 reports by agency personnel;

The procedure ident~fied for payments for services furnished and the terms of those payments;

The duration of the greement, including provisions for renewal, if applicable; and

Assurances that the gency shall comply with:

(I) All applicabll home health Provider policies, including the

assurance thJt contract personnel meet the qualifications and

fulfill the resJ1

onsibilities of agency employees in accordance with these rues;

(2) All insuranc and bonding requirements as set forth in section 5002 of thes rules; and

(3) All applicabl federal and District laws and rules, including all relevant lice sing requirements imposed by the District of Columbia;

Each Home Health Provide contracting with a staffing agency for personal

care services shall:

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DISTRICT OF COLUMBIA VOL. 59 ~ NO. 9 MARCH 2 1 2012

5001.3

5001.4

(a) Ensure that the staf,ng agency obtains NPI numbe"' for the agency and all personnel prfonning personal care services;

(b) Provide DHCF wit~ a copy of any and all contract(s) entered into with a staffing agency f<f the delivery of all personal care services on behalf ofthe Provider. Ea~h of these contracts shall contain the personal care staffing agency NP~ number and a list ofNPI numbers for all individuals providi g personal care services under the auspices of the personal care staffi g agency on the date of the contract;

(c) Require that each s fling agency providing personal care services conduct a perform ce assessment of each personal care aide after the first three (3) mont s of service under the auspices of the staffing agency and annuall thereafter.

Marketing and solicitation by staffing agencies shall solicitation activities shall

f Medicaid beneficiaries or their representatives prohibited. Those prohibited marketing and

nclude, but not be limited to:

(a) Direct advertising r marketing to Medicaid beneficiaries;

(b) Representation oft e staffing agency as the Medicaid Provider of personal care servi es; and

(c) Offering financial r other types of inducements to individuals for the referral of Medicai beneficiaries, their names, or other identifying information to the mg agency.

Ownership rights between orne health Providers and staffing agencies shall be prohibited. Ownership r ghts may include but not be limited to:

(a) A direct or indirect wnership or investment interest (including an option or non-veste interest) by the staffing agency in any home health agency. This interest may be in the fonn of equity, debt, or other means and includes any indirect ownership or investment interest;

(b) A direct or indirect wnership of investment interest (including an option or non-veste interest) by the home health agency in any staffing agency; or

(c) A compensation a ngement other than the contract between the home health agency and e staffing agency in performance of personal care services.

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DISTRICT OF COLUMBIA VOL. 59 • NO. 9 MARCH 2 1 2012

5001.5

5001.6

5002

5002.1

5002.2

5003

5003.1

5003.2

5003.3

A staffing agency providin personal care services shall be considered an agent of the Provider.

All beneficiary records ac mulated by a staffing agency in delivery of personal care services shaJJ be the property of the home health Provider and maintained within the homb health Provider's office.

lNSURANCE

Each applicant or Provider shall maintain the following minimum amounts of insurance coverage:

(a) Blanket malpracti insurance for all employees in the amount of at least one million d liars($ 1,000,000) per incident;

(b) Genera\ liability in urance covering personal property damages, bodily injury, libel and sl der of at least one million dollars ($ 1 ,000,000) per occurrence; and

(c) Product liability in urance, when applicable.

Each applicant or Provider shall post a continuous surety bond in the amount of fifty thousand dollars ($ 0,000) against all personal care services claims, suits, judgments, or damag s including court costs and attorney's fees arising out ofthe negligence or o~issions of the Provider in the course of providing services to a Medicaid beneficiary or a person believed to be a Medicaid

beneficiary. Th~ number ot bonds required shal~ be predicau:d u~on the number of Provtder offi enrolled by the appltcant or Provtder m the Medicaid program.

ADMINISTRATION AN STAFFING

NPI numbers for Providers staffing agencies and all personnel delivering personal care services shal be included in all Medicaid billings.

Each Provider shall have a current organizational chart that clearly describes the organizational structur , management responsibilities, staff responsibilities, and lines of authority.

Each Provider shall maint n current copies of all fully executed contracts in the Provider's home health agency office and make them available to DHCF, CMS, or their agents when requested.

001765

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DISTRICT OF COLUMBIA VOL. 59 • NO. 9 MARCH 2, 2012

5003.4

5003.5

5003.6

A Provider shall be prohibhed from waiving liability or assigning contract authority to any other entit~ for covered services provided to Medicaid

beneficiaries. I

Each Provider shall providF to all employees and contractors (such as, staffing

agencies) a current policy ~anual which sets forth all of its policies and procedures.

Each policy manual shall i elude, but not be limited to, the following information:

(a) A description ofth services to be provided;

(b)

(c) The reimbursemen methodology or fee schedules;

(d)

(e) Quality assurances

(f) A statement of ben ficiary rights and responsibilities;

(g) Financial and recor -keeping requirements;

(h) Procedures for em gency care, infection control and reporting of unusual incidents;

(i) A description ofs positions and personnel policies, which shall be reviewed annually, evised as necessary, and dated at time of review;

Policies and proce s for employee hiring, assessments, grievances,

(k) An up-to-date listin ofprofessionaJ staff licensure and registration information;

(I) Policies, procedur , and presentation materials for owners, managers, and employees for n-service education on the following subject matters:

(1) Complianc with federal and local False Claims Acts;

001766

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DISTRICT OF COLUMBIA VOL. 59 - NO. 9 MARCH 2 1 2012

5003.7

5003.8

5003.9

(2) Preventing, d\etecting, and reporting fraud, waste, and abuse; and

(3) Rights of empl yees to be protected as whistleblowers.

Each Provider shall be staffi d with individuals who are qualified to perform the following functions:

(a)

(b)

(c)

Verify and documen1 each beneficiary's Medicaid eligibility;

Provide quality serv~es in accordance with the plan of care, including the proper assignmett and supervision of personal care aides; and

Coordinate the prov+on of personal care services with home health services, as appropri te.

Each Provider shall employ registered nurse who is responsible for the following:

(a)

(b)

Performing the initiJ assessment of the beneficiary and regularly reassessing the bene tciary's needs;

Developing and revi wing the plan of care and preparing clinical and progress notes;

(c) Monitoring the quali ofthe personal care services on a regular basis;

(d) Supervising the pers nal care aides which shall include on-site supervision at least nee every sixty-two (62) days;

(e) Coordinating servic and communicating with primary care physicians and adva ced registered practice nurses regarding changes in the beneficiary's c ndition and needs;

(t) Gathering informati n regarding the beneficiary's condition and the need for continued c e; and

(g) Counseling the bene 1ciary and the beneficiary's family regarding nursing and related eds.

The registered nurse shall vi it each beneficiary within forty-eight (48) hours of initiating personal care se ices to monitor the quality of services, and no less than every sixty-two (6 ) days thereafter for assessment of the beneficiary and update of the plan of c

8


5003.10

5003.11

5003.12

5003.13

5003.14

I

The registered nurse may ~rovide an additional supervisory visit to each

beneficiary if the situation rarrants an additional visit, such as the assignment

of a new personal care aid, or change in the beneficiary's health status.

Each Provider shall discontinue personal care services when such services are no longer required.

Each Provider shall notify pHCF and the beneficiary or beneficiary~s

representative, in writing, qo less than fifteen ( 15) calendar days prior to any

termination or reduction o services, discharge or referral consistent with the

requirements set forth in strict and Federal law. The beneficiary's record

shall contain documentatio of the date the notice was mailed to the

beneficiary and a copy oft e notice to the beneficiary. An oral notice may be

provided in lieu of the fift n (15) day written notice if:

(a) The discharge or re erral is the result of one (1) ofthe following:

(I) A medical mergency;

(2) A primary c re physician's order to admit the beneficiary to a

facility;

(3) ion by the home health agency that the discharge

necessary to protect the health, safety or welfare of

agency s or

( 4) A determin ion by a primary care physician that the

beneficiary' condition, that required the delivery of personal

care service , no longer exists; and

(b) Documentation ind eating a reason to omit the fifteen (15) day notice

is included in the b neficiary's record.

If the beneficiary seeks to hange his or her personal care services Provider,

the Provider shall assist th beneficiary in selecting a new Provider. Until the

beneficiary is transferred t a new personal care services Provider, the Home

Health Provider shall conti ue providing personal care services to the

beneficiary until the transfi r has been completed successfully and the

beneficiary is receiving pe lsonal care services from the new Provider.

Each Provider shall immed ately terminate the services of a personal care aide

and instruct the personal c e aide to discontinue all services to the beneficiary,

in any case where the Prov der believes that the beneficiary's physical or

9

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DISTRICT OF COLUMBIA VOL 59· NO.9 MARCH 2, 2012

5003.15

5003.16

5004

5004.1

mental weJI-being is endan ered by the care or lack of care provided by the

aide, or that the beneficiary F property is at risk.

• I f Each Provtder shall conducll a perfonnance assessment o each personal care aide after the first three (3) onths of employment and annually thereafter.

Each Provider shall develo contingency staffing plans to provide coverage for each beneficiary in the ent the assigned personal care aide cannot provide the services or is te inated.

Each PCA shall meet the fo lowing qualifications:

(a) Be at least eighteen 18) years of age;

(b) Be a citizen of the to work in the Unit

ited States or an alien who is lawfully authorized States;

(c) Complete a home h lth aide training program that includes at least seventy- five (75) hours of classroom training with at least sixteen ( 16) hours devoted to su ervised practical training and pass a competency evaluation for those .ervices which the PCA is required to perfonn consistent with the r quirements set forth in 42 C.F.R. § 484.36;

(d) Be certified in cardi. pulmonary resuscitation (CPR) and thereafter obtain CPR certifica ion annually;

(e) rite the English language at least at the fifth (5th) grade level and c out instructions and directions in English;

(g) Be knowledgeable a ut infection control procedures;

(h) Be acceptable to the beneficiary;

(i) Demonstrate annual y that he or she is free from communicable disease

as con finned by anEnual PPD Skin Test or documentation from a primary care physic or advanced practice registered nurse stating

that the person is fr from communicable disease;

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01769

DISTRICT OF COLUMBIA VOL. 59 - NO. 9 MARCH 2 1 2012

5005

5005.1

5005.2

5005.3

5005.4

5005.5

I G) Pass a criminal bacfground check pursuant to the Health-Care Facility

Unlicensed Person~el Criminal Background Check Act of 1998, effective April20, 999 (D.C. Law 12-238; D.C. Official Code, §§

44-551, et seq.(200 Rep!. & 2011 Supp.));

(k) Provide documenta ion of acceptance o.r declination of the Hepatitis vaccine; and

(l) Have an individual ational Provider Identification (NPI) number

obtained from the ational Plan and Provider Enumeration System (NPPES).

PROGRAM SERVICES

Personal care aide services shall be prescribed by a primary care physician or advanced practice register nurse who has had a relationship with the beneficiary that extended t an examination(s) provided in a hospital, primary care physician's office, nu ing facility, or at the beneficiary's home prior to the prescription of the pers nal care services.

Each prescription for PCA ervices under this section shall include the

prescriber's NPI number o 1tained from NPPES;

PCA services shall be initi ted no later than forty-eight ( 48) hours after

completion of the initial as essment unless the beneficiary or the beneficiary's representatives agree to be in the services at a later date.

An individual or family m mber other than a spouse, parent of a minor beneficiary, or any other le ally responsible relative may provide personal care services. Each family ember providing personal care services shall meet

the requirements of these r les.

Personal care services shal include, but not be limited to, the following:

(a) Performance of or ssistance in performing routine activities of daily living (such as, bat ing, transferring, toileting, dressing, eating and feeding self, maint "ning bowel and bladder control [continence]);

(b) Assistance with be pan use or changing urinary drainage bags;

(c) Assisting beneficia ·es with a range ofmotion exercises;

(d) Assisting beneficia 'es with self-administered medications;

001770

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DISTRICT OF COLUMBIA I VOL 59 - NO. 9 MARCH 2, 2012

5005.6

5005.7

5005.8

.,

(e) Reading and record ng temperature, pulse, and respiration;

(f) Observing and doc menting the beneficiary's status and reporting all services provided;

(g) Meal preparation in accordance with dietary guidelines and assistance with eating;

(h) Tasks related to kee ing areas occupied by the beneficiary in a condition that prom tes the beneficiary's safety;

(i) Accompanying the eneficiary to medically-rehited appointments or place of employme t;

U) Providing assistan at the beneficiary's place of employment;

(k)

(I)

Shopping for items elated to promoting the beneficiary's nutritional status and other health needs;

Recor<ling and repo~ing to the supervisory health professional, changes in the beneficiary's physical condition, behavior or appearance;

(m) Infection control;

(n) Accompanying the eneficiary to recreational activities prescribed by the beneficiary's pri ary care physician or advanced practice registered nurse.

PCA services shall not incl de:

(a) Services that requir the skills of a licensed professional as defined by the Health Professi nal Licensing Administration (HPLA); and

(b) Tasks usually perfo ed by chore workers, such as cleaning of areas not occupied by the beneficiary and shopping for items not used by the beneficiary.

PCA services shall be mad available seven (7) days per week.

Persona] care services shall not be provided in a hospital, nursing facility, intennediate care facility fi persons with intellectual and developmental disabilities (ICFIIDD), or a y institutional setting.

12

DISTRICT OF COLUMBIA I VOL 59 - NO. 9

IMENTS

MARCH 2, 2012

5006

5006.1

5007

5007.1

5007.2

5007.3

5007.4

5007.5

5007.6

ELIGIBILITY REQU

A Medicaid beneficiary wh meets the following qualifications is eligible to receive PCA services:

(a) The Medicaid bene ciary has received an initial assessment from his or her primary car physician or advanced practice registered nurse and the assessment as found the beneficiary to be unable to

independently perfo one (1) or more activities of daily living for which personal care services are needed; and

(b) The referring prim care physician or advanced practice registered nurse has an expectdtion that the Medicaid beneficiary's health care needs can be safely, ~dequately, and appropriately met while the

beneficiary resides ill the beneficiary's home.

PLAN OF CARE

Each Provider shall conduc an initial assessment of the beneficiary's functional status and needs ithin forty-eight ( 48) hours of receiving the referral for services.

Each Provider shall docum t in writing, a written plan of care within seventy-two (72) hours oft e initial assessment ofthe beneficiary based upon the beneficiary's functional ·imitations.

The plan of care shall speci the frequency, duration and expected outcome of

the services rendered.

The plan of care shall only ~· e approved and signed by the beneficiary's primary care physician or a vanced practice registered nurse who has a prior relationship with the benefi iary and has examined the beneficiary in a

hospital, nursing facility, or rimary care physician's offi~ or at the beneficiary's home; and sh I be re-certified no less than every six (6) months after the initial certification d each re-certification thereafter.

The plan of care shall be re- ertified by the primary care physician or

advanced practice registere1nurse after any interruption of service, greater than fourteen (14) calendar ays, including hospital admissions.

A registered nurse who is e ployed by the Provider shall review the plan of

care at least once every six two (62) days and shall update or modifY the plan of care as needed. The vised plan of care shall be signed by the

01772

13


5007.7

5008

5008.1

5008.2

5008.3

5008.4

5008.5

5008.6

5008.7

5008.8

5008.9

referring primary care physi ian or advanced practice registered nurse within thirty (30) days ofprescripti n

If a plan of care is revised b telephone order, the telephone order shall be immediately documented in !writing and signed by the primary care physician or advanced practice registe~d nurse within thirty (30) days of its prescription.

RECORDS

Each Provider shall maintai complete and accurate records reflecting past and current findings, the initial d subsequent plans of care, and the ongoing progress of each beneficiary

Each Provider shall maintai complete and accurate records reflecting the specific personal care servi s provided to each beneficiary.

Each Provider shall maintai beneficiary records that are confidential, complete and contain up-to- ate information relevant to each beneficiary's care and treatment. For pu ses of record confidentiality, the disclosure of treatment information by th Provider is subject to all the provisions of applicable District and Fede al Laws.

Each beneficiary's record sh II include clear written documentation of the beneficiary's treatment need and services. The documentation shall be written so that it is easily understoo by a lay person.

Each beneficiary's record sh 11 be kept in a locked room or file maintained and safeguarded against loss or nauthorized use.

Copies of all records for PC services provided to beneficiaries by the Provider and/or the Provide s contractors shall be maintained at the location of the Provider's place ofbu iness that is identified on the Provider's Medicaid Provider application.

Each Provider shall permit o -site inspections to be conducted by CMS, its agents, DHCF and its agents to determine Provider compliance with aJI applicable laws.

Each Provider shall maintai beneficiary records for ten ( l 0) years.

Each beneficiary's record sh II include, but is not limited to, the following information:

01773

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DISTRICT OF COLUMBIA VOL. 59 a NO. 9 MARCH 2, 2012

5009

5009.1

5009.2

5009.3

(a) Medical infonnatio , including the initial and annual assessments, and

the initial certificat on and re-certifications ofthe plan of care;

(b) Genera] infonnatio~j including the beneficiary's name, Medicaid

identification num er, address, telephone number, age, sex, name and

telephone of emerg ncy contact person, primary care physician's or

advanced practice 1 gistered nurse's name, address and telephone

number;

(c) Description and da s of services rendered, including the name and

NPI of the personal care aide performing the services;

(d) Documentation of ach supervisory visit ofthe registered nurse

including signed an dated clinical progress notes;

(e) Extended authoriza ions for services;

(g) Any other appropri te identifying information that is pertinent to

beneficiary care.

BENEFICIARY RIGHT AND RESPONSIBILITIES

Each Provider shall develo a written statement of the beneficiary's rights and

responsibilities consistent ith the requirements of this section, which shall be given to each beneficiary i advance of receiving services or during the initial

assessment before the initi tion of services.

The written statement ofth beneficiary's rights and responsibilities shall be

prominently displayed at e Provider's business location and available at no

cost upon request by a me ber of the general public.

Each Provider shall develo and implement policies and procedures outlining

the following beneficiary's rights:

(a) To be treated with urtesy, dignity and respect;

(c) To participate in th planning of his or her care and treatment;

(d) To receive treatme

and to have the pi

care and services consistent with the plan of care

of care modified for achievement of outcomes;

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001774

DISTRICT OF COLUMBIA VOL. 59 • NO. 9 MARCH 2 1 2012

(e) To receive service by competent personnel who can communicate with the beneficia in accordance with the Language Access Act of 2004, effective Jun~ 19, 2004 (D.C. Law 15-167; D.C. Official Code §§ 2-1931, et seq. ( 007 Rep!.)).

(f) To refuse all or part fany treatment, care or service and be informed ofthe consequences

(g) To be free from me tal and physical abuse, neglect and exploitation from persons provi ng services;

(h) To be assured that~ r purposes of record confidentiality, the disclosure of the contents ofth beneficiary's records is subject to all the provisions of applic ble District and federal laws;

(i) To voice a complain or grievance about treatment, care, or Jack of respect for personal roperty by persons providing services without fear of reprisal;

0) To have access to hi or her records; and

{k) To be informed oral y and in writing of the following:

(I) Services to provided, including any limits;

(2) Amount ch ged for each service, the amount of payment required fro the beneficiary and the billing procedures, if applicable;

(3) Whether se ices are covered by health insurance, Medicare, Medicaid or y other third party sources;

( 4) Acceptance, enial, reduction or termination of services;

(5) Complaint a d appeal procedures;

(6) Name, addre sand telephone number of the Provider;

(7) Telephone n mber ofthe District of Columbia Medicaid fraud hot line;

(8) Beneficiary' freedom from being forced to sign for services that were no provided or were unnecessary; and

01775

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DISTRICT OF COLUMBIA VOL 59- NO.9 MARCH 2, 2012

5009.4

5009.5

5010

5010.1

5010.2

5010.3

5010.4

5010.5

(9) A statement, rovided by DHCF, defining health care fraud and

ways to repo suspected fraud.

Each beneficiary shall be r ponsible for the following:

(a) Treating all Provider personnel with respect and dignity;

(b) Providing accurate i formation when requested;

(c) Informing Provider ersonnel when instructions are not understood or

cannot be followed;

(d) Cooperating in maid g a safe environment for care within the home.

Each Provider shaH take ap priate steps to ensure that each beneficiary, including beneficiaries who annat read or those who have a language or communication barrier, has eceived the information required pursuant to this

section. Each Provider shall ocument in the records the steps taken to ensure

that each beneficiary has rec ived the information.

REIMBURSEMENT

Each Provider shall be reim ursed sixteen dollars and thirty cents ($ 16.30) per hour for services rende d by a personal care aide.

Reimbursement for PCA se ices shall not exceed eight (8) hours of service per day per beneficiary. Rei bursement for services shall not exceed one thousand forty (1 ,040) hour during a calendar year, unless previously approved by DHCF or its ag t

Each Provider shall agree to accept as payment in full the amount determined by DHCF as Medicaid reim ursement for the authorized services provided to beneficiaries. Providers shal not bill the beneficiary or any member of the beneficiary's family for PC services.

Each Provider shall agree to bill any and all known third-party payers prior to billing Medicaid.

All reimbursable claims for CA services shall include the NPI numbers for the:

(a) Provider;

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DISTRICT OF COLUMBIA VOL 59- NO.9 MARCH 2, 2012

5010.6

5010.7

5010.8

5010.9

(b)

(c)

(d)

Primary care physic~an or advanced practice registered nurse who

ordered the personal~ care services;

Staffing agency pro~iding the personal care service, if the staff

performing persona]· care services were obtained from a staffing agency; and

Personal care aide ho provided the personal care services.

No more than ten percent (I %) of the billed units of service for PCA services,

billed by date of service, in ny given four ( 4) month period, may be claimed

by a Provider for PCA servi es provided through the use of personnel from a staffing agency or agencies.

Medicaid shall deny, pursu t to 42 C.F.R. § 424.22(d), home health services claims or recoup paid claim when Provider records or other evidence indicate that the primary care physic an or advanced practice registered nurse ordering a beneficiary's treatment h a significant ownership interest in, as defined in § 5010.8, or a significant fi ancial or contractual relationship with, as defined in§ 5010.9, the home heal agency billing for the services.

A primary care physician or advanced practice registered nurse shall be considered to have a signifi ant ownership interest in a home health agency if

either of the following cond tions apply:

(a) The primary care physician or advanced practice registered nurse has a direct or indirect ow ership of five percent (5%) or more in the capital,

stock, or profits. oft e home health agency; or

(b) The primary care ph sician or advanced practice registered nurse has an ownership offiv percent (5%) or more of any mortgage, deed of trust, or other obliga ion that is secured by the agency, if that interest equals five percent ( %) or more of the agency's assets.

A primary care physician or advanced practice registered nurse is considered to

have a significant financial r contractual relationship with a home health agency if any of the followi g conditions apply:

(a) The primary care ph sician or advanced practice registered nurse receives any compe sation as an officer or director of the home health agency;

(b) The primary care ph sician or advanced practice registered nurse has indirect business tra sactions, such as contracts, agreements, purchase

18

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DISTRJCT OF COLUMBIA VOL. 59 • NO. 9 MARCH 2, 2012

5010.10

5011

5011.1

5011.2

5011.3

5011.4

5011.5

orders, or leases to btain services, supplies, equipment, space, and salaried employme t with the home health agency; or

(c) The primary care p ysician or advanced practice registered nurse has

direct or indirect bu iness transactions with the home health agency that, in any fiscal year, ount to more than twenty-five thousand dollars ($25,000) or five p rcent (5%) of the agency's total operating expenses,

whichever is less.

Claims resulting from st

face-to-face solicitation at beneficiary Medicaid num

ng agency referrals, marketing (such as,

actors' offices, home visits), requests for rs, or otherwise directing beneficiaries to any

Medicaid Provider shall no be reimbursed.

AUDITS AND REVIEW

DHCF shall perform audi to ensure that Medicaid payments are consistent

with efficiency, economy d quality of care and made in accordance with federal and District rules g veming Medicaid.

The audit process shall be utinely conducted by DHCF to determine, by

statistically valid scientific ampling, the appropriateness of services rendered and billed to Medicaid. Th se audits shall be conducted on-site or through an off-site, desk review.

Each Provider shall allow cess, during an on-site audit or review by DHCF, ovemment officials and representatives of the

United States Department fHealth and Human Services, to relevant records

and program documentatio

lfDHCF denies a claim, D CF shall recoup, by the most expeditious means

available, those monies e neously paid to the Provider for denied claims, following the period of Ad inistrative Review as set forth in §501 I of these

rules.

The recoupment amounts f; r denied claims shall be determined by the following formula:

(a) Afraction shall be alculated with the numerator consisting of the number of denied p id claims resulting from the audited sample. The denominator shaJI the total number of paid claims from the audit sample; and

(b) This fraction shall multiplied by the total dollars paid by DHCF to

the Provider during the audit period, to determine the amount recouped.

19

001778


5011.6

5012

5012.1

5012.2

5012.3

5012.4

5012.5

5099

5099.1

For example, if a Pfvider received Medicaid reimbursement often thousand dollars ($ 0,000) during the audit period, and during a review

of the claims from e audited sample, it was detennined that ten (10)

claims out of one hhnctred (1 00) claims are denied, then ten percent

(1 0%) of the amou t reimbursed by Medicaid during the audit period,

or one thousand do Iars ($1 000), would be recouped.

DHCF shall issue a Notice of Proposed Medicaid Overpayment Recovery

(NR), which sets forth the easons for the recoupment, including the specific

reference to the particular ections of the statute, rules, or provider agreement,

the amount to be recouped and the procedures for requesting an

administrative review.

APPEALS FOR PRO MADE

ERS AGAINST WHOM A RECOUPMENT IS

The Provider shall have si ty (60) days from the date of the NR to request an

administrative review of

NR shall be submitted to

ofHealth Care Finance.

NR. The request for administrative review of the

anager, Division of Program Integrity, Department

The written request for ad inistrative review shall include a specific

description of the item to reviewed, the reason for the request for review,

the relief requested, and d cumentation in support of the relief requested.

DHCF shall mail a written determination relative to the administrative review

to the provider no later th one hundred twenty ( 120) days from the date of

the written request for ad inistrative review pursuant to §50 12.1.

Within forty-five (45) day of receipt of the Medicaid Program's written

determination, the Provide may appeal the written determination by filing a

written notice of appeal wi the Office of Administrative Hearings (OAH),

441 41h Street, NW, Suite 4 0 North, Washington, DC 2000 I.

AH shall not stay any action to recover any

overpayment.

DEFINITIONS

When used in this chapter, the following terms and conditions shall have the

following meanings:

Activities of Daily Living- The ability to bathe, transfer, dress, eat and feed

self, engage in toileting, a d maintaining bowel and bladder control

(continence).

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20


Advanced Practice Regist red Nurse- A person who is licensed or authorized to practice as an dvanced practice registered nurse pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law -99; D.C. Official Code§§ 3-1201, et seq. (2007

Repl.; &2011 Supp.)).

Family -Any person relat to the client or beneficiary by blood, marriage, or

adoption.

Licensed Staffing Agency defined per the Nurse Staffing Agency Act of 2003, effective March 10, 2004 (D.C. Law 15-74, D.C. Official Code §§ 44-1051.0 I, et seq. (2005 R pl.)

Primary care physician - person who is licensed or authorized to practice medicine pursuant to the Di trict of Columbia Health Occupations Revisions Act of 1985, effective Marc 25, 1986 (D.C. Law 6-99; D.C. Official Code,§§ 3-1201, et seq. (2007 Repl. 2011 Supp.)).

Registered Nurse- A perso who is licensed or authorized to practice registered nursing pursuant o the District of Columbia Health Occupations Revisions Act of 1985, effe ive March 25, 1986 (D.C. Law 6-99; D.C. Official Code, §§ 3-120 I, et seq. (2007 Rep!. & 2011 Supp.)).

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21

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