OAR 411-066-0015
Certification

ADS programs that enroll with APD to provide services must be certified.

(1) INITIAL CERTIFICATION.

(a) To receive APD Adult Day Service certification, which is required to become a DHS Medicaid-enrolled provider, an ADS program must complete all of the following certification process steps:

(A) Contact APD to schedule an initial on-site visit.

(B) Provide a cover letter detailing qualifications as an ADS.

(C) In preparation for the on-site inspection, the ADS will Complete the ADS certification self-assessment which demonstrates the program meets the standards for adult day services in OAR 411-066-0020 (Standards for Adult Day Services Programs).

(D) Participate in a follow-up on-site inspection by APD.

(b) APD must complete an on-site certification assessment visit, citing standards (OAR 411-066-0020 (Standards for Adult Day Services Programs)) as “met” or “unmet”.

(A) If all standards are met, APD shall certify the ADS program.

(B) If any of the standards are unmet, the application for certification shall be denied.

(i) The ADS program may bring the unmet standards into compliance and request APD complete a follow-up site certification assessment.

(ii) A request for a site certification reassessment must be made within 30 calendar days after denial. If the request for the site certification reassessment is more than 30 calendar days, the ADS program shall be required to resubmit the information in (1)(a)(B) - (D) of this rule.

(C) If the denial is upheld after a site certification reassessment, the ADS program may request an informal conference in writing within 10 business days of receipt of the denial notice. Within 10 business days of receipt of the request for an informal conference, the Deputy Director shall review all material relating to the denial of the certification.

(i) The Deputy Director shall determine, based on a review of the material, whether to uphold the denial.

(ii) If the Deputy Director does not sustain the decision, certification shall be granted immediately.

(iii) The decision of the Deputy Director is subject to a contested case hearing under ORS 183.413 (Notice to parties before hearing of rights and procedure) to 183.470 (Orders in contested cases), if requested within 90 days.

(c) APD may perform an unannounced on-site certification review any time during the certification period to ensure quality and safety standards continue to be met.

(2) MEDICAID PROVIDER ENROLLMENT. The ADS program must be an enrolled Medicaid provider in order to be eligible to receive payment from the Department for claims in connection with services provided by the ADS. The criteria for Medicaid provider enrollment and issuance of a provider number include, but are not limited to:

(a) Meeting all program-specific requirements.

(b) Providing a copy of the ADS program’s current certification.

(c) Current business registration and assumed business name (ABN), if applicable, with the Oregon Secretary of State’s Corporation Division.

(d) Completing an Adult Day Services Medicaid Provider Enrollment Application and Agreement (PEA) upon enrollment and renewal and meeting all Medicaid provider enrollment requirements.

(e) Maintaining the insurance requirements as defined in the PEA.

(3) MAINTAINING CERTIFICATION. Certification for an ADS program may continue for up to two years, or longer as defined below, from the effective date, if the ADS program complies with the standards for certification as established in OAR 411-066-0020 (Standards for Adult Day Services Programs).

(a) ADS programs wanting to renew certification and Medicaid provider enrollment must:

(A) Complete an ADS certification self-assessment demonstrating the program meets these rules. ADS certification self-assessments received by DHS APD prior to the ADS certification expiration date may allow the ADS certification to remain in effect at the discretion of APD until a final recertification decision is issued.

(B) Participate in a follow-up on-site inspection by APD.

(b) APD must complete an on-site certification assessment form after the visit, citing standards (OAR 411-066-0020 (Standards for Adult Day Services Programs)) as “met” or “unmet”.

(A) If all standards are met, APD shall notify the ADS program that certification shall be renewed.

(B) If any of the standards are unmet, the application for certification shall be denied.

(i) The ADS program may bring the unmet standards into compliance and request APD complete a follow-up site certification assessment.

(ii) A request for a site certification reassessment must be made within 30 calendar days after denial. If the request for the site certification reassessment is more than 30 calendar days, the ADS program shall be required to resubmit the information in (1)(a)(B) – (D) of this rule.

(iii) Depending upon the nature of the inadequacy, APD may perform a follow-up inspection to confirm compliance.

(iv) APD may immediately suspend certification for threat to the participant’s health, safety, welfare, or failure to comply with the standards.

(C) If the site reassessment result is not accepted in full, or the follow-up inspection reveals non-compliance, APD may deny, revoke or refuse to renew the certification and provider enrollment. The ADS program shall be notified in writing of the decision.

(D) If the denial or revocation is upheld after reviewing the site reassessment results, or follow-up inspection, the ADS program may, submit a written request for an informal conference within 10 business days of receipt of the notice. Within 10 business days of receipt of the request for the informal conference, the Deputy Director shall review all material regarding the denial or revocation.

(i) The Deputy Director shall determine, based on a review of the material, whether to uphold the denial or revocation.

(ii) If the Deputy Director does not sustain the decision, certification shall be granted immediately.

(iii) The decision of the Deputy Director is subject to a contested case hearing under ORS 183.413 (Notice to parties before hearing of rights and procedure) to 183.470 (Orders in contested cases) if requested within 90 days.

(c) APD may perform an unannounced on-site certification review any time during the certification period to ensure quality and safety standards continue to be met.

(4) Termination of Medicaid provider enrollment.

(a) Enrolled Medicaid providers of ADS may be denied enrollment, terminated, or prohibited from providing ADS for any of the following:

(A) Violation of any part of these rules.

(B) Violation of the protective service and abuse rules in OAR chapter 411, division 020 and OAR chapter 407, division 045.

(C) Failure to keep required certifications current.

(D) Failure to maintain Medicaid provider enrollment.

(E) Failure to provide copies of the records described in these rules to designated Department or Oregon Health Authority entities.

(F) Failure to comply with the Background Check rules in OAR 407-007-0200 (Purpose and Scope) through 407-007-0370 (Variances).

(b) Enrolled Medicaid providers may appeal a termination of their Medicaid provider number based on OAR 407-120-0360 (Consequences of Non-Compliance and Provider Sanctions)(8)(g) and OAR chapter 410, division 120, as applicable.

(c) Enrolled Medicaid providers of ADS must provide advance written notice to the Department at least 30 days prior to no longer providing ADS.