D.C. Mun. Regs. tit. 29, r. 29-5018

Current through Register 71, No. 45, November 7, 2024

Rule 29-5018 - ALTERNATIVE SANCTIONS

5018.1

DHCF may impose alternative sanctions against a Provider in response to receiving complaints or incident reports or upon a recommendation by the Department's Division of Program Integrity or the Long Term Care Administration.

5018.2

DHCF shall determine the appropriateness of alternative sanctions against a Provider based on the following factors:

(a) Seriousness of the violation(s);

(b) Number and nature of the violation(s);

(c) Potential for immediate and serious threat(s) to beneficiaries;

(d) Potential for serious harm to beneficiaries;

(e) Any history of prior violation(s) or sanction(s);

(f) Actions or recommendations by the Department's Division of Program Integrity or the Long Term Care Administration; and

(g) Other relevant factors.

5018.3

DHCF may impose one (1) or more alternative sanctions against a Provider, if the violation does not place the beneficiary's health or safety in immediate jeopardy, as set forth below:

(a) Impose a corrective action plan (CAP);

(b) Prohibit new admissions or place a cap on enrollment;

(c) Place the Provider on an enhanced monitoring plan;

(d) Withhold payments; or

(e) Temporarily suspend the Provider from the DC Medicaid program.

5018.4

A Provider that also provides EPD Waiver services shall be subject to all alternative sanctions set forth in Chapter 42 of Title 29 DCMR.

5018.5

DHCF shall publicize the imposition of an alternative sanction on its website.

5018.6

A CAP may include actions such as publicizing information during regular provider meetings and posting provider performance cards on DHCF's website.

5018.7

DHCF shall issue a written notice of provider termination if DHCF determines that the sanctions listed under Subsection 5018.3 are not appropriate to address the incident(s) and/or complaint(s). DHCF shall reserve the right to terminate a Medicaid provider agreement without a sanction depending on the severity of the violations.

5018.8

If DHCF initiates an action to terminate a provider agreement, DHCF shall follow the procedures set forth in Chapter 13 of Title 29 DCMR governing termination of the Medicaid provider agreement.

5018.9

DHCF may also take actions in lieu of or in addition to an alternative sanction when appropriate. These include the following:

(a) Referral of the incident to another entity, including but not limited to the Medicaid Fraud Control Unit of the Office of the Inspector General for investigation; or

(b) Referral to Adult Protective Services (APS).

5018.10

If DHCF initiates an action to impose an alternative sanction, DHCF shall issue a written not ice to the Provider notifying the Provider of the imposition of an alternative sanction.

5018.11

The notice shall include the following:

(a) The basis for the proposed action;

(b) The specific alternative sanction that DHCF intends to take;

(c) The Provider's right to dispute the allegations and to submit evidence to support his or her position; and

(d) Specific reference to the particular sections of the statutes, rules, provider's manual, and/or provider agreements involved in the sanction.

5018.12

The Provider may submit documentary evidence to DHCF's Long Term Care Administration, 441 4^th St. N.W., Ste. 1000, Washington D.C. 20001 to refute DHCF's argument for imposition of an alternative sanction within thirty (30) days of the date of the notice described in Subsections 5018.10 and 5018.11.

5018.13

DHCF may extend the thirty (30) day period prescribed in Subsection 5018.12 for good cause on a case-by-case basis.

5018.14

If DHCF decides to impose an alternative sanction against the Provider after the Provider has submitted documentary evidence in accordance with Subsection 5018.12, DHCF shall send a written notice to the Provider at least fifteen (15) days before the imposition of the alternative sanction. The notice shall include the following:

(a) The reason for the decision;

(b) The effective date of the sanction; and

(c) The Provider's right to request a hearing by filing a notice of appeal with the District of Columbia Office of Administrative Hearings.

5018.15

If the Provider files a notice of appeal within fifteen (15) days of the date of the notice of the alternative sanction under Subsection 5018.14, then the effective date of the proposed action shall be stayed until the D.C. Office of Administrative Hearings has rendered a final decision.

5018.16

The Director of DHCF may consider modifying the alternative sanction upon occurrence of one of the following:

(a) Circumstances have changed and resulted in changes to the programmatic requirement violation(s) in such a manner as to immediately jeopardize a beneficiary's health, safety, and welfare; or

(b) The Provider makes significant progress in achieving compliance with the programmatic requirements through good faith efforts.

5018.17

A Provider shall be prohibited from submitting an application for participation in the DC Medicaid program for two (2) consecutive years from the date of receipt of the final notice of termination of a Medicaid Provider Agreement.

5018.18

A Provider that has bee n terminated from the DC Medicaid program shall not be paid for claims submitted for dates of service on or after the effective date of the termination decision after the provider exhausts all appeal rights and an official decision of termination has been made.

D.C. Mun. Regs. tit. 29, r. 29-5018

Final Rulemaking published at 64 DCR 10531 (10/20/2017)