Effective: September 29, 2013
Latest Legislation: House Bill 59 - 130th General Assembly
As used in this section, "a resident's rights" means the rights of a nursing facility resident under sections 3721.10 to 3721.17 of the Revised Code, the "Social Security Act," sections 1819(c) and 1919(c), 42 U.S.C. 1395i-3(c) and 1396r(c), and federal regulations issued under those sections of the "Social Security Act."
As used in sections 5165.60 to 5165.89 of the Revised Code:
(A) "Certification requirements" means the requirements for nursing facilities established under the "Social Security Act," sections 1819 and 1919, 42 U.S.C. 1395i-3 and 1396r.
(B) "Compliance" means substantially meeting all applicable certification requirements.
(C) "Contracting agency" means a state agency that has entered into a contract with the department of medicaid under section 5165.63 of the Revised Code.
(D)(1) "Deficiency" means a finding cited by the department of health during a survey, on the basis of one or more actions, practices, situations, or incidents occurring at a nursing facility, that constitutes a severity level three finding, severity level four finding, scope level three finding, or scope level four finding. Whenever the finding is a repeat finding, "deficiency" also includes any finding that is a severity level two and scope level one finding, a severity level two and scope level two finding, or a severity level one and scope level two finding.
(2) "Cluster of deficiencies" means deficiencies that result from noncompliance with two or more certification requirements and are causing or resulting from the same action, practice, situation, or incident.
(E) "Emergency" means either of the following:
(1) A deficiency or cluster of deficiencies that creates a condition of immediate jeopardy;
(2) An unexpected situation or sudden occurrence of a serious or urgent nature that creates a substantial likelihood that one or more residents of a nursing facility may be seriously harmed if allowed to remain in the facility, including the following:
(a) A flood or other natural disaster, civil disaster, or similar event;
(b) A labor strike that suddenly causes the number of staff members in a nursing facility to be below that necessary for resident care.
(F) "Finding" means a finding of noncompliance with certification requirements determined by the department of health under section 5165.66 of the Revised Code.
(G) "Immediate jeopardy" means that one or more residents of a nursing facility are in imminent danger of serious physical or life-threatening harm.
(H) "Medicaid eligible resident" means a person who is a resident of a nursing facility, or is applying for admission to a nursing facility, and is eligible for nursing facility services under the medicaid program.
(I) "Noncompliance" means failure to substantially meet all applicable certification requirements.
(J) "Nursing facility" includes a skilled nursing facility to the extent the context requires.
(K) "Repeat finding" or "repeat deficiency" means a finding or deficiency cited pursuant to a survey, to which both of the following apply:
(1) The finding or deficiency involves noncompliance with the same certification requirement, and the same kind of actions, practices, situations, or incidents caused by or resulting from the noncompliance, as were cited in the immediately preceding standard survey or another survey conducted subsequent to the immediately preceding standard survey of the facility. For purposes of this division, actions, practices, situations, or incidents may be of the same kind even though they involve different residents, staff, or parts of the facility.
(2) The finding or deficiency is cited subsequent to a determination by the department of health that the finding or deficiency cited on the immediately preceding standard survey, or another survey conducted subsequent to the immediately preceding standard survey, had been corrected.
(L)(1) "Scope level one finding" means a finding of noncompliance by a nursing facility in which the actions, situations, practices, or incidents causing or resulting from the noncompliance affect one or a very limited number of facility residents and involve one or a very limited number of facility staff members.
(2) "Scope level two finding" means a finding of noncompliance by a nursing facility in which the actions, situations, practices, or incidents causing or resulting from the noncompliance affect more than a limited number of facility residents or involve more than a limited number of facility staff members, but the number or percentage of facility residents affected or staff members involved and the number or frequency of the actions, situations, practices, or incidents in short succession does not establish any reasonable degree of predictability of similar actions, situations, practices, or incidents occurring in the future.
(3) "Scope level three finding" means a finding of noncompliance by a nursing facility in which the actions, situations, practices, or incidents causing or resulting from the noncompliance affect more than a limited number of facility residents or involve more than a limited number of facility staff members, and the number or percentage of facility residents affected or staff members involved or the number or frequency of the actions, situations, practices, or incidents in short succession establishes a reasonable degree of predictability of similar actions, situations, practices, or incidents occurring in the future.
(4) "Scope level four finding" means a finding of noncompliance by a nursing facility causing or resulting from actions, situations, practices, or incidents that involve a sufficient number or percentage of facility residents or staff members or occur with sufficient regularity over time that the noncompliance can be considered systemic or pervasive in the facility.
(M)(1) "Severity level one finding" means a finding of noncompliance by a nursing facility that has not caused and, if continued, is unlikely to cause physical harm to a facility resident, mental or emotional harm to a resident, or a violation of a resident's rights that results in physical, mental, or emotional harm to the resident.
(2) "Severity level two finding" means a finding of noncompliance by a nursing facility that, if continued over time, will cause, or is likely to cause, physical harm to a facility resident, mental or emotional harm to a resident, or a violation of a resident's rights that results in physical, mental, or emotional harm to the resident.
(3) "Severity level three finding" means a finding of noncompliance by a nursing facility that has caused physical harm to a facility resident, mental or emotional harm to a resident, or a violation of a resident's rights that results in physical, mental, or emotional harm to the resident.
(4) "Severity level four finding" means a finding of noncompliance by a nursing facility that has caused life-threatening harm to a facility resident or caused a resident's death.
(N) "State agency" has the same meaning as in section 1.60 of the Revised Code.
(O) "Substandard care" means care furnished in a facility in which the department of health has cited a deficiency or deficiencies that constitute one of the following:
(1) A severity level four finding, regardless of scope;
(2) A severity level three and scope level four finding, in the quality of care provided to residents;
(3) A severity level three and scope level three finding, in the quality of care provided to residents.
(P)(1) "Survey" means a survey of a nursing facility conducted under section 5165.64 of the Revised Code.
(2) "Standard survey" means a survey conducted by the department of health under division (A) of section 5165.64 of the Revised Code and includes an extended survey.
(3) "Follow-up survey" means a survey conducted by the department of health to determine whether a nursing facility has substantially corrected deficiencies cited in a previous survey.
Structure Ohio Revised Code
Chapter 5165 | Medicaid Coverage of Nursing Facility Services
Section 5165.01 | Definitions.
Section 5165.011 | Nursing Facility References.
Section 5165.03 | Admission of Mentally Ill Person to Nursing Facility.
Section 5165.04 | Assessment to Determine Level of Care.
Section 5165.06 | Nursing Facility Eligibility.
Section 5165.07 | Provider Agreement Requirements.
Section 5165.071 | Facility Operator May Contract With More Than One Provider.
Section 5165.072 | Revalidation.
Section 5165.08 | Nursing Facilities' Provider Agreement Terms.
Section 5165.081 | Action Against Facility for Breach of Provider Agreement or Other Duties.
Section 5165.082 | Qualification of Beds.
Section 5165.10 | Annual Cost Report.
Section 5165.101 | Cost of Franchise Permit Fee Not Reimbursable Expense.
Section 5165.102 | Fines Excluded From Cost Report.
Section 5165.103 | Completion of Cost Reports.
Section 5165.104 | Form of Cost Reports; Guidelines.
Section 5165.105 | Addendum for Disputed Costs.
Section 5165.106 | Termination for Failure to File Report.
Section 5165.107 | Amendments to Cost Reports.
Section 5165.108 | Desk Review of Cost Report.
Section 5165.1010 | Nursing Facility Fines.
Section 5165.15 | Calculation of Payments to Nursing Facility Providers.
Section 5165.151 | Initial Rates for New Nursing Facilities.
Section 5165.152 | Payments for Services Provided to Low Resource Utilization Residents.
Section 5165.153 | Rates for Outlier Facilities or Units.
Section 5165.155 | Amount of Payments for Dual Eligible Individuals.
Section 5165.156 | Centers of Excellence Component.
Section 5165.157 | Alternative Purchasing Model for Nursing Facility Services.
Section 5165.16 | Per Medicaid Day Payment Rate for Ancillary and Support Costs; Peer Groups.
Section 5165.17 | Per Medicaid Day Payment Rate for Reasonable Capital Costs.
Section 5165.19 | Per Medicaid Day Payment Rate for Direct Care Costs.
Section 5165.191 | Resident Assessment Data.
Section 5165.192 | Case-Mix Scores for Nursing Facilities.
Section 5165.193 | Exception Review of Assessment Data.
Section 5165.21 | Per Medicaid Day Payment Rate for Tax Costs.
Section 5165.23 | Critical Access Incentive Payments to Qualified Facilities.
Section 5165.26 | Nursing Facility's per Medicaid Day Quality Incentive Payment Rate.
Section 5165.261 | Nursing Facility Payment Commission.
Section 5165.28 | Rate for Added, Replaced, or Renovated Beds.
Section 5165.29 | Cost of Operating Rights for Relocated Beds Not Allowable Cost.
Section 5165.30 | Related Party Costs to Pass Through.
Section 5165.32 | Reduction in Rate Not Permitted.
Section 5165.33 | No Payment for Discharge Date.
Section 5165.34 | Payments Made to Reserve Bed During Temporary Absence.
Section 5165.35 | Payments Made to Facility for Services Provided After Involuntary Termination.
Section 5165.37 | Calculating Rates and Making Payments.
Section 5165.38 | Reconsideration of Rate.
Section 5165.40 | Adjustment of Rates.
Section 5165.41 | Redetermination of Rates.
Section 5165.42 | Additional Penalties.
Section 5165.43 | Determination of Interest Rate.
Section 5165.45 | Deposits to General Revenue Fund.
Section 5165.46 | Administrative Adjudication.
Section 5165.47 | Claim for Medicaid Payment for Service Provided to Nursing Facility Resident.
Section 5165.49 | Post-Payment Reviews of Nursing Facility Medicaid Claims.
Section 5165.50 | Notice of Facility Closure or Withdrawal of Participation.
Section 5165.501 | Compliance With Social Security Act Required.
Section 5165.51 | Notice of Change of Operator.
Section 5165.511 | Agreements With Entering Operators Effective on Date of Change of Operator.
Section 5165.512 | Agreements With Entering Operators Effective on a Later Date.
Section 5165.513 | Entering Operator Duties Under Provider Agreement.
Section 5165.514 | Exiting Operator Deemed Operator Pending Change.
Section 5165.515 | Provider Agreement With Operator Not Complying With Prior Agreement.
Section 5165.516 | Medicaid Reimbursement Adjustments; Change of Operator.
Section 5165.517 | Determination of Change of Operator for Purposes of Licensure Not Controlling.
Section 5165.52 | Overpayment Amounts Determined Following Notice of Closure, Etc.
Section 5165.521 | Withholding Amounts Owed From Medicaid Payments to Exiting Operator.
Section 5165.522 | Cost Report by Exiting Operator; Waiver.
Section 5165.523 | Failure to File Cost Report; Payments Deemed Overpayments.
Section 5165.524 | Final Payment Withheld Pending Receipt of Cost Reports.
Section 5165.525 | Determination of Debt of Exiting Operator; Summary Report.
Section 5165.526 | Release of Amount Withheld Less Amounts Owed.
Section 5165.527 | Release of Amount Withheld on Postponement of Change of Operator.
Section 5165.528 | Disposition of Amounts Withheld From Payment Due an Exiting Operator.
Section 5165.53 | Adoption of Rules Regarding Change in Operators.
Section 5165.60 | Definitions for Sections 5165.60 to 5165.89.
Section 5165.61 | Adoption of Rules.
Section 5165.62 | Enforcement of Provisions.
Section 5165.63 | Contracts With State Agencies for Enforcement.
Section 5165.64 | Annual Standard Surveys.
Section 5165.65 | Exit Interview With Administrator.
Section 5165.66 | Citations for Failure to Comply With One or More Certification Requirements.
Section 5165.67 | Survey Results.
Section 5165.68 | Statement of Deficiencies.
Section 5165.69 | Plan of Correction.
Section 5165.70 | On-Site Monitoring.
Section 5165.71 | Deficiencies Not Substantially Corrected.
Section 5165.72 | Uncorrected Deficiencies Constituting Severity Level Four Findings.
Section 5165.75 | Imposing Remedies and Fines.
Section 5165.76 | Fine Collected if Termination Order Does Not Take Effect.
Section 5165.77 | Emergency Remedies.
Section 5165.771 | Special Focus Facility Program.
Section 5165.78 | Appointment of Temporary Resident Safety Assurance Manager.
Section 5165.79 | Terminating Provider Agreements.
Section 5165.80 | Transfer of Residents to Other Appropriate Care Settings.
Section 5165.81 | Qualifications of Temporary Manager of Nursing Facility.
Section 5165.82 | Residents to Whom Denial of Medicaid Payments Applies.
Section 5165.84 | Order Denying Payment When Deficiency Is Not Corrected Within Time Limits.
Section 5165.85 | Termination of Participation for Failure to Correct Deficiency Within Six Months.
Section 5165.86 | Delivery of Notices.
Section 5165.88 | Confidentiality.
Section 5165.89 | Hearing on Transfer or Discharge of Resident Who Medicaid or Medicare Beneficiary.