Chapter 514 - Nursing Facility Services - DHHR - State of West ...

eimbursement and annually thereafter. The nursing facility provider agreement will certify thatthe nursing facility agrees to follow the Code of Federal Regulations, (42 CFR, Part 483, therequirements for States and long term care facilities) and West Virginia Legislative Rule Title 64,Series 13 (the Nursing Home Licensure Rule) as updated. Upon acceptance for participation asa nursing facility in the Medicaid program, the administrator of the facility, under the delegatedauthority of the facility’s governing body becomes responsible for ensuring the nursing facilityremains in compliance with the terms of the agreement and Medicaid rules and regulations. It isthe responsibility of each nursing facility’s administrator to stay apprised of any revisions to theMedicaid Provider Manual. Payment to the nursing facility, for covered items and services itfurnishes on or after the approval date of the agreement, will require that the facility have arecord keeping capability sufficient for determining the cost of medically necessary servicesfurnished to any Medicaid resident. (See Appendix 1)As a provider participating in the Medicaid program, the governing body/designee must agree toadmit and provide care and services equitably to all individuals, no matter the payment sourceof the individual seeking care.The agreement for participation in the Medicaid program by a governing body/designee islimited by compliance with Federal and State laws, certification rules and regulations. OHFLACdetermines whether a prospective provider is in compliance with the nursing homerequirements. When the facility is in compliance, OHFLAC certifies and recommends that BMSenter into an agreement with the facility. If the facility is determined not be to be in compliance,OHFLAC recommends that BMS deny participation.If OHFLAC recommends that BMS deny participation and BMS accepts that recommendation,BMS will notify the facility in writing of the denial of participation in the Medicaid program, andinclude, in the letter the appeal rights available under 42 CFR 431.153 and 42 CFR 498.3 (b).514.2.4 EnforcementBMS is required by Federal regulations to impose certain enforcement actions on nursingfacilities which are not in compliance with certification rules and regulations. Enforcementaction may include but is not limited to: termination of the provider agreement; temporarymanagement of the nursing facility by a designee appointed by the Department of Health andHuman Resources; denial of payment for new admissions; civil money penalty; state monitoring;transfer of resident; transfer of resident with closure of a facility; and/or reduction of bed quotawithout reduction of staff. (See 42 CFR 488 Subpart F and WV Legislative Rule 64CSR 13).CMS is responsible for enforcement of dually certified facilities.514.2.5 OwnershipOwners include any individual, organization, partner and all stockholders of organizations whichhave a financial interest in the facility’s operations.Nursing facilities that are in compliance with all applicable requirements may participate in theMedicaid program and receive payments regardless of the ownership category, i.e., proprietary,Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 12January 1, 2013DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures,and must be supplemented with all State and Federal Laws and Regulations.