Chapter 514 - Nursing Facility Services - DHHR - State of West ...
Chapter 514 - Nursing Facility Services - DHHR - State of West ...
Chapter 514 - Nursing Facility Services - DHHR - State of West ...
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eimbursement and annually thereafter. The nursing facility provider agreement will certify thatthe nursing facility agrees to follow the Code <strong>of</strong> Federal Regulations, (42 CFR, Part 483, therequirements for <strong>State</strong>s and long term care facilities) and <strong>West</strong> Virginia Legislative Rule Title 64,Series 13 (the <strong>Nursing</strong> Home Licensure Rule) as updated. Upon acceptance for participation asa nursing facility in the Medicaid program, the administrator <strong>of</strong> the facility, under the delegatedauthority <strong>of</strong> the facility’s governing body becomes responsible for ensuring the nursing facilityremains in compliance with the terms <strong>of</strong> the agreement and Medicaid rules and regulations. It isthe responsibility <strong>of</strong> each nursing facility’s administrator to stay apprised <strong>of</strong> any revisions to theMedicaid Provider Manual. Payment to the nursing facility, for covered items and services itfurnishes on or after the approval date <strong>of</strong> the agreement, will require that the facility have arecord keeping capability sufficient for determining the cost <strong>of</strong> 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 source<strong>of</strong> the individual seeking care.The agreement for participation in the Medicaid program by a governing body/designee islimited by compliance with Federal and <strong>State</strong> 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 <strong>of</strong> the denial <strong>of</strong> participation in the Medicaid program, andinclude, in the letter the appeal rights available under 42 CFR 431.153 and 42 CFR 498.3 (b).<strong>514</strong>.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 <strong>of</strong> the provider agreement; temporarymanagement <strong>of</strong> the nursing facility by a designee appointed by the Department <strong>of</strong> Health andHuman Resources; denial <strong>of</strong> payment for new admissions; civil money penalty; state monitoring;transfer <strong>of</strong> resident; transfer <strong>of</strong> resident with closure <strong>of</strong> a facility; and/or reduction <strong>of</strong> bed quotawithout reduction <strong>of</strong> staff. (See 42 CFR 488 Subpart F and WV Legislative Rule 64CSR 13).CMS is responsible for enforcement <strong>of</strong> dually certified facilities.<strong>514</strong>.2.5 OwnershipOwners include any individual, organization, partner and all stockholders <strong>of</strong> organizations whichhave a financial interest in the facility’s operations.<strong>Nursing</strong> facilities that are in compliance with all applicable requirements may participate in theMedicaid program and receive payments regardless <strong>of</strong> the ownership category, i.e., proprietary,Department <strong>of</strong> Health and Human Resources <strong>Chapter</strong> <strong>514</strong>: <strong>Nursing</strong> <strong>Facility</strong> <strong>Services</strong> Page 12January 1, 2013DISCLAIMER: This manual does not address all the complexities <strong>of</strong> Medicaid policies and procedures,and must be supplemented with all <strong>State</strong> and Federal Laws and Regulations.