[42 Pa.B. 3230]
[Saturday, June 9, 2012]
[Continued from previous Web Page] § 51.27. Misuse and abuse of funds and damage of participant's property.
(a) A provider's records and invoices may be reviewed and the provider may be required to provide a written explanation of billing practices during an audit, fiscal review or provider monitoring.
(b) If the Department's audit, fiscal review or provider monitoring indicates that a provider has been billing for HCBS that are inconsistent with this chapter, unnecessary or inappropriate to a participant's needs or contrary to the participant's ISP, the Department will suspend payment for not more than 120 days pending the Department's review of billing and HCBS.
(c) The Department will notify a provider in writing of a suspension of payment under subsection (b).
(d) In addition to sanctions provided for in this chapter, a provider shall adhere to §§ 1101.74, 1101.75, 1101.76 and 1101.77.
(e) A provider shall either replace property that was lost or damaged, or pay the participant the replacement value for the lost or damaged item if confirmed by the provider, Department or the Department's designee through a review of the circumstances that a participant's personal property was lost or damaged by the provider while providing an HCBS to the participant.
(f) Subsections (a)—(c) do not apply to an SSW provider.
§ 51.28. SCO requirements for Consolidated and P/FDS Waiver.
(a) Payment for supports coordination services is limited to waiver supports coordination, provision of TSM supports coordination and base-funded supports coordination.
(b) An SCO provider shall ensure the following information is included in the ISP:
(1) The assessed need and outcome of the participant that each HCBS addresses.
(2) The type, amount, duration and frequency of each HCBS.
(3) Risk factors and risk mitigation strategies the ISP team determined will mitigate risk factors.
(4) Participant preferences.
(5) Medical history.
(6) Health information.
(7) Functional ability information.
(8) Communication abilities and needs.
(9) Financial information.
(10) HCBS and supports.
(c) An SCO shall ensure the SC completes the following when developing an initial ISP and annual review ISP:
(1) Collaboration with the participant, family, provider and other ISP team members to coordinate a date, time and location for the annual review ISP meeting at least 90 days prior to the end date of the ISP.
(2) Coordination of information gathering and assessment activity, which includes the results from the Statewide needs assessment for the annual review ISP meeting at least 90 days prior to the end date of the ISP.
(3) Distribution of invitations to ISP team members at least 30 days before the ISP meeting is held.
(4) Facilitation of the ISP meeting with team members invited at least 60 days prior to the end date of the ISP.
(5) Submission of the annual review ISP to the Department's designee for approval and authorization at least 30 days prior to the end date of the ISP.
(6) Resubmission of the ISP for approval and authorization within 7 days of the date it was returned to the SCO for revision.
(7) Distribution of the ISP to the participant, family and ISP team members who do not have access to HCSIS within 14 days of its approval and authorization.
(8) Revision of the ISP when there is a change in an assessed need for a participant during an ISP year.
(d) An SCO shall review the Department's residential habilitation service criteria in subsection (e) with the participant and ISP team during the initial ISP, annual review ISP, any other ISP team meeting when a residential habilitation service is being considered for a participant who is currently not authorized for a residential habilitation service and during the 6-month review of the residential habilitation service.
(e) The following residential habilitation service criteria shall be utilized to assist the ISP team in determining if a residential habilitation service is needed or continues to be recommended by the ISP team at the 6-month review:
(1) A person is not willing or able to provide the needed natural supports or paid supports for the participant in a private home.
(2) The participant health, safety and welfare would not be met with a nonresidential habilitation service or natural supports in a private home.
(3) Others would be at risk of harm if a residential habilitation service was not provided for the participant.
(4) Assessments indicate the participant's needs can only be met through the provision of a residential habilitation service.
(5) The residential habilitation setting is the least restrictive and most appropriate size to ensure the participant's health and welfare while continuing to meet the assessed need.
(f) If a residential habilitation service is determined to be needed by the ISP team during the initial ISP, annual review ISP or other ISP team meeting when a residential habilitation service is being considered for a participant who is currently not authorized for a residential habilitation service based on the residential habilitation criteria in subsection (e), the family living residential habilitation service shall be considered first by the ISP team.
(g) When the ISP team proposes a residential habilitation service other than family living residential habilitation services, the proposal must be in accordance with the ISP manual developed by the Department and found on the Department's web site.
(h) For a participant authorized for a residential habilitation service, the SCO shall conduct a monitoring visit and review the residential habilitation service criteria in subsection (e) at least once every 6 months to determine if the participant continues to need the authorized residential habilitation HCBS.
(i) If the 6-month review during a monitoring visit identifies a change in need, an ISP meeting will be convened to discuss potential changes to the ISP.
(j) When an SCO receives a request for enhanced staffing to the residential habilitation service, the SCO shall ensure the SC documents the following in the ISP:
(1) The change in the participant need, including how this change affects the participant's health and welfare.
(2) The assessments used to support the need for residential habilitation enhanced staffing.
(3) What the enhanced staffing support will specifically provide to address the participant's needs.
(4) The plan to reduce the residential habilitation enhanced staffing based on specific outcomes of the participant.
(5) The time frames and the person responsible for monitoring the progression of the plan to reduce the residential habilitation enhanced staffing.
(6) The results of meetings held to re-evaluate the need for continuation of the residential habilitation enhanced staffing.
(7) Adjustments to the participant's ISP.
(k) An SCO shall monitor risk factors and the implementation and impact of risk mitigation strategies during participant monitoring activities.
(l) An SCO shall ensure the SC documents the results of discussions regarding services that require a review more frequently than annually as determined in the approved applicable waiver, including approved waiver amendments.
(m) An SCO shall ensure the SC documents contacts and actions regarding a participant in a service note in HCSIS.
(n) An SCO shall ensure the SC completes the monitoring documents in HCSIS to document findings and concerns of monitoring, as well as resolution of those findings and concerns.
(o) An SCO shall ensure the SC includes in the ISP the participant and ISP team's decision regarding how the participant chooses to use personal funds in the ISP.
(p) This section does not apply to an SCA provider in the Adult Autism Waiver.
§ 51.29. SCA requirements for Adult Autism Waiver.
(a) Payment for SC HCBS is limited to participants who are enrolled in waivers which include SC HCBS.
(b) An SCA shall:
(1) Use assessments to inform HCBS planning.
(2) Develop the participant's ISP when the participant enrolls in the waiver.
(3) Ensure each participant is offered choice of willing and qualified providers by providing the participant and ISP team a list of willing and qualified providers at the annual review ISP meeting or as requested by the participant.
(4) Document annually that the participant or his representative understands the right of choice of willing and qualified providers and have the participant sign the documentation.
(5) Convene the ISP team to conduct a comprehensive review of the ISP at least annually.
(c) An SCA shall complete the following when developing an ISP:
(1) Collaborate with the participant, family, provider and other ISP team members to coordinate a date, time and location for the annual review ISP meeting at least 90 days prior to the end date of the ISP.
(2) Coordinate information gathering and assessment activity for the annual review ISP meeting at least 90 days prior to the end date of the ISP.
(3) Distribute invitations to ISP team members at least 30 days before the ISP meeting is held.
(4) Facilitate the ISP meeting with all ISP team members invited at least 60 days prior to the end date of the ISP.
(5) Submit the ISP to the Department for approval and authorization at least 30 days prior to the end date of the ISP.
(6) Resubmit the ISP for approval and authorization within 7 days of the date it was returned to the SCA for revision.
(7) Distribute the ISP to the participant, family and ISP team members who do not have access to HCSIS within 14 days of its approval and authorization.
(8) Review ongoing HCBS quarterly to ascertain the participant's progress towards each goal specified in the ISP.
(9) Ensure an HCBS is necessary to achieve goals identified in the participant's ISP.
(10) Contact the participant, his guardian or a representative designated by the participant at least once per month to ensure the participant's health and welfare.
(11) Meet with the participant in person at least quarterly. At least one visit each year shall occur in the participant's home and if the participant receives HCBS outside the home one other visit each year shall occur while the participant is receiving the HCBS at the location outside the home and do the following:
(i) Monitor the participant's health and welfare.
(ii) Complete a quarterly summary report and enter it in the Department's designated information system.
(iii) Inform the Department immediately whenever the participant's health and welfare is in jeopardy.
(iv) Take immediate action to assure a participant's health and welfare if the SC believes that a participant's health and welfare is in jeopardy.
(v) Convene an ISP team meeting within 10 days of a crisis to discuss the need to change the ISP if a participant has exhibited serious challenging behaviors or has experienced a crisis episode and does not presently have behavioral specialist HCBS in the ISP or other additional services to ensure a participant's health and welfare.
(12) Ensure that the ISP is being implemented as written.
(13) Assess whether the ISP needs to be revised.
(14) For all ISP updates that change the amount and frequency of an HCBS, the SC shall meet with the participant or reconvene the ISP team to discuss needed changes and revise the ISP.
(15) Review by the SC of the right to fair hearing procedures during the annual review of the ISP and at any time requested by the participant or participant's representative or when HCBS are denied or decreased in the ISP.
(16) Ensure the participant's behavioral support plan and crisis intervention plan are consistent with the ISP if the participant receives Behavioral Specialist HCBS. The SC shall reconvene the ISP team if the behavioral support plan is not consistent with the ISP or the behavioral support plan indicates a change in the ISP may be warranted.
(17) Ensure that the participant's annual level of care re-evaluation is completed and documented by the anniversary date of the current level of care evaluation.
(18) Document activities in HCSIS.
(19) Ensure that staff providing SC are qualified.
(20) Ensure that the maximum caseload for an SC does not exceed the number of participants specified in the approved applicable waiver, including approved waiver amendments, including participants in other HCBS waivers, unless the requirement is waived by the Department or the Department's designee.
(21) Ensure that a conflict of interest does not exist in the delivery of the supports coordination service.
(22) Not provide any other HCBS for a participant unless it enrolls as an OHCDS to provide other HCBS in accordance with the approved applicable waiver, including approved waiver amendments.
§ 51.30. AWC/FMS requirements.
(a) In addition to meeting the requirements in § 51.13 (relating to ongoing responsibilities of providers), an AWC/FMS provider shall ensure the Department's standard AWC/FMS-managing employer agreement is completed with each managing employer when:
(1) A participant is choosing to self-direct HCBS that are determined to be needed and authorized by the Department or the Department's designee in the ISP.
(2) A participant has elected to enroll in the AWC/FMS-managing employer option.
(b) An AWC/FMS provider shall ensure the managing employer complies with the responsibilities outlined in the signed AWC/FMS-managing employer agreement.
(c) An AWC/FMS provider shall fulfill unmet responsibilities of the managing employer.
(d) An AWC/FMS provider shall identify and implement corrective action for managing employer performance issues in accordance with the AWC/FMS-managing employer agreement.
(e) An AWC/FMS provider shall be qualified for participant-directed services.
(f) An AWC/FMS provider shall process and provide vendor goods and services authorized by the Department or the Department's designee to self-directing participants covered by their monthly per participant administrative fee.
(g) An AWC/FMS provider shall distribute a Department-approved satisfaction survey to participants in AWC/FMS.
(h) This section does not apply to a provider of HCBS in the Adult Autism Waiver.
§ 51.31. Transition of participants.
(a) When a participant selects another willing and qualified provider to replace the current provider, both providers shall cooperate with the Department or the Department's designee, the participant and the participant's SCO or SCA during the transition between providers.
(b) The current provider shall ensure the following:
(1) Participation in transition planning meetings to aid in the successful transition to the new willing provider.
(2) Cooperation with visitation schedules identified during the transition meeting.
(3) Arrangement for transportation of the participant to support the visitation schedule.
(4) Closing of open incidents in HCSIS.
(5) Undue influence is not exerted when the participant is making the choice to a new willing and qualified provider.
(c) A provider that is no longer willing to provide an HCBS to a participant shall provide written notice at least 30 days prior to the date of discharge to the participant, the Department, the Department's designee and the SC when the provider is not the SCO or SCA.
(d) The provider shall provide written notification that includes the following:
(1) The HCBS the provider is unwilling or unable to provide.
(2) The HCBS location where the HCBS is currently provided.
(3) The reason the provider is no longer willing to provide the HCBS to the participant.
(4) A description of the efforts made to address or resolve the issue that has led to the provider becoming unwilling or unable to deliver the HCBS to the participant.
(5) Suggested time frames for transitioning the delivery of the HCBS to a selected willing and qualified provider.
(6) The current provider name and Master Provider Index number.
(e) A provider shall continue to provide the authorized HCBS during the transition period to ensure continuity of care until a willing and qualified provider is selected unless otherwise directed by the Department or the Department's designee.
(f) A provider shall provide written notification to the Department or the Department's designee if the provider cannot continue to provide the HCBS until another willing provider is selected due to emergency circumstances.
(g) A selected willing provider shall cooperate with transition planning activities including participation in transition planning meetings.
(h) A current SCO provider shall cooperate with transition planning activities including utilization of HCSIS transfer functionality and participation in all transition planning meetings that occur during the transition period.
(i) A provider shall provide available records to the selected willing provider within 7 days of the date of transfer.
(j) This section does not apply to an SSW provider and an AWC/FMS provider.
§ 51.32. Back-up plans.
(a) A provider shall develop and provide detailed information on the back-up plan for each HCBS the provider renders for a participant to the participant and the SC for inclusion in the ISP.
(b) A provider shall develop a written protocol to ensure the successful implementation of each participant's back-up plan that contains information that:
(1) Assures and verifies the HCBS is being provided at the frequency and duration established in the participant's ISP.
(2) Verifies that the HCBS is provided during a change in staff, such as shift changes or changes in staffing patterns.
(c) A provider shall implement the participant's back-up plan when a participant is available for the authorized HCBS to be delivered and an event occurs which requires the provider to implement the back-up plan so the HCBS continues to be rendered as specified in the approved ISP.
(d) A deviation in frequency or duration of HCBS as specified in the ISP due to failure to implement a back-up plan when a participant is available to receive the HCBS will result in an incident report of provider neglect as specified in § 51.17 (relating to incident management).
(e) This section does not apply to an SSW provider.
§ 51.33. Conflict of interest.
(a) A provider shall develop an internal conflict of interest protocol that, at a minimum, addresses the following areas:
(1) Unbiased decision making by the provider, managers and staff.
(2) No involvement of board members with other provider agencies that are not in accordance with ethical standards of financial and professional conduct.
(3) Documented procedures to determine whether a conflict of interest exists within the organization, including the steps to take if a change in circumstances occurs.
(4) Documented procedures to follow when a conflict of interest is disclosed within the organizational structure.
(5) Documented procedures to follow when a conflict of interest is determined to exist.
(b) A provider shall self-disclose a conflict of interest to the Department.
(c) For payment to be provided for supports coordination HCBS, an SCO shall comply with the conflict free requirements in the approved applicable waiver, including approved waiver amendments.
(d) Subsection (c) does not apply to a provider of HCBS in the Adult Autism Waiver.
(e) Subsections (a), (c) and (d) do not apply to an SSW provider.
§ 51.34. Waiver of a provision of this chapter.
(a) The Department may grant a waiver to a provision of this chapter which is not otherwise required by Federal, State or local requirements and does not jeopardize the health, safety or well-being of the participant.
(b) A waiver request shall be in writing on a form prescribed by the Department.
Subchapter C. PAYMENTS FOR SERVICES GENERAL REQUIREMENTS
Sec.
51.41. SSW provider. 51.42. Definitions. 51.43. Department rates and HCBS classification. 51.44. Payment policies. 51.45. Provider billing. 51.46. Audit requirements. 51.47. Reporting requirements for ownership change. 51.48. Provider in the Adult Autism Waiver. FEE SCHEDULE SERVICES
51.51. Fee schedule applicability. 51.52. Fee schedule rate. 51.53. Fee schedule rate reimbursement. VENDOR GOODS AND SERVICES
51.61. Vendor goods and services applicability. 51.62. Vendor goods and services reimbursement. COST-BASED SERVICES
51.71. Definitions. 51.72. Cost-based rate assignment. 51.73. Cost report requirements. 51.74. Approval of a cost-based rate for nontransportation HCBS. 51.75. Approval of a cost-based rate for transportation. COST-BASED ALLOWABLE COSTS
51.81. Allowable costs. 51.82. Revenues that off-set allowable costs. 51.83. Bidding and procurement. 51.84. Management fees. 51.85. Consultants and contracted personnel. 51.86. Corporate boards. 51.87. Staff development. 51.88. Staff recruitment. 51.89. Travel. 51.90. Supplies and rental of equipment. 51.91. Communications. 51.92. Rental of administrative, residential and nonresidential buildings. 51.93. Other occupancy and allocated occupancy expenses. 51.94. Fixed assets. 51.95. Motor vehicles. 51.96. Capital assets—administrative and nonresidential buildings. 51.97. Capital assets—residential buildings. 51.98. Residential habilitation vacancy. 51.99. Indirect costs. 51.100. Moving expenses. 51.101. Interest expense. 51.102. Insurance. 51.103. Other allowable costs. START-UP COSTS
51.111. Start-up costs. ROOM AND BOARD REQUIREMENTS FOR RESIDENTIAL HABILITATION SERVICES
51.121. Room and board. 51.122. Room and board contract. 51.123. Actual room and board costs. 51.124. Modifications to the room and board contract. 51.125. Completing and signing the room and board contract. 51.126. Copy of room and board contract. 51.127. Delay in a participant's income. 51.128. SNAP, energy assistance, rent rebates and similar benefits. DEPARTMENT-ESTABLISHED FEES
51.131. Department-established fees. ORGANIZED HEALTH CARE DELIVERY SYSTEM
51.141. Organized health care delivery system.
GENERAL REQUIREMENTS § 51.41. SSW provider.
This subchapter does not apply to an SSW provider.
§ 51.42. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
Allowable cost—A necessary cost directly or indirectly associated with the provision of a cost-based services.
Approved cost report—A cost report which complies with the Department's cost-based reporting instructions and passes the Department's desk review.
Attestation engagement—The term includes audits, examinations, reviews, compilations and agreed-upon procedures.
Board—The participant's share of food and food preparation costs.
Cost-based rate-setting methodology—The Department's process of reviewing approved cost reports, aggregating the cost of each cost-based service and then determining the provider specific rate for each cost-based services.
Cost-based services—An HCBS reimbursed through a rate established by aggregating provider cost reports.
Cost report—A data collection tool issued by the Department to collect cost and utilization information from providers that includes supplemental schedules or addenda requested by the Department.
Department-established fee—A non-MA funded fee established by the Department for a portion of an HCBS not eligible for Federal financial participation.
Eligible expenses—Allowable costs that are eligible for Federal financial participation.
FASB—The Financial Accounting Standards Board.
Fee schedule HCBS—An HCBS listed on the MA Program fee schedule.
Fiscal review—A review of billing records against provider documentation to ensure HCBS were provided in the type, amount, duration and frequency as required by the approved ISP.
Fixed asset—A major item, excluding real estate, which can be expected to have a useful life of more than 1 year or that can be used repeatedly without materially changing or impairing its physical condition by normal repair, maintenance or replacement of components.
Funded equity—The value of property over the liability on the property.
GAAP—Generally Accepted Accounting Principles—The standard framework of guidelines for financial accounting used in any given jurisdiction which are generally known as accounting standards.
Indirect cost—Expense allocations and functions which are needed for program operations but not directly related to participant HCBS.
Ineligible costs—Allowable costs that are not eligible for Federal financial participation but are eligible for reimbursement by the Department.
Management fees—Expenses related to charges from a parent or affiliated company of the provider.
Market-based approach—A process used to develop MA or Department-established fees based on independent data sources for a particular waiver service's cost components, including the consideration of reasonable and necessary costs for the delivery of a waiver service.
OMB Circular A-122—Office of Management and Budget Circular A-122, Cost Principles for Non-Profit Organizations.
Rate adjustment factor—A downward adjustment to a rate based on an analysis of State and Federal expenditures that are projected using the proposed payment rates and projected provider utilization compared to the appropriation amounts.
Related party—The term as defined in FASB Accounting Standards Codification Section 850-10-20 as may be amended or superseded by FASB or a successor organization.
Representative payee—A person or organization appointed by the Social Security Administration to receive benefits on behalf of a participant.
Reserved capacity—The capacity held for a participant when the participant has been discharged from the waiver and has been identified by the Department for re-enrollment into the waiver.
Respite care ineligible—The portion of payment for respite care HCBS that is not eligible for Federal financial participation.
Restricted gift—A donation or gift given to an HCBS provider for a specific purpose.
Room—A participant's share of lodging costs which includes utility costs such as electricity, heating, water and sewage. The term also includes annual upkeep costs of the residential habilitation service location including trash collection, general maintenance, necessary repairs and renovation costs.
SNAP—Supplemental Nutrition Assistance Program. The term is also known as food stamps.
SSI—Supplemental Security Income.
Third-party resource—Private or governmental health insurance benefits.
Vacancy factor—A standard factor applied to a provider's cost-based rate to account for when a participant is absent from the residential habilitation service location.
§ 51.43. Department rates and HCBS classification.
(a) An HCBS will be paid as one of the following under §§ 51.53, 51.62, 51.72 and 51.131:
(1) MA fee schedule service.
(2) Vendor good and services.
(3) Cost-based service.
(4) Department-established fee.
(b) The Department will reimburse providers of vendor goods and services in accordance with § 51.62 (relating to vendor goods and services reimbursement).
(c) The Department may establish a fee per unit of HCBS as a Department-established fee by publishing a notice in the Pennsylvania Bulletin.
(d) The Department-established fees are the maximum amount the Department will pay.
(e) A provider may not negotiate a fee or rate with another ODP-funded entity when there is a Department-established fee or rate for the same HCBS at the waiver HCBS location.
§ 51.44. Payment policies.
(a) The Department will only pay for HCBS in accordance with this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies).
(b) When a provision specified in Chapter 1101 or 1150 is inconsistent with this chapter, this chapter is applicable.
(c) The Department will only pay for compensable HCBS up to the amount, duration and frequency as listed on the participant's ISP as approved by the Department or the Department's designee and rendered by the provider.
(d) If an HCBS is allowable under a third-party medical resource, the provider shall bill the third-party medical resource in accordance with § 1101.64 (relating to third-party medical resources (TPR)) before billing a Federal or State-funded program.
(e) If the HCBS is billable under the MA State Plan, a provider shall bill the program under the MA State Plan before billing the HCBS waiver or State-funded programs.
(f) The provider shall retain documentation of the third-party medical resource denial and billing attempts and submissions for an HCBS under the MA State Plan or a third-party medical resource agency for at least 5 years from the provider's State fiscal year-end.
(g) Payments made to a provider under the MA Program constitute payment in full to the provider.
(h) A provider who receives a supplemental payment other than room and board from the Department, the participant or another person for an HCBS shall return the supplemental payment to the payer.
(i) A provider shall comply with §§ 1101.63 and 1101.68 (relating to payment in full; and invoicing for services).
(j) The Department will only pay for HCBS in accordance with the approved applicable waiver and this chapter.
(k) The Department will recoup payments which are not made in accordance with this section.
§ 51.45. Provider billing.
(a) A provider shall submit claims in accordance with § 1101.68 (relating to invoicing for services).
(b) A provider shall use the Department's MMIS to submit claims.
(c) A provider shall only submit claims that are substantiated by documentation in the participant's record.
(d) A provider shall complete and maintain documentation on HCBS delivery in accordance with §§ 51.15 and 51.16 (relating to provider records; and progress notes).
§ 51.46. Audit requirements.
(a) A provider shall comply with audit requirements including:
(1) The Single Audit Act of 1984 (31 U.S.C.A. §§ 7501—7507).
(2) The revised OMB Circular A-133, Audits of States, Local Governments, and Non-Profit Organizations.
(3) Part 92 of 45 CFR (relating to uniform administrative requirements for grants and cooperative agreements to state, local, and tribal governments).
(4) Other applicable Federal and State audit requirements.
(b) A provider that is required to receive a Single Audit or an audit in accordance with 45 CFR 74.26 (relating to non-Federal audits) shall comply with the audit requirements.
(c) The Department or the Department's designee may request a provider to have the provider's auditor perform an attestation engagement in accordance with any of the following:
(1) Government Auditing Standards issued by the Comptroller General of the United States (Generally Accepted Government Auditing Standards).
(2) Standards issued by the Auditing Standards Board.
(3) Standards issued by the American Institute of Certified Public Accountants.
(4) Standards issued by the International Auditing and Assurance Standards Board.
(5) Standards issued by the Public Company Accounting Oversight Board.
(6) Standards of a successor organization to the organizations in paragraphs (1)—(5).
(d) The Department or the Department's designee may perform an attestation engagement in accordance with subsection (c).
(e) A Federal or State agency may request a provider to have the provider's auditor perform an attestation engagement in accordance with subsection (c).
(f) The Department may perform nonaudit services such as technical assistance or consulting engagements.
(g) The Department or the Department's designee may conduct a performance audit in accordance with the standards in subsection (c).
(h) The Department or the Department's designee a Federal agency or State agency may direct the provider to conduct a performance audit in accordance with the standards in subsection (c).
(i) A provider which is not required to have a Single Audit during the State fiscal year shall maintain records in compliance with subsection (c).
(j) The Department or the Department's designee may perform a fiscal review on a provider.
(k) Electronic records must be in accordance with § 51.15 (relating to provider records) and accessible to an auditing agency.
(l) A provider shall make audit documentation available, upon request, to authorized representatives of the Department.
(m) A provider shall preserve books, records and documents related to the State fiscal year for a period that is the greatest of the following:
(1) At least 5 years from the provider's State fiscal year-end.
(2) Until all opened audit issues are closed.
(3) As required under applicable Federal law.
(n) If a program is completely or partially terminated, the records relating to the terminated program shall be preserved and made available for at least 5 years from termination.
(o) A provider shall retain records that relate to litigation or the settlement of claims arising out of performance or expenditures under this program until the litigation, claim or exceptions have reached final disposition or for at least 5 years from the provider's State fiscal year-end, whichever is greater.
§ 51.47. Reporting requirements for ownership change.
(a) A change in ownership or control interest of 5% or more shall be reported in writing to the Department or the Department's designee at least 30 days prior to the date the change is to occur.
(b) If the provider is unable to report an ownership or controlling interest change at least 30 days prior to the date the change is to occur, the provider shall report the change as soon as possible, but no later than 2 business days after the change occurs.
(c) The notification to the Department or the Department's designee must include the following:
(1) The effective date of sale or change.
(2) A copy of the sales agreement or document that related to the change in controlling interest.
(3) A detailed explanation regarding why the provider was unable to report the change within 30 days as specified in subsection (a).
(d) If the provider fails to notify the Department or the Department's designee as specified in subsections (a)—(c), the provider forfeits payment in full for each day after the change occurred.
§ 51.48. Provider in the Adult Autism Waiver.
Sections 51.71—51.75 and 51.81—51.103 (relating to cost-based services; and cost-based allowable costs) do not apply to an HCBS provider in the Adult Autism Waiver.
FEE SCHEDULE SERVICES § 51.51. Fee schedule applicability.
Sections 51.52 and 51.53 (relating to fee schedule rate; and fee schedule rate reimbursement) apply to HCBS provided under the P/FDS, Consolidated or Adult Autism waiver.
§ 51.52. Fee schedule rate.
(a) Fee schedule rates are established using the following methodology:
(1) Market-based approach using the following cost considerations:
(i) Wages for staff.
(ii) Staff-related expenses.
(iii) Productivity.
(A) Indirect program expenses.
(B) Administration-related expenses.
(C) Geographical cost considerations.
(2) Review of approved HCBS definitions and determinations made about cost components which reflect costs that are necessary and related to the delivery of each HCBS.
(3) Use of independent data sources such as the Pennsylvania-specific compensation study and data from previously approved cost reports, as applicable.
(b) The Department will pay for fee schedule services at the rate determined by the Department.
(c) The Department will update the fee schedule rates under the MA Program fee schedule as a notice in the Pennsylvania Bulletin.
(d) Subsection (a)(1)(iii)(C) does not apply to a provider under the Adult Autism Waiver.
§ 51.53. Fee schedule rate reimbursement.
(a) A provider of a fee schedule service shall keep fiscal records as required under § 51.46 (relating to audit requirements).
(b) The following fee schedule services apply to HCBS in the Consolidated and P/FDS Waiver, providers of targeted services management and when a provider provides an HCBS to both waiver and base-funded participants in a waiver HCBS location for the following periods:
(1) For the period July 1, 2011, through November 14, 2011:
(i) Nursing.
(ii) Physical therapy.
(iii) Occupational therapy.
(iv) Speech and language therapy.
(v) Behavior therapy.
(vi) Visual/mobility therapy.
(vii) Companion.
(viii) Supplemental habilitation.
(ix) Additional individualized staffing.
(x) Older adult day habilitation.
(xi) Behavior support.
(xii) Supports broker.
(xiii) Home finding.
(xiv) Homemaker/chore.
(2) For the period beginning November 15, 2011:
(i) Nursing.
(ii) Physical therapy.
(iii) Occupational therapy.
(iv) Speech and language therapy.
(v) Behavior therapy.
(vi) Visual/mobility therapy.
(vii) Companion.
(viii) Supplemental habilitation.
(ix) Additional individualized staffing.
(x) Older adult day habilitation.
(xi) Behavior support.
(xii) Supports broker.
(xiii) Home finding.
(xiv) Homemaker/chore.
(xv) Supports coordination.
(c) AWC/FMS HCBS billed on a fee schedule in accordance with the approved applicable waiver, including approved waiver amendments, must include the following HCBS:
(1) Companion.
(2) Home and community habilitation (unlicensed).
(3) Supports broker.
(4) Supported employment.
(5) Unlicensed respite with the exclusion of respite camp.
(6) Homemaker/chore.
(d) Changes in the list of HCBS under the MA Program fee schedule will be published as a notice in the Pennsylvania Bulletin.
(e) HCBS provided through the Adult Autism Waiver are a fee schedule HCBS in accordance with the approved Adult Autism Waiver.
(f) Subsections (b) and (c) do not apply to a provider of HCBS in the Adult Autism Waiver.
VENDOR GOODS AND SERVICES § 51.61. Vendor goods and services applicability.
Section 51.62 (relating to vendor goods and services reimbursement) applies to HCBS provided as part of the Consolidated, P/FDS and Adult Autism Waivers and when a provider provides an HCBS to both waiver and base-funded participants from a waiver HCBS location as specified in the approved applicable waiver, including approved waiver amendments.
§ 51.62. Vendor goods and services reimbursement.
(a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise:
Vendor—A company that sells goods and services to the general public that also agrees to sell those goods or services to a participant at the same cost they charge to the general public.
Vendor goods and services—A type of service that is offered to the general public and a participant.
(b) In accordance with the approved applicable waiver, including approved waiver amendments, vendor goods and services include the following in the Consolidated and P/FDS Waiver:
(1) Public and mile transportation.
(2) Education support.
(3) Home accessibility adaptations.
(4) Vehicle accessibility adaptations.
(5) Assistive technology.
(6) Respite camp.
(7) Specialized supplies
(c) In accordance with the approved applicable waiver, including approved waiver amendments, vendor goods and services include the following in the Adult Autism Waiver:
(1) Community transition.
(2) Assistive technology.
(3) Environmental modification.
(d) The Department will publish changes to vendor goods and services as a notice in the Pennsylvania Bulletin.
(e) For a provider of a vendor goods and services to receive payment directly from the Department, the vendor shall meet the requirements in §§ 51.11 and 51.13 (relating to prerequisites for participation; and ongoing responsibilities of providers).
(f) A provider of a vendor goods and services may only include administrative expenses in the cost of the vendor goods and services when the following are met:
(1) The amount does not exceed $25 or 15% of the cost of the good or service, whichever is less.
(2) The administrative activity performed must be required for the provider to deliver the vendor goods or services to a participant.
(3) A provider of a vendor goods and services shall document the activity that supports the administrative expense included in the cost of the vendor goods and services.
(g) A provider of vendor goods and services may not be reimbursed for rendering vendor goods and services if it contracts with an entity or participant who is listed on the LEIE, EPLS or Medicheck list.
(h) A provider of vendor goods and services may not be reimbursed for rendering vendor goods and services if it contracts with a provider or individual who employs staff that are listed on the LEIE or EPLS.
(i) A provider of vendor goods and services is responsible for ensuring that each subcontractor with which it contracts meets the applicable provisions of this chapter and the HCBS is rendered in accordance with the approved applicable waiver, including approved waiver amendments.
(j) A vendor shall provide the SCO, the Department or the Department's designee with a signed statement that attests that the:
(1) Cost of the vendor goods or services is the same cost charged to the general public.
(2) Amount added to the cost for administration expenses is in accordance with the Department's requirements in subsection (f)(1)—(3).
(k) The Department or the Department's designee may review documentation of a provider of vendor goods and services at any time.
(l) Subsections (b) and (f) do not apply to a provider of HCBS in the Adult Autism Waiver.
(m) Subsection (c) does not apply to a provider of HCBS in the Consolidated and P/FDS Waivers.
COST-BASED SERVICES § 51.71. Definitions.
The following words and terms, when used in §§ 51.72—51.75, have the following meaning, unless the context clearly indicates otherwise.
Area adjusted average—The assigned rate for an HCBS based on a designated geographical area and mathematical formulary.
Cost of Living Adjustment—An annual adjustment, as appropriated by the General Assembly, applied to a provider's total unit costs.
SSD—Services and Supports Directory—An online database of HCBS providers by geographical area.
§ 51.72. Cost-based rate assignment.
(a) The following HCBS are cost-based services for the Consolidated and P/FDS Waivers, providers of targeted services management and when a provider provides an HCBS to both waiver and base-funded participants from a waiver service location for the following periods as specified in the approved applicable waiver:
(1) For the period July 1, 2011, through November 14, 2011:
(i) Residential habilitation (eligible and ineligible).
(ii) Transportation trip.
(iii) Transportation per diem.
(iv) Supports coordination.
(v) Home and community habilitation (unlicensed).
(vi) Licensed day habilitation under Chapter 2380 (relating to adult training facilities).
(vii) Prevocational.
(viii) Supported employment.
(ix) Transitional work.
(x) Respite, excluding respite camp.
(2) For the period beginning November 15, 2011:
(i) Residential habilitation (eligible and ineligible).
(ii) Transportation trip.
(iii) Transportation per diem.
(iv) Home and community habilitation (unlicensed).
(v) Licensed day habilitation under Chapter 2380.
(vi) Prevocational.
(vii) Supported employment.
(viii) Transitional work.
(ix) Respite, excluding respite camp.
(b) Changes in the list of HCBS as cost-based services will be published as a notice in the Pennsylvania Bulletin.
(c) A provider shall be assigned a cost-based rate for an existing service and service location if the following apply:
(1) The provider is currently billing and is reimbursed for a service that is a cost-based service.
(2) A provider is signed up for both the service and service location in the SSD.
(3) A provider submitted both the service and service location in its approved cost report.
(d) A provider shall be assigned the average of the provider's cost-based rates for an existing service at a new service location if the provider has an approved cost-based rate at another service location.
(e) A provider shall be assigned the area adjusted average of provider cost-based rates for new HCBS if:
(1) The cost report of the provider did not contain the new HCBS because the HCBS was not delivered during the reporting period.
(2) A provider is a new provider who was not delivering HCBS during the reporting period of the cost report.
(f) A provider shall be assigned the lowest rate calculated Statewide based on all provider cost reports for HCBS if a provider was required to submit a cost report and failed to submit a cost report.
(g) A provider who is required to submit an audit who then fails to submit an audit shall receive the lowest rate calculated Statewide.
(h) A provider who submits an audit which indicates the information in the cost report requires adjustment and the provider does not submit a revised cost report, the provider shall be assigned the lowest rate calculated Statewide.
(i) A provider that chooses to not submit a cost report or the cost report the provider submitted is not approved will be assigned the lowest rate calculated Statewide for each cost-based services the provider provides.
§ 51.73. Cost report requirements.
(a) A provider of cost-based services shall submit a cost report as instructed by the Department.
(b) A provider who has one Master Provider Index number shall submit one cost report for that Master Provider Index number.
(c) A provider with multiple Master Provider Index numbers may submit one cost report for all of its Master Provider Index numbers or one cost report for each Master Provider Index number.
(d) Information on the cost report must meet the following:
(1) The cost report must accurately reflect:
(i) The actual cost of the HCBS provided.
(ii) The allowable administration fee for the HCBS provided.
(2) An allowable cost must meet the requirements in § 51.81 (relating to allowable costs).
(e) A cost report or a cost report addenda must:
(1) Comply with the Department's cost report instructions.
(2) Be consistent with this chapter.
(3) Be on a form prescribed by the Department.
(4) Be submitted to the Department by the provider on or before the last business day in the second week of November for nontransportation cost-based services and on or before the last business day in the third week of February for transportation cost-based services as provided in the cost report instructions.
(f) A provider shall do the following to obtain approval of a cost report:
(1) Submit a completed cost report by the due date established by the Department as indicated in the cost report instructions. The cost report must contain information for the development of a cost-based rate as required under this section.
(2) Pass the Department's desk review process.
(3) Include an audit, if required under § 51.46 (relating to audit requirements).
(4) Submit a revised cost report if a provider's audited financial statement differs from a provider's cost report.
(g) When applicable, a provider of a cost-based service shall allocate allowable costs, both eligible and ineligible appropriately in accordance with OMB Circular A-122 or any approved revisions to the OMB Circular A-122.
(h) The Department or the Department's designee will review the cost report for completeness and accuracy based on the Department's cost report instructions.
(i) The Department will use the cost-based rate-setting methodology to establish a rate for cost-based services for each provider with an approved cost report.
(j) The Department will publish the cost-based rate-setting methodology as a public notice in the Pennsylvania Bulletin.
(k) The Department will use the providers' approved cost report as the initial factor in the rate setting methodology to develop the allowable costs for cost-based services.
§ 51.74. Approval of a cost-based rate for nontrans- portation HCBS.
To establish a cost-based rate, the Department will:
(1) Utilize cost data submitted by providers on the standardized cost report developed by the Department.
(2) Review each cost report to ensure the cost report is completed in accordance with § 51.73 (relating to cost report requirements).
(3) Adjust current cost report information based on any changes in the service definitions in the approved applicable waiver, including approved waiver amendments, from the prior cost reporting period.
(4) Identify provider cost reports which are an outlier in comparison to other cost reports submitted. An outlier occurs when the cost report information is at least one standard deviation outside the average unit cost.
(5) Review the outlier information by identifying the average of the unit costs and determining how far above or below the standard deviation they fall.
(6) From July 1, 2011, through June 30, 2012, unit costs flagged as outliers that are determined to be within 5% of the provider's prior year rate for an HCBS will be used to determine the cost-based rate.
(7) From July 1, 2011, through June 30, 2012, the Department will review unit costs flagged as outliers that are not within 5% of the provider's prior year rate for an HCBS and these costs will undergo further review as follows:
(i) If the outlier unit costs are justified by the review, the outlier rate will be accepted.
(ii) If the outlier unit costs are not justified by the review, the outlier rate will be adjusted to be within the standard deviation.
(8) Prior to the effective date of rates, the Department will publish the methodology for calculating unit costs that includes the outlier review process and rate assignment process as a notice in the Pennsylvania Bulletin.
(9) The Department may apply a cost of living adjustment during the rate development and assignment process.
(10) A rate adjustment factor may be applied during the rate development and assignment process.
(11) Prior to rates being established each fiscal year, the outlier analyses, cost of living adjustment and a rate adjustment factor are calculated and may be applied to all cost-based rates.
(12) The Department will publish changes in the rate-setting methodology, including the cost report review, outlier analyses, vacancy factor, rate adjustment factor and rate assignment process, as a notice in the Pennsylvania Bulletin.
(13) The cost-based rate for the residential habilitation service includes necessary household goods and furniture provided for the participant.
(14) A vacancy factor shall be applied to finalize a provider's residential rate.
(15) A provider may request additional staffing costs above what is included in the approved cost report rate for current staffing if there is a new participant entering the program that has above average staffing needs.
(16) If a provider did not submit a cost report, the lowest rate calculated Statewide will be assigned for the HCBS offered in the SSD. If there was a new provider that started HCBS and did not have historical experience, the area average rate will be assigned.
§ 51.75. Approval of a cost-based rate for transportation.
A cost-based rate for transportation is established as follows:
(1) From July 1, 2011, through November 14, 2011, the Department will use data in the Year 2 transportation cost reports (Version 5.0 SFY 2008-2009 Historical Expense Period) submitted by providers and approved by the Department when the procedure codes in the transportation cost reports were the same as those entered in the SSD as of February 2010.
(2) From November 15, 2011, through June 30, 2012, the Department will use data in the Year 3 transportation cost reports (Version 6.0 SFY 2009-2010 Historical Expense Period) submitted by providers and passed the Department's desk review, when available, when the procedure codes in the transportation cost reports were the same as those entered in the SSD as of January 2011.
(3) The Department will review unit costs on a provider transportation cost report that are at the upper or lower end of the range of unit cost for each transportation trip service. When there is an exact match between the procedure code reported on the cost report and the procedure code in the SSD, and the provider was not at the upper or lower end of the range of unit cost, the cost-based rate will be assigned.
(4) If there was not an exact match between the cost report and SSD, the area-average rate will be assigned to the HCBS offered in the SSD but not reported on the cost report.
(5) If the transportation provider did not submit a cost report, the lowest rate calculated Statewide will be assigned for the HCBS offered in the SSD. If there was a new provider that started HCBS and did not have historical experience, the area average rate will be assigned.
COST-BASED ALLOWABLE COSTS § 51.81. Allowable costs.
(a) The allowable cost must be the best price made by a prudent buyer.
(b) Costs must relate to the administration or provision of the HCBS.
(c) Costs must be allocated and distributed to various HCBS or other lines of business among cost categories in a reasonable and fair manner in proportion with the benefits provided to the HCBS or other lines of business among cost categories.
(d) To be an allowable cost under this chapter, the cost must be documented and meet the following:
(1) Be reasonable for the performance of the HCBS.
(2) Conform to any limitations or exclusions in the regulation in accordance with the requirements in the approved applicable waiver, including approved waiver amendments.
(3) Be consistent with policies and procedures that apply uniformly to both Federally-funded and other activities of the organization.
(4) Be determined in accordance with GAAP as a notice in the Pennsylvania Bulletin.
(5) Not be included as a cost or used to meet cost sharing or matching requirements of any other Federally-financed program in either the current or a prior period adjustment.
(e) Transactions involving allowable costs between related parties shall be disclosed to the Department on the cost report.
(f) A cost not listed in this chapter is not an allowable cost.
(g) Effective July 1, 2011, through June 30, 2012, allowable costs that are ineligible may be included in the cost report as instructed.
§ 51.82. Revenues that off-set allowable costs.
(a) A provider shall report donations and contributions according to the following:
(1) List unrestricted cash donations which benefit the direct or indirect expenditures on the cost report as income.
(2) Reduce gross eligible expenditures in arriving at the amount eligible for Departmental participation by the amount of the donation or contribution.
(3) Fully disclose noncash donations to include estimated value and intended use of the donated item.
(4) Treat the proceeds from the sale of a donated item as a cash donation when the donated item is sold rather than used in the HCBS program.
(b) If a donated item is used in an HCBS program, the provider shall claim an expense and offsetting revenue on the donated or contributed item.
(c) A restricted gift used for HCBS may include eligible or ineligible costs to receive the restricted gift.
(d) When a provider solicits for donations, the provider shall publicly identify the purpose for which contributions are solicited and their restricted use, if any.
(e) To receive the donation or gift, the provider shall adhere to the donor's intent for the gift.
§ 51.83. Bidding and procurement.
(a) The provider shall obtain supplies and HCBS at the lowest cost and use a system of competitive bidding or written estimates for any supply and HCBS over $5,000.
(b) Fixed assets for which the contracted agency will hold the title shall be obtained at the lowest cost. Provisions for accomplishing this objective are competitive bidding and written estimates. Should sole source purchases be necessary, a provider is required to obtain and maintain records supporting the justification for the sole source purchase.
§ 51.84. Management fees.
A cost included in a provider's management fees must meet the standards under § 51.81 (relating to allowable costs).
§ 51.85. Consultants and contracted personnel.
(a) The cost of an independent consultant and contracted personnel necessary for the administration or provision of an HCBS is an allowable cost.
(b) A provider shall have a written agreement with a consultant or contracted personnel which must include the following:
(1) The administration or provision of HCBS to be provided.
(2) The method of payment.
(c) The provider shall not include benefits as an allowable cost for contracted staff.
§ 51.86. Corporate boards.
(a) The Department will not participate in wage compensation for members of boards.
(b) Allowable expenses for board members includes payments for actual expenses incurred in connection with meetings and authorized work of the board and the following:
(1) Meals.
(2) Lodging.
(3) Transportation.
(4) Liability insurance coverage for claims against board members that were a result of the board members acting in their official duties.
(5) Training expenses related to the delivery of HCBS.
§ 51.87. Staff development.
The Department will allow the cost of staff training or the cost of continued training to the extent that the training is related to the delivery or improvement of an HCBS.
§ 51.88. Staff recruitment.
The cost incurred in staff recruitment activity is an allowable cost as follows:
(1) Informational mailings to recruit potential staff.
(2) Informational mailings to prospective staff, upon request by a participant or family member.
(3) Job fairs.
(4) Creation and maintenance of web sites providing information.
(5) Responses to participant and family member inquiries regarding recruiting potential staff.
(6) Market research.
(7) Advertisements.
§ 51.89. Travel.
(a) Travel costs related to supporting the administration or provision of an HCBS are allowable and include the following:
(1) Transportation.
(2) Lodging.
(3) Meals.
(b) A provider shall ensure the transportation cost is limited to the Department-established travel reimbursement provisions.
§ 51.90. Supplies and rental of equipment.
(a) The purchase of supplies and equipment are allowable costs in accordance with OMB Circular A-122.
(b) A provider claiming supplies or equipment as an allowable cost shall only claim supplies or equipment used in the normal course of business.
(c) Rental of program equipment or furnishings are allowable costs if normal usage does not warrant its purchase or if renting is more cost-efficient.
(d) A provider shall ensure equipment not expensed in the current fiscal year is depreciated by using the straight line method of depreciation.
§ 51.91. Communications.
Communication and supply costs to support the administration or provision of an HCBS are allowable costs, which include the following:
(1) Telephone—conventional and cellular.
(2) Internet connectivity.
(3) Digital imaging.
(4) Postage.
(5) Stationery.
(6) Printing.
§ 51.92. Rental of administrative, residential and nonresidential buildings.
(a) The cost of a building or office rented or leased from a related or unrelated party for a programmatic purpose for an HCBS is an allowable cost, subject to the following:
(1) A provider shall ensure a new lease with an unrelated party contains a provision that the cost of rent may not exceed the rental charge for similar space in that geographical area.
(2) A provider shall ensure that under a lease with a related party the cost of rent is limited to the lessor's actual allowable costs, as provided in § 51.96 (relating to capital assets—administrative and nonresidential buildings).
(3) A provider shall ensure the rental cost under a sale-leaseback transaction, as described in FASB Accounting Standards Codification Section 840-40, as may be amended or superseded by FASB, or any successor organization, is only considered an allowable cost up to the amount that would have been allowed had the provider continued to own the property.
(b) The allowable cost amount may include an expense for the following:
(1) Maintenance.
(2) Real estate taxes, as limited by § 51.93 (relating to other occupancy and allocated occupancy expenses).
(c) A provider shall only include expenses related to the minimum amount of space necessary for the provision of the HCBS.
(d) A rental cost under a lease which is required to be treated as a capital lease under FASB Accounting Standards Codification Section 840-10-25-1, as may be amended or superseded by FASB or a successor organization, is allowable up to the amount that would have been allowed had the provider purchased the property on the date the lease agreement was executed. An unallowable cost includes an amount paid for the following:
(1) Profit.
(2) Management fee.
(3) A tax not incurred had the provider purchased the facility.
§ 51.93. Other occupancy and allocated occupancy expenses.
(a) The following are considered allowable costs:
(1) The cost of a required occupancy-related tax and payment made instead of a tax.
(2) An associated occupancy cost charged to a given service location. The provider shall ensure the cost is prorated in direct relation to the amount of space utilized by the service location.
(3) The cost of an occupancy-related tax or payment made instead of a tax, if it is stipulated in a lease agreement.
(4) The cost of a required occupancy permit.
(b) A provider shall maintain documentation in accordance with § 51.46 (relating to audit requirements) that a utility charge is at fair market value.
(c) The cost of real estate taxes, net of rebates or discounts available to the provider, whether taken or not, is an allowable cost.
(d) The cost of a penalty resulting from a delinquent tax payment, including a legal fee, is not an allowable cost.
§ 51.94. Fixed assets.
(a) A fixed asset is an allowable cost.
(b) A provider shall determine whether an allowable fixed asset shall be capitalized, depreciated or expensed under the following conditions:
(1) The maximum allowable fixed asset threshold as defined in the OMB Circular A-122 or subsequent updates.
(2) Purchases below the maximum allowable fixed asset threshold shall be expensed.
(c) A provider shall select the method used to determine the amount of depreciation charged in that year for the year of acquisition.
(d) A provider shall include depreciation based on the number of months or quarters the asset is in service or a half-year or full-year of depreciation expense.
(e) A provider may not change the method or procedure, including the estimated useful life and the convention used for an acquisition, for computing depreciation without prior written approval from the Department.
(f) A provider acquiring a new asset shall have the asset capitalized and depreciated in accordance with GAAP. The provider shall continue using the depreciation method previously utilized by the provider for assets purchased prior to July 1, 2011.
(g) A provider shall retain the following:
(1) The title to any fixed assets which are depreciated.
(2) The title to any fixed assets which are expensed or loans amortized using Department funding.
(h) A provider shall use income received when disposing of fixed assets to reduce gross eligible expenditures in determining the amount eligible for Departmental participation as determined by the cost report.
(i) A provider in possession of a fixed asset shall do the following:
(1) Maintain a fixed asset ledger or equivalent document.
(2) Utilize reimbursement for loss, destruction or damage of a fixed asset by using the proceeds towards eligible waiver program expenditures.
(3) Perform an annual physical inventory at the end of the funding period or State fiscal year. An annual physical inventory is performed by conducting a physical verification of the inventory listings.
(4) Document discrepancies between physical inventories or fixed asset ledgers.
(5) Maintain inventory reports and other documents in accordance with § 51.46 (relating to audit requirements).
(6) Offset the provider's total depreciation expense in the period in which the asset was sold or retired from service by the gains on the sale of assets.
(j) The cost basis for depreciable assets must be determined and computed as follows:
(1) The purchase price if the sale was between unrelated parties.
(2) The seller's net book value at the date of transfer for assets transferred between related parties.
(3) The cost basis for assets of an agency acquired through stock purchase will remain unchanged from the cost basis of the previous owner.
(k) Participation allowance is permitted up to 2% of the original acquisition cost for fully depreciated fixed assets.
(1) Participation allowances can only be taken for as long as the asset is in use.
(2) Participation amounts must be used for maintaining assets, reinvestment in the program or restoring the program due to an unforeseen circumstance.
(3) Depreciation and participation allowance cannot be expensed at the same time for the same asset.
§ 51.95. Motor vehicles.
(a) The Department will pay for the cost of the purchase or lease of motor vehicles and the operating costs of the vehicles.
(b) The Department will pay for the cost of the purchase or lease of motor vehicles according to the following:
(1) The Department will participate in the cost of motor vehicles through depreciation, expensing or amortization of loans for the purchase. The Department will limit depreciation or lease payments, or both, in accordance with the annual limits established under section 280F of the Internal Revenue Code (26 U.S.C.A. § 280F).
(2) A provider shall maintain a daily log detailing the use, maintenance and services activities of vehicles.
(3) Cost differentials between leasing and purchase of vehicles shall be explored and the most feasible economic alternative selected. Documentation showing the options that were explored shall be maintained.
(4) The personal use of a provider's motor vehicles used by staff is prohibited unless a procedure for payback is established and the staff reimburses the program for the personal use of the motor vehicle.
§ 51.96. Capital assets—administrative and nonresidential buildings.
(a) An administrative or nonresidential building acquired prior to June 30, 2009, that is in use for which a provider has an outstanding original loan with a term of 15 years or more is an allowable cost for the provider to continue to claim principal and interest payments for the administrative or nonresidential building over the term of the loan.
(b) A provider shall ensure a down payment made as part of the asset purchase must be considered part of the cost of the administrative or nonresidential building or capital improvement and depreciated over the useful life of the administrative or nonresidential building or capital improvement.
(c) A provider shall receive prior written approval from the Department for a planned major renovation of an administrative or nonresidential building with a cost above 25% of the original cost of the administrative or nonresidential building being renovated.
(d) A provider shall use the depreciation methodology in accordance with § 51.94 (relating to fixed assets).
(e) A provider may not claim a depreciation allowance on an administrative or nonresidential building that is donated.
(f) If an administrative or nonresidential building is sold or the provider no longer provides an HCBS at the administrative or nonresidential building, the Department shall recoup the funded equity either directly or through rate setting. The provider shall be responsible for calculating the amounts reimbursed and the amounts shall be verified by an independent auditor. As an alternative to recoupment, with Department approval, the provider can reinvest the reimbursement amounts from the sale of the administrative or nonresidential building into any capital asset used in the program.
(g) The title of any administrative or nonresidential building acquired and depreciated shall remain with the enrolled provider.
§ 51.97. Capital assets—residential buildings.
For a provider owning new or existing residential buildings, the following shall apply for the costs of the residential buildings to be an allowable cost:
(1) A provider shall ensure an allowable cost for a capital asset for a residential building acquired prior to July 1, 2011, is governed by applicable agreements in place at the time of purchase.
(2) A provider shall depreciate a capital improvement of a residential building or land identified over the estimated useful life of the residential building or improvements using the straight line method of depreciation.
(3) A down payment made by the provider as part of the asset purchase shall be considered part of the cost of the residential building or capital improvement and depreciated over the useful life of the residential building or capital improvement.
(4) A provider shall receive written approval from the Department prior to a planned major renovation of a residential building with a cost above 25% of the original cost of the residential building being renovated.
(5) If a residential building is sold or the provider no longer provides an HCBS in that residential building, the Department shall recoup the funded equity either directly or through rate setting. The provider shall be responsible for calculating the amounts reimbursed and the amounts shall be verified by an independent auditor. As an alternative to recoupment, with Department approval, the provider can reinvest the reimbursement amounts from the sale of the residential building into any capital asset used in the program.
(6) The title of any residential building acquired and debt-free shall remain with the enrolled provider.
§ 51.98. Residential habilitation vacancy.
(a) From July 1, 2011, through November 14, 2011, the Department's residential habilitation vacancy policy consists of the following:
(1) Payments to residential habilitation service providers operating waiver service locations for an unlimited number of medical leave days per participant each fiscal year are as follows:
(i) The first day of absence for medical leave is the date the participant is admitted to the medical facility regardless of the length of the absence.
(ii) The last day of the medical leave is the day before the date of discharge from the medical facility.
(iii) On the date of discharge, the HCBS is considered a residential habilitation service day, not a medical leave day, regardless of the number of hours the residential habilitation service is provided on that day.
(2) Payments to residential habilitation service providers operating waiver HCBS locations for up to 48 days of therapeutic leave per participant each State fiscal year. The first day of absence for therapeutic leave is defined as 12 to 24 hours of continuous absence within a 24-hour period between 12:00 a.m. and 11:59 p.m. when the participant is not accompanied by or receiving HCBS from the residential habilitation service provider.
(3) Payments to licensed residential habilitation providers under Chapters 3800, 5310 and 6400 (relating to child residential and day treatment facilities; community residential rehabilitation services for the mentally ill; and community homes for individuals with mental retardation) will be made for permanent vacancies for participants enrolled in the Consolidated Waiver up to 60 days unless the provider uses the permanent vacancy for an alternative purpose.
(b) From November 15, 2011, through June 30, 2012, the Department will make payments to residential habilitation service providers for therapeutic and medical leave days up to a combined maximum of 60 days per participant, per fiscal year.
(c) From November 15, 2011, through June 30, 2012, the Department will provide payments to licensed residential habilitation service providers under Chapters 3800, 5310 and 6400 up to a maximum of 30 days per participant per State fiscal year for a permanent vacancy that occurs in the licensed residential habilitation community home.
(d) The Department will establish a vacancy factor for all waiver residential habilitation services by publication of a notice in the Pennsylvania Bulletin.
(e) The vacancy factor for residential habilitation services shall be managed by the provider across all the provider's residential habilitation service locations.
(f) A provider may submit a request for a waiver to the Department under § 51.34 (relating to waiver of a provision of this chapter) for exception to the vacancy factor when a provider's total vacancy amount for waiver residential HCBS locations exceeds the vacancy factor.
(g) To submit a request for a waiver under § 51.34 to the Department for exception to the vacancy factor, the provider shall do the following:
(1) Demonstrate that without being granted an exception to the vacancy factor the provider's continued operation is jeopardized. This demonstration shall be based on actual utilization data from the provider's waiver residential habilitation service locations to show that leave days resulting from hospital and rehabilitation care for all residential sites the provider operates falls below the vacancy factor set by the Department.
(2) Describe the financial impact to the provider if a vacancy exception is not approved. The financial impact must include:
(i) The information related to personnel expenses.
(ii) The need for borrowing above historic numbers.
(iii) The impacts on a provider's ability to fulfill ISP requirements.
(3) Explain the circumstances related to vacancies and revenue the provider has received for rendering another service in the vacancies.
(h) Approval of the request for a waiver under § 51.34 to the Department for exception to the vacancy factor will be at the sole discretion of the Department.
(i) A provider may not have a policy that limits the leave days to a participant.
(j) A provider may not discuss the vacancy factor with a participant or the participant's family.
(k) A provider may not initiate a discharge of a participant due to the participant's vacancy from the program until after the provider has contacted the Department to discuss and resolve the provider's concern related to the vacancy.
(l) A provider shall comply with reserved capacity requirements in the approved applicable waiver, including approved waiver amendments.
(m) A provider shall cooperate with the Department or the Department's designee when a participant is identified in reserved capacity to ensure the participant can return to the waiver residential habilitation service location in accordance with the reserved capacity timelines in the approved applicable waiver, including approved waiver amendments.
§ 51.99. Indirect costs.
(a) Indirect costs are allowable costs if the following criteria are met:
(1) The provider shall have a cost allocation plan.
(2) Costs are authorized in accordance with OMB Circular A-122 and § 51.81 (relating to allowable costs).
(b) A provider shall consider the actual circumstances impacting the expense when determining how to allocate the expense to each benefiting HCBS or function.
(c) If a cost is identified as an indirect cost, the cost will remain an indirect cost as long as circumstances remain unchanged.
(d) A provider shall select an allocation method to assign an indirect cost which must comply with the following:
(1) The method is best suited for assigning a cost with a benefit derived.
(2) The method has a traceable cause and effect relationship.
(3) The method is based on logic and reason when neither the cause nor the effect of the relationship is determinable.
(e) A provider shall allocate a general expense in a cost group which is more general in nature which produces a result that is equitable to both the Department and the provider.
(f) The Department may request the allocation method be reviewed by an auditor.
§ 51.100. Moving expenses.
(a) With prior written approval from the Department or the Department's designee, the actual cost associated with the relocation of a waiver service location is an allowable cost.
(b) Moving expenses for a participant's move are an allowable cost provided that the provider notifies and receives the Department's or the Department's designee authorization prior to the participant moving.
§ 51.101. Interest expense.
Interest cost of short-term borrowing from an unrelated party to meet actual cash flow requirements for the administration or provision of an HCBS is an allowable cost.
§ 51.102. Insurance.
The cost of insurance is an allowable cost if it is limited to the minimum amount needed to cover the loss or provide for replacement value. Cost of insurance includes the following:
(1) General liability.
(2) Casualty.
(3) Property.
(4) Theft.
(5) Burglary insurance.
(6) Fidelity bonds.
(7) Rental insurance.
(8) Flood insurance, if required.
(9) Errors and omissions.
§ 51.103. Other allowable costs.
(a) The following fees and costs are allowable costs if they are related to the administration of HCBS:
(1) Legal fees with the exception of those listed in subsection (b).
(2) Accounting fees, including audit fees.
(3) Information technology costs.
(4) Membership dues.
(b) Legal fees for prosecution of claims against the Commonwealth and expenses incurred for claims against the Commonwealth are not allowable costs unless the provider prevails at the hearing.
START-UP COSTS § 51.111. Start-up costs.
(a) The Department will participate in start-up costs for residential habilitation service providers in accordance with SOP 98-5 issued by the American Institute of Certified Public Accountants or a statement of position that supersedes the current position.
(b) Start-up costs are contingent on Federal approval of a waiver or available State-only funds within the waiver appropriation.
(c) The Department shall recoup start-up costs if the residential habilitation service location is sold within a 5-year period. As an alternative to recoupment, with Department approval, the provider can reinvest the reimbursement amounts from the start-up funds into any capital asset used in the program.
(d) Start-up costs that have been reimbursed by the Department shall be reported as income.
(e) Start-up costs within the scope of SOP 98-5 need to be expensed as they are incurred, rather than capitalized.
(f) Start-up costs will be capped at $5,000 per new participant to the provider.
(g) Start-up costs defined to be outside the scope of SOP 98-5 shall include the following:
(1) Costs of acquiring or constructing long-lived assets and preparing them for intended uses.
(2) Costs of acquiring or producing inventory.
(3) Costs of acquiring intangible assets.
(4) Costs related to internally developed assets.
(5) Costs that are within the scope of FASB Statement No. 2, Accounting for Research and Development Costs (superseded by FASB Accounting Standards Codification Section 730) and FASB Statement No. 71, Accounting for the Effects of Certain Types of Regulation (superseded by FASB Accounting Standards Codification Section 980) available at http://cpaclass.com/gaap-accounting-standards/codification-900/asc-codification-900-index.htm.
(6) Costs of raising capital.
(7) Costs incurred in connection with existing contracts as stated in paragraph 75d of AICPA Statement of Position No. 81-1, Accounting for Performance of Construction-Type and Certain Production Type Contracts (SOP 81-1) (superseded by FASB Accounting Standards Codification Section 605-35-25-41).
ROOM AND BOARD REQUIREMENTS FOR RESIDENTIAL HABILITATION SERVICES § 51.121. Room and board.
(a) A provider shall cooperate with monitoring of room and board charges and collections conducted by the Department or the Department's designee.
(b) If a participant is not currently receiving SSI benefits, assistance shall be provided to the participant to contact the appropriate county assistance office so that the participant can obtain benefits.
(c) If a participant is denied benefits, the provider shall assist the participant in filing an appeal if desired.
(d) If actual room and board costs are 72% or more of the SSI maximum rate, the Department will use the following criteria to establish room and board rates:
(1) A participant's share of room and board shall not exceed 72% of the SSI maximum rate.
(2) The proration of board costs is to occur for every day the participant is on leave from the residence. This proration can occur monthly, quarterly or semiannually as long as there is a record that the board costs were returned to the participant for every day of leave.
(e) If a participant has earned wages, personal income from inheritance, Social Security or other types of income, the agency provider may not assess the room and board cost for the participant in excess of 72% of the SSI maximum rate.
(f) If available income for a participant is less than the SSI maximum rate, the provider shall charge 72% of the participant's available monthly income as the participant's monthly obligation for room and board.
(g) A participant shall receive at least the monthly amount as established by the Commonwealth and the Social Security Administration for the participant's personal needs allowance.
(h) If actual room and board charges to a participant are less than 72% of the SSI maximum rate, the agency provider shall retain the following documentation:
(1) The actual value of the room and board is less than 72% of the current maximum SSI monthly benefit.
(2) The Social Security Administration's denial of the participant's initial application for SSI benefits, but also the upholding of the initial denial as a result of at least one appeal.
(i) The provider shall assist the participant to secure information regarding the continued eligibility benefits of the participant.
(j) There may not be a charge for room and board to the participant for respite care if respite care is provided for 30 or fewer days in a State fiscal year.
(k) There may not be a charge for room and board to the participant from the waiver after 30 consecutive days of being in a hospital or rehabilitation facility and the participant is placed in reserved capacity.
(l) The provider shall collect the room and board from the participant or representative payee directly and shall not delegate that responsibility.
(m) There may be no charge for board to the participant if the participant is tube-fed and takes nothing by mouth.
§ 51.122. Room and board contract.
(a) A Department-approved room and board contract shall be used by a provider for a participant receiving a residential habilitation service.
(b) A provider shall ensure a standard room and board contract is signed and complete for a participant as specified in subsection (a) on an annual basis.
§ 51.123. Actual room and board costs.
(a) A provider shall ensure the total amount charged for room and board to a participant does not exceed the actual documented value of room and board provided to the participant.
(b) A provider shall compute and document actual room and board costs each time a participant signs a new standard room and board contract under § 51.122 (relating to room and board contract).
(c) A provider shall keep documentation of actual room and board costs on file.
§ 51.124. Modifications to the room and board contract.
(a) If a participant pays rent directly to a landlord, but food is supplied through a provider, ''room'' shall be deleted from the room and board contract and the following shall apply:
(1) The participant shall pay 32% of the SSI maximum rate for board.
(2) If a participant's income is less than the SSI maximum rate, 32% of the available income shall be charged to fulfill the participant's monthly obligations for board.
(b) If a participant pays rent to a provider, but the participant purchases the participant's own food, ''board'' shall be deleted from the room and board contract and the following shall apply:
(1) The participant shall pay 40% of the SSI maximum rate for room.
(2) If a participant's income is less than the SSI maximum rate, 40% of the available income shall be charged to fulfill the participant's monthly obligations for room.
§ 51.125. Completing and signing the room and board contract.
(a) If a participant is adjudicated incompetent to handle finances, the participant's surrogate shall sign the room and board contract.
(b) If a participant is 18 years of age or older and is not the representative payee for the participant's benefits, the representative payee and the participant shall sign the room and board contract.
(c) The written room and board contract shall be completed and signed in accordance with one of the following:
(1) Prior to a participant's admission to a residential habilitation service location.
(2) Prior to a participant's transfer from one residential habilitation service location or provider to another residential habilitation service location or provider.
(3) Within 15 days after an emergency residential habilitation service location placement.
§ 51.126. Copy of room and board contract.
(a) A copy of the completed and signed room and board contract shall be given to the participant or participant's surrogate under § 51.125(a) (relating to completing and signing the room and board contract).
(b) A copy of the completed and signed room and board contract shall be maintained in the participant's record at the agency provider.
§ 51.127. Delay in a participant's income.
If a portion or all of the participant's income is not received for a month or more, the following apply:
(1) The requirements for the completion and signing of the Department-approved room and board contract under §§ 51.121—51.126 shall be fulfilled.
(2) The participant shall be informed in writing that payment is not required or only a small amount of room and board payments will be required until retroactive monthly benefits are received.
(3) Room and board shall be charged to make up the accumulated difference between room and board actually paid and room and board charged according to the signed room and board contract under § 51.122 (relating to room and board contract).
§ 51.128. SNAP, energy assistance, rent rebates and similar benefits.
(a) A provider shall assist a participant in applying for SNAP, energy assistance, rent rebates and similar benefits.
(b) If energy assistance, rent rebates or similar benefits are received, the provider shall deduct the value of these benefits from the room and board costs before reductions are made from the participant's share of room and board costs.
(c) A participant's SNAP may not be considered as part of a participant's income or resources.
(d) A provider may not use the value of SNAP to increase the participant's share of room and board costs.
DEPARTMENT-ESTABLISHED FEES § 51.131. Department-established fees.
(a) From July 1, 2011, through June 30, 2012, the Department is authorized to establish fees for the ineligible portion of the payment for respite care ineligible HCBS.
(b) The Department will establish fees for the ineligible portion of payment for residential habilitation services and publish the fees as a notice in the Pennsylvania Bulletin.
(c) The Department will apply a vacancy factor to the ineligible portion of payment across the provider's residential habilitation service locations.
(d) The Department-established fees are established using the following methodology:
(1) Market-based approach.
(2) Use of independent data sources including validation against previously approved cost reports, as applicable.
(3) Geographic cost considerations.
(e) Subsections (a) and (d)(3) do not apply to a provider of HCBS in the Adult Autism Waiver.
ORGANIZED HEALTH CARE DELIVERY SYSTEM § 51.141. Organized health care delivery system.
(a) An OHCDS shall:
(1) Be an enrolled MA waiver provider.
(2) Be enrolled in the Department's MMIS.
(3) Provide at least one direct MA service.
(4) Agree to provide the identified vendor goods or services to participants.
(5) Bill the Department's MMIS for the amount of the vendor goods or services.
(6) Pay the vendor which provided the vendor goods or services the amount billed for in the MMIS.
(b) An OHCDS may bill a separate administrative fee under the following:
(1) The administrative per transaction fee may not exceed $25 or 15% of the cost of the HCBS, whichever is less.
(2) The administrative activities must be required to deliver the vendor good or HCBS to a participant and must be documented to support the separate administrative fee.
(c) An OHCDS will not be reimbursed for the HCBS or the Department-established administrative fee if it contracts with a provider who is listed on the LEIE, EPLS or Medicheck list.
(d) An OHCDS will not be reimbursed for rendering OHCDS if it contracts with a provider who employs staff who is listed on the LEIE or EPLS.
(e) The OHCDS is responsible for ensuring that each vendor with which it contracts meets the applicable provisions of this chapter and in accordance with the requirements specified in the approved applicable waiver, including approved waiver amendments.
(f) Only vendor goods and services may be subcontracted through the OHCDS. A provider who subcontracts shall have written agreements specifying the duties, responsibilities and compensation of the subcontractor.
(g) An OHCDS shall provide the SC, the Department or the Department's designee with a signed statement including the following:
(1) Attestation that the cost of the good is the same cost charged to the general public.
(2) Identification of the administrative fee that is in accordance with the Department's established administrative fee.
(h) Subsections (c)(1) and (2) and (h)(2) do not apply to an OHCDS under the Adult Autism Waiver.
Subchapter D. CLOSURES AND TERMINATION Sec.
51.151. Definitions. 51.152. Termination of provider agreement. 51.153. Sanctions. 51.154. SCO and SCA provider closure requirements. 51.155. Provider closure requirements. 51.156. AWC/FMS closure requirements. 51.157. Appeals. § 51.151. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
Attestation engagement—The term includes audits, examinations, reviews, compilations and agreed-upon procedures.
Closing provider—A provider that is terminating HCBS for the participants it serves.
Closing SCO provider—An SCO or SCA that is terminating support coordination HCBS for the participants it serves.
Compliance attestation—A document issued by a third party that assures a provider's compliance with this chapter.
Selected and willing provider—The HCBS provider which the participant is transferring to.
Selected and willing SCO provider—The SCO provider the participant is transferring to.
§ 51.152. Termination of provider agreement.
(a) A provider's MA provider agreement or MA waiver provider agreement, or both, may be terminated based upon one of the following:
(1) The provider has not complied with the terms of the MA waiver provider agreement or MA provider agreement.
(2) The provider has committed a violation as listed under §§ 1101.75 and 1101.77 (relating to provider prohibited acts; and enforcement actions by the Department).
(3) The provider fails to render the HCBS and protect the health and welfare of a participant.
(4) The provider fails to meet a provision of this chapter.
(5) The provider fails to deliver an HCBS in the type, amount, frequency and duration authorized in the ISP when the participant is available for the delivery of the HCBS.
(6) The provider submits a fraudulent claim.
(7) The provider fails to develop or implement a CAP or DCAP timely.
(8) The provider fails to comply with the provider monitoring requirements in § 51.24 (relating to provider monitoring).
(9) The provider fails to comply with applicable Federal and other State laws and this chapter.
(10) The provider is identified on one of the following lists:
(i) EPLS.
(ii) LEIE.
(iii) Medicheck.
(b) This section does not apply to an SSW provider.
§ 51.153. Sanctions.
If a provider fails to provide an attestation engagement, fiscal review or compliance attestation that is accepted by the Department or is in noncompliance with this chapter, the Department may initiate sanctions against the provider including the following:
(1) Withholding or disallowing all or a portion of future payments.
(2) Suspending payment or future payments pending compliance.
(3) Recouping payments for HCBS the provider cannot verify through documentation as rendered in the amount, duration and frequency billed.
§ 51.154. SCO and SCA provider closure requirements.
(a) In addition to the requirements in § 51.155 (relating to provider closure requirements), a closing SCO or SCA shall meet the requirements of this section.
(b) A closing SCO or SCA provider shall provide written notice to the participant and the Department or the Department's designee at least 90 days prior to the SCO or SCA closing. The written notice must include verification of the activities as required under subsection (c).
(c) A closing SCO or SCA shall complete the following activities when terminating supports coordination HCBS:
(1) Provide written notification to the Department of its intent to terminate the MA provider agreement and the MA waiver provider agreement.
(2) Provide an effective date of termination.
(3) Develop a transition plan for each participant that affords participant choice and provide it to the Department's designee for prior approval.
(4) Cooperate with the development of a participant's transition plan prior to the effective date of the participant's transition.
(5) Provide a transition plan for the SCO's or SCA's operations.
(6) Prepare SCO or SCA participant records for transfer to the selected and willing SCO or SCA provider within 14 days of the selected and willing SCO or SCA provider accepting the transfer.
(7) Update and maintain HCSIS data and records until the effective date of transfer.
(d) The closing SCO or SCA provider shall continue to provide supports coordination HCBS to a participant until the participant is transferred to the receiving selected and willing SCO or SCA provider unless otherwise directed by the Department or the Department's designee.
(e) The closing SCO or SCA provider may not transfer a participant during a closure until after the Department or the Department's designee approves the participant's transition plan.
§ 51.155. Provider closure requirements.
(a) A closing provider shall complete the following activities when terminating HCBS:
(1) The closing provider shall notify each participant to whom it renders HCBS, the Department or the Department's designee and each SCO and SCA providing supports coordination to the participant, that the provider is closing.
(2) The closing provider shall follow § 51.31 (relating to transition of participants).
(3) The closing provider shall notify applicable licensing or certifying entities of the provider's closure in accordance with the rules established by the licensing or certifying entity.
(b) The provider shall send the Department or the Department's designee a copy of the notification sent to the participant and SCO or SCA as required under subsection (a)(1).
(c) If the provider fails to notify the Department or the Department's designee as specified in subsections (a) and (b), the provider may not be paid for HCBS rendered after the date the notice is due to the Department or the Department's designee.
(d) The closing provider shall prepare participant records for transfer to the selected and willing provider within 14 days of the selected and willing provider accepting the transfer.
(e) A closing provider shall update and maintain records until the effective date of transfer.
(f) A closing provider shall maintain records verifying compliance with this chapter for a minimum of 5 years in addition to the current year, even after closure as specified in § 51.15 (relating to provider records).
(g) The section does not apply to an SSW provider.
§ 51.156. AWC/FMS closure requirements.
(a) A closing AWC/FMS provider shall complete the following activities:
(1) The AWC/FMS provider shall first notify the Department of its intent to close.
(2) The notice must be sent to the Department at least 60 days prior to closure.
(3) The AWC/FMS provider shall cooperate with transitioning participants to the new AWC/FMS provider that is identified by the Department.
(4) The AWC/FMS provider shall complete the following transition activities once notice has been provided by the Department:
(i) Notify each participant in writing of the AWC/FMS provider's decision to no longer provide AWC/FMS.
(ii) Provide the Department with suggested time frames for transitioning the participant to the new AWC/FMS provider.
(iii) Prepare participant records for transfer to the new AWC/FMS provider identified by the Department within 14 days of the new AWC/FMS provider becoming the AWC/FMS.
(iv) Update and finalize records until the effective date of the transfer to the new AWC/FMS.
(b) If the AWC/FMS provider fails to notify the Department as specified in subsection (a), the AWC/FMS provider may not be paid for HCBS and administrative fees after the date the notice is due to the Department.
(c) An AWC/FMS provider shall maintain records verifying compliance with this chapter for a minimum of 5 years in addition to the current year, even after closure as specified in § 51.15 (relating to provider records).
(d) The section does not apply to an SSW provider or a provider of HCBS in the Adult Autism Waiver.
§ 51.157. Appeals.
A provider may file an appeal of a Departmental action in accordance with Chapter 41 (relating to Medical Assistance provider appeal procedures).
[Pa.B. Doc. No. 12-1043. Filed for public inspection June 8, 2012, 9:00 a.m.]
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