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Optional Supplemental Care for Assisted Living Program
MISSION STATEMENT
The mission of the Optional Supplemental Care for Assisted Living Program (OSCAP) is to enhance the quality of life for Medicaid consumers in licensed Community Residential Care Facilities (CRCFs). We are steadfastly committed to promoting and advancing high quality, evidenced-based, efficient, innovative, person-centered care and services.
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OPTIONAL SUPPLEMENTAL
CARE FOR OF ASSISTED LIVING PROGRAM
o An entitlement program and is a state supplement to Supplemental Security Income (SSI) for enrolled CRCFs to provide room and board for eligible consumers and a degree of personal care.
o South Carolina will provide payment to all SSI/SSA beneficiaries who meet the state’s net income limits and have a medical necessity.
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QUICK FACTS Number of Consumers 4,557 (OSS & IPC)
54% Female & 46% Male
CRCF Medicaid enrolled facilities: 415
Consumer Payment Source :
SSA: 43%
SSI: 59% ($710)
Current OSS Rate: $1,193
Average yearly cost = $14,316 annual (single occupancy)
OSCAP PRIOR AUTHORIZATION
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Current OSS/IPC consumers will be reassessed after July 2013 based on the new OSCAP standards
Enrollment numbers will decrease effective July 1st do to prior authorization (PA) of the current OSCAP population.
PA will give a clear sense of inappropriate consumers in Community Residential Care Facilities (i.e. homeless, and released inmates).
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OSCAP TIERS
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Three Levels of Payment (Tiers) • Current OSS consumers that have not been
reassessed Tier 0
• New applicants and reassessed participants who meet NIL and Medical Necessity (current IPC standards: 1 functional dependency & 1 cognitive impairment, or 2 functional dependencies)
Tier 1
• Participants who qualified for CLTC waiver: OSCAP entitlement payment + services rate
Tier 2
PROPOSED OSCAP PROVISO
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o Maximum Optional State Supplement facility rate per eligible consumers
o Proposed Rate: $1,500 (increase of $307.00)
o Existing OSS recipients and providers will be assessed to see if they meet the enhance OSCAP requirements
o Consumer Requirements Medical Necessity
o Maintain $2.00 increase of PNA when COLA increase
o Establish Quality of Care Standards for consumers and CRCF’s
o Approval of 1915c Wavier
Net Income Limit by Tiers
Tier 0 - $1193
OSCAP Tier 1- $1500 (reassessed)
OSCAP Tier 2 1500 + CLTC service rate
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PROVIDER ENROLLMENT FOR NEW CRCF FACILITIES
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• Licensure in good standing as a Community Residential Care Facility (CRCF) by the DHEC, and LLR agencies
• Comply with all federal and state laws and regulations
• Accurately complete the facility enrollment information application on the SC DHHS website www.provider. scdhhs.gov
• Contact information – 1- 888-289-0709 Option 4
• SCDHHS will collect the 2013 application fee of $532.00 prior to executing a provider agreement whether upon an initial enrollment, reactivation, revalidation or an enrollment to add a new practice location.
• Official notification of enrollment identifying the participating facility’s and assigned identification number.
CURRENT OSS PROVIDERS DON’T HAVE TO PAY THE APPLICATION FEE OF $532 TO ENROLL AS AN OSCAP PROVIDER.
BECOMING A OSCAP PROVIDER
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• Prior to the initiation of a OSCAP contract, potential providers Must have:
– A Computer
– Internet access
– An email address in order to receive correspondence and authorizations from SC DHHS
– Complete the pre-enrollment Application to Participant in the Optional Supplemental Care for Assisted Living Program (OSCAP)
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PRE-ENROLLMENT SCREENING TOOL
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Certified evidence of operating capital
Current copy of CRCF Administrator license
Copies of Criminal Background check for all administrative/office employees
Copy of the provider agency’s Workers’ Compensation Insurance Policy
Copy or letter of certification of the provider agency's current liability insurance policy
A copy of your articles of incorporation or other document that established you as a legal entity.
A copy of your Employer Identification Number (EIN) confirmation letter.
Copy of current license for your Nurse Supervisor.
A completed Pre-contractual Information Form.
DOCUMENTATION NEED WITH THE PRE-ENROLLMENT SCREENING
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• SCDHHS has an agreement with the Lieutenant Governor’s Office on Aging (LGoA) for the purposes of designing, implementing and maintaining a web-based nursing facility bed registry.
• The registry will provide current information on available Medicaid nursing facility and community residential care facilities beds throughout South Carolina. This information will be available to hospitals, consumers and anyone interested in identifying available Medicaid nursing facility beds.
NURSING FACILITY BED LOCATOR
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NURSING FACILITY BED LOCATOR
Facility Information
The NFBL website providers demographic information on Nursing Homes and Community Residential Care Facilities. This includes:
• Facility Name
• Facility Address
• Business Phone Number
• Business email address/ website
• Total number of Beds in the Facility
• Total Number of Private Pay Beds and Number of Available Private Pay Beds
• Total Number of Medicaid Beds and number of available Medicaid Beds
Nursing Facility Bed Locator (NFBL) website
www.nfbl.sc.gov
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NURSING FACILITY BED LOCATOR
Facility Information
WHO WOULD QUALIFY FOR OSCAP SERVICES?
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An Individual that is Assessed to have:
At least two functional dependencies
Or
At least one functional dependency one cognitive impairment
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WHO WOULD QUALIFY FOR OSCAP SERVICES?
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• Functional Dependencies: Inability to perform an activity of daily living independently and thereby requiring limited assistance from another person to perform the activity.
• The Seven Functional Areas are:
– Transferring
– Locomotion
– Bathing and Personal Grooming
– Dressing
– Eating and Meal Set Up
– Toileting and Maintaining Continence
– Incontinence Care
WHO WOULD QUALIFY FOR OSCAP SERVICES?
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• Cognitive Impairment:
– Supervision of moderate/severe memory, either long or short term, manifested by disorientation, bewilderment, and forgetfulness which requires significant intervention in overall care planning.
– Supervision of moderately impaired cognitive skills manifested by decisions which may reasonable be expected to affect an individual’s own safety.
– Supervision of moderate problem behavior manifested by verbal abusiveness, physical abusiveness, or socially inappropriate/disruptive behavior.
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WHO WOULD QUALIFY FOR OSCAP SERVICES?
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• Examples of Individuals that Meet Medical Necessity And Those that Do Not:
– Nancy M.
– Jack G.
– Sally
– Nadine
– Bert
– Charles
– Angel
CONDITIONS OF PARTICIPATION
Meet all current state licensure standards and maintain a current license from the Department of Health and Environmental Control (DHEC) as a CRCF.
Not have any uncorrected Class I or Class II violations of licensing regulations within one year prior to enrollment.
Meet specific basic requirements of the Americans with Disabilities Act
Utilize the automated systems mandated by SCDHHS to document and bill for the provision of services.
Verify the participant’s Medicaid eligibility upon acceptance of a referral and monthly
OSCAP services must be both authorized and delivered to be eligible for reimbursement.
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CONDITIONS OF PARTICIPATION
45 % of total census whose placement is due to mental illness
Not be at risk of classification as an Institute for Mental Diseases (IMD)
A facility licensed for more than 16 beds, or is part of a larger entity that exceeds 16 beds, shall not admit or maintain a census of more than 45% of residents whose current need for placement as determined by SCDHHS is due to a mental illness.
Institute for Mental Disease (IMD)
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CONDITIONS OF PARTICIPATION
OPERATING CAPITAL • Minimum operational capital level. Operating
Capital is defined as the difference between current assets and current liabilities. It is the capital available for the operations of a business, allows the CRCF to perform its day to day activities and meet its functional requirements.
― The minimum operating capital levels are:
4-10 Beds - $2500
11-25 Beds - $5000
26 and above – $10,000
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Definition - capital available for the operations of a business to perform its day to day activities and meet its functional requirements
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CONDITIONS OF PARTICIPATION
Implement admission policies that facilitate maintaining, at a minimum, the following bathroom accommodations for participants:
At least one accessible and fully functioning toilet and sink on the accessible path.
At least one accessible and fully functioning toilet and sink for every six physically impaired residents.
At least one fully functioning toilet and sink for every six residents
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DESCRIPTION OF SERVICES TO BE PROVIDED
Resident assistants assist the participant with the following according to their level of care and as specified in the participant’s service plan, individual care plan and resident care log:
• Observing, monitoring, and documenting the resident’s overall condition (temperature, pulse rate, observation of respiratory rate, blood pressure (as needed), and weight)
• Reporting changes in resident’s condition to the appropriate supervisor
• Responding appropriately and according to planned approaches to behavioral symptoms
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STAFFING
ADMINISTRATOR
• Currently licensed by the South Carolina Board of Examiners for Long Term Health Care Administrators.
• Administrator in the building no fewer than 20 hours a week, and maintain posted schedule
• CRCF will identify the position and qualifications of the individual who will provide the daily supervision of unlicensed resident assistants
• Notify SCDHHS within ten (10) business days in the event of a change in the administrator, the extended absence of the administrator, or a change in the Provider’s address or telephone number.
61-84
Definition:
“…designated by the licensee to have the authority and responsibility to manage the facility, is in charge of all functions and activities of the facility…”
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STAFFING
DIRECT CARE STAFF
• At least one direct care staff with certification in First Aid and CPR in the facility at all times.
• Direct care staff or nurse cannot perform any job/task related to OSCAP while on duty at any other health care entity.
• Resident assistant will be trained and determined competent to provide services by a licensed nurse.
• Facilities with residents housed in detached buildings or units, must have at least one qualified and trained direct care staff present and available in each building or unit when residents are present in the building or unit.
• There must be at least one direct care staff member for each eight residents on duty during all periods of peak hours (7:00 am – 7:00 pm.)
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Definition: Trained staff providing hands-on assistance or supervision to CRCF residents who require assistance or supervision in self-care, activities of daily living, or instrumental activities of daily living.
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STAFFING
DIRECT CARE STAFF
• CRCF facilities having 8 residents or less must have at least one or more qualified and trained direct care staff, immediately available, in the facility during resident sleeping hours (7:00 pm – 7:00 am).
• CRCF facilities with 9 residents or more must have qualified and trained direct care staff awake and on duty in the facility during resident sleeping hours.
• If any resident has been assessed as having night needs or is incapable of calling for assistance, staff must be awake and on duty.
• There must be at least one night staff person awake and on duty if any resident with dementia or resident who requires supervision and/or monitoring due to being a danger to himself/herself or others.
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STAFFING
BACKGROUND CHECKS
• Required for Employees providing direct care and administrative/office employees
• No limit on the timeframe being searched.
• Must include statewide (South Carolina) data
• Completed annually for all employees
• Felony convictions within the last ten (10) years cannot provide services or work in an administrative/office position.
• Resident Assistants with non-violent felonies dating back ten (10) or more years can provide services under the following circumstances:
– Participant/responsible party is notified of the conviction and year.
– Provider obtains a written statement, signed by the participant/responsible party acknowledging awareness of the felony and agreement to have the assistant provide care; this statement must be placed in the participant record.
• Administrative/office employees with non-violent felony convictions dating back ten (10) or more years and with misdemeanors hired at the provider’s discretion.
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STAFFING
RESIDENT ASSISTANTS
• Able to read, write, and communicate effectively with participant and supervisor.
• Able to use the Care Call IVR system (Computer or Telephone).
• Capable of assisting with the activities of daily living and following a care plan with minimal supervision.
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STAFFING
RESIDENT ASSISTANTS
• Are at least 18 years of age.
• Have successfully completed a competency training and evaluation performed by a licensed nurse prior to providing services to participants and annually.
• All assistants including those who are Certified Nursing Assistant’s (CNA), are required to complete a competency evaluation
• Have a minimum of ten (10) hours relevant in-service training per calendar year in addition to DHEC required training (The annual ten-hour requirement will be on a pro-rated basis during the resident assistant’s first year of employment). Documentation shall include topic, name and title of trainer, training objectives, outline of content, length of training, list of trainees, and location.
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STAFFING
CRCF NURSE
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• Employ or contract with a licensed registered nurse (RN), or a licensed practical nurse (LPN) under the supervision of a licensed registered nurse (RN), currently licensed by the SC State Board of Nursing. LPN must have a minimum of two years of experience and be under the supervision of a licensed registered nurse.
• Verify nurse licensure at time of employment and ensure that the license remains active.
• Maintain a copy of the current license in the employee’s personnel file.
• Notify SCDHHS in writing within ten (10) days of any change in the CRCF Nurse or extended absence.
STAFFING
CRCF NURSE
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• Not be without nursing coverage for more than 30 days.
• The CRCF will maintain the necessary arrangements to have:
• A Licensed nursing staff available for consultation with the SC DHHS Representatives upon request.
• A Licensed nursing staff available to the CRCF unlicensed personnel for consultation upon request.
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CONDUCT OF SERVICE
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• After approval for eligibility for OSCAP a service authorization is issued from SCDHHS. A copy of the most current service authorization should be kept in the participant’s record/file.
• Provider is responsible for verifying the participant’s Medicaid eligibility at the time of referral and monthly to ensure continued eligibility.
• Provider shall contact SCDHHS within 5 business days if any of the following changes occur
– Resident’s condition requires more care than may be provided according to 25A S.C. Code Ann. Regs. §61-84 (Supp. 2008)
– Resident dies or moves out of the facility,
– Resident is admitted to a hospital, nursing facility or other institution,
– Resident is involved in a physical altercation with another resident, or
– Resident is being served by a hospice agency.
• The Provider is responsible for coordinating placement when the resident can no longer be adequately cared for in the facility.
SERVICE AUTHORIZATION
CONDUCT OF SERVICE
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• A statement of the identified problems or needs, goals of the services for the participant, and the tasks required to accomplish them.
• It is a document that directs the provision of OSCAP services.
• Developed by an OSCAP Nurse, is based on a SCDHHS assessment of functional dependencies and cognitive impairments of the resident.
• A copy of the most current service plan should be kept in the participant’s record/file.
SERVICE PLAN
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– Provider will develop an Individual Care Plan (ICP) for each resident in OSCAP. Will be update to reflect the resident’s status in OSCAP.
– Developed with participation by the participant, administrator (or designee), the responsible party when appropriate, and OSCAP Nurse within seven (7) days of admission, or within seven (7) days of the change to OSCAP.
• Utilizes information from the OSCAP Nurse’s assessment and Service Plan, along with any other relevant resident information obtained from CRCF staff, the resident, and if appropriate, the party responsible for the resident. The ICP is to direct the services provided to the resident and the resident care log.
INDIVIDUAL CARE PLAN
CONDUCT OF SERVICE
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• Reviewed every six (6) months by the resident, administrator, responsible party when appropriate after being reviewed and/or revised by the CRCF Nurse. The ICP must be signed and dated by the resident, administrator, responsible party when appropriate, and the CRCF Nurse. The revisions signed and dated by the CRCF registered nurse must be maintained in the resident’s record.
• Available for a DHHS representative to review upon request.
INDIVIDUAL CARE PLAN
CONDUCT OF SERVICE
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– Resident Care Logs must completed daily by the resident assistant.
– The facility administrator (or designee) will review them weekly and sign-off on their accuracy and completion.
– The completed resident care logs will be reviewed every four (4) months by the CRCF nurse, and signed-off for completion and relation to the ICP.
– At least 12 months of each participant’s Resident Care Logs should be maintained in the resident’s current record/file.
– All Resident Care Logs should be available for review by a SC DHHS representative upon request. Payment for OSCAP services will be recouped if the service is not delivered and documented as required.
RESIDENT CARE LOG
CONDUCT OF SERVICE
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– Broad assortment of regularly scheduled, purposeful activities, including recreational, spiritual, education, social, craft, and work oriented activities.
• At least one staff person shall be trained and responsible for providing and coordinating recreational activities for the residents. Prior to contact with residents the staff person should have appropriate training, and at least annually thereafter. Documentation of staff training for providing/coordinating recreational activities shall be maintained.
• There shall be at least one different structured recreational activity provided daily that accommodates participants’ needs, interests, and capabilities as indicated in the ICP.
ACTIVITIES AND RECREATION
CONDUCT OF SERVICE
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• A current month's schedule shall be posted in order for residents to be made aware of activities offered. This schedule shall include activities, dates, times, and locations.
• Up-to-date calendar large enough for persons with vision difficulty to see, posted in conspicuous places, and in view of all residents. Monthly calendars should also be posted in the residents’ rooms.
• An individual activity participation record indicating patient or resident participation in and reaction to activities should be maintained. This record should include the name of the activities, the dates, the times, and the locations.
ACTIVITIES AND RECREATION
CONDUCT OF SERVICE
CONDUCT OF SERVICE
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• An ongoing training program on medication administration provided by a registered pharmacist or licensed nurse (a minimum of 2 hours per year; may be included as part of yearly in-service requirement)
• The Provider shall have an ongoing basic infection control program that includes policies and procedures in regards to communicable diseases. Training on the infection control program must be provided to resident assistants prior to performing OSCAP services and annually.
• Orientation for a new staff member or volunteer should be completed within seven (7) business days of as outlined in the OSCAP Provider Manual.
• Every employee providing direct care or supervising those who provide direct care must complete an Initial competency evaluation as a part of the orientation process, and annually thereafter.
ORIENTATION, IN-SERVICES AND EDUCATION
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CONDUCT OF SERVICE
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• The annual competency evaluation is in addition to the training requirements of DHEC and 10 hours of in-service training. All competency evaluations must be completed and signed by a licensed nurse.
• Documentation of all in-services will be maintained in the employee’s file.
• The following training shall be provided by appropriate resources, e.g., licensed/registered persons, video tapes, books, etc., to all staff members/direct care volunteers and private sitters in the context of their job duties and responsibilities, prior to resident contact and annually unless otherwise specified by certificate, e.g., cardiopulmonary resuscitation (CPR):
– Basic first-aid to include emergency procedures as well as procedures to manage/care for minor accidents or injuries
ORIENTATION, IN-SERVICES AND EDUCATION
CONDUCT OF SERVICE
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– Procedures for checking and recording vital signs
– Management/care of persons with contagious and/or communicable disease, e.g., hepatitis, tuberculosis, HIV infection
– Medication management including storage, administration, receiving orders, securing medications, interactions, and adverse reactions;
– Depending on the type of residents, care of persons specific to the physical/mental condition being cared for in the facility, e.g., Alzheimer's Disease and/or related dementia, cognitive disability, etc., to include communication techniques (cueing and mirroring), understanding and coping with behaviors, safety, activities, etc.
– Use of restraints
– OSHA standards regarding blood-borne pathogens
ORIENTATION, IN-SERVICES AND EDUCATION
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CONDUCT OF SERVICE
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– Cardiopulmonary resuscitation for designated staff members/volunteers to insure there is a certified staff member/volunteer present whenever residents are in the facility
– Confidentiality of resident information and records and the protecting of resident rights (review of Bill of Rights for Long-Term Care Facilities [Resident's Bill of Rights], etc.)
– Fire Safety/Emergency procedures/disaster preparedness within 24 hours of their first day on the job in the facility and annually thereafter.
– Hand washing and basic infection control procedures.
– Prevention of and reporting abuse, neglect, or exploitation of a vulnerable adult
ORIENTATION, IN-SERVICES AND EDUCATION
CONDUCT OF SERVICE
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– Assisting residents with activities of daily living (ADL’s)
– Topics should include, but not limited to: urinary and bowel incontinence care; skin care; techniques for giving bed baths; nutrition and hydration; Identifying, reporting and documenting physical and mental changes.
– Accurate documentation of direct care and record keeping.
– Ethics and interpersonal relationships.
– Training in lifting and transfers.
ORIENTATION, IN-SERVICES AND EDUCATION
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ADMINISTRATIVE REQUIREMENTS
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• CRCF has policies and regulations with respect to safeguarding confidential information.
• Accurate daily census report that accounts for all residents, regardless of pay source, and available to SCDHHS upon request.
• Designate a private area for use by SCDHHS personnel to either conduct an assessments or hearing of an appeal requested by residents not meeting OSCAP level of care.
• Have an effective back-up service provision plan in place to ensure adequate nursing supervision and adequate numbers of resident assistants.
• Provide the supplies needed for personal care including, not limited to:
soap
shampoo
toothpaste
denture cleaner
toothbrush
denture brush
razors
shaving lotion
shaving cream dry skin lotions towels washcloths brush comb
ADMINISTRATIVE REQUIREMENTS
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• Participant and personnel records, including financial records regarding participants’ personal needs allowance, available to SCDHHS and/or its agents at any time
• Assure timely claims are submitted according to SCDHHS billing procedures.
• Provider shall not delegate administrative and supervisory functions to another agency, facility or organization.
• Maintain a section in its existing policy and procedure manual describing the provision of OSCAP services
• Policy and procedure manual available for review by any SCDHHS representative.
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ADMINISTRATIVE REQUIREMENTS
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POLICY AND PROCEDURE MANUAL
– Development/approval process for the Individual Plan of Care
– Training requirements and plan for required staff training and in-services.
– Policy for maintaining a licensed nurse; reflects the relationship with the provider and the role of the nurse.
– Policy and Procedure for maintaining the daily census of all (regardless of pay source) – identifies OSCAP participants, medical/non-medical bed holds, admitted/discharged on that date, or transported for emergency treatment.
– Post most recent full general inspection report and response; and subsequent complaint inspection reports and responses. Location specified in the CRCF’s policy and procedure manual.
ADMINISTRATIVE REQUIREMENTS
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POLICY AND PROCEDURE MANUAL
– The CRCF’s emergency plan (sheltering agreement)
– Grievance/complaint procedure to be exercised on behalf of the OSCAP residents to enforce the Resident's Bill of Rights which includes at a minimum the address and phone number of the SC DHEC Division of Health Licensing, SC DHHS Division of Long term Care Transformation, the Regional Long Term-Care Ombudsman, and local Adult Protective Services. There should be a provision prohibiting retaliation.
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ADMINISTRATIVE REQUIREMENTS
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– The provider must have a written, implemented quality improvement program which meets the requirements specified in 25A SC Code Ann. Regs. §61-84 (Supp. 2010) and as outlined in the OSCAP Provider Manual.
– Quality assurance committee that meets at least quarterly. Include CRCF nurse, administrator, direct care staff or person administering medications, and a pharmacist consultant if a medication problem is to be monitored or investigated. Maintain minutes of all Quality Assurance meetings, and have them available for SCDHHS upon request.
– Complete and submit Quality Assurance self-reports and evaluations and OSCAP required reports, reviews and audits as requested.
QUALITY IMPROVEMENT PROGRAM
ADMINISTRATIVE REQUIREMENTS
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• Compliance Reviews to establish the provider meets the requirements outlined in the applicable
• Scope of Services;
• The provider is in compliance with the OSCAP Contract
• OSCAP Provider Manual,
• State and Federal enrollment requirements; and to verify the accuracy of the information submitted to SCDHHS.
• Compliance review and sanction scoring process
• All providers must permit SCDHHS, its agents or designated contractor, to conduct unannounced on-site inspections of any and all provider locations during normal business hours.
• Failing to permit access for on-site visits will result is termination from the OSCAP Contract.
COMPLIANCE REVIEWS
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ADMINISTRATIVE REQUIREMENTS
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Corrective Action Plan (CAP)
• Lowest sanction
• Indicates substantial compliance with the contractual requirements.
• Submitted within 30 days
• Outlines how deficiencies will be corrected (or have been corrected) and how they will avoid future deficiencies.
• Failure to submit the CAP within 30 days results suspension level
SANCTION TYPES
ADMINISTRATIVE REQUIREMENTS
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Suspension
• New referrals/admissions suspended for a minimum of 30 days; CAP must be submitted to SCDHHS within 15 days from start of suspension.
• SCDHH reviews CAP to determine if the response is acceptable. If CAP is not acceptable, clarification of additional information will be requested.
• Suspension lifted when a corrective action plan (15 days from receipt of an acceptable CAP) is submitted and accepted
• A suspension lasting more than 90 days results in termination.
• Indicates moderate deficiencies.
SANCTION TYPES
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ADMINISTRATIVE REQUIREMENTS
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Termination
• Indicates very serious and widespread deficiencies, generally coupled with a history of bad reviews.
• Termination is a last resort.
SANCTION TYPES
ADMINISTRATIVE REQUIREMENTS
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Correction Plan
• Imposed until the facility develops and adheres to a corrective action plan
Suspension
• Has multiple substantiated complaints with in 12 months submitted to SCDHHS and/or from various agencies such as Long Term Care Ombudsman, Protection & Advocacy, DHEC, etc., related to the physical conditions and/or quality of care in the CRCF
• A Compliance review score reflecting moderate non-compliance according to the compliance review and sanction scoring process
• Imposed until the facility develops and adheres to a corrective action plan, and a compliance review is conducted by a SCDHHS representative(s).
SCDHHS LEVELS OF SANCTIONING
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ADMINISTRATIVE REQUIREMENTS
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Recoupment
• Referral to SCDHHS Program Integrity (PI) for investigation of potential fraud /quality of care issues.
• Failure to follow the policies and procedures.
• Billing for more residents than facility’s licensed beds.
• Holding of OSCAP reimbursement.
• Failure to submit monthly billing by due date
• Failure to notify the SCDHHS of admissions, discharges, transfers, and deaths within five (5) business days.
• Failure to follow policy and procedures related to PNA.
SCDHHS LEVELS OF SANCTIONING
ADMINISTRATIVE REQUIREMENTS
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Termination
• In addition to those located in ARTICLE VII TERMINATION OF CONTRACT
• Significant non-compliance according to the compliance review and sanction scoring process
• DHEC Health Licensing Division sends a notice to suspend or revoke the license.
• DHEC or law enforcement substantiates life threatening physical conditions.
• Three suspensions with in a 24 month period
• Continuous substantiated complaints and/or violations of licensing regulations.
SCDHHS LEVELS OF SANCTIONING
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OSCAP CONTACT INFORMATION
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• Alexis Martin, MBA
– OSS Program Coordinator II
• Russell Morrison, LMSW
– Quality Assurance Coordinator
Providers must follow the Scopes of Service as well as meet all other contractual obligations in
order to participant in the OSCAP program. You should print a copy to review before
completing this application.
Each client is required to choose a provider from a Client Choice of Provider Form that lists all
OSCAP providers in the area by county. Because of the client choice of provider policy we
cannot guarantee the number of participants any provider will be authorized to serve.
Therefore, we urge all providers not to rely upon Medicaid as the primary source for
reimbursement. Business decisions should not be made based on any agency’s or individual’s
anticipation of receiving any reimbursement from OSCAP.
Check the appropriate boxes and fill in the information that is requested. You must also include
the items listed in addition to completing this application.
Applications should be sent to: Division of Long Term Care Transformation , Post Office Box
8206, Columbia, SC 29202-8206, Attention: Alexis Martin . If you have any questions regarding
this process or the stated requirements please see the OSCAP provider manual located at:
Pre-enrollment Screening Tool for the
Optional Supplemental Care for Assisted Living Program (OSCAP)
Becoming a Provider of OSCAP Service
Prior to the initiation of a contract, potential providers Must Have A Computer, internet access
and an email address in order to receive correspondence and authorizations from SC DHHS.
Additionally, anyone interested in participating in the OSCAP program it is recommended that
you attend a training session. The dates and times will be announced in the OSCAP Advisory.
The Division of Long Term Care Transformation contracts with qualified providers to provide
OSCAP I services to Medicaid recipients. These services are prior authorized by OSCAP nurses.
The authorization gives consent to provide services to eligible participants in OSCAP.
Contracting as an OSCAP provider allows the providers to provide service to residents who are
blind, age, or disabled and meet the medical necessity and financial eligibility.
https://www.scdhhs.gov
OSCAP 1
OSCAP 2
I agree to abide by all requirements and policies of the SCDHHS as described in my
contract and any other communication received from SCDHHS.
I have read and have a general understanding of the scope of services for the program for
which I am applying to become a provider.
I certify that neither I, nor any officer, director, administrator, billing agent, managing
employee, affiliated person or partner, or shareholder having an ownership interest has
been involuntarily terminated or has involuntarily withdrawn from participation in the OSS
or IPC Programs within the 1 year.
Note: Facilities has to be enrolled as an OSCAP 1 provider before permitted
to apply for OSCAP Tier 2
I understand that it will be necessary to schedule a South Carolina Department of Health
and Human Services (SCDHHS) compliance review visit as part of the contracting process
and that I will be contacted prior to this visit.
Upon implementation of electronic billing I understand that persons providing OSCAP
services must use the Care Call system to document their service delivery and adherence
to this contract.
The following items must be checked and/or enclosed for this application to be considered
for processing:
I wish to become a provider of the following services: (Check all for which you are applying)
By checking this box I am indicating that my agency requires Medicaid participants to sign
Admission agreements. I understand that I must include a copy of the agreement form.
I certify that this agency will submit any subcontracts to SCDHHS for prior approval (i.e.
license nurse contract, recreation, VA, home health, and hospice).
I certify that a governing body or person(s) so functioning shall assume full legal authority
for the operation of the provider agency.
My regularly scheduled holidays are listed on the attached sheet.
I understand that this agency may be reviewed by SCDHHS or their representatives at any
time during normal business hours. This review can be announced or unannounced. I also
understand that my agency must produce all requested records related to the
administration of the agency, staff records and individual client records.
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I understand that I must abide by all marketing limitations as indicated in the contract
I understand that I must not give any type of gifts, samples or other products to SC DHHS
staff
I understand that my staff must report incidents of abuse, neglect or exploitation of adult
beneficiaries in accordance with the Omnibus Adult Protection Act (S.C. Code of Laws
Section 43-35-5, et seq.) to the SC Department of Health of Health Services.
Print the name and address of the person who will sign the contract (ownership):
The name of the person designated to serve as the agency administrator:
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The following items must be submitted with your application:
The minimum operating capital levels are:• 4-10 Beds - $2500• 11-25 Beds - $5000• 26 and above – $10,000
Administrator must provide a copy of current community residential care facility license.
A copy of your Employer Identification Number (EIN) confirmation letter.
Copy of current license for your CRCF Nurse.
A completed Pre-contractual Information Form. (See attached form)
Copies of Criminal Background check for all administrative/office employees. Criminal
Background check must contain no less than ten (10) years of data.
A copy of the provider agency’s Workers’ Compensation Insurance Policy. If you do not yet
have one, please indicate on your application. A copy of the policy must be presented
prior to the provision of services.
A copy or letter of certification of the provider agency's current liability insurance policy
showing coverage to include date of application.
Certified evidence of operating capital that will show that the provider agency has the
capability to operate for a minimum of 60 days in the event Medicaid reimbursement is
delayed or withheld for any reason. This must be a written statement from an officer of a
financial institution or a certified accountant. Operating capital may be verified prior to
final approval for a contract.
A copy of your articles of incorporation or other document that established you as a legal
entity. If you do not already have this, it must be obtained from the Secretary of State. If
you are a Sole Proprietor, this is not required. Sole Proprietors must provide a copy of your
business license.
I certify that all information given with this form is true. I understand that any false
information will result in this application being denied.
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Applicant’s Name Printed:
Applicant’s Signature:
Title and Date:
Agency Telephone No:
Agency Fax No:
Alternate Telephone/Cell No. (specify type) :
Agency Name:
Agency Address:
Agency Hours:
Mailing Address (if different from agency address):
Email Address:
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New Year’s Day
Martin Luther King’s Birthday
Presidents Day
Good Friday
Easter
Monday after Easter
Memorial Day
Independence Day (July 4th or day observed)
Labor Day
Columbus Day
Veterans Day
Thanksgiving
Day after Thanksgiving
Christmas Eve
Christmas
Day after Christmas
List additional holidays here
List of Scheduled Holidays
Check each holiday observed by your agency and indicates additional holidays below.
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Yes No
Have you ever worked for an agency that has received Medicaid funds?
If yes, what agency and what was your position?
Have you have ever been an enrolled or contracted Medicaid provider?
If yes, when (dates)
which state?
What service did you provide?
What was/is your previous/current Medicaid provider number?
Are you currently enrolled or contracted with DHHS for any service provision?
If not, when did contract or enrollment end?
If terminated, was termination voluntary or involuntary?
If yes, when?
Dates
Which state?
What type of service was provided?
If yes, when? (dates)
For what service?
Reason
Signature :
Date:
What was/is the agency’s or corporate entity’s previous/current Medicaid
provider number?
Have any officers, agents or employees been terminated, been denied participation in
the Medicaid Program or denied a contract with DHHS?
If this is an agency or corporate entity, has the agency ever been enrolled or
contracted with Medicaid?
Any falsification of information submitted is grounds for denial or termination of a contract.
Pre-Contractual Information Form
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Pre-Enrollment Screening Tool Onsite Visit
Yes No N/A
Accessible parking
If no → No sign
Accessible path, free of obstruction
If no → curb yard or maintenance equipment in path
broken/uneven pavement or concrete decorative items in path
Accessible ramp at one entrance in good order
If no → broken/uneven pavement or concrete railing broken or unstable wood railing rough and slintering
railing necessary, but not present surface is not stable, firm and slip resistant
Unfenced open body of water or other liquid hazard on property
If no → Pool Sewage treatment pond
Pond/lake Open sewage due to septic problems
Unfenced open body of water on adjacent/nearby
If no → Pool Sewage treatment pond
Pond/lake Open sewage due to septic problems
Excessive yard trash present
If yes → General household trash Other
Abandoned vehicles on property
If yes → Number:
Abandoned mobile home(s) on property
If yes → Number:
Other abandoned items on property
If yes → List:
Residents outside of building
If yes → Supervised by staff Unsupervised and negative behaviors present
Engaged in positive activity Other
Unsupervised and unengaged
EXTERIOR
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Yes No N/A
Administrator present at time of arrival
If no → Arrived within ½ hour Did not arrive prior to departure of SCDDHS representative
Arrived within 1 hour Administrator on vacation or out sick
Arrived within ______ hours
Comments:
Odor detected upon entry
If yes → Mild and limited Strong and pervasive
Strong and limited to specific areas
Most recent general inspection report posted in an obvious location
If no → Not posted at all
Posted but not in an acceptable location
Incomplete report posted
Most/Many residents present during on site visit
If no → All/most residents at DMH Clubhouse or CMHC Some residents on field trip
Some residents at DDSN workshop Some residents at medical appointment
Residents observed at entrance were involved/engaged
If yes → Residents were present and unsupervised Residents were observed exhibiting unacceptable behavior
Residents were unengaged
Many residents observed at/near entrance appear to be lacking personal care
If no → Appeared not to be clean as evidence by dirty faces, hair, clothing, etc.
One or more residents sitting in own urine/feces
All/most residents observed near entrance appear to be clean and well-kempt
Yes No N/A
Residents are present
Room is well lighted
Room is clean
INTERIOR - Administrative Area
INTERIOR - Common Area
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Yes No N/A
Room is free of obvious evidence of insect infestation
Room is free of obvious evidence of rodent infestation
Room is adequate in size to accommodate residents present
Staff is present at all times; in and out frequently or immediately available
Staff observed to be needed and unavailable
Residents appear to be engaged
If no → No resident present Residents just sitting and apparently bored
Residents appear to be clean and neat
Personal care needs of resident appear to be adequately met
Yes No N/A
Dining room includes adequate tables and chairs
Dining room table height accommodates wheelchairs
Dining room is clean and dust free
Dining room is well lighted
Dining room is free of offensive odors
Dining room is free of insects
Dining room represents a home-like environment
Yes No N/A
Resident’s room is equipped with window treatments that provide privacy, are in good repair and clean
If no → Blinds broken No window treatments; privacy lacking Dirty and/or torn window treatments
Bedroom is well lighted
Bedroom presents a homelike environment
Bedroom is clean and free of dust
Bedroom is free of obvious evidence of insect/rodent infestation
Bedroom is free of offensive odors
Mattress are clean, dry, and in good repair
INTERIOR - Dining Area
INTERIOR - Bedrooms
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Yes No N/A
Bed linens are clean, dry, and in good repair
Bedroom provides adequate storage for personal belongings
Furniture is clean, and in good repair/working order
Bedroom allows for resident’s privacy
Room temperature is comfortable for residents
If no → Hot Cold A/C or heat not working properly
Yes No N/A
Adequate privacy provided for residents
Bathroom appears reasonably clean
Bathroom is reasonably odor free
Liquid soap is in the bathroom
Paper towels or operational hand dryer(s) are present in the bathroom
Tubs include grab bars
Bathroom is obviously handicap accessible
Toilet is operational
Grab bars are available next to toilet
Sink is operational
If no → One of more faucets do not work Sink is non-operational
Sink is stopped up
One accessible and fully functioning toilet and sink on the accessible path
One accessible and fully functioning toilet and sink for every six physically impaired residents.
At least one fully functioning toilet and sink for every six residents
INTERIOR - Bathroom
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Yes No N/A
Facility produced a quality improvement plan (QIP)
Quality improvement (QI) committee meets regularly
Meeting records indicate problems identified by DHEC inspection are being reviewed at each meeting
QI meeting notes indicate the team is reviewing falls
Qi meeting notes indicate the team is addressing staff performance
Qi meeting addresses policy and procedure effectiveness
Analyzes appropriateness of ICP's and the necessity of care/services rendered
Analyzes the effectiveness of the fire plan
Analyzes all incidents and accidents, to include all medication errors and resident deaths
Yes No N/A
Yes No N/A
A current, monthly recreation/activity calendar is posted in common area(s)
A current, monthly recreation/activity calendar is posted in the residents rooms
The facility provides at least one different structured activity every day of the week
The facility provides activities that meet the residents’ needs
The facility maintains adequate recreational supplies
There is evidence the activity posted for this date was actually conducted
There is a staff member responsible for the development of the recreational program and responsible for obtaining and maintaining recreational supplies.
Documents and facilitates obtaining feedback from residents and other interested persons, e.g., family members and peer organizations, as expressed by the level of
satisfaction with care/services received.
Analyzes any infection, epidemic outbreaks, or other unusual occurrences which threaten the health, safety, or well-being of the residents
Meeting records indicate residents are being given an opportunity to identify problems and those are being considered by the QI team.
QUALITY IMPROVEMENT PROGRAM
ACTIVITIES
Record of incident(s) and/or accident(s), documented, reviewed, investigated, and if necessary, evaluated in accordance with facility policies and procedures, and
retained.
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Participant Name:
Medicaid Number:
SSN:
Yes No N/A
Resident photo in record
Physician consultation notes within the last year present in record
Current physician orders for medications in record
Current physician orders for care, services, procedures and diets in record
Staff notes regarding observations regarding the resident during last 30 days present in record
Record contains a written assessment of the resident
Current individual care plan present
Yes No N/A
Record indicates skilled services needed
If yes → Short term intermittent services being provided by a Home Health Agency
Short term intermittent services needed, but are not provided
Record indicates resident experienced incidence(s) of abuse/neglect by staff
Record indicates incidence(s) of resident to resident abuse
Record includes documentation of injuries of unknown origin
Record includes documentation resident has had falls within the last six (6) months
If yes → Number:
Record accounting of residents' personal needs allowance; evidence of purchases on behalf resident
Evidence a balance of resident finances is physically provided to each resident on a quarterly basis
Documentation of quarterly reports to residents readily available for review
Resident needs but does not receive services and the CRCF did not produce records indicating actively seeking SNF or other appropriate
placement
RESIDENT RECORD REVIEW
Resident needs and receives daily nursing services via HH and the facility has records indicating actively seeking SNF placement
Resident needs being met by the accommodations and services provided by the facility (meets appropriate level of care for CRCF placement)
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COMMUNITY RESIDENTIAL CARE FACILITY ACCESSIBILITY CHECKLIST
Facility Name
1 - APPROACH AND ENTRANCE
Yes No
A - Parking Yes No
1 - 25 1
26 - 50 2
51 - 75 3
76 - 100 4
Of the accessible spaces, is at least one a van accessible space?
Are the access aisles marked so as to discourage parking in them?
Do the access aisles adjoin an accessible route?
B - Exterior Accessible Route Yes No
Is the route of travel stable, form and slip resistant?
Is the route at least 36 inches wide.
Is there at least one route from site arrival points (parking, passenger
loading zones, public sidewalks and public transportation stops) that does
not require the use of stairs?
If parking is provided for the public, are an adequate number of accessible
spaces provided?
Can all objects protruding into the circulation paths be detected by a person
with a visual disability using a cane?
Note: For every 6 or fraction of 6 parking spaces required by the table above, at least 1 should be
a van accessible space. If constructed before 3/15/2012, parking is compliant if at least 1 in every
8 accessible spaces is van accessible.
Total
Spaces
Accessible
Spaces
Is the van accessible space at least 11 feet wide with an access aisle of at
least 5 feet wide or at least 8 feet wide with an access aisle at least 8 feet
wide?
Are accessible routes identified with a sign that includes the International
Symbol for Accessibility
Are accessible spaces at least 8 feet wide with an access aisle at least 5 feet
wide?
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C - Curb Ramps Yes No
If the accessible route crosses a curb, is there a curb ramp?
At the curb ramp is there a level landing
D - Ramps Yes No
Is the surface stable, firm and slip resistant?
E - Entrance Yes No
Is the main entrance accessible?
If not all entrances are accessible, is there a sign at the accessible entrance
with the International Symbol of Accessibility?
Is the clear opening width of the accessible entrance door at least 32 inches,
between the face of the door and the stop when the door is open 90
degrees?
Is there a front approach to the pull side of the door, is there at least 18
inches of maneuvering clearance beyond the latch side plus 60 inches of
clear depth?
Are the operable parts of the door hardware no less than 34 inches and no
greater than 48 inches above the floor or ground surface?
Is there a level landing at the top and bottom of the ramp, and that is at
least 60 inches long and at least as wide as the ramp?
If the ramp has a rise higher than 6 inches , are there handrails on both
sides?
Is the top of the handrail gripping surface no less than 34 inches and no
greater than 38 inches above the surface?
If the main entrance is not accessible is there an alternative accessible
entrance?
Do all accessible entrances have signs indicting the location of the nearest
accessible entrance?
Is there a ramp (other than curb ramps), is it at least 36 inches wide?
For each section of the ramp, is the running slope no greater than 1:12, i.e.
for every inch of height change there are at lease 12 inches of ramp run?
Is the curb ramp, excluding flare, no steeper than 1:48, and at least 36
inches wide?
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Yes No
2. ACCESS TO GOODS AND SERVICES
Yes No
A - Interior Accessible Route Yes No
Are all public spaces on at least one accessible route?
Is the route stable, firm and slip resistant?
Is the route at least 36 inches wide?
Are there elevators or platform lifts to all public stories?
B - Interior Doors Yes No
Is the door threshold edge no more than 1/4 inch high?
Can the doors be opened easily (5 pounds maximum force)?
C - Signs Yes No
Is the door equipped with hardware that is operable with one hand and
does not require tight grasping, pinching and twisting of the wrist?
Are the operable parts of the hardware no less than 34 inches and no
greater than 48 inches above the floor?
If there are signs designating permanent rooms and spaces do the text
characters contrast with their background, are the text letters raised, in
Braille and mounted on the latch side of the door?
Are edges of carpets or mats securely attached to minimize tripping
hazards?
Does the accessible entrance provide direct access to the main floor, lobby
and elevator (if applicable)
Do all objects on circulation paths through public areas protrude no more
than 4 inches into the path? (e.g. fire extinguishers, signs, drinking
fountains, etc.)
If an elevator is present, are the key pads at a height a person can reach
when sitting? (no higher than 42 inches)
Is the door opening width at least 32 inches clear, between the face of the
door and the stop, when the door is open 90 degrees?
If there are two doors in a series, is the distance between the doors at least
48 inches plus the width of the doors when swinging into the space?
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Yes No
D - Rooms and Spaces Yes No
Are hall pathways at least 36 inches wide?
Are floor surfaces stable, firm and slip resistant?
E - Light Switches Yes No
Are the switches no higher than 48 inches above the floor?
F - Seating Yes No
Are an adequate number of wheelchair spaces provided?
4 - 25 1
26 - 50 2
51 - 150 4
see standards 221.2.1
Is there a route at least 36 inches wide to accessible dining seating?
Are the tops of counters or tables between 28 and 34 inches wide?
Are aisles between tables at least 36 inches wide?
3 ACCESSIBLE TOILETS AND BATHROOMS
Yes No
At the dining space is the top of the accessible surface no less than 28
inches and no greater than 34 inches above the floor?
Is there clear floor space at least 30 inches wide by at least 48 inches long
for a forward or parallel approach?
Can the switch be controlled with one hand and without tight pinching,
grasping, or twisting of the wrist?
# of SeatsWheelchai
r Spaces
Are wheelchair spaces dispersed to allow location choices and viewing
angles equivalent to other seating.
If there is carpet is it no higher than 1/2 inch thick and is it attached
securely along the edges?
If there are signs providing direction to or information about the interior
space do the text characters contrast with their background, are the text
letters raised, in Braille and mounted on the latch side of the door?
Is there at least one wheelchair accessible bathroom (stall, if applicable) in
the facility?
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Yes No
Is the threshold edge no more than 1/4 inch high?
Can the door be opened easily (5 pounds maximum force)?
Are there signs at accessible toilets that include the International Symbol of
Accessibility?
Is the door opening width at least 32 inches clear, between the face of the
door, and the stop, when the door is open 90 degrees?
Does the entry configuration provide adequate maneuvering space for a
person using a wheelchair (18 inches beyond the latch side plus 60 inches
clear depth)?
Can the faucet be operated without tight grasping, pinching, or twisting of
the wrist?
Are soap and other dispensers and hand dryer (if applicable) within reach
ranges and usable without tight grasping, pinching, or twisting of the wrist?
Does at least one lavatory have a clear floor space for a forward approach
at least 30 inches wide and 48 inches long?
Do no less than 17 inches and no greater than 25 inches of the clear floor
space extend under the lavatory so a person using a wheelchair can get
close enough to the faucet?
Is the front of the lavatory or counter surface, whichever is higher, no more
than 34 inches above the floor?
Are the pipes below the lavatory insulated or otherwise configured to
protect against contact?
Is there door equipment that is operable with one hand and does not
require tight grasping, pinching, or twisting of the wrist?
Are the operable parts of the door hardware mounted no less that 34
inches and no greater than 48 inches above the floor.?
Is there a clear path to each type of fixture, e.g. lavatory, hand dryer, etc.
that is at least 36 inches wide?
Is there floor space available for a person to turn around (a circle at least 60
inches in diameter or a t-shaped space within a 60 inch square)?
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Yes No
Is there a hand-held shower?
4 ADDITIONAL ACCESSIBILITY
Yes No
If there is a public phone is it accessible to those in a wheelchair
Do fire alarm systems, have both flashing lights and audible signals?
I, of
Signature
Name Printed
Disclaimer:
License Number
Date
Being duly sworn on my oath, depose and say I have inspected the Community residential Care Facility
identified on page one of this document and the statements contained herein are correct and true to the best
of my knowledge and belief.
The South Carolina Department of Health and Human Services (SCDHHS) is not responsible for enforcement of
the Americans with Disabilities Act (ADA). The information, presented here is intended solely as informational
guidance and contract compliance in regards to the Optional Supplementation for Assisted Living Program
(OSCAP), and is neither a determination of your legal rights or responsibilities under the ADA, nor binding on
any agency with enforcement responsibility under ADA.
Is there a roll-in shower, or transfer shower? If not is there a transfer bench
in the shower?
Does the phone have a volume control, have large numbers, braille
numbers, and large control buttons (volume, redial, etc.)?
If the facility has hearing impaired residents, does one telephone have TTY?
Is there a grab bar at the toilet at least 42 inches long on the side wall, and
located no more than 12 inches from the rear wall?
If the flush control is hand operated, can it be operated with one hand and
without tight grasping, pinching, or twisting of the wrist?
