4253 TERMINATIONS AND ALTERNATIVE SANCTIONS

4253.1 In order to qualify for Medicaid reimbursement, EPD Waiver Providers shall comply with programmatic requirements as part of its Provider Readiness Review and enrollment. The programmatic requirements include adherence to acceptable standards in the following areas:

(a) Service Delivery as governed by the provider requirements and duties established in this chapter;

(b) Program administration as governed under mandated policies and procedures;

(c) EPD Waiver-related Performance Measures;

(d) Staffing and training; and

(e) Home and Community Based Services (HCBS) setting requirements.

4253.2 In accordance with the approved Waiver, DHCF may impose alternative sanctions against an EPD Waiver Provider in response to receiving complaints and/or incident reports via the electronic case management system or EPD waiver complaint database, or upon recommendation by the Department's Division of Program Integrity or Long Term Care Administration's EPD Waiver Monitoring Unit.

4253.3 DHCF shall determine the appropriateness of alternative sanctions against a Waiver provider based on the following factors:

(a) Seriousness of the violation(s);

(b) Number and nature of the violation(s);

(c) Potential for immediate and serious threat(s) to EPD Waiver participants;

(d) Potential for serious harm to Waiver participants;

(e) Any history of prior violation(s) and/or sanction(s);

(f) Actions or recommendations by the Department's Division of Program Integrity or Long Term Care Administration's EPD Waiver Monitoring

Unit; and

(a) Other relevant factors.

4253.4 DHCF may impose one (1) or more alternative sanctions against an EPD Waiver Provider, if the violation does not place the beneficiary's health or safety in immediate jeopardy, as set forth below:- (a) Impose a corrective action plan (CAP);

- (b) Prohibit new admissions or place a cap on enrollment;

- (c) Place the provider on an enhanced monitoring plan;

- (d) Withhold payments; or

- (e) Temporarily suspend the provider from the EPD Waiver Program.4253.5 DHCF shall publicize the imposition of an alternative sanction on its website.4253.6 A CAP may include actions such as publicizing information during the EPD Waiver mandatory monthly meeting, and posting provider performance cards on DHCF's website.4253.7 DHCF shall issue a written notice of provider termination where the agency determines that the sanctions listed under Subsection 4253.4 are not appropriate to address the incident(s) and/or complaint(s). DHCF shall reserve the right to terminate a Medicaid provider agreement without a sanction depending on the severity of the violations.4253.8 If DHCF initiates an action to terminate a provider agreement, DHCF shall follow the procedures set forth in Chapter 13 of Title 29 DCMR governing termination of the Medicaid provider agreement.4253.9 The DHCF may also take actions in lieu of or in addition to an alternative sanction when appropriate. These include the following:- (a) Referral of the incident to another entity, including but not limited to the Medicaid Fraud Control Unit of the Office of the Inspector General for investigation; or

- (b) Referral to Adult Protective Services (APS).4253.10 If DHCF initiates an action to impose an alternative sanction, a written notice

shall be issued to each EPD Provider notifying the provider of the imposition of an alternative sanction.

4253.11 The written notice shall inform the provider that DHCF intends to impose an alternative sanction.

4253.12 The notice shall also include the following:

1. (a) The basis for the proposed action;
2. (b) The specific alternative sanction that DHCF intends to take;
3. (c) The provider's right to dispute the allegations and to submit evidence to support his or her position; and
4. (d) Specific reference to the particular sections of the statutes, rules, provider's manual, and/or provider agreements involved.

4253.13 The EPD Waiver provider may submit documentary evidence to DHCF's Long Term Care Administration, 441 4th St. NW, Ste. 1000, Washington D.C. 20001 to refute DHCF's argument for imposition of an alternative sanction within thirty (30) days of the date of the notice described in Subsections 4253.10 through 4253.12.

4253.14 DHCF may extend the thirty (30) day period prescribed in Subsection 4253.13 for good cause on a case-by-case basis.

4253.15 If DHCF decides to impose an alternative sanction against the EPD provider after the provider has issued a response under Subsection 4253.13, DHCF will send a written notice at least fifteen (15) days before the imposition of the alternative sanction. The notice shall include the following:

1. (a) The reason for the decision;
2. (b) The effective date of the sanction; and
3. (c) The provider's right to request a hearing by filing a notice of appeal with the District of Columbia Office of Administrative Hearings.

4253.16 If the provider files a notice of appeal within fifteen (15) days of the date of the notice of the alternative sanction under Subsection 4253.15, then the effective date of the proposed action shall be stayed until the D.C. Office of Administrative Hearings has rendered a final decision.

4253.17 The Director of DHCF shall consider modifying the alternative sanction upon occurrence of one of the following:

(a) Circumstances have changed and resulted in changes to the programmatic requirement violation(s) in such a manner as to immediately jeopardize a beneficiary's health, safety, and welfare; or

(b) The EPD Provider makes significant progress in achieving compliance with the programmatic requirements through good faith efforts.

4253.18 A provider that is denied enrollment or terminated from District Medicaid program participation shall be temporarily barred from participation in the EPD Waiver program, in accordance with the timeframes set forth in 29 DCMR §§ 9410.9–9410.10.

4253.19 A provider that has been terminated from the District's Medicaid EPD Waiver program shall be precluded from submitting any claims for payment, either personally or through claims submitted by any entity for any services provided under the EPD Waiver program, for dates of service on or after the effective date of the termination decision after the provider exhausts all appeal rights and an official decision of termination has been made.

SOURCE: Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025).