9714.1 In order to qualify for Medicaid reimbursement, ADHP providers shall comply with programmatic requirements as part of its Provider Readiness Review. The programmatic requirements include adherence to acceptable standards in the following areas:

1. (a) Service delivery;
2. (b) Program administration as governed under mandated policies and procedures;
3. (c) Staffing and training; and
4. (d) Home and Community Based Services (HCBS) setting requirements.

9714.2 An ADHP that fails to maintain compliance with the programmatic requirements and any requirements set forth in this chapter may be subject to alternative sanctions and/or termination of its participation in the Medicaid program.

9714.3 If DHCF initiates an action to terminate, DHCF shall follow the procedures set forth in Chapter 13 of Title 29 DCMR governing termination of the Medicaid provider agreement.

9714.4 If DHCF initiates an action to impose an alternative sanction, a written notice shall be issued to each ADHP provider notifying the provider of the imposition of an alternative sanction.

9714.5 The written notice shall inform the provider that DHCF intends to impose an alternative sanction.

9714.6 The written 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's agreement involved.

9714.7 Within thirty (30) days of the date of the notice, an ADHP provider may submit documentary evidence to DHCF's Long Term Care Administration, 441 4^th St., NW, Ste. 1000, Washington, DC 20001 to refute DHCF's argument for imposition of the alternative sanction.9714.8 On a case-by-case basis, DHCF may extend the thirty (30) day period prescribed in Subsection 9714.7.9714.9 If DHCF determines to impose an alternative sanction against the ADHP provider after the provider has issued a response under Subsection 9714.7, DHCF will send a written notice at least fifteen (15) days before the imposition of the alternative sanction. The notice shall include the following:- (a) The reason for the decision; - (b) The effective date of the sanction; and - (c) The provider's right to request a hearing by filing a notice of appeals with the District of Columbia Office of Administrative Hearings.9714.10 If the ADHP provider files a notice of appeal within fifteen (15) days of the date of the notice of the alternative sanction under Subsection 9714.9, then the effective date of the proposed sanction shall be stayed until the District of Columbia Office of Administrative Hearings has rendered a final decision.9714.11 The Director of DHCF shall consider modifying the alternative sanction upon the occurrence of one of the following:- (a) Circumstances have changes and resulted in alterations of the programmatic requirement violation(s) in such a manner as to immediately jeopardize a participant's health, and safety; or - (b) The ADHP makes significant progress in achieving compliance with the programmatic requirements through good faith efforts.9714.12 When a participant's health or safety is in immediate jeopardy, the provider must implement the safety and emergency preparedness plan. One the participant is safe and is no longer in immediate jeopardy, the ADHP shall submit a corrective action plan to DHCF within one (1) business day with specific timelines for implementation.9714.13 The Director of DHCF may also modify the denial of payment sanction in accordance with Section 9716.

SOURCE: Final Rulemaking published at 63 DCR 1031 (January 29, 2016).