Or. Admin. Code § 411-323-0040

Current through Register Vol. 63, No. 11, November 1, 2024

Section 411-323-0040 - Inspections and Investigations

(1) Agencies certified under these rules must allow and fully cooperate in all the following types of investigations and inspections:

(a) Quality assurance, onsite inspections, and certificate and endorsement request reviews.

(b) Complaint investigations.

(c) Abuse investigations.

(d) Death reviews.

(e) Financial reviews or audits.

(f) Fraud, waste, or financial investigations.

(g) Service monitoring by a case management entity.

(2) The Department or the designee of the Department, including case management entities, are authorized to perform inspections and investigations.

(3) Any inspection or investigation may be unannounced.

(4) All documentation and written reports required by these rules or program rules must be:

(a) Open to inspection and investigation by the Department, the designee of the Department, including a case management entity, or proper authority; and

(b) Provided to the Department, the designee of the Department, including the case management entity that authorized the agency to deliver a service, or proper authority within the time frame established by the Department, the designee of the Department, or proper authority. All copies of the requested documentation and written reports are made at the expense of the agency.

(5) When abuse is alleged or death of an individual has occurred and a law enforcement agency, the Department, or the designee of the Department has determined to initiate an investigation, the agency may not conduct or cause to conduct, an internal investigation without prior authorization from the Department. For the purposes of this section, an "internal investigation" is defined as:

(a) Conducting interviews of the alleged victim, witness, the accused person, or any other person who may have knowledge of the facts of the abuse allegation or related circumstances;

(b) Reviewing evidence relevant to the abuse allegation, other than the initial report; or

(c) Any other actions beyond the initial actions of determining:

(A) If there is reasonable cause to believe that abuse has occurred;

(B) If the alleged victim is in danger or in need of immediate protective services;

(C) If there is reason to believe that a crime has been committed; or

(D) Any immediate personnel actions necessary to ensure individual safety.

(6) The Department, or the designee of the Department, shall conduct abuse investigations as described in OAR chapter 419, division 100 and shall complete an Abuse Investigation and Protective Services Report according to OAR 419-100-0080.

(7) Upon notification to an agency of the completion of an abuse investigation by the Department, the Department's designee, or a law enforcement agency, the agency may conduct an investigation without further Department approval to determine if any personnel actions are necessary.

(8) For all violations discovered under an investigation or inspection listed in section (1) of this rule, the Department shall provide a statement of deficiency to the agency. The agency must submit a plan of correction to the Department within 30 calendar days of receiving a written notification of a violation when required by the Department. Agencies requiring more than 30 calendar days must contact the Department for approval of an extension. An agency's submitted plan of correction must include documented evidence demonstrating the violations were corrected, when applicable as determined by the Department, and identify systemic causes of the failures to comply with program rules and affirmative steps the agency will take to ensure future compliance. The Department may reject a plan of correction the Department determines is inadequate to ensure compliance with a rule, statute, or regulation.

(9) An agency must correct a violation within the time frame determined by the Department after receiving a serious violation letter identifying a violation.

(10) An agency must correct a violation within the time frame specified by the Department upon receiving an advisory letter.

(11) When the Department or the Oregon Health Authority receives an allegation of fraud it determines is credible, the Department or Oregon Health Authority is required to suspend all payments to the agency unless there is good cause to not suspend payments. 42 CFR 455.23(a).

(12) When an agency or an agency executive director is notified of investigation of Medicaid fraud, the agency and executive director are prohibited from notifying, discussing the matter, or taking any administrative action against the employee, contractor, or vendor who is subject to the investigation unless necessary to assure individual safety.

(13) In accordance with 42 CFR 455.21(a), the agency must comply with, and cause subcontractors and providers to comply with, a request from DOJ MFCU for records and information related to program services when DOJ MFCU determines the information is necessary to carry out its responsibilities. The records and information must be provided without charge and in the form requested by DOJ MFCU.

(a) The agency must make available and cause subcontractors and providers to make available to the Department, the Oregon Health Authority, or DOJ MFCU, copies of all procedural and policy statements, directives, and proposed or adopted regulations concerning the Medicaid program, and any other information relevant to the work of DOJ MFCU.

(b) The agency must comply with and cause subcontractors and providers to comply with, a request from the Department, the Oregon Health Authority, or DOJ MFCU for access to any records and information kept by providers to which the Oregon Health Authority, the Department, and DOJ MFCU are authorized access by 42 CFR 431.107, including, but not limited to, any records necessary to disclose the extent of services provided to beneficiaries and any information regarding payments claimed by the provider for furnishing said services. The records and information must be provided without charge and in the form requested by DOJ MFCU.

(14) The agency must comply and cause all subcontractors and providers to comply with federal regulations and refer all cases of suspected provider fraud to the Oregon Health Authority and DOJ MFCU.

(15) The agency must not undertake independent administrative action related to program services, including termination of any provider agreement or contract, against a provider, employee, or executive director who has been referred to the DOJ MFCU or is being investigated by the DOJ MFCU unless the health and safety of individuals are endangered or the Department provides written approval of the planned action.

(16) NON-RETALIATION. An agency shall not discharge, demote, suspend, or in any manner discriminate or retaliate against an employee with regard to promotion, compensation, or other terms, conditions, or privileges of employment for the reason that the employee has in good faith reported information that the employee believes is evidence of a violation of a state or federal law, rule, or regulation.

Or. Admin. Code § 411-323-0040

SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 12-2011, f. & cert. ef. 7-1-11; Reverted to SPD 12-2011, f. & cert. ef. 7-1-11; SPD 1-2012, f. & cert. ef. 1-6-12; APD 42-2014, f. 12-26-14, cert. ef. 12/28/2014; APD 44-2019, amend filed 10/29/2019, effective 11/1/2019; APD 16-2023, amend filed 09/30/2023, effective 10/1/2023; APD 37-2024, minor correction filed 07/03/2024, effective 7/3/2024

Statutory/Other Authority: ORS 409.050, 427.104, 430.662 & SB 1548 (2022 OR Law, Ch. 91)

Statutes/Other Implemented: ORS 409.010, 427.007, 427.104, 430.215, 430.610, 430.662 & SB 1548 (2022 OR Law, Ch. 91)