Subsection 144-101-III-50-8000 - APPEAL PROCEDURES - DEFICIENCY RATE - RATE LIMITATION8010Procedures8010.1 A facility may administratively appeal any of the following types of Office of Audit determinations: 8010.11. Audit Adjustment; or8010.12. Calculation of final settlement.8010.2 An Administrative appeal will proceed in the following manner: 8010.21 Within sixty (60) days of receipt of an audit or other appealable determination, the facility must request, in writing, an informal review before the Director of the Office of Audit or his/her designee. The facility must forward, with the request, any and all specific information it has relative to the issues in dispute, note the monetary amount each issue represents, and identify the appropriate principle supporting the request. Only issues presented in this manner and time frame will be considered at an informal review or at a subsequent administrative hearing.8010.22 The Director or his/her designee shall notify the facility in writing of the decision made as a request of such informal review. If the facility disagrees with the results of the informal review, the facility may request an administrative hearing before the Commissioner or a presiding officer designated by the Commissioner. Only issues presented in the informal review will be considered at the administrative hearing. A request for an administrative hearing must be made, in writing, within sixty (60) days of receipt of the decision made as a result of the informal review.
8010.23 To the extent the Department rules in favor of the facility, the audit report or prospective rate will be corrected. 8040Deficiency per diem rate. When a facility is found not to have provided the quality of service or level of care required, reimbursement will be made on ninety (90%) of the provider's per diem rate. This "deficiency rate" will be applied following written notification to the facility of the effective date of the reduced rate for any of the following service deficiencies:8041 Staffing over a period of two (2) weeks or more does not meet the Federal Certification and State Licensing requirements, except where there is written documentation of a good faith effort to employ licensed nurses to meet the licensed nurse requirements over and above the full time director of nursing;8042 Food service does not meet the Federal Certification and State Licensing requirements;8043 Specific, documented evidence that the care provided does not meet the Federal Certification and State Licensing requirements. Such penalty to be effective no sooner than thirty (30) days from written notification that such deficiencies exist;8044 Failure to correct, within the time frames of an accepted Plan of Correction, deficiencies in meeting the Federal Certification and State Licensing requirements, which cause a threat to the health and safety of members in a facility or the surrounding community;8045 Failure to submit acceptable cost reports and maintain auditable records as required. A reduction in rate because of service deficiencies shall remain in effect until the deficiencies have been corrected, as verified by representatives of the Department of Health and Human Services, following written notification by the provider that the deficiencies no longer exist. No retroactive adjustments to the full rate shall be made for the period that the deficiency rate is in effect. 8051 In no case may payment exceed the facility's customary charges to the general public for such services. This determination will be based on the Principles described in the Medicare Provider Reimbursement Manual (CMS Pub15) in effect at the time of such determination. C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-50, subsec. 144-101-III-50-8000