Child & Adult Care Food Program Serious Deficiency Process & Provider Appeals.
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Transcript of Child & Adult Care Food Program Serious Deficiency Process & Provider Appeals.
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Child & Adult Care Child & Adult Care Food ProgramFood Program
Serious Deficiency Serious Deficiency ProcessProcess& Provider Appeals& Provider Appeals
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OverviewOverviewFederal law (ARPA) mandated changes for providers
Established serious deficiency process for providers
Suspension for health or safety violations
Provider appeals
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Why do we need provider Why do we need provider appeal rights?appeal rights?
• Problem of non-compliant providers switching sponsors
• Federal law requires USDA to maintain a National Disqualified List of terminated providers
• Importance of protecting provider rights
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Termination for cause or for Termination for cause or for convenienceconvenience
• Violation of agreement = termination for cause
Initiated by the Sponsor
• Termination for convenience = non-performance issues
Initiated by the provider or the Sponsor
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A rose by any other nameA rose by any other name
• Fair hearing = administrative review = appeal
• Administrative review official = hearing official = hearing officer = appeal officer
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What can be appealed?What can be appealed?
• Proposed termination for cause and proposed disqualification
• Suspension for health or safety violations
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What cannot be appealed?What cannot be appealed?
Anything else
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WhenWhen is an action is an action appealable?appealable?
• Sponsor issues a Notice of Proposed Termination for Cause and Proposed Disqualification
• Sponsor issues a Suspension Notice
A provider may request an appeal when:
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How will providers know How will providers know about their appeal rights?about their appeal rights?
• Language in the agreement between the sponsor and the provider
• Sponsor gives a copy of the appeal procedures to the provider– Annually
– When any appealable action is taken
– Upon request
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Minimum appeal Minimum appeal proceduresprocedures
• Uniformity
• Representation
• Review of record and opposition
• In-person hearing not required
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Minimum appeal Minimum appeal procedures (cont.)procedures (cont.)
• Basis for decision
• Timeframes for issuing a decision
• Final administrative decision
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Supplemental proceduresSupplemental procedures
• Must be consistent with minimum procedures
• Examples– Timeframe for appeal decision– Deadline for requesting an appeal– Deadline for submitting additional
written documentation
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Supplemental proceduresSupplemental procedures(cont.)(cont.)
• More examples
– In-person hearing
– Additional appealable actions
• State agency approval required
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Ensuring complianceEnsuring compliance
• State agency must ensure sponsors properly implement provider appeal process
– Part of state agency review of sponsors
– Improper implementation of a provider appeal process = Seriously Deficient
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Serious deficienciesSerious deficiencies
• Submission of false information
• Submission of false claims
• Simultaneous participation under more than 1 sponsor
• Meal pattern non-compliance
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Serious deficienciesSerious deficiencies
• Failure to keep required records
• Imminent threat to health or safety
• Conviction indicating lack of business integrity during the past 7 years
• Any other circumstance related to non-performance under agreement
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Convictions indicating a Convictions indicating a lack of business integritylack of business integrity
• Past 7 years
• Criminal convictions only
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Sponsor discretionSponsor discretion
• Distinguish between:
– Occasional errors and systemic errors
– Minor errors and major errors
• Improper use of termination for cause = serious deficiency
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Error or serious deficiencyError or serious deficiency
Factors to consider:– Frequency of the error– Severity of the error– Length of program experience– Literacy level or English proficiency
Provider must move to full compliance ASAP
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Serious Deficiency Serious Deficiency Process for ProvidersProcess for Providers
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Steps in the processSteps in the process
• Serious deficiency determination
• Serious deficiency notice
• Opportunity for corrective action
• Proposed termination/disqualification
• Appeal
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Seriously Deficient noticeSeriously Deficient notice Notice must be in writing and contain
certain information: Fully describe the serious deficiency Specify the corrective action required
to resolve the serious deficiency & deadline
State that serious deficiency determination is not subject to appeal
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Seriously Deficient noticeSeriously Deficient notice
Must state that failure to fully and permanently correct the serious deficiency by the deadline will result in:
• proposed termination of the provider’s agreement for cause, and
• proposed disqualification of the provider.
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Seriously Deficient noticeSeriously Deficient notice
• Must inform provider if she/he will receive CACFP payments during the period of corrective action
• Must state that if the provider voluntarily terminates her/his agreement after receiving the notice, the sponsor will still proceed with the proposed disqualification.
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Seriously Deficient noticeSeriously Deficient notice
Sponsor must continue to pay valid claims
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Timeframes for corrective Timeframes for corrective actionaction
• Deficiency must be corrected within 30 days
• Ensure prompt resolution
• No provision that allows sponsors to give providers additional time
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Opportunity for corrective Opportunity for corrective actionaction
Yes, but …
No corrective action allowed before suspension for imminent threat to health or safety
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False or Fraudulent False or Fraudulent ClaimsClaims
• No provision to suspend provider participation
• Opportunity to correct
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False or Fraudulent False or Fraudulent Claims (conClaims (con’’t)t)
• Declare the provider seriously deficient
• Opportunity for corrective action
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False or Fraudulent False or Fraudulent Claims (conClaims (con’’t)t)
Deny the claim/recover payment
– Never reimburse providers for invalid claims
– Do not reimburse for invalid portion of claim
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An Example of False or An Example of False or Fraudulent ClaimsFraudulent Claims
• Four enrollment forms, three children in care.
• Claiming 5-7 children for 3 months
• No explanation
• Provider is declared Seriously Deficient
• While corrective action and appeal occur, the invalid portion of the provider’s claims must not be paid.
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Verifying Corrective Verifying Corrective ActionAction• Unannounced
follow-up review recommended
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What Happens Next?What Happens Next?
• If serious deficiency is corrected – Notify provider & state agency
• If serious deficiency is not corrected
– Notice of Proposed Termination/placement on National Disqualified List is sent to provider & state agency
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Notice of Notice of Proposed Proposed Termination/DisqualificationTermination/Disqualification
• Propose to terminate agreement for cause
• Propose to disqualify provider
• Basis for actions = inadequate corrective action
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Notice of Notice of Proposed Proposed Termination/DisqualificationTermination/Disqualification
• Procedures for appeal
• Status of program payments
• Voluntary termination = disqualification
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Status of Program PaymentsStatus of Program Payments
• General rule: Program participation, including Program payments, continues during the serious deficiency process
• One exception– Suspended providers
• Sponsors must always deny invalid claims
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Provider decides to Provider decides to appealappeal• Provider must submit request for
administrative review/hearing within time frame specified by sponsor
• Provider & sponsor submit documentation to hearing official
• Hearing official reviews the record or sets date for in-person hearing
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The hearing officialThe hearing official
• Hearing official must be:– Independent– Impartial
• Hearing official may be:– An employee or board member of the
sponsor– A contractor (e.g. sponsor
association)
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Role of the hearing officialRole of the hearing official
• Review the evidence, documentation and testimony
• Remain objective
• Determine if the sponsor complied with regulatory procedures
• Issue a decision based on the facts, not opinion or feelings
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Review of record or Review of record or hearinghearing
• Review all evidence and testimony
• Issue decision in writing
– Decision sent to provider and sponsor at same time
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No place to set policyNo place to set policy
• The hearing official is being asked:
Has the program requirement been properly applied?
NOT
Do you agree with the requirement?
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In-person hearingsIn-person hearings
• Allow both sides to present their case, introduce evidence, call witnesses
• Keep proceedings on track
• Maintain decorum
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In-person hearingsIn-person hearings
• Remain objective
• Tape record proceedings, if desired
• Don’t issue your decision at the hearing
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Resources for hearing Resources for hearing officersofficers• Federal
Regulations 7 CFR 226
• Copy of sponsor/provider agreement
• Copy of sponsor’s appeal procedures
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Resources for hearing Resources for hearing officersofficers
• Copy of sponsor’s manual or handbook for providers
• Copies of sponsor’s administrative memos or other communication to providers
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Termination of the Termination of the AgreementAgreement
• Provider fails to appeal
• Hearing official rules in favor of sponsor
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Removal fromRemoval fromthe National Disqualified the National Disqualified ListList
• Generally removed after 7 years
• Two exceptions:– If SD is permanently corrected,
removal before 7 years– If provider still owes a debt after 7
years, will remain on list until paid
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Applying after Applying after DisqualificationDisqualification
• What if a provider is on National Disqualified List?
• Sponsor is not required to:
– Offer provider an appeal
– Assist provider with removal from National Disqualified List
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How Long?How Long?
• Provider is placed on the National Disqualified List or on a state agency list prior to July 29, 2002, will remain for 7 years
• Must remain on the list until July 29, 2009; longer if a debt is still owed
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AAQQ&&
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Question?Question?
What if the provider wins the appeal?
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AnswerAnswer
• Notify provider/state agency
• Remove the seriously deficient determination
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Wouldn’t it be simpler to allow the home to terminate for convenience after serious deficiency is declared?
Question?Question?
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AnswerAnswer
Easier, but the provider could participate with another sponsor
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Who is the action taken against when the provider is incorporated—the provider or the corporation?
Question?Question?
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AnswerAnswer
Both
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Can a sponsor permit more than 30 days for corrective action?
Question?Question?
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AnswerAnswer
NO
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QuestionsQuestions
• Will homes be notified they are off the National Disqualified List after 7 years?
– No. This is not required.
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And justice for all . . .And justice for all . . .
Thank you for your contributions to maintaining integrity in the Child and Adult Care Food Program.