West Virginia Code 16-5C-12a – Independent informal dispute resolution
(a) A facility or licensee adversely affected by an order or citation of a deficient practice issued pursuant to this article or by a citation issued for a deficient practice pursuant to federal law may request the independent informal dispute resolution process. A facility may contest a cited deficiency as contrary to law or unwarranted by the facts or both.
Terms Used In West Virginia Code 16-5C-12a
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Contract: A legal written agreement that becomes binding when signed.
- Deficiency: means a nursing home's failure to meet the requirements specified in §. See West Virginia Code 16-5C-2
- Director: means the director of the office of Health Facility Licensure and Certification. See West Virginia Code 16-5C-2
- facility: means any institution, residence or place, or any part or unit thereof, however named, in this state which is advertised, offered, maintained or operated by the ownership or management, whether for a consideration or not, for the express or implied purpose of providing accommodations and care, for a period of more than 24 hours, for four or more persons who are ill or otherwise incapacitated and in need of extensive, ongoing nursing care due to physical or mental impairment or which provides services for the rehabilitation of persons who are convalescing from illness or incapacitation. See West Virginia Code 16-5C-2
- in writing: includes any representation of words, letters, or figures, whether by printing, engraving, writing, or otherwise. See West Virginia Code 2-2-10
- Review organization: means any committee or organization engaging in peer review or quality assurance, including, but not limited to, a medical audit committee, a health insurance review committee, a professional health service plan review committee or organization, a dental review committee, a physician's advisory committee, a podiatry advisory committee, a nursing advisory committee, any committee or organization established pursuant to a medical assistance program, any committee or organization established or required under state or federal statutes, rules or regulations, and any committee established by one or more state or local professional societies or institutes, to gather and review information relating to the care and treatment of residents for the purposes of:
Evaluating and improving the quality of health care rendered. See West Virginia Code 16-5C-2
- Secretary: means the Secretary of the Department of Health and Human Resources or his or her designee. See West Virginia Code 16-5C-2
- State: when applied to a part of the United States and not restricted by the context, includes the District of Columbia and the several territories, and the words "United States" also include the said district and territories. See West Virginia Code 2-2-10
(b) The secretary shall contract with up to three independent review organizations to conduct an independent informal dispute resolution process for facilities. The independent review organization shall be accredited by the Utilization Review Accreditation Commission.
(c) The independent informal dispute resolution process is not a formal evidentiary proceeding and utilizing the independent informal dispute resolution process does not waive the facility’s right to a formal hearing.
(d) The independent informal dispute resolution process consists of the following:
(1) No later than 10 working days following the last day of the survey or inspection, or no later than 20 working days following the last day of a complaint investigation, the secretary shall transmit to the facility a statement of deficiencies committed by the facility. Notification of the availability of the independent informal dispute resolution process and an explanation of the independent informal dispute resolution process shall be included in the transmittal;
(2) When the facility returns its plan to correct the cited deficiencies to the secretary, the facility may request in writing the independent informal dispute resolution process to refute the cited deficiencies;
(3) Within five working days of receipt of the written request for the independent informal dispute resolution process made by a facility, the secretary shall refer the request to an independent review organization from the list of certified independent review organizations approved by the state. The secretary shall vary the selection of the independent review organization on a rotating basis. The secretary shall acknowledge in writing to the facility that the request for independent review has been received and forwarded to an independent review organization for review. The notice shall include the name and address of the independent review organization.
(4) Within 10 working days of receipt of the written request for the independent informal dispute resolution process made by a facility, the independent review organization shall hold an independent informal dispute resolution conference unless additional time is requested by the facility. Before the independent informal dispute resolution conference, the facility may submit additional information.
(5) The facility may not be accompanied by counsel during the independent informal dispute resolution conference. The manner in which the independent informal dispute resolution conference is held is at the discretion of the facility, but is limited to:
(A) A desk review of written information submitted by the facility;
(B) A telephonic conference; or
(C) A face-to-face conference held at the facility or a mutually agreed upon location.
(6) If the independent review organization determines the need for additional information, clarification, or discussion after conclusion of the independent informal dispute resolution conference, the director and the facility shall present the requested information.
(7) Within 10 calendar days of the independent informal dispute resolution conference, the independent review organization shall provide and make a determination, based upon the facts and findings presented, and shall transmit a written decision containing the rationale for its determination to the facility and the director.
(8) If the secretary disagrees with the determination, the secretary may reject the determination made by the independent review organization and shall issue an order setting forth the rationale for the reversal of the independent review organization’s decision to the facility within 10 calendar days of receiving the independent review organization’s determination.
(9) If the secretary accepts the determination, the secretary shall issue an order affirming the independent review organization’s determination within 10 calendar days of receiving the independent review organization’s determination.
(10) If the independent review organization determines that the original statement of deficiencies should be changed as a result of the independent informal dispute resolution process and the secretary accepts the determination, the secretary shall transmit a revised statement of deficiencies to the facility within 10 calendar days of the independent review organization’s determination.
(11) Within 10 calendar days of receipt of the secretary’s order and the revised statement of deficiencies, the facility shall submit a revised plan to correct any remaining deficiencies to the secretary.
(e) A facility has 10 calendar days after receipt of the secretary’s order to request a formal hearing for any deficient practice cited under this article. If the facility requests a formal hearing, the secretary and the facility shall proceed in accordance with the provisions of § 29A-5-1 et seq. of this code.
(f) Under the following circumstances, the facility is responsible for certain costs of the independent informal dispute resolution review, which shall be remitted to the secretary within 60 days of the informal hearing order:
(1) If the facility requests a face-to-face conference, the facility shall pay any costs incurred by the independent review organization that exceed the cost of a telephonic conference, regardless of which part ultimately prevails.
(2) If the independent review organization’s decision supports the originally written contested deficiency or adverse action taken by the director, the facility shall reimburse the secretary for the cost charged by the independent review organization. If the independent review organization’s decision supports some of the originally written contested deficiencies, but not all of them, the facility shall reimburse the secretary for the cost charged by the independent review organization on a pro rata basis.