HCBS Settings Evaluation Module 4ohiohcbs.pcgus.com/documents/evaluation/module4... · The intent...

Contents Home and Community Based Services (HCBS) Settings Evaluation Tool ............................................ 2

Welcome ........................................................................................................................................ 2

Intent of the CMS HCBS Rule ........................................................................................................... 3

HCBS Settings Verification Checklist ................................................................................................ 4

Qualities Required for All Home and Community-Based Services Settings......................................... 5

Additional Conditions Required for Provider Owned or Controlled Residential Settings .................... 6

Additional Conditions Required for Provider Owned or Controlled Residential Settings, continued ... 7

Recovery Manager Responsibilities ................................................................................................. 8

Section I: Qualities Required for All Home and Community-Based Settings ......................................10




Section II: Additional Conditions Required for Provider-Owned or Controlled Residential Settings ...17


Section II: Additional Conditions Required for Provider-Owned or -Controlled Residential Settings ..20




Recommendation Options .............................................................................................................26

Thank you......................................................................................................................................27

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Home and Community Based Services (HCBS) Settings Evaluation Tool

Welcome

Welcome to Module 4 in the Home and Community-Based Services Settings Training Series.

In this module, we will refer to “home and community-based services” as “HCBS.”

This module will review the components of the HCBS Settings Verification Tool. Specialized Recovery Services Program recovery managers will use the tool to gather information about an individual’s experience with community integration, and the qualities of his or her choice of residence.

For background information on the federal regulation, you may want to l isten to the HCBS Settings Module, which is found on PCG’s website.

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Intent of the CMS HCBS Rule

In January 2014, The Centers for Medicare and Medicaid Services (or, CMS) published regulations in the Federal Register implementing new requirements for Medicaid’s HCBS programs furnished through a 1915(c) waiver or a 1915(i) state plan option. The final federal rule was developed over a five-year period and represents significant input from a wide range of stakeholders and perspectives. The regulation became effective on March 17, 2014.

The intent of the federal rule is for individuals receiving Medicaid-funded HCBS to have the opportunity to receive these services in a manner that protects individual choice and promotes community integration.

In Ohio, the final federal rule applies to all eight of the State’s 1915(c) and 1915(b)(c) waivers.

The final federal rule also applies to the State’s 1915(i) state plan option: Specialized Recovery Services Program (or, SRSP).

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HCBS Settings Verification Checklist

The Ohio Department of Medicaid (or, ODM) developed the HCBS Settings Verification Tool using CMS’s final rule and the CMS exploratory questions.

The HCBS Settings Verification Checklist is an official form and is available in PDF format on the ODM website. Its number is 10173.

The HCBS Settings Verification Checklist has two sections:

• Section 1 includes nine questions intended to gather information on an individual’s current experience with community access and to identify any obstacles an individual may experience related to privacy, choice, and control.

• Section 2 includes 16 questions to determine if the provider-owned or -controlled setting in which the individual resides demonstrates the additional conditions required to qualify as an HCBS setting.

Click here for Form 10173

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https://urldefense.proofpoint.com/v2/url?u=http-3A__medicaid.ohio.gov_Portals_0_Resources_Publications_Forms_ODM10173fillx.pdf&d=CwIFAg&c=A-GX6P9ovB1qTBp7iQve2Q&r=JYiseEFKQ1JR8nMudZ4gHFMTAeNkvtf72pNbF4edN9Y&m=SPcWoZ6gMJfDdvQ-Y9-w0QyRox8NCx9TuQ1ozm9NiHQ&s=NMG604cLKon1hsTeclEXnocj2-uLRRUq5EoZesDIyt8&e

Qualities Required for All Home and Community-Based Services Settings

Any residential or non-residential setting where individuals l ive and/or receive HCBS must exhibit the five qualities, l isted in this slide.

The HCBS Settings Verification Checklist focuses on gathering information about the setting where an individual l ives.

Only individuals who reside in an HCBS-compliant setting may receive SRSP services.

An individual’s private home or a relative’s home where an individual lives is presumed to meet the HCBS settings requirements. However, the state is responsible to ensure that individuals l iving in a private home or a relative’s home have opportunities for full access to the greater community.

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Additional Conditions Required for Provider Owned or Controlled Residential Settings

What is a “provider-owned or–controlled residential setting? It is a physical place, which is owned, co-owned, and/or operated by an HCBS provider. Examples of a provider-owned or -controlled residential setting include an adult foster home, adult care facility or residential facilities that is licensed by the Ohio Department of Mental Health and Addiction Services, OR a residential care facility that is licensed by the Ohio Department of Health. In addition to the qualities outlined on Slide 4, provider-owned or -controlled residential settings must also comply with five additional conditions.

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Additional Conditions Required for Provider Owned or Controlled Residential Settings, continued

The additional conditions support the individual’s experiences of community integration, privacy, choice, and control, and ensure the setting is community, not institutional.

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Recovery Manager Responsibilities

Recovery managers must complete the HCBS Settings Verification Checklist for each individual upon initial assessment, annual assessment, and when a permanent change of residence occurs.

The purpose of the checklist is to obtain information about the individual’s experience; therefore, the recovery manager must solicit input from the individual, to the degree in which he or she is able and willing to participate. The tool provides a consistent structure for the case management conversations that are occurring around choice, participation, and individuals rights.

The current practice of permitting a legal representative or an individual’s informal support to provide input on behalf of the individual will continue.

Additionally, the individual’s authorized representative or legal representative (defines as power of attorney or legal guardian) may provide input, on behalf of the individual.

The HCBS Verification Checklist is one component of the larger conversation with the individual, which occurs at that time. Responses to the questions in the HCBS Settings Verification Checklist will be based on the individual’s responses and the recovery manager’s observations.

In Section I: if an individual’s response is “No “to any question, the recovery manager must take action to educate the individual on available options and resources.

In Section II, if individual responds “No” to any question, the provider is responsible for taking actions to demonstrate the setting is compliant.

The HCBS Settings Verification Checklist form is comprised of yes/no boxes to check and comment space to write observations. While recovery managers are not required to write observations in every comment space, they must do so if they discover a setting that compromises the individual’s health and safety.

When the recovery manager has completed the HCBS Settings Verification Checklist, he or she will make a recommendation to the independent entity as to whether the individual’s setting is HCBS-compliant. The recovery manager’s notations on the HCBS Settings Verification Checklist form will help the independent entity to make a final determination.

The recovery manager’s recommendation includes where the individual l ives (either a private residence or a provider owned or -controlled setting) and the level of community access, choice, and privacy the individual experiences. The

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recovery manager should not share with the individual whether his or her residence possesses the qualities of an HCBS setting.

As part of the eligibility determination process, the independent entity will make the final determination regarding whether the setting meets the HCBS settings requirements. When the independent entity determines that the setting does not comply with the HCBS settings regulation, the SRSP transdisciplinary team will identify options for the individual.

Options include, but are not l imited, to:

• Resolving the obstacles identified in Section 1 through the person-centered planning process;

• Collaborating with the owner or controller of the setting to resolve the obstacles identified in Section 2, or

• Identifying an alternative l iving arrangement for the individual that demonstrates the required qualities of an HCBS setting.

When the individual resides in a setting l icensed by the Ohio Department of Mental Health and Addiction Services (or ODMHAS), the mental health case manager will be responsible for working with the provider to ensure the setting comes into compliance with the setting requirements.

In the event the individual resides in a setting that is not l icensed by the ODMHAS or the individual does not have a mental health case manager, the transdisciplinary team will determine who is responsible for working with provider to ensure the setting comes into compliance with the setting requirements.

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Section I: Qualities Required for All Home and Community-Based Settings

This section of the HCBS Settings Verification Checklist establishes the individual’s current l iving arrangement and addresses the first HCBS quality: the setting is integrated in, and supports full access of, an individual receiving Medicaid HCBS services in the greater community.

Question 1 asks whether the individual resides in a private residence or a provider-owned or -controlled residence.

• A “Yes” response to Question 1 indicates the individual resides in a private residence. Complete questions 3 through 9 of Section 1. Do not complete Questions 10 through 25 of Section 2.

Question 2 asks whether the individual resides in a provider-owned or controlled residence.

• A “Yes” response to Question 2 indicates the individual resides in a provider-owned or -controlled setting. Complete Questions 3 through 9 of Section 1 and complete Questions 10 through 25 of Section 2.

Question 3 gathers information about an individual’s involvement with the community outside of his or her private residence.

Integration in, and access to, the community includes:

• Opportunities to seek employment,

• Work in competitive integrated settings,

• Engage in community l ife,

• Control personal resources, and

• Receive services in the community with the same degree of access as individuals who do not receive Medicaid HCBS.

The control of personal resources is based on an individual’s preferences and goals, and permits an individual to choose the arrangement that is best suited to him or her such as having an authorized representative, representative payee, durable power of attorney or legal guardian.

The level of involvement in any of the activities discussed in Slide 7 are based on the individual’s preference, regardless of whether the individual resides in a private residence or a provider-owned or -controlled setting.

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Examples of community integration include participation in community events and activities in typical community venues, such as civic organizations, faith communities, fitness centers, and community recreation centers. In a provider owned or -controlled setting, activities that indicate community integration include not only those organized by the setting for a group of individuals with disabilities and/or involving only paid staff but also activities outside of the setting that foster relationships with community members unaffiliated with the setting.

• If an individual is unable to describe access to the community but expresses desire for community engagement, the response to Question 3 is “No”. Education, referrals, and community resources must be offered to assist the individual in achieving his or her desired level of community integration and access.

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This section of the HCBS Settings Verification Checklist addresses the second HCBS quality: the setting is selected by the individual from among setting options including non-disability specific settings and an option for a private unit in a residential setting.

This requirement ensures an individual has the necessary information to make informed decisions about where he or she wants to l ive.

• If an individual indicates he or she is aware of other places to l ive and chooses the current setting, the response to Question 4 is“Yes”.

• If an individual indicates he or she did not know other options were available, the response to Question 4 is“No”. The individual must be educated about other options.

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This section of the HCBS Settings Verification Checklist addresses the third HCBS quality: the setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

The methods for ensuring this quality is present may vary depending on whether the individual l ives in a private residence or a provider-owned or -controlled setting.

The Long Term Care Ombudsman Program is available to assist individuals in a variety of settings, including private residences and adult care facilities, to resolve concerns regarding quality of l ife and access to the greater community.

Ohio Revised Code rule 3721.13 and the Ohio Department of Mental Health and Addiction Services’ adult care facility resident rights Ohio Administrative Code 5122-33-23 outline the rights of privacy, dignity, respect, and freedom from coercion and restraint for individuals in l icensed residential care facilities and adult care facilities.

Please note that “freedom from coercion and restraint” focuses on the unauthorized and unmonitored use of a restraint or restrictive intervention. However, this requirement does not prohibit the use of an intervention to ensure the health and welfare of an individual when it is managed through the Person-Centered Service Planning process.

In addition to the individual’s input, the recovery manager’s observations will inform the level of privacy, dignity and respect, and freedom from coercion and restraint that is present in the setting.

• If an individual indicates he or she is able to have private, personal communications at any time the response to Question 5 is “Yes”.

• If an individual indicates he or she is not able to have private, personal communication at any time the response to Question 5 is “No”. The recovery manager must educate the individual on options to address barriers that l imit access. .

• If an individual indicates he or she knows how to resolve concerns, the response to Question 6 is “Yes”.

• If an individual does not know how to fi le a complaint, the response to Question 6 is “No”. The recovery manager must educate the individual on available resources to fi le a complaint.

• If an individual reports his or her daily activities are unrestricted, the response to Question 7 is “Yes”.

• If an individual reports his or her daily activities are restricted, the response to Question 7 is “No”.

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When the response to Question 7 is “No” the recovery manager must document his or her observations in the tool next to the individual’s response. If the recovery manager determines the restrictions negatively affects the individual’s health and safety, he or she must make a referral to the appropriate oversight or regulatory authority.

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This section addresses the fourth HCBS quality: the setting optimizes opportunities for the individual to choose and control his or her own schedules regarding daily activities, physical environment, and with whom to interact.

The ability to choose and control a schedule that meets an individual’s preferences factors in to whether the individual experiences a setting as community or institution.

A reliable indicator for this quality, in either a private residence or a provider owned or -controlled setting, is whether the individual is aware that he or she is not required to adhere to a pre-determined schedule created by someone else, and that his or her schedule can vary from those who are in the same setting.

Individuals must be encouraged to make as many decisions as they can. This is true even when the individual has a legal representative, such as a power of attorney or legal guardian.

• If an individual reports he or she is controlling his or her own schedule and decisions, the response to Question 8 is “Yes”.

• If an individual reports he or she is not controlling his or her own schedule and decisions, the response to Question 8 is “No”. The recovery manager must educate the individual on how to address the barriers that l imit his or her choices and how to access ombudsman services.

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This section addresses the fifth HCBS quality, which focuses on facilitating choice regarding services and supports and who provides them.

In both a private residence and a provider-owned or -controlled setting, this quality is closely aligned with the fourth HCBS quality. The emphasis is on empowering the individual to make choices regarding which services to receive and from whom to receive them.

• If an individual makes choices, to the degree he or she prefers and is able, the response to Question 9 is “Yes”.

• If an individual does not make choices to the degree he or she prefers and is able, the response is “No”. The recovery manager must educate the individual about how to address barriers l imiting his or her involvement in making choices.

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Section II: Additional Conditions Required for Provider-Owned or Controlled Residential Settings

This section address the first additional condition: the specific unit or dwelling is owned, rented, or occupied under a legally enforceable agreement.

An example of a legally enforceable agreement is a lease or a resident agreement.

A legally enforceable agreement is required when an individual l ives in a provider-owned or controlled setting that is not subject to Ohio landlord tenant laws.

When tenant laws do not apply to the setting, the legally enforceable agreement must include the same responsibilities and protections from eviction as tenants under landlord tenant law of the state, county, city, or other designated entity. It must provide protections to address eviction processes and appeals comparable to those provided under the jurisdiction’s landlord tenant law.

The setting is responsible for ensuring the legally enforceable agreement contains all the required components.

• If an individual reports he or she has a lease or resident agreement, the response to Question 10 is “Yes”. • If an individual reports he or she does not have a lease or resident agreement, the response to Question 10 is “No”.

• If an individual reports the lease or resident agreement includes the additional provisions, the responses to Questions 11, 12 and 13 is “Yes”.

• If an individual reports the lease or resident agreement does not include the additional provisions, the response to Questions 11, 12, and 13 is “No”.

• If an individual is unsure if the lease or resident agreement includes the additional provisions, the response to Questions 11, 12, and 13 is “Don’t Know”.

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Sl ides 13 through 16 address the second additional condition: Each individual has privacy in his or her sleeping or l iving unit. The following illustrate protections of the individual’s privacy:

• Sleeping or living unit’s configuration;

• Units have lockable entrance doors with the individual has keys;

• Individual has the choice of roommates; and

• Individual is free to furnish and decorate his or her sleeping or living units within the lease or other agreement.

In addition to the individual’s report, the recovery manager’s observations of the sleeping or l iving unit configuration, door locks, and how the sleeping or living unit is furnished, will inform the degree to which the individual’s privacy is protected.

The sleeping or living unit configuration is important to ensure privacy when the individual has a roommate. • If an individual reports he or she is comfortable with the level of privacy provided, the response to Question 14 is “Yes”.

• If an individual reports a lack of privacy or a desire for more privacy in the l iving unit, the response to Question 14 is “No”.

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The ability to control access to a l iving or private sleeping unit and secure personal belongings are basic characteristics of a home and community-based setting.

Examples of l iving units include:

• An adult foster home,

• A l icensed residential facility or adult care facility in which the individual resides, or

• An individual’s apartment within a licensed residential care facility.

An example of a sleeping unit is an individual’s bedroom.

When an individual resides in an adult foster home, l icensed residential facility or adult care facility, the individual must have a key to both the l iving unit and the sleeping unit.

• If there is a lock on the door or doors of the sleeping or l iving unit, the response to Question 15 is “Yes”.

• If there is no lock on the door or doors of the individual’s sleeping or l iving unit, the response to Question 15 is “No”.

• If an individual has the key or keys to both the doors of the l iving unit and the sleeping unit, the response to Question 16 is “Yes”.

• If an individual does not have the key or keys to the doors of the l iving unit and the sleeping unit, the response to Question 16 is “No”.

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Section II: Additional Conditions Required for Provider-Owned or -Controlled Residential Settings

The ability to choose with whom to l ive, including the choice of roommate when sharing a sleeping unit, are indications of the level of choice and control a setting offers to an individual.

The process an individual uses to choose a roommate is important. The following i llustrates two scenarios:

Scenario 1: The provider identifies the roommate options for the individual. In this situation, the individual’s involvement and choice is limited by what the setting offers. In some cases, the ability to l ive in a specific setting may be available only if the individual accepts the provider’s choice of roommate.

Scenario 2: The individual initiates the roommate decision by relaying to the provider whom he or she has selected for a roommate.

• If an individual shares a bedroom with the person of his or her choice, the response to Question 18 is “Yes”.

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The ability to personalize the place one l ives indicates choice and control.

• If an individual has furnished and decorated his or her sleeping or l iving unit, the response to Question 17 is “Yes”.

• If an individual is unable to furnish and decorate his or her sleeping or living unit, the response to Question 17 is “No”.

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This section addresses the third additional condition: Individuals have the freedom and support to control his or her own schedule including having access to food at any time.

This additional condition continues to emphasize that individuals are empowered to make decisions and control the events in his or her daily life. As noted in the fourth quality for all settings, an individual’s ability to choose and control a schedule that meets his or her preferences is a key indicator as to whether the setting is home and community-based or institutional.

Individuals must be encouraged to make as many decisions as they can. . This is true even when the individual has a legal representative, such as a power of attorney or legal guardian.

A provider-owned or -controlled setting, may present challenges to the individual’s ability to make and execute decisions about his or her schedule, including access to food at any time.

In a provider-owned or -controlled setting, there cannot be a standard policy that arbitrarily limits the opportunities for individuals to choose service delivery methods and schedules. Examples of non-HCBS settings practices include:

• Established meal times for everyone,

• All individuals who reside on a certain floor receive personal care services on a certain day at a certain time.

• The provider, not the individual, determines the schedules for errands or outings to the community.

An HCBS setting cannot have a standard policy that arbitrarily limits the opportunities of individuals to make choices regarding how to function within a physical environment.

An example of non-compliance with this additional condition would be to restrict the use of a specific area of the physical environment or the amenities available in the setting.

An HCBS setting cannot have a standard policy that arbitrarily establishes the parameters regarding with whom and when an individual can interact.

• If an individual reports he or she controls his or her own schedule and makes decisions, the response to Question 19 is “Yes”.

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• If an individual reports he or she is does not control his or her own schedule and makes decisions, the response to Question 19 is “No”.

• If an individual reports he or she has access to the typical home areas, the response to Question 20 is “Yes”.

• If an individual reports he or she is prohibited from using typical home areas, the response to Question 20 is “No”.

• If an individual reports he or she has access to food at any time, the response to Question 21 is “Yes”.

• If an individual reports he or she does not have access to food at any time, the response to Question 21 is “No”.

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This section addresses the fourth additional condition: Individual may have visitors at any time.

Many take for granted the ability to choose with whom and when to interact. A key component of community integration is the degree of choice and control one has in managing social relationships

An individual may experience barriers in a provider-owned or -controlled setting. A setting policy may impose arbitrary l imits on visitors that are incompatible with the requirement of having visitors at any time. In some cases, limitations are outlined in legally enforceable agreements (or resident handbooks) provided to an individual prior to moving into the setting.

A review of these documents will provide evidence of the setting’s compliance (or non-compliance) with the additional condition about having visitors.

CMS clarifies, however, that while no restrictions on the ability to have visitors should be imposed for convenience purposes, the regulation does not supersede orders of protection or other parameters governing the movement or actions of individuals.

• If an individual reports he or she makes decisions about when and how many visitors with which to interact, the response to Question 22 is “Yes”.

• If an individual reports he or she does not make decisions about when and how many visitors with which to interact, the response to Question 22 “is “No”.

• If an individual was aware of the setting’s policy on visitors prior to moving into the setting, the response to Question 23 is “Yes”.

• If an individual was not aware of the any policy on visitors prior to moving into the setting, the response to Question 23 is “No.

Enter the Closed Caption Text

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Section II: Additional Conditions Required for Provider-Owned or -Controlled Residential Settings

This section addresses the fifth and final additional condition: The setting is physically accessible.

The ability to execute decisions about daily activities and access the greater community is often dependent upon the accessibility of the physical environment. Environmental modifications, the availability of adaptive equipment, and the placement of furniture and supplies can all improve the individual’s ability to remain independent and ensure his or her unrestricted access throughout the setting.

In addition to the individual’s report, the recovery manager’s observations will also inform the degree to which the setting is physically accessible.

• If an individual reports there are accessibility supports available, the response to Questions 24 is “Yes”.

• If an individual reports there are no accessibility supports or the accessibility supports are inadequate, the response to Question 24 is “No”. The recovery manager must document his or her observations in the tool next to the individual’s response.

• If an individual reports there are no barriers restricting his or her ability to move about the setting, the response to Question 25 is “Yes”.

• If an individual reports there are barriers restricting his or her ability to move about the setting, the response to Question 25 is “No”. The recovery manager must document his or her observations in the tool next to the individual’s response. The recovery manager must also make a referral to the appropriate oversight or regulatory authority if he or she determines that the barriers negatively affect the individual’s health and safety.

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Recommendation Options

Upon completing the HCBS Settings Verification Checklist, the Recovery Manager will have three recommendation options from which to choose:

Option 1: The individual l ives in a private residence and experiences community integration, privacy, choice, and control.

• Any “No” responses to questions in Section I must be resolved by the recovery manager through education, referrals, and the person-centered planning process.

Option 2: The individual l ives in a provider-owned or -controlled setting and experiences community integration, privacy, choice, and control.

Option 3: The individual l ives in a provider-owned or -controlled setting and does not experience community integration, privacy, choice and control.

• The provider is responsible for resolving issues identified by any “No” responses to questions in Section I or II in order to demonstrate the setting is compliant with the HCBS setting requirements.

The recovery manager’s recommendation about whether the individual l ives in an HCBS compliant setting is determined by tallying the individual’s responses to the questions on the HCBS Settings Verification Checklist.

The recovery manager’s recommendation will be included with the assessment package and submitted to the independent entity.

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Thank you

This concludes HCBS Settings Verification Checklist webinar.

Thank you for your attention.

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