hcbs settings evaluation module 2

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Table of Contents

HCBS Settings: Evaluation Module 2 .......................................................................................................................... 2

Introduction ................................................................................................................................................................ 2

HCBS Settings Evaluation Tool .................................................................................................................................... 3

Qualities Required for All HCBS Explanation ............................................................................................................. 4

Qualities Required for all HCBS Federal Regulations .................................................................................................. 5

Qualities Required for All HCBS Federal Citations ..................................................................................................... 6

Qualities Required for All HCBS Federal Citations continued ..................................................................................... 8

Qualities Required for All HCBS Federal Citations Remediation Plan ....................................................................... 9

Qualities Required for All HCBS Federal Citations Remediation Yes/No .................................................................. 10

Qualities Required for All HCBS Federal Citations Remediation No ........................................................................ 11

Qualities Required for All HCBS Federal Citations No to Both ................................................................................ 12

Qualities Required for All HCBS Choices ................................................................................................................... 13

Qualities Required for All CBS Facilitating Choices ................................................................................................... 14

For Current Providers of Medicaid HCBS Services .................................................................................................... 15

For Prospective Providers of Medicaid HCBS Services ............................................................................................. 16

For More Information ............................................................................................................................................... 17

Making Ohio Better ................................................................................................................................................... 18

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HCBS Settings: Evaluation Module 2

Introduction

Welcome to Module 2 in the Home and Community-Based Services Settings Training Series. This module will focus on the qualities for all home and community-based services settings.

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

The purpose of this module is to review the components of the HCBS Settings Evaluation Tool. We will focus on the qualities required for all HCBS settings.

Before proceeding with Module 2, we recommend that you complete Module 1, which provides an overview of the CMS HCBS Regulations.

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HCBS Settings Evaluation Tool

The Ohio Department of Medicaid (or, ODM) and the Ohio Department of Aging (or, ODA) developed the HCBS Settings Evaluation Tool using the Centers for Medicare and Medicaid (or, CMS) final rule, the CMS exploratory questions, and with input from provider trade associations.

The HCBS Settings Evaluation Tool is registered as ODM Form #10172 and is available in PDF format on the ODM website at http://medicaid.ohio.gov/RESOURCES/Publications/MedicaidForms.aspx .

The HCBS Settings Evaluation Tool has two sections:

• Section 1, which addresses qualities required for all HCBS settings, and

• Section 2, which addresses the additional conditions required for provider-owned or -controlled settings.

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Qualities Required for All HCBS Explanation

In January 2014, CMS published regulations in the Federal Register implementing new requirements for Medicaid’s HCBS programs furnished either through a 1915(c) waiver or through a 1915(i) state plan option. The regulation became effective on March 17, 2014.

Any residential or non-residential setting where individuals live and/or receive HCBS must exhibit the five qualities of a community-based setting, listed in Slide 3, by March 2019.

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

The HCBS Settings Evaluation Tool gathers information about how a specific setting meets four of the five qualities.

The fifth quality is “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”. The individual’s choice is documented in the Person-Centered Services Plan. The setting does not have any responsibility for demonstrating how this quality is met.

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Qualities Required for all HCBS Federal Regulations

This section of the HCBS Settings Evaluation Tool addresses the first HCBS quality, which ensures an individual’s integration in, and access to, the greater community.

In accordance with the federal regulations and Ohio Administrative Code rule 5160-44-01, the state is obligated to identify any settings presumed to be institutional and that may have the effect of isolating individuals from the broader community.

Settings in this category may not be included in the state’s HCBS programs unless the state determines, through an in-depth assessment process, that there is enough evidence to demonstrate the settings do possess the qualities of an HCBS setting.

If the setting is in a building or on grounds with institutional characteristics, there must be a meaningful distinction between the facility and the community-based setting, including, but not limited, to:

• Minimal or non-existent administrative or financial interconnectedness,

• Separate entrances and signage,

• Cross-training of facility staff to meet the same qualifications as HCBS staff, and

• The setting is integrated in the community to the extent that a person without disabilities would consider it a part of the community and not only for the provision of services to persons with disabilities.

A remediation plan is required when the response is no to one or both questions.

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Qualities Required for All HCBS Federal Citations

This section continues to focus on the first quality of integration in, and access to, the greater community.

The characteristics of a setting that is presumed to be institutional include, but are not limited, to:

• The setting is designed to provide people with disabilities multiple types of services and/or activities on-site such as housing, day services, medical, behavioral and therapeutic services, and/or social and recreational activities,

• The people in the setting have limited, if any, interaction with the broader community, and

• The setting uses or authorizes interventions or restrictions used in institutional settings or that are deemed unacceptable in Medicaid institutional settings, such as secluding an individual.

The trend toward re-urbanization, walkable neighborhoods and mixed-use living spaces and access to amenities that both individuals with and without disabilities can use, is expected to promote meaningful community integration.

Activities available in an integrated setting include not only those organized by the setting specifically 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.

Examples of community integration include the following:

• Participation in community events and activities in typical community venues, such as fitness centers, community recreation centers, libraries, and religious centers, and

• At times when venues are open to the public.

Current Ohio Department of Health (or, ODH) residential care facility licensure rule OAC 3701-17-61 (B) and Ohio Department of Mental Health and Addiction Services (or, OMHAS) adult care facility licensure rule OAC 5122-33-23 (A)(10) require the setting to provide access to the community at large.

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CMS has indicated that most Continuing Care Retirement Communities (CCRCs), which are designed to allow aging couples with different levels of need to remain together or close by, do not raise the same concerns around isolation, because CCRCs typically include residents who live independently in addition to those who receive HCBS.


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Qualities Required for All HCBS Federal Citations continued

This section of the HCBS Settings Evaluation Tool continues to focus on the first quality of integration in, and access to, the greater community.

The desire to continue or seek employment is based on an individual’s preferences and goals. Regardless of the average age or level of disability of the individuals served by a setting, an HCBS setting must demonstrate the capacity and willingness to support an individual who is employed or is seeking competitive and integrated employment.

The setting should consider whether there are any barriers, such as policies or procedures, service delivery schedules, staff training or staffing patterns that could be modified to support an individual’s employment goals.

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Qualities Required for All HCBS Federal Citations Remediation Plan

This section of the HCBS Settings Evaluation Tool continues to focus on the first quality of integration in, and access to, the greater community.

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

An HCBS setting cannot have a standard policy that requires all individuals in the setting to access and manage their personal resources in the same prescribed manner and/or for the convenience of the setting.

The requirements outlined in Ohio Revised Code 3721.13 (A)(27)(b) and ODH residential care facility licensure rule 3701-17-61 (C) and OMHAS adult care facility resident rights set forth in OAC 5122-33-23 are aligned with the federal requirement. Implementation of the requirements is evidence of compliance.


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Qualities Required for All HCBS Federal Citations Remediation Yes/No

This section of the HCBS Settings Evaluation Tool addresses the second HCBS quality, which is to ensure the individual’s right to privacy, dignity, respect and freedom from coercion and restraint.

The requirements outlined in Ohio Revised Code 3721.13 and OMHAS adult care facility resident rights set forth in OAC 5122-33-23 are aligned with this federal requirement. Implementation of the requirements is evidence of compliance.

In addition, the ODH residential care facility rule OAC 3701-17-65 (H) requires a telephone to be available to all residents to make private telephone calls and OAC 3701-17-57 (B)(3) prohibits the use of physical and chemical restraints. Implementation of the requirements is evidence of compliance.

It is important to note that the use of a modification to ensure the health and welfare of an individual with cognitive impairment would be managed through the Person-Centered Service Planning process and not necessarily be viewed as coercion or restraint.

In an adult day health setting, the provision of health care or personal care does not require a private room for each individual. The focus is on how the setting can deliver care in a manner and a location that preserves the individual’s dignity and privacy.

A remediation plan is required when the response is yes to the use of interventions or restrictions used in an institutional setting.

When the setting has a secure memory impairment unit, the response is “yes”. The remediation/explanation should establish this level of support is only permitted through the modification to the individual’s person-centered care plan and in accordance with residential care licensing requirement established in OAC 3710-17-59 (L)(2)(c).

A remediation plan is required when the response is no to one or more of the remaining questions.

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Qualities Required for All HCBS Federal Citations Remediation No

This section of the HCBS Evaluation Tool addresses the third HCBS quality, which optimizes opportunities for individuals to make choices and control 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 in accordance with a Person-Centered Services Plan is a contributing factor to whether the individual will experience the setting as community or institutional.

An HCBS setting is indicated when an individual is educated that they do not have to adhere to a set schedule and that an individual’s schedule can vary from others in the same setting.

An HCBS setting may not have a standard policy that arbitrarily limits the opportunities of individuals to make choices about service delivery and schedules.

An example of a non-HCBS settings practice would be all individuals who reside on the second floor receive personal care services on Tuesday between 8 and 10 a.m.

When the Person-Centered Planning principles are applied and it is determined what matters most to the individual, compliance with this requirement does not result in either compromising the health and safety of an individual or the infringement upon others’ ability to make his or her own choices and control his or her own schedules.

The requirements outlined in Ohio Revised Code 3721.13, the ODH residential care licensure rule OAC 3701-17-50, 51, 57 and 59 and the OMHAS adult care facility resident rights rule OAC 5122-33-23 are aligned with this federal requirement. The way these statutes and rules are implemented gives evidence of compliance with the federal requirement.


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Qualities Required for All HCBS Federal Citations No to Both

This section of the HCBS Settings Evaluation Tool continues to focus on the third HCBS quality, which optimizes opportunities for individuals to make choices and control schedules regarding daily activities, physical environment and with whom to interact.

This requirement is closely related to the previously discussed requirement regarding the individual’s ability to make choices and control schedules regarding daily activities.

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

For certain settings, such as the communal spaces used in most adult day programs, there may be fewer choices regarding the physical environment and how and when it can be used, but the focus remains on the individual’s ability to choose within the community’s resources.

An example of non-compliance with this requirement would be restricting the use of a specific area of the physical environment or the amenities because an individual is receiving HCBS services.

When the Person-Centered Planning principles are applied, and it is determined what matters most to the individual, compliance with this requirement does not compromise the health and safety of an individual or infringe on others’ ability to make choices regarding the physical environment.


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Qualities Required for All HCBS Choices

This section of the HCBS Settings Evaluation Tool continues to address the third HCBS quality, which optimizes opportunities for individuals to make choices and control schedules regarding daily activities, physical environment and with whom to interact.

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


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Qualities Required for All CBS Facilitating Choices

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

Although identified as a quality of an HCBS setting, this is not a new requirement. In accordance with 42 CFR 431.51, an individual enrolled on a 1915(c) waiver can select any willing and qualified provider to furnish the waiver services included in the Person-Centered Service Plan.


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For Current Providers of Medicaid HCBS Services

CMS requires the state to conduct site-specific assessments of settings where individuals live and/or receive Medicaid HCBS services.

Based on Ohio’s regulatory review and the physical location of each service setting, and an analysis of paid claims, each setting was assigned one of the following categories of compliance:

• One, the setting meets with modifications, which is Category B, or

• Two, the setting is presumed to have the effect of isolating individuals, which is Category C.

In April 2016, ODA-certified providers of the Assisted Living Service, ODM-approved providers of the Adult Day Health Service, and ODA-certified providers of the Adult Day Health service were asked to complete a self-evaluation using the HCBS Settings Evaluation Tool.

For Category B providers: Validation of the setting’s self-assessment and the implementation and effectiveness of the remediation plan will be incorporated into the established provider oversight processes conducted by ODM and ODA, or their designees.

For Category C providers: Beginning in October 2016, ODM or ODA staff or their designees will conduct on-site evaluations of the settings to validate each setting’s self-assessment, assess the implementation and effectiveness of the remediation plan, and gather information needed to determine whether the setting demonstrates the qualities of an HCBS setting.

If the setting is residential, they will evaluate it to see if it complies with the additional conditions required for provider-owned or -controlled settings.

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For Prospective Providers of Medicaid HCBS Services

All prospective providers seeking ODM-approval or ODA-certification as a 1915(c) waiver provider must demonstrate full compliance with the federal regulation and the Ohio Administrative Code Rule 5160-44-01 at the time of application.

Prospective providers are encouraged to use the HCBS Settings Evaluation Tool and CMS resources to complete a self-assessment and take action to ensure full compliance before requesting approval or certification as a waiver provider.

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For More Information

CMS has web pages that provide resource materials to determine if a setting possesses the characteristics of a home and community-based setting.

The websites are as follows:

Final Regulation

https://www.federalregister.gov/articles/2014/01/16/2014-00487/medicaid-program-state-plan-home-and-community-based-services-5-year-period-for-waivers-provider

The Settings Requirements Compliance Toolkit is available at:

https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html

Finally, the OAC Rule 5160-44-01 titled Nursing facility-based level of care home and community-based services programs: home and community-based settings will be effective July 1, 2016.

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Making Ohio Better

This concludes Module 2, Qualities for All HCBS Settings.

Thank you for your attention!

hcbs settings evaluation module 2

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