ADHC Provider Self-Assessment

Instructions

Each Adult Day Care Center (ADCC) provider providing EDCD waiver ADHC services must complete a separate self-assessment for each ADHC services setting. The self-assessment contains a set of questions designed to measure a provider’s level of compliance with the HCBS settings requirements.

ADHC service providers must demonstrate compliance with the HCBS settings provisions by responding to each question and indicating the evidence available for review in order to validate that policies and procedures are in place to ensure compliance and ongoing monitoring. The types of documentation that will be deemed acceptable evidence to demonstrate compliance includes, but is not limited, the following:

Provider Policies & Procedures Participant Handbook Staff Training Curriculum Training Schedules Activity Schedules Menus Person Centered Service Plan

The Department for Medical Assistance Services will conduct a combination of on-site and desk reviews to validate provider self-assessments and review evidence. Settings not in full compliance with the HCBS settings provisions will need to develop and submit remediation plans to bring the ADHC setting into full compliance with the HCBS settings provisions. Once the self-asessments have been completed and submitted, DMAS will follow-up with ADHC providers with further details on developing and implementing remediation plans.

Note: As you assess your setting’s compliance with the HCBS settings provisions keep in mind not only the setting itself, but also whether or not compliance with the requirements is applied to each EDCD waiver individual served.

Please review the guidance instructions emailed to providers. The guidance pertains to the questions and will assist with completing the self-assessment. Also, please note that DMAS recommends that providers use the Word document template of the survey to draft responses to all of the questions and identify evidence prior to inputting the responses into the survey online. Unfortunately, the survey cannot save your responses to return to at a later date or time.

Each Adult Day Care Center (ADCC) provider providing EDCD waiver ADHC services must complete a separate self-assessment for EACH ADHC services setting.

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ADHC Provider Self-Assessment

Provider and Contact Information

* Provider Information

ADCC Provider Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

* Contact Person

Name

Title

Email

Phone Number

Intention

* Before beginning your self-assessment process, please indicate if you intend to meet all HCBS settings compliance requirements:

Yes

No

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ADHC Provider Self-Assessment

Self-Assessment

The following questions are designed to demonstrate that the setting has access to integrated community living in which individuals’ ability to interact with the broader community is not limited.

* 1. The service setting is NOT located in a building that is also a publically or privately operated facility that provides inpatient institutional treatment (e.g. NF, IMD, ICF/IID, hospital)?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 1 here:

Choose File

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ADHC Provider Self-Assessment

* 2. The service setting is NOT located in a building on the grounds of, or immediately adjacent to a public institution?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 2 here:

Choose File

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ADHC Provider Self-Assessment

* 3. The service setting is NOT in a gated/secure “community” for people with disabilities?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 3 here:

Choose File

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ADHC Provider Self-Assessment

* 4. The service setting is NOT located in a farmstead or disability-specific community?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 4 here:

Choose File

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ADHC Provider Self-Assessment

* 5. Do individuals have options for activities in the community and use community services/resources in lieu of onsite services (medical services, recreational activities, meals out, barber/haircut)?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 3here:

Choose File

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ADHC Provider Self-Assessment

* 6. Does the ADHC setting have partnerships with other community organizations and volunteers?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 6here:

Choose File

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ADHC Provider Self-Assessment

* 7. Do individuals have the opportunity to access the community as part of their service in the ADHCsetting?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 7here:

Choose File

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ADHC Provider Self-Assessment

* 8. Are individuals aware of or do they have access to materials and/or resources to become aware of activities occurring outside the setting?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 8here:

Choose File

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ADHC Provider Self-Assessment

* 9. Do paid and unpaid staff receive training and continuing education related to the rights of individuals receiving services and member experience as outlined in HCBS rules?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 9 here:

Choose File

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ADHC Provider Self-Assessment

* 10. Are provider policies outlining rights of individuals receiving services and member experience made available to individuals receiving services?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 10here:

Choose File

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ADHC Provider Self-Assessment

* 11. Are provider policies on member experience and HCBS rules regularly reassessed for compliance and effectiveness and amended, as necessary?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 11 here:

Choose File

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ADHC Provider Self-Assessment

* 12. Does the setting engage with the broader community?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 12 here:

Choose File

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ADHC Provider Self-Assessment

* 13. Do individuals receiving ADHC services, or a person of their choosing, have an active role in the development and update of their person-centered service plan?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 13 here:

Choose File

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ADHC Provider Self-Assessment

* 14. Does the setting ensure freedom from coercion and restraint?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 14 here:

Choose File

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ADHC Provider Self-Assessment

* 15. How does the person centered service planning process ensure individuals’ choices and preferences are honored and respected?

Yes

No

Please provide a brief overview and identify your evidence of compliance:

Please upload your evidence for Question 15 here:

Choose File

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ADHC Provider Self-Assessment

* 16. Please describe your setting's approach to completing the self-assessment process.

Re-Checking Intention

After reviewing information on the HCBS settings requirements and completing the self-assessment do you still intend to meet all HCBS settings compliance requirements?

Yes

No

Transitions Needed?

Please enter the total number of individuals currently served through the EDCD waiver that will need to be transitioned to another provider. Note: This total should reflect all of your EDCD participants, not just the number present on a certain day of the week.

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