Assessment Review Tool: Residential Settings

(iBudget Waiver)

Instructions (Pages 3-5)

Probing Questions (Pages 7-9)

Self-Assessment Review Tool(Pages 10-18)

Remediation Plan Template (Pages 20-22)

November 2015

Instructions
Provider Self-Assessment Review Tool

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Review Tool Instructions

The assessment tool is designed for assessors to determine whether a residential or non-residential setting in which individuals receive Florida Medicaid funded home and community-based services (HCBS) are:

  • Home-like (HLE)
  • Promote community inclusion (CI)
  • Person centered (PC)

Who Uses the Tool?

  • HCBS Providers

Providers are required to complete the assessment tool pertinent to the setting and maintain a copy on file. Providers must contact the Agency for Health Care Administration (AHCA) immediately, if they determine the setting meets one or more of the criteria of a presumptively institutional setting.

  • Florida Medicaid Health Plans

Health plans providing Long-term Care HCBS are required to ensure providers are compliant with the HCBS Settings Rule (CMS-2249-F).

  • State Monitors

The Agency for Health Care Administration, or its delegate, uses the tool to validate provider self-assessments and health plan credentialing. The Agency for Persons with Disabilities, Department of Elder Affairs or other delegate performs the assessments.

Tool Layout

The tool consists of 3 sections:

  1. Setting Information

Assessors complete demographic and identifying information about the setting.

  1. Presumptively Institutional Settings

Assessors document whether the setting meets one of the three Centers for Medicare and Medicaid Services (CMS)-defined characteristics that indicate a setting exhibits the characteristics of an institution.

Answering “YES” to any of the presumptively institutional criteria may result in the setting being subject to heightened scrutiny. The heightened scrutiny process may include collecting additional evidence of the setting’s compliance with the HCBS Settings Rule, remediation action, a determination by the State the setting complies with the HCBS Settings Rule and a final determination by CMS.

Providers performing self-assessments that answer “YES” to any of the presumptively institutional criteria must send a copy of the fully completed assessment to AHCA at mmediately upon completion including the following additional information with the submission:

  • Contact telephone number,
  • Contact email address, and
  • Any evidence/documentation to-date demonstrating the setting meets the requirements of the HCBS Settings Rule despite meeting the criteria for being presumptively institutional.
  1. HCBS Characteristics

Assessors document whether the setting meets the requirements of the HCBS Settings Rule.

Assessors may use the companion HCBS Settings Rule Probing Questions to assist in determining whether a setting meets each requirement. Answering “NOT MET” to any of the standards will require the provider to remediate to come into compliance with the HCBS Settings Rule.

Providers performing self-assessments must work to remediate any deficiencies they identify. Providers may contact AHCA to request technical assistance by sending the fully completed assessment to including the following additional information with the request:

  • Contact telephone number,
  • Contact email address,
  • Request for technical assistance, and
  • Proposed remediation steps and timeframes.

Florida Medicaid health plan or state assessors will inform providers of any deficiencies and will follow the respective remediation process accordingly.

Completing the Tool

Assessors must complete the tool fully and include brief explanations in the comments section to justify their findings.

The assessment sections of the tool have 3 columns:

  1. Criteria/Standard

A statement or question pertaining to a specific aspect of the HCBSSetting Rule requirements. The standards include an expectation explaining what is required in order for the setting to meet the accompanying standard.

  1. Setting Meets Criteria/Standard Met

The assessor must record whether the setting meets the criteria of a presumptively institutional; setting by indicating “YES” or “NO”.

The assessor must record whether the setting meets the requirements of the HCBS Settings Rule by indicating whether a standard is “MET” or “NOT MET”.

  1. Comments

Assessors must justify their findings for each criteria/standard with a brief explanation.

Assessment Process

Assessors must ensure the settings’ operational guidelines comport with whether the individuals receiving HCBS in the setting experience reflects the requirements of the HCBS Settings Rule. Assessors may use the accompanying probing questions as a guide to determine whether a setting is compliant, however, the probing questions are not exhaustive, nor is the assessor required to ask/use all probing questions provided.

Assessors may employ multiple assessment methods such as:

  • Policy Review

Review of written policy and procedure documentation when available.

  • Provider/Staff Interview

Questioning setting staff on how operations comply with the HCBS Settings Rule and asking them to demonstrate how the setting implements specific requirements.

  • Record Review

Observing how requirements are documented in the recipient’s person-centered plan or file.

  • Observation

Observing how HCBS Setting Rule requirements are met in the course of service provision.

  • Recipient Interview*

Questioning individuals to determine whether their experience demonstrates that the setting fully complies with the HCBS Setting Rule requirements.

*If conducted, the recipient interviews will be conducted at the setting being assessed.

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Probing Questions
Provider Self-Assessment Review Tool

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Probing Question: Residential Settings
iBudget Waiver
Standard / 1. Setting
1.1 / -Is the facility surrounded by high walls/fences and/or have closed/locked gates?
-Is the facility setting among private residences/businesses and community resources?
-Does the facility purposefully separate individuals receiving Medicaid HCB services from those who do not, or groups of individuals from others?
-Is the facility on the grounds of, or adjacent to, a public institution?
-Is the facility on a gross lot area exceeding 8 acres?
-Is the facility located on a parcel of land that contains more than one State licensed facility?
-Is there an ADT program, or a licensed residential facility on the same or adjacent parcels of land?
-Does the licensed capacity of the facility exceed 15 residents?
-Are individuals able to come and go from the facility and its grounds at will?
-Can individuals engage in community and social activities of their preference outside of the facility at will?
-Does the facility impose a curfew, or otherwise restrict individuals’ ability to enter or leave the facility at will?
-Do individuals have access to public transportation; are transport options accessible to the individual?
-Are public transport schedules and contact information readily accessible to individuals?
-Does the facility provide accessible transportation so individuals may access the community?
-Does the facility offer training to individuals on how to use public transportation?
1.2 / -Are the common areas decorated in a home-like fashion (paint, artwork, home furnishings etc.)?
-Is there a common living room/social area with home-like furnishings?
-Are individuals free to move around common areas, e.g., kitchen, den, living room?
1.3 / -Are supports provided for individuals who need them to move around the facility independently/at will (grab bars, ramps, viable emergency exits, etc.)?
-Are appliances/amenities accessible to individuals with varying access needs?
-Can individuals make use of furniture and spaces conveniently and comfortably?
-Are hallways/common areas accessible to individuals of varying needs?
-Are individuals, or groups of individuals, restricted from areas of the facility because it is inaccessible to individuals with specific ambulatory needs?
1.4 / -Are visiting hours restricted?
-Are individuals or visitors required to give advance notice for visitation?
-Are there provisions for private visitation in home-like settings?
-Are there restricted visitor meeting areas?
1.5 / -Which areas are individuals restricted from entering?
-How are individuals prevented from entering restricted areas (industrial gates, locked door, barriers, etc.)?
1.6 / -Do individuals have access to laundry facilities?
-Do individuals have access to cooking/food preparation facilities?
-Are individuals able to complete personal chores/housekeeping if necessary?
Standard / 2. Room/Privacy
2.1 / -Do individuals have the option to elect a private room?
-Can individuals chose their roommate if applicable?
-How can an individual select a roommate (identify character requirements, nominate a specific person, personality/needs matching, etc.)?
-Does the individual talk positively about his/her roommate?
-Do individuals know how to request a roommate change?
-Can married couples elect to share, or not to share, a room?
2.2 / -How many beds are in the bedroom?
-Can individuals decorate their personal space?
-Can individuals personalize their furnishing?
-Can individuals have home furnishings in their personal space?
-Can individuals personalize their furniture arrangement?
-Does the individual have the ability to keep and/or prepare food/snacks in his/her personal space?
-Are visitors allowed in the individuals’ personal space?
2.3 / -Do the individuals’ room and bathroom have a locking door?
-Who has keys to access the individual’s rooms?
-Do furniture arrangements ensure privacy?
-Do staff, other residents and visitors always knock, and receive permission prior to entering an individual’s room or bathroom?
-Are cameras present in the facility?
2.4 / -Under what circumstances would an individual’s room be accessed without his/her permission, or without prior notification; were these provisions discussed with, and agreed to by the individual?
-Provide/describe the facility’s privacy and access policy.
2.5 / -Under what circumstances can an individual change room and/or roommate?
-How do individuals request a change of room/roommate?
-Does the facility alert individuals that room/roommate preference is available?
2.6 / -Are individuals able to contact persons of their choosing at will?
-Do individuals have private cell phones, computers, telephones or other communication devices for personal communications?
-Do the individuals’ rooms have telephones/telephone jack/internet access or internet capabilities?
-Are individuals able to contact persons of their choosing in privacy?
2.7 / -How does the facility make information about how to register an anonymous complaint available to individuals?
-Is information about filing complaints posted in obvious and accessible areas?
-Are individuals comfortable with discussing concerns?
2.8 / -Is there a support plan in place for the individual?
-Are restrictions documented on an individual basis with complete reasoning and evidentiary support?
Standard / 3. Meals
3.1 / -Can individuals eat at times of their choosing?
-Do individuals have access to food/snacks outside of prescribed meal times?
-If an individual misses a meal, can they eat it, or a replacement at another time?
-How are an individual’s preferences incorporated into the facility’s menus?
-Can individuals make special menu/meal requests?
-Can individuals request an alternate meal?
-What restrictions are there on individuals requesting alternate meals?
3.2 / -Are individuals required to wear bibs or other protection equipment?
-Does the facility use home-like dishes and cutlery or disposable tableware?
-Are individuals required to stay in the dining room/at the table during meal times?
-Are individuals required to sit in an assigned seat for meals?
3.3. / -Do individuals have to ask staff for a snack?
-Can individuals prepare their own snack at will?
-What facilities are available for individuals to prepare their own snack?
-Does the facility provide snacks; if so, how can individuals access them?
-How/where can individuals store snacks/personal food items?
Standard / 4. Activities/Community Integration
4.1 / -What publications are available to individuals?
-Where are publications kept?
-Can individuals choose which publications are available?
-Do individuals have access to radios and televisions?
-Does the facility afford individuals access to the internet for personal use and/or computers with internet access for communal use?
4.2 / -How does the facility organize appropriate transportation to community activities?
-Provide/describe the facility’s policies and procedures regarding transportation to community activities.
-Does the facility have a sign-up sheet and information about provided transportation accessible to individuals?
Standard / 5. Respect/Rights/Choice
5.1 / -Do individuals have the option of having personal bank accounts?
-How can individuals access their personal funds?
-Can the individuals access their funds at any time (i.e. afterhours, weekends, holidays)
-How does the facility ensure individuals understand they are not required to sign over their personal resources to the provider?
-How does the facility ensure an individual knows they do not have to conform to prescribed schedule for activities of daily living and social activities?
-Do individual’s schedules vary from others?
-Do any facility policies or practices inhibit individuals’ choices?
-Can individuals choose from a variety of menu options?
-May individuals eat alone, or with people of their choosing?
-May individuals eat in their private living quarters or in areas of the facility other than a designated dining room?
-Are individuals able to participate in community activities?
-Are individuals required to participate in any activities?
-How does the facility aid individuals who wish to pursue competitive employment?
-Are individuals satisfied with the services/supports received and those who deliver them?
-Are individuals’ requests accommodated?
-Are individuals’ choices facilitated such that the individuals feel empowered to make decisions?
-Can the individual choose from whom they receive services and supports?
5.2 / -Does staff ask the individual about their needs/preferences?
-Are individuals aware of how to make service requests?
-Do individuals know how to request a change of service provider or support staff?
-Is/are the individuals/chosen representative(s) aware of how to schedule a person-centered planning meeting?
-Can individuals explain how they would initiate a person-centered plan meeting/update?
-Were individuals/representatives present during the last person-centered plan meeting?
-Do planning meetings occur at times convenient to the individual/representative(s)?
Standard / 6. Other
6.1 / -Does documentation note if positive interventions and supports were used prior to any plan modifications and/or the restriction of an HCB characteristic requirement?
-Were less intrusive methods of meeting the need tried and documented first?
-Does the plan include a description of condition that is directly proportional to the assessed need, data to support the ongoing need for modification, informed consent and an assurance the intervention will not cause harm to the individual?
6.2 / -Does the individual have a lease, or for facility in which landlord/tenant laws do not apply, a residency agreement?
-Are individuals aware of their housing rights?
-Do individuals know how to relocate and request new housing?
-Does the lease/agreement include protections to address eviction processes and appeals comparable to Florida’s landlord tenant laws?

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Assessment Review Tool – Residential Settings

Developmental Disabilities Individual Budgeting (iBudget) Waiver

Name of Provider:
Contact Person for Provider:
Address:
County:
Telephone Number:
Email Address:
Medicaid Provider ID Number:
License Number:
Provider Type: / Assisted Living Facility
Group Home
Residential Habilitation Center
Other Residential Provider
Explain:
Setting Location: / Urban
Rural
Number of Recipients Served Daily:

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All standards are in accordance with Title 42, Code of Federal Regulations, Section 441.301

Presumptively Institutional Settings
Criteria / Setting Meets Criteria
Yes / No / Comments
A. The setting is located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment. / YES NO
B. The setting is in a building on the grounds of, or immediately adjacent to, a public institution. / YES NO
C. The setting has the effect of isolating individuals receiving Medicaid HCBS from the broader community. Check all that apply: / YES NO
  • Farmstead or disability-specific farm community

  • Gated/secured community for specific disabilities.

  • Multiple settings co-located and operationally related.

  • Residents who live at the setting and attend work or
    school on site.

  • Setting is designed to only serve individuals with
    specific disabilities.

  • Setting uses/authorizes interventions/restrictions that
    are used, or are deemed unacceptable in an institutional setting (ex. seclusion).

HCB Setting Characteristics
Standard / Setting Met Criteria
MET / NOT MET / Comments
1. Setting
1.1 The setting does not intentionally, or effectively, isolate Individuals from the surrounding community and persons who are not receiving Medicaid HCBS.
Expectation:
Individuals do not live in isolated compounds, or settings that limit their potential integration with the community at large. / MET NOT MET
1.2The setting’s common areas have a home-like feel.
Expectation:
Communal areas do not resemble an institution and are conducive to comfortable and social interactions free from undue restrictions. / MET NOT MET
1.3The settingis traversable by the Individuals it serves; it meets the needs of Individuals who require supports.
Expectation:
Individuals are able to make their way through the hallways, doorways, and common areas with or without assistive devices. Supports are available to Individuals who require them. / MET NOT MET
1.4Visitors are not restricted from entering the setting and there is a private meeting room to receive visitors.
Expectation:
Individuals are able to receive visitors. Visitation is not restricted or hampered by setting policies or practices. Standard visiting hours are posted and Individuals are made aware of afterhours visiting policy. Visitors must be allowed outside of standard visiting hours, but restrictions to accommodate other residents, such as limiting visitors to certain areas of the setting and observing “quiet hours,” may be imposed. There is a comfortable private place for Individuals to have visitors. / MET NOT MET
1.5There are no areas within the setting that theIndividual cannot enter without permission or an escort. If there are such areas, list in Comments.
Expectation:
Individuals are able to access all areas of the setting unless their safety would be jeopardized, e.g., Individuals do not have access to maintenance rooms, janitor’s closets, etc. / MET NOT MET