Self-Assessment Review Tool:
Non-Residential Settings
(Long-term Care Waiver)
v Instructions (Pages 3-5)
v Probing Questions (Pages 7-8)
v Self-Assessment Review Tool (Pages 10-14)
v Remediation Plan Template (Pages 16-17)
November 2015
Instructions
Provider Self-Assessment Review Tool
6
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.
2. 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 immediately 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.
3. 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 HCBS Setting Rule requirements. The standards include an expectation explaining what is required in order for the setting to meet the accompanying standard.
2. 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”.
3. 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
.
6
Probing Questions
Provider Self-Assessment Review Tool
6
Probing Questions: Non-ResidentialLong term-Care Waiver /
Standard / 1. Community Integration
1.1 / - 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 free to move around common areas?
- Are individuals, or groups of individuals, restricted from areas of the facility because it is inaccessible to individuals with specific ambulatory needs?
1.2 / - Is the location where the service is provided surrounded by high walls/fences and/or have closed/locked gates?
- Is the facility where the service is provided among businesses and community resources?
- Does the facility where the service is provided purposefully separate individuals receiving Medicaid HCBS from those who do not, or groups of individuals from others?
- Are there opportunities for community activities (not funded by Medicaid) for the period of time desired by the individual?
- Are visitors or other people encouraged from the greater community (aside from paid staff) to be present, and is there evidence that visitors have been present at regular frequencies? For example, do visitors greet/acknowledge individuals receiving services with familiarity when they encounter them, or does the facility otherwise encourage interaction with the public?
- Are individuals or visitors required to give advance notice for visitation?
Standard / 2. Respect/Rights/Choice
2.1 / - Was the facility chosen by the individual from among several options?
- Are individuals support plans reflective of their changing needs/goals?
- Are individuals aware of how to discuss/update their support plan?
- Was the individual/representative(s) present during the last person-centered plan meeting?
- Do planning meetings occur at times convenient to the individual/representative(s)?
- Does the facility and service provision afford individuals the opportunity for individual schedules that focus on their needs and goals?
2.2 / - Does the facility optimize the individual’s initiative, autonomy and independence in making choices about activities of daily living?
- Is the service provided in a manner that encourages the individual to make choices?
- Is individual choice facilitated such that the individual feels empowered to make decisions?
- Does staff ask individuals about their needs/preferences?
- Do individual schedules vary from others?
- Are individuals aware of how to make service requests?
- Are individuals satisfied with the services/supports received and those who deliver them?
- Are individual requests accommodated?
- Can the individual choose from whom they receive services and supports?
- Do individuals know how to request a change of service provider or support staff?
- Do any facility policies or practices inhibit individuals’ choices?
- Does the facility allow individuals to bring in personal resources such as money, food or other person items?
- Can individuals keep/control their own resources?
2.3 / - Are files containing individuals’ specific information maintained in a secure location and available only to appropriate staff for use in providing the authorized service?
- Is staff trained to provide the authorized service with respect for the individual’s privacy, dignity, and free from restraint and coercion?
- Do individuals greet and chat with staff?
- Does staff converse with individuals while providing assistance/services and during the course of the day?
- Does staff talk to other staff in front of individuals as if they are not there?
- Does staff address individuals in the manner they like to be addressed?
2.4 / - How does the facility make information available to individuals about how to register an anonymous complaint?
- Is information about filing complaints posted in obvious and accessible areas?
- Are individuals comfortable with discussing concerns?
2.5 / - Is there a written support plan in place for the individual?
- Are restrictions documented on an individual basis with complete reasoning and evidentiary support?
Standard / 3. Employment
3.1 / - How does the facility aid individuals who wish to pursue competitive employment in the community?
- Does the facility assist individuals with resume building?
- Are individuals provided with job searching assistance?
- Does the facility provide assistance with completing employment applications?
- Are individuals offered preparation for employment interviews?
6
Provider Self-Assessment Review Tool
6
Assessment Review Tool – Non-Residential Settings
Waiver: / Long-term CareName of Provider:
Contact Person for Provider:
Address:
County:
Telephone Number:
Email Address:
Medicaid Provider ID Number[1]:
License Number:
Provider Type: / Adult Day Center
Setting Location: / Urban
Rural
Number of Recipients Served Daily:
10
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 Characteristics
Standard / Standard Met
MET / NOT MET / Comments
1. Community Integration
1.1 Setting’s common areas are accessible and traversable.
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
1.2 Setting is among community resources accessible to the same degree of access as Individuals not receiving Medicaid HCBS.
Expectation:
Settings should be in community settings similar to those not receiving HCBS. / MET NOT MET
1.3 Setting is among community resources accessible to the same degree of access as Individuals not receiving Medicaid HCBS.
Expectation:
Settings should be in community settings similar to those not receiving HCBS. / MET NOT MET
2. Respect/Rights/Choice
2.1 Individuals are part of the person-centered planning process.
Expectation:
Individuals and/or their representatives are active participants in the planning process. / MET NOT MET
2.2 Individual choices are accommodated including:
· Option to bring and keep control of their own resources.
· Opportunity to engage in activities of the individual’s choosing.
· Ability to interact with people of the individual’s choosing.
· Meal options (if applicable) including where, when and with whom to eat.
Expectation:
Individuals have the right to receive services in an environment free from coercion where their choices are accounted for and honored in accordance with the person-centered plan unless the Individual’s safety would be jeopardized. / MET NOT MET
2.3 Setting promotes an individual’s rights of privacy, dignity, and respect, and freedom from coercion and restraint.
Expectation:
Confidential information about the Individual should be maintained in a secure file with only appropriate staff provided access to this information. Staff should be trained in service provision without coercion or loss of the Individual’s privacy, dignity, respect or restraint. Individuals are given privacy. / MET NOT MET
2.4 Individuals know how to file an anonymous complaint.
Expectation:
Information is available to Individuals on how to file an anonymous complaint. Telephone numbers for the Agency Consumer Complaint Hotline and the Abuse and Exploitation Hotline are posted in a common area of the setting. / MET NOT MET
2.5 Restrictions are identified, documented and based on the Individual’s needs and preferences.
Expectation:
The service setting should not unduly restrict an Individual / MET NOT MET
3. Employment
3.1 Setting assists individuals who wish to gain competitive employment and/or refers them to appropriate resource(s).
Expectation:
The setting does not impede, but aids, individuals who wish to pursue employment in the community. / MET NOT MET
Additional Comments:
Reviewer Name: ______/ Date:
Reviewer Signature and credentials:
10
Remediation Plan Template
Provider Self-Assessment Review Tool
Providers must maintain a written remediation plan in the provider files. The remediation plan must document deficiencies identified during the self-assessment, remediation actions to be taken, and a timeline for completion. Providers are encouraged to use the following template but may use other templates that include the required information.
10
Provider Remediation Plan Template – Non-Residential Facilities
Provider Name: ______
Provider Medicaid ID: ______
Facility Address: ______
County: ______
Presumptively Institutional Setting Criteria / Describe why setting meetspresumptively institutional setting criteria. / Describe remediation plan and timeline / Date Remediation Completed
A.
B.
C.
Standard 1
Community Integration / Describe deficiency / Describe remediation plan and timeline / Date Remediation Completed
1.1
1.2
Standard 2
Respect/Rights/ Choice / Describe deficiency / Describe remediation plan and timeline / Date Remediation Completed
2.1
2.2
2.3
2.4
2.5
Standard 3
Employment / Describe deficiency / Describe remediation plan and timeline / Date Remediation Completed
3.1
3.2
10