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Form Odm 10172 - Home And Community-Based Services (Hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid

Ohio Department of Medicaid

Home and Community-Based Services (HCBS) Settings Evaluation Tool

Contact Information

Name

Address

(individual Name or Business)

Primary Phone

Secondary Phone

Instructions

In January 2014, the federal Centers for Medicare and Medicaid Services (CMS) released new requirements for Medicaid Home and

Community-Based Services (HCBS) programs administered by states. The federal rule identifies the qualities of a home and

community based setting. For more information please use links at the bottom of this form. This is an evaluation to help identify

how your setting currently demonstrates the home and community based qualities outlined in the federal regulation. Review each

topic carefully and answer all questions. For each quality listed, there is at least one criteria statement. Please mark the response

that best describes your setting. Examples of acceptable evidence of compliance are provided. If you mark the Remediation

Needed box, please describe how your setting will demonstrate the home and community based quality in question, including when

you expect this to occur. Maintain a copy of your Home and Community-Based Services Settings Evaluation along with your

remediation documents onsite with your other provider files.

Qualities Required for all Home and Community-Based Services Settings

The setting is not located in building/on grounds with institutional characteristics.

Is the setting co-located in the same building as a publicly or

Is the setting located in a building on the grounds of, or adjacent

privately operated facility that provides inpatient institutional

to, a public institution?

treatment?

Yes

Examples of Acceptable Evidence of Compliance

Secretary of State filing, floor plans, pictures of signage and entrances.

Remediation Needed

(explain)

The setting does not isolate individuals from the broader community of individuals not receiving HCBS.

Are there individuals residing in the

Is the setting located among other

Does the setting operate in a manner that

setting who are not receiving HCBS

residential buildings, private and retail

congregates individuals so that they

services?

businesses, etc., that facilitate

live/receive services in an area separate from

integration with the greater community?

individuals not receiving Medicaid HCBS

Yes

services?

Yes

Examples of Acceptable Evidence of Compliance

Floor plans, site maps, setting policies and procedures, activity schedules, a legally enforceable or resident agreement, orientation

or admission materials given to new residents or participants, resident or participant handbook, Residents’ Rights staff training.

Remediation Needed

(explain)

ODM 10172 (3/2016)

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Form Odm 10172 - Home And Community-Based Services (Hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid

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