Looking for a Medicaid Forms And Templates? Download it for free!

The setting provides opportunities and support for employment in competitive, integrated settings.

If individuals are employed or choose to work outside the setting, does the setting assist them by planning services around their

work schedule, prompting individuals when it is time to go to work, and ensuring transportation is available?

Yes

Examples of Acceptable Evidence of Compliance

Orientation or admission materials given to new residents or participants, resident or participant handbook, setting policies and

procedures, employment referral processes, employment supportive services, Residents’ Rights staff training, staffing patterns.

Remediation Needed

(explain)

The setting provides opportunities for control of personal resources.

Does the setting facilitate/support individuals to access

Do individuals have bank accounts or other means to control

accounts/funds as they choose?

their money?

Yes

Examples of Acceptable Evidence of Compliance

Legally enforceable or resident agreement, orientation or admission materials given to new residents or participants, resident or

participant handbook, setting policies and procedures, Residents’ Rights staff training.

Remediation Needed (

)

explain

The setting has a process for protecting individuals’ rights of privacy, dignity, respect and freedom from coercion

and restraint.

Do individuals have access to telephones

Does the setting use interventions/restrictions

Do individuals receive instructions

or other electronic devices to use for

like those that might be used in institutional

from the setting on how to file a

personal communication in private and

settings (seclusion, physical or chemical

complaint?

at any time?

restraints or locked doors)?

Yes

Examples of Acceptable Evidence of Compliance

Setting policies and procedures, legally enforceable or resident agreement, orientation or admission materials given to new

residents or participants, resident or participant handbook, Residents’ Rights staff training, grievance committee meeting minutes.

Remediation Needed

(explain)

The setting optimizes opportunities for individuals to make choices and control schedules regarding daily activities.

Do the setting policies afford the opportunity for individuals to

Do the setting policies promote opportunities for the individuals to

make informed choices about who to receive their services from

make informed choices about when tasks, services and activities are

and when?

are furnished?

Yes

Examples of Acceptable Evidence of Compliance

Setting policies and procedures; legally enforceable or resident agreement, orientation or admission materials given to new

residents or participants, resident or participant handbook, Residents’ Rights staff training, staffing patterns, satisfaction survey

results.

Remediation Needed

(explain)

ODM 10172 (3/2016)

Page 2 of 6

Form Odm 10172 - Home And Community-Based Services (Hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid Page 2

Related Articles

Related forms

Related Categories