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Form Odm 10172 - Home And Community-Based Services (Hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid Page 3

The setting optimizes opportunities for individuals to make choices regarding their physical environment.

Do the setting policies allow individuals’ freedom to move

Are individuals assisted to access amenities

(e.g. pool or gym, etc.)

about inside and outside of the setting as opposed to one

that are used by individuals not receiving Medicaid HCBS

restricted room or area within the setting?

services?

Yes

Examples of Acceptable Evidence of Compliance

Floor plans, 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)

The setting optimizes opportunities for individuals to choose with whom to interact.

Does the setting require individuals to

Does the setting provide an area for

Are individuals restricted to meeting

occupy assigned seating for activities or

individuals who wish, on occasion, to not

visitors in an area designated for that

meals?

participate in activities or to be alone?

purpose?

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, and satisfaction

survey results, pictures displaying activities and seating arrangements.

Remediation Needed

(explain)

The setting facilitates choice regarding services/supports and agency staff who provide them.

Does the setting solicit input from individuals regarding

Does the setting assist individuals to change providers or to

satisfaction with the setting, staff and services received?

obtain other requested services?

Yes

Examples of Acceptable Evidence of Compliance

Setting policies and procedures, Residents’ Rights staff training, staffing patterns, legally enforceable or resident agreement,

orientation or admission materials given to new residents or participants; resident or participant handbook, training, grievance

committee meeting notes, satisfaction survey results.

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 Page 3

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