Form Odm 10172 - Home And Community-Based Services (Hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid Page 4
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6Additional Conditions Required for Provider-Owned or Controlled Residential Settings
The following additional conditions are not applicable to non-residential settings such as adult day health settings.
The setting offers privacy in the sleeping/living unit.
Do the setting policies afford privacy in
Do the setting policies permit individuals
Are shared living units configured so that
the individual’s living/sleeping unit?
who share a sleeping/living unit to choose
privacy is protected when assistance is
their roommate?
provided to individuals?
Yes
No
Yes
No
Yes
No
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, waiver provider structural compliance review results, and
satisfaction surveys.
Remediation Needed
(explain)
The setting offers residential options based on individual resources for room and board.
Does the setting have a policy regarding how the individual will be informed when residential services are limited because of the
individual’s resources?
Yes
No
Examples of Acceptable Evidence of Compliance
Setting policies and procedures, legally enforceable or resident agreement, orientation or admission materials given to new
residents, resident handbook.
Remediation Needed
(explain)
The setting has a legally enforceable agreement specifying responsibilities and protections from eviction.
Does the agreement specify the
Does the agreement specify the
Does the agreement address the steps an
responsibilities of the individual and the
circumstances under which the
individual can follow to request a review
provider with respect to the setting?
individual’s residency may be terminated?
of or appeal the termination of
residency?
Yes
No
Yes
No
Yes
No
Examples of Acceptable Evidence of Compliance
Legally enforceable or resident agreement, orientation or admission materials given to new resident, resident handbook,
Residents’ Rights, setting policies and procedures.
Remediation Needed
(explain)
The setting provides living unit doors lockable by individual.
Can the doors to the unit be locked?
Do individuals have keys to their own living unit?
Yes
No
Yes
No
Examples of Acceptable Evidence of Compliance
Setting policies and procedures, legally enforceable or resident agreements, orientation or admission materials given to new
residents; resident handbook, Residents Rights staff training, grievance committee meeting minutes, waiver provider structural
compliance review results.
Remediation Needed
(explain)
ODM 10172 (3/2016)
Page 4 of 6
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