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Form Odm 10172 - Home And Community-Based Services (Hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid Page 5

The setting provides a living unit key availability limited to appropriate staff.

Do the setting policies permit the use of master key/unit keys

Do the setting policies describe the circumstances when the

used to enter units only in limited circumstances agreed upon

master key/unit keys may be used by staff and which staff may

with the individual?

use those keys?

Yes

Examples of Acceptable Evidence of Compliance

Setting policies and procedures, Legally enforced or resident agreement, orientation or admission materials given to new

residents; Residents’ Rights staff training.

Remediation Needed

(explain)

The setting has a legally enforceable agreement that addresses how individuals may furnish/decorate sleeping/living units.

Are individuals informed that they may furnish and decorate their units as they please within the terms spelled out in in the legally

enforceable agreement?

Yes

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, satisfaction survey results.

Remediation Needed

(explain)

The setting supports individuals’ freedom to control schedules and activities.

Does the setting make clear to individuals that they are not

Do individuals have access to typical home areas such as

required to adhere to a set schedule for waking, bathing, eating,

cooking and dining areas, laundry, and living and entertainment

exercising, or activities?

areas?

Yes

Examples of Acceptable Evidence of Compliance

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

residents, satisfaction survey results, Residents’ Rights staff training, staffing patterns.

Remediation Needed

(explain)

The setting ensures food is available to individuals at all times.

Are provisions made for food to be available between and after

Can individuals eat in locations other than the dining area, e.g.,

regularly scheduled meal times?

in an entertainment area or in private in a sleeping/living unit,

etc.?

Yes

Examples of Acceptable Evidence of Compliance

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

residents; satisfaction survey results, staff training, staffing patterns.

Remediation Needed

(explain)

ODM 10172 (3/2016)

Page 5 of 6

Form Odm 10172 - Home And Community-Based Services (Hcbs) Settings Evaluation Tool - Ohio Department Of Medicaid Page 5

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