11 Categories for the HCBS Settings Compliance Requirements

The Federal Home and Community Based Services (HCBS) Settings Rule released in 2014 applies to all services and supports funded through Medicaid HCBS waivers. Below is a summary of HCBS Settings Rule expectations. While the state has focused on validating provider-controlled sites as compliant with the HCBS Settings Rule by March 17, 2023, ALL services funded through HCBS waivers should comply with the areas below where relevant. DDD encourages all stakeholders including people receiving services, families, guardians, advocates, independent services coordination agencies (ISCs) and providers, to become experts on the HCBS Settings Rule. ISCs and provider agencies should establish trainings and policies that reflect these rules.

For All Sites/Services

Expectation	What does this mean?
The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including: 1a) Opportunities to seek employment and work in competitive integrated settings Not provider responsibility	People have the right to be supported to access competitive integrated employment. The state/ISC are responsible for this especially through the person centered planning process. Providers also can share any expressed interest in employment and make referrals to DRS.
1b) Engage in Community Life	People have the right to engage in life in the community generally. Providers need to support people to engage in community life in the ways they choose. This means responding to and recording choices and expressed interests and supporting those requests as much as they can.
1c) Control Personal Resources	People have the right to control their personal resources as much as they choose. This can include having their own bank account, access to their funds at any time, having a bank card, and choice of rep payee. Providers need to support people to have as much independence as possible in controlling, directing, and accessing their resources.
1d) Receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.	People have the right to go out into the community to access services such as healthcare, groceries, and other general services in an integrated manner as much as they choose. Providers need to support people to have choice about utilizing integrated services and participating in community services with other people not receiving waiver services.
2a) The setting is selected by the participant from among setting options including non-disability specific settings and an option for a private unit in a residential setting. - Not provider responsibility	People have the right to choose a variety of services in different settings including in non-disability specific settings. The state is responsible for offering this opportunity to people receiving waiver services. ISCs should use the person centered planning process to identify interest in changes in services and support people to identify new services. Providers should share with the ISCs if people express the desire for different services.
2b) Setting options are based on the individual's needs, preferences - Not provider responsibility	People have the right to have choice in the types of services and who providers them. The state is responsible to ensuring service capacity across the state. ISCs should use the person centered planning process to identify interest in changes in services and support people to identify new services. Providers should share with the ISCs if people express the desire for different services.
3a) Ensures an individual's right of privacy	People have the right to have privacy in their homes, day programs and bedrooms. For Providers, this could include understanding and supporting what people want related to privacy and what is important to them and working to address privacy issues. If a person wants their own room, this should be documented, and steps taken to address it. ISC should also explore what privacy might mean for a person through the person centered planning process.
3b) Ensures an individual's right to dignity and respect	People have the right to dignity and respect in how they are treated in their homes and at their services including verbally and by staff action. Providers should train staff on this concept, share the rights document to people receiving services and guardians and have policies in place that support this.
3c) Ensures an individual's right of freedom from coercion	People have the right to freedom from coercion in their homes and in their services. Coercion can include threats and efforts to influence or pressure individuals to choose something they do not want. Providers should train staff on this concept, share the rights document to people receiving services and guardians and have policies in place that prohibit this.
3d) Ensures an individual's right of freedom from restraint	People have the right to freedom from restraint in their homes and in their services. Providers should train staff on this concept, share the rights document to people receiving services and guardians and have policies in place that prohibit this.
4a) The setting optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to daily activities	People have the right to choose their daily activities and direct their schedules. This should be an individualized approach that is not fixed and can change over ime. They have the right to be as independent as they want.
4b) Optimizes, but does not regiment individual autonomy, and independence in making life choices, including but not limited to physical environment	People have the right to have access to all areas of their homes. CDS, as a commercial site, can limit access to some areas, but should still consider making as much of the site accessible to people as possible.
4c) Optimizes, but does not regiment individual autonomy, and independence in making life choices, including but not limited to with whom to interact	People have the right to choose with whom to interact in their homes and other service sites whether friends, housemates, or staff. Providers should support and encourage people to identify opportunities for building friendships, community, and natural supports.
5) Facilitates individual choice regarding services and supports, and who provides them	People have the right to choose their services and be involved with who provides them. Providers should work with people to support individualized schedules. Providers should have a clear process of complaints regarding staff support and support people when there are clear preferences related to staffing.
6a) Individuals have the freedom and support to control their own schedules and activities	People have the right to control their own schedule and the right to be supported to make decisions. Individuals should be supported in expressing choice, and Providers should work to support the person in that choice or interest.
6b) Individuals have access to food at any time	People have the right to access food at any time in their kitchens or at CDS programs. The kitchen is never "closed", and people can choose to eat their meals when they would like. At CDS programs, they can access food they bring when they want.
7) Individuals are able to have visitors of their choosing at any time.	People have the right to have visitors at any time. Even with COVID protocols, people cannot be told that they cannot see people. Providers should work with a person and visitor to assure visitation. If conflict arises between housemates because of visitors, conflict resolutions efforts should be made to establish agreed upon boundaries. If they cannot, referrals to the ISC should be made to identify other service options.
8)The Setting is physically accessible to the individual	People have the right to have a home that is physically accessible for them. A provider should help identify any areas of assistive technology needs or modifications needs. If circumstances change, the ISC, state and provider should help the person move to more accessible supports.
9) Any modification of the additional conditions, under §441.301(c)(4)(vi)(A) through (D), must be supported by a specific assessed need and justified in the person-centered service plan. The following requirements must be documented in the person-centered service plan Identify a specific and individualized assessed need. Document the positive interventions and supports used prior to any modifications to the person-centered service plan Document less intrusive methods of meeting the need that have been tried and did not work Include a clear description of the condition that is directly proportionate to the specific assessed need Include regular collection and review of data to measure the ongoing effectiveness of the modification Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated Include the informed consent of the individual Include an assurance that interventions and supports will cause no harm to the individual	People have clear rights under the HCBS Settings Rules. Stakeholders should approach modifications of these rights with the idea that everyone should start with them, and they are only limited temporarily if an assessed need is identified within the personal plan. The settings rule outlines steps that must be taken including revisiting modifications to assure people are not limited permanently. This modification process is critical to fulfilling the goals of autonomy and independence for people receiving waiver services reflected in the HCBS settings rule.

For All Sites

Expectation	What does this mean?
10) The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the State, county, city, or other designated entity. For settings in which landlord tenant laws do not apply, the State must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS participant, and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord tenant law	People have the right to a lease or residency agreement that lays out their rights in their own home for which they are paying rent. Residency agreements cannot conflict with Illinois Landlord Tenant law.
11a) Each individual has privacy in their sleeping or living unit.	People have the right to have privacy in their homes and bedrooms. Providers and ISCs must understand what people want related to privacy and what is important to them and work to address privacy issues. If a person wants their own room, this should be documented, and steps taken to address it.
11b) Units have entrance doors lockable by the individual, with only APPROPRIATE staff having keys to door	People have the right to receive locks to their homes and to their bedrooms if they want. Locks and keys should be provided, and people can choose to use or not use them. Where there are guardians, they should be involved in the discussion, and if it is determined a modification due to safety should be made, the ISC should be involved with outlining this in the personal plan. Physical accessibility accommodations should be made where needed.
11c) Individuals sharing units have a choice of roommates in that setting	People have the right to choose their roommates if they have them.
11d) Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or agreement	People have the right to decorate their homes and bedrooms how they like. This goes once again to the fact that this is the person's home, not a facility.

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