HCBS Provider Toolkit

The Illinois Department of Human Services, Division of Developmental Disabilities (IDHS/DDD), in conjunction with the Illinois Department of Health and Family Services (HFS), is committed to working with all providers of services to individuals with developmental disabilities to come into and remain in compliance with the federal Settings Rule. Our providers play an important role in making sure individuals with developmental disabilities make their own choices and pursue their desired opportunities, contribute to their communities and are treated with dignity and respect.

To assist providers in their efforts to achieve compliance with the Settings Rule, DDD offers this toolkit as a resource. Here you will find frequently asked questions, guidance, examples of promising practices that support choice and independence for individuals who receive waiver services and other resources for your use. We encourage you to use this toolkit to help generate ideas on how you can better serve individuals with developmental disabilities in ways that align with the Settings Rule. Please note, we will continue to add to this toolkit as additional questions and issues arise.

Included in this Toolkit:

  1. Acronyms
  2. Frequently Asked Questions
    1. HCBS Settings Rule
    2. Compliance Concerns
    3. Person Centered Planning and Informed Choice
    4. Residential Concerns
    5. Transportation
    6. Rights and Modifications to Rights
    7. Community Integration and Engagement
  3. Promising Practices
  4. Resources

Acronyms:

  • CILA: Community Integrated Living Arrangement
  • CMS: Centers for Medicare and Medicaid Services
  • DDD: Division of Developmental Disabilities
  • HCBS: Home and Community Based Services
  • HFS: Healthcare and Family Services
  • ISC: Independent Service Coordination Agency
  • IDHS: Illinois Department of Human Services

Frequently Asked Questions:

HCBS Settings Rule

1. What is the HCBS Settings Rule?

In 2014, the Centers for Medicare and Medicaid services (CMS) released new federal regulations requiring states to provide enhanced opportunities for community integration and to ensure certain rights and protections are in place for individuals who receive Medicaid-funded Home and Community Based Services. These services are commonly referred to as HCBS and the regulation is known as the Settings Rule.

The Settings Rule was developed to ensure that individuals receiving long-term services and supports through Medicaid-funded HCBS have full access to the benefits of community living and the opportunity to receive services in the most integrated settings that can meet their needs and enable them to achieve their goals. Simply put, the rule ensures individuals get the most out of community living and receive person-centered services in the most integrated setting possible.

The Settings Rule sets out standards for all HCBS settings and additional standards for provider owned or controlled settings. DDD must assure that all existing HCBS settings are in full compliance or have exhibited the ability to come into full compliance by March 2023. After this date, any setting that is not in full compliance or has not exhibited the ability to come into full compliance will not be eligible for federal HCBS funding. As a result, DDD will no longer be able to authorize services at that setting.

The link to the Settings Rule is: Home & Community Based Services Final Regulation | Medicaid

2. What rights do individuals who receive HCBS waiver services have especially outlined by the HCBS Settings Rule?

Individuals have the right to person-centered service planning, conflict-free case management and homes and workplaces that have characteristics that are home and community-based. More specifically, individuals have the right to:

  • Seek employment and work in competitive, integrated settings
  • Engage in community life
  • Control their personal resources
  • Receive services in the community with the same degree of access as individuals who do not receive HCBS services
  • Choose their home and workplace from available options
  • Privacy, dignity and respect
  • Freedom from coercion and restraint
  • Optimized individual initiative, autonomy and independence in making life choices, including setting a daily schedule and choosing with whom to interact
  • Choose services and supports and who provides them.

Provider-owned and -controlled residential settings must meet additional standards. Individuals in these setting also have a right to:

  • A lease or other legally enforceable residential agreement
  • Privacy in their bedroom, including lockable doors
  • The choice of roommates if it is a shared home
  • Freedom to furnish and decorate their home and bedroom
  • Freedom and support to control their schedule and activities, including access to food at any time
  • Freedom to have visitors at any time
  • Physical accessibility

3. On the Settings Rule, generally, will there be a combined training for ISCs and providers?

Both ISCs and providers participated in the two recent webinars. We will add additional training in the new year to continue to support understanding of Settings Rule implementation for all parts of the service system and encourage all who are interested to attend including providers, ISC staff, individuals and families. We are also working with ISC on the person centered planning process update to reflect HCBS settings requirements.

Compliance Concerns

4. My agency was found to be in compliance with the Settings rule when DDD went through this process several years ago. Why do I have to go through it again?

In the years that followed DDD's initial effort to assess compliance with the Settings Rule, federal CMS has issued new guidance and clarified some aspects of the rule. In order to ensure that Illinois is fully compliant, we felt it was necessary to begin with a clean slate and treat all service providers the same.

5. If any of my sites are found to be out of compliance with the Settings Rule, how long will I have to bring the site into compliance?

All sites must be in compliance by March 17, 2023 in order to continue to receive funding through the waiver. If, during the policy and evidence validation process a site is found to be deficient in any area of the Settings Rule, a compliance action plans will need to be created to address the issue. In order to continue to receive funding, they will need to be completed by March 17, 2023. In Illinois, sites with compliance action plans will be assigned a staff person from DDD who will track progress and work with the provider to trouble-shoot issues, should they arise.

6. What will happen if it is determined that a site cannot achieve compliance with the Settings Rule?

The State will no longer fund the site through the HCBS waiver and will offer individuals living in or working at that site opportunities to move to funded waiver settings. While DDD recognizes the reality that this situation could arise, it also believes that all sites can achieve compliance with the Settings Rule if the provider has the interest and the will to do so.

7. How will providers be affected if lack of staff is a barrier to meeting some of the Settings Rule's requirements?

DDD recognizes the current struggle to attract and retain DSPs. We have had conversations with our CMS Techincal advisors regarding this and understand that Illinois is by no means alone in this struggle. CMS in 2021 acknowledged the challenges of staffing and the pandemic in implementing the settings rule. However, they have made no indication that the deadline for compliance will change. Therefore, providers must have the appropriate policies in place to be compliant and make efforts toward implementation of those policies. This includes working with individuals and ISCs to meet their needs and choices. As DDD continues to make financial investments in the community and the staffing crisis eases, we would expect to see increased efforts toward full implementation compliance.

8. Why is there an issue with CDS sites serving both individuals in CILAs and ICF/DDs? Are we truly saying that we need to segregate individuals in CDS based on their living arrangement?

First, no. Please do not segregate individuals in your CDS based on their living arrangement. That's not the concern here. The concern is that individuals receiving HCBS funded supports must be afforded access to the community through their day program as well as their residential setting. There is no such requirement for individuals attending CDS from an ICF/DD. If the CDS is treating individuals from both settings the same, allowing them access to the community through various outings and choices of programming, there should be no compliance issue with the Settings Rule. However, if the reverse is occurring and no one is accessing the community because there is no requirement on the ICF/DD regulatory side, that is a compliance issue with the Settings Rule.

9. I believe 30 states have yet to receive final approval status. Is there any discussion with CMS about potentially extending deadlines, noting the pandemic?

While we can't know for certain what CMS might decide to do as we move toward that important March 2023 date, there is no indication at this point that CMS plans to extend the deadline. We are operating as if all sites will need to be validated as compliant by March 17, 2023. If CMS decides to extend the deadline again, we will work with our state and community partners on an updated timeframe.

10. Are there any resources available to make access adaptations for rented sites that provide community day services?

DDD is not aware of any resources currently available for these sites and suggests that if modifications to the physical plant are necessary for individuals currently receiving day services in such a location, the provider should work with the landlord to try to get those modifications in place. Otherwise, the setting is probably not appropriate for any individual(s) who is not able to fully access the setting due to barriers to physical accessibility. Feel free to reach out to the appropriate Regional staff within DDD to have a more in-depth conversation about this topic.

Person Centered Planning and Informed Choice

11. What are person-centered practices and what do they address?

Person-centered practices are support and service-planning practices that are not driven by professional opinion or provider specific service options. Instead, planning looks at services and supports in the context of what it takes for a person to have the life he or she wants. The person, along with his or her support team, identifies support and services that will help them live, learn, work and participate in preferred communities on his or her own terms.

Person-centered practices increase an individual's quality of life and helps him or her to create or maintain a life they enjoy in the community. Person-centered practices are flexible and adaptable and encourage informed choice and creativity.

12. How can we be more person-centered?

Providers can think in a more person-centered manner by recognizing the whole person, communicating the belief that everyone has gifts to share and maintaining a focus on the person. Finding a balance between what is important to someone (e.g., what makes them happy) and what is important for someone (e.g., what keeps them healthy and safe) is a core concept of person-centered thinking. Having the freedom to explore new things is very important; however, it is incumbent upon the service provider to assist an individual in weighing the risks and benefits of their decisions.

13. What does it mean for a person to have informed choice?

Informed choice is decision-making based on accurate and complete information. Informed choice happens through ongoing person-centered conversations and activities. A person making an informed choice understands the options - as well as the risks and benefits - in any given decision. With informed choice, community resources and supports are valued and explored.

14. How can providers make sure individuals have informed choice?

The Settings Rule supports individuals' rights to make informed choices and determine what is important to them and for them. Providers can ensure individuals have informed choice by:

  • Providing or helping individuals to get information that allows them to exercise informed choice in creating individualized plans when it comes to the selection of outcomes, providers, supports and services, the most integrated settings in which the supports and services will be provided and methods of getting services.
  • Putting in place policies that help them to provide supports and services and afford individuals meaningful choices.
  • Notifying individuals through appropriate methods of communication about opportunities to exercise informed choice, including the availability of support for individuals who need help to exercise informed choice.
  • Helping individuals exercise informed choice in making decisions.

15. How can we better learn about individual's preferences and needs?

There are many techniques that can be used to help providers better learn about individual's preferences and needs. Some suggestions for making those opportunities more productive include:

  • Asking a person open-ended questions about choice, independence, individual rights, and community access and integration. Specific questions could range from "What types of opportunities do you have to spend time in the community with other community members?" to "What types of interactions are common for you to have with members of your community?" Other things to ask include:
    • "What do you like about your work?"
    • "What do you like about your home?"
    • "What do you like about your services?"
    • "What would you change about each of them, if anything?"
    • Other important questions are: "Have you felt like there are situations in which you haven't been treated fairly? If that's the case, can you describe them?"
  • Listening carefully to the person's answers and following up on their responses. This can be done by seeking details and examples of how individuals's services have supported or hindered the opportunities they would like to have to be integrated members of the community.
  • Observing the person while they answer questions to evaluate if body language or other signs suggest individuals's true feelings are different from their words. It is helpful to reassure individuals that their answers will not be used against them, but instead to help improve services they or others receive.
  • Using visual aids or technology solutions such as photos or communication devices to learn the preferences of a person who is unable to verbalize his or her responses. For example, a staff member may show a person pictures of community activities and ask the person to select a preference and identify a friend who might want to come along.
  • Learning about preferences can also include trying new things and watching a person's response and level of engagement. Talking with staff who work frequently with the person will also reveal preferences.

Staff can have structured conversations to learn more about individual's needs and preferences during their intake meeting, following up at future annual, semi-annual or support team meetings, during day-to-day interactions and at a regular one-on-one meeting.

Providers may also want to engage individuals in a more formal process to help learn more about what is important to them. Through annual or semi-annual meetings, individuals and the staff supporting them can discuss what they would like to accomplish in the next year and beyond. After each meeting, a staff member can share the person's dreams and passions with the individuals who work closely with him or her.

Residential Issues

16. If an individual is renting their own house or apartment, does the Settings Rule apply?

The Settings Rule applies to all provider-controlled or owned homes. Individuals in individually owned or controlled homes and apartments in which the individual receiving Medicaid HCBS Waiver services lives independently or with family members, friends, or roommates are presumed to be in compliance with the regulatory criteria of a home and community-based setting. Individually owned or controlled means a physical setting in which the individual resides that is owned, co-owned, leased, or rented by the individual. This setting is not provider owned or controlled.

Settings where the individual lives in a private residence owned by an unrelated caregiver (who is paid for providing HCBS to the individual) are considered provider owned or controlled settings and will be evaluated as such. If an individual is renting a home from a provider or an affiliate of the provider from whom they receive HCBS services, this is considered a provider controlled home and all parts of the Settings rule apply. These rules include requiring a residency agreement, visitor requirements, and lockable doors. Note: a waiver provider cannot set up a separate agency or company to manage properties to avoid Settings Rule compliance. This would still be considered a provider-controlled setting.

17. Who signs the residency agreement?

Whenever possible, the individual should sign the residency agreement even if a guardian also needs to sign it. It is the provider's responsibility to meet with the individual to help him/her understand what it is and what rights it contains, taking as much time as needed to answer questions, etc. Even in situations where an individual may not be able to fully comprehend what is contained in the lease, the provider should make every effort to involve and engage the individual.

18. Do the residency agreements have to be renewed every year? What happens if a waiver participant lapses in signing the lease renewal? Does that mean they would need to leave?

The residency agreements must be renewed annually. If an individual has not signed the agreement, he or she should be asked if they want to continue living in the setting. If the answer is yes, they should sign the agreement. Any modifications to the agreement requested by the individual should be documented. If the answer is no, the ISC should be contacted to mediate the signing of the lease/agreement or to begin working with the individual to find a new setting.

19. Currently if a resident breaks a door in the house, we would go to our HRC to get approval for the client to pay for the repair over time. If it is in the lease or residency agreement, would we still need to go to the HRC?

HRC approval is not necessary in all cases for the resident to pay for the door. If the door was broken during an incident and paying for the door is a consequence for behavior, then it may need to go through HRC to make sure it isn't an inappropriate consequence. If replacing broken or damaged home items is part of the residential agreement, then repayment in of itself would not require HRC approval. The broken door does not decide if it goes through HRC but the circumstances of how the door got broken might.

20. Is it OK to have house rules?

House rules are voluntary and are intended to identify ways that individuals who share a home may live respectfully with each other. House rules that are followed by the individuals living in the home but not enforced by staff are allowable. Individuals living in the home must have the opportunity to provide input into any house rules that are established. To be compliant with the Settings Rule, house rules must:

  • Ensure an individual's right of privacy, dignity and respect and freedom from coercion and restraint;
  • Optimize but…not regiment individual initiative, autonomy and independence in making life choices, including but not limited to, daily activities, physical environment and with whom to interact; and
  • Facilitate individual choice regarding services and supports and who provides them.

To be compliant with the Settings rule, the following house rules are prohibited:

  • Rules that limit certain rights through broad-based requirements that everyone waive certain rights;
  • Rules that use improper qualifiers (e.g., visitors are allowed during "reasonable" hours only or only with "prior approval");
  • Rules that use arbitrary cutoffs to the exercise of rights; and
  • Rules that deny access to appropriate areas of the home.

If there are disagreements between residents about issues such as timing of visitors, then the provider should support conflict resolution efforts and individuals can discuss with their ISCs about possible changes to their services or housing.

21. What kinds of locks are allowable under the Settings Rule but that also comply with the State Fire Marshal's regulations?

Per the Office of the State Fire Marshal:

Regarding the option for a lockable front door to their home; have access (through keys, key fobs, codes, key cards and any other devices used to gain access through any door lock mechanism) to their bedroom and/or home. 42 CFR § 441.301 (c) (4) (vi) (B) (1)

(B) Each individual has privacy in their sleeping or living unit:

(1) Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors.

OSFM Considerations

  • All door locking mechanisms and systems for individual rooms and spaces must also comply with NFPA 101 Life Safety Code, Chapter 7 and Chapters 32.2 or 33.2 for small residential board and care.
  • Chapter 7 permits a door to have a locking device provided it allows the door to be easily unlocked / opened from within the room or space for the purpose of egress.
  • A single-cylinder lock utilizing a button pressed into the doorknob to lock from the inside, and when turn the knob to exit the room or space, the door automatically unlocks.
  • This type of lock is allowed to have a key, fob, code pad, keycard, etc. to unlock from the outside the facility or room by individual room occupant and any other authorized persons.
  • This type of lock cannot utilize any key, special tools, or knowledge to unlock from the egress side;
    • Special tools would involve a fob, keycard, etc.
    • Special knowledge would be a code, more than one process to unlock, etc.
  • Locks not meeting NFPA 101, Life Safety Code requirements and not permitted would include:
    • Ordinary double-cylinder locks that require keys on both sides of the door to lock and unlock.
    • Chain locks, slide bolts, hasps mounted on the inside, and other type latches if they cannot be unlocked from outside the door by authorized persons during an emergency.

22. How do we handle a situation where an individual is unable to understand having a lockable door with keys?

The Settings Rule indicates that having a lockable door with a key is an option that must be made available. An effort must be made by the provider to explain the concept and determine whether it is a viable option. If, in the end, it is determined that the person does not want a key or lockable door, it should be noted in the Person-Centered Plan and documented as such.

23. If an individual is unable to use a key, will this need to be written as a restriction in the person-centered plan and implementation plan?

If an individual desires a key but, due to their disability, is unable to manipulate a key, consider other options that might be more manageable such as a keypad or swipe card. Physical accommodations must be made to enable the person to be able to access their space. This would not be considered a restriction but is something that the provider needs to continue to work toward on behalf of the individual.

The Settings Rule only states that the option must be made available to individuals. If an individual does not want a key, there is no requirement that they have one. However, if an individual decides they do not want a key, this should be noted in their personal plan.

24. How does the right to have a key to the bedroom affect 15-minute bed checks? Are we supposed to use a key to open their room every 15 minutes to check on them through the night? Do we knock on the door and disturb them every 15 minutes?

First, it is important to understand why the 15-minute bed check is occurring. If it is because it is a DCFS requirement for a Child Group Home, the key requirement doesn't apply for anyone under 18 years of age and the provider should continue to conduct the bed checks as is currently happening. For young adults 18+, the provider/staff should meet with the individual to come up with an agreement on how best to conduct the checks while promoting the individual's privacy and ensuring their safety.

Similarly, if an adult in a CILA has a particular reason related to their disability that requires frequent overnight bed checks, the provider/staff should meet with the individual and come to an agreement on how those checks will be accomplished. If the individual has no disability-related reason for frequent bed checks, the staff should stop doing them.

Any agreements should be noted in the Implementation Strategy.

25. What will be the process for determining whether an individual wants a private bedroom?

The question of whether an individual would like to have a private bedroom can be addressed at several points. If the individual is just entering residential services, the ISC Case Manager should explore the option. That may mean more than just having a conversation. It may be helpful to have the individual visit several residential options so they can see for themselves the difference between having a roommate or having a private room. Even if a private room is desired but not available, if the individual chooses to proceed with moving, the ISC Case Manager should note that ultimately, the individual would like a private room. This should continue to be a part of the Person-Centered planning process and something the ISC Case Manager and provider work toward.

If the individual is already receiving residential services, at a minimum during the Person-Centered planning meeting, the ISC Case Manager should explore the desire for a private room with the individual. Again, visiting a home with a private room may be desirable in helping the individual understand what having a private room might mean. If the individual indicates that yes, a private room is desirable, the ISC Case Manager will explore the possibility with the provider. If the provider has no current private room availability and the individual wishes to remain with the current provider, the ISC Case Manager should note this in the person-centered plan and continue to raise it with the individual until such time that a private room becomes available. If the individual expresses a willingness to move to a different provider if a private room is available, the ISC Case Manager should handle this as they would any other request for a change in residential provider, focusing on the need for private room capacity.

The ISC Case Manager and the provider should also explore with individuals what kind of privacy they would like in their rooms and homes and how they might be able to address this if they do not have a private bedroom.

Finally, it should be acknowledged that the DSPs in the home are the people who are in daily contact with the individual and who, outside of family and close friends, know the individual best. If a DSP becomes aware that an individual really wants a private room, contact with the QIDP, Supervisor or ISC Case Manager should be made. The individual should not be made to wait for the next Person-Centered planning meeting or ISC Case Manager contact in order to express their desire.

26. How do we handle a situation where an individual is unable to state or express their choice of a private bedroom?

In a situation such as this, the most important thing is that the provider and the ISC Case Manager, through the Person-Centered planning process which engages the person, attempt to explain this to an individual in their preferred form of communication. The provider and Case Manager could also look for clues as to what an individual's preference might be. For instance, someone who seems to prefer to spend their free time alone might be more inclined toward desiring a private bedroom than another individual who is more social. In the end, though, the important thing is to try to explain it and document those efforts.

Transportation

27. How will the Settings Rule affect a public transportation agency that provides paratransit services to individuals receiving HCBS services?

Public transportation is not directly affected by the Settings Rule. Case management should work with an individual to identify if transportation is a concern that needs to be addressed in the person-centered plan. The provider is also required to support the person to problem solved transportation issues, Doeseither by providing or identifying ways to partner to provide transportation or work with the person to utilize natural supports or other more independent transportation options.

Rights and Modifications to Those Rights

28. What do I do if someone living in a CILA with others cannot have free access to food, per the Settings Rule, because of his disability?

Access to food can be restricted only on an individualized basis. If one person has a rights modification in place restricting their access to food at any time, and part of this modification includes locking the pantry and/or refrigerator, other individuals not subject to this modification must have a way to obtain access to food at any time (e.g., have a key to the lock, a passcode, etc.). Please note, modification or rights restrictions related to the Settings Rule should be documented in the Person-Centered Plan and Implementation Strategies and reviewed by the provider's Human Rights Committee on a regular basis.

29. Does full access to food mean being able to eat whatever, whenever? What about an individual with a special diet? Should the individual still have free access to food?

As a general rule, full access to food does mean being able to eat whatever, whenever. However, if an individual has a special diet, there should be a restriction in place as stated above. The provider should work with the individual with a special diet to try to find ways to allow access foods that fall within the special diet; balancing "wants" with safety.

30. What are some strategies to explain individual's rights in a way they understand?

Individuals have the right to know their rights and to have their rights explained o them in a way they understand. Explaining individual's rights in a variety of way will help to promote understanding. DDD created an information bulletin on Individual Rights and Autonomy: 

Here are some strategies for talking with individuals about their rights:

  • Meet with each person you serve in person and individually to talk about his or her rights.
  • Find a good place to meet and have this discussion. Minimize any distractions.
  • Ask open-ended questions that cannot be simply answered by "yes" or "no." This will allow you to learn more about how a person is understanding his or her rights.
  • Take your time, and don't rush communication. Give individuals time to think about what they are hearing.
  • Use examples, photos, pictures or role playing to make the information more understandable.

31. How should Direct Support Professionals support individuals in expressing their rights?

The role of the DSP in supporting individuals to express their rights is to ensure that they know and understand their rights. This can be done through formal teaching, such as individually organized training sessions (e.g., role playing, small group activities) and through teachable moments, such as witnessing and learning from another person who is expressing his or her rights and by pointing out the right while a person is supported to exercise it. In addition, the provider will share the individual rights document yearly with people.

32. Will the Office of the Inspector General (OIG) be on board with the right to risk? As long as required supports or training are met, will providers be held responsible by the OIG?

DDD has and will continue to meet with the OIG to help them understand what the Settings Rule tells us about individual rights, including the dignity of risk. This may be a new way of looking at service delivery for the OIG and may take some time for them to implement. Once a setting has been found compliant with the Settings Rule, issues that arise with OIG's interpretation or understanding of the Settings Rule should be raised up to the DDD.

33. Do individuals have the right to determine their schedule for attending community day services? For instance, two people living in the same CILA choose to attend at different times. Is this something the Settings Rule requires to be implemented?

The Settings Rule says that individuals have the right to set their schedules and make this choice. DDD understands from an implementation perspective this will be challenging. The important thing is that individuals are asked what they want and providers work with individuals to try to meet their desires.

34. I have a question about physical modifications that may restrict movement - for instance the use of a seatbelt on a wheelchair, where the individual is in agreement about the reasoning for use but cannot modify it independently?

If the seatbelt in question is required by law, for instance a seatbelt in a vehicle - even if it is a special seatbelt designed for a wheelchair -- this is not a rights restriction. However, if the seatbelt is being used as a lap belt to prevent an individual from falling out of the wheelchair, this would need to go through the HRC for approval, even if the individual is in agreement with its use.

35. How do you reconcile guidance regarding a CILA resident's right to having visitors at any time with other tenants' right to the Covenant of Quiet Enjoyment of the premises, particularly when this Covenant is recognized in the local jurisdictions' landlord-tenant ordinance?

The Settings Rule gives individuals the right to have visitors at any time. However, this right does not supersede any laws or ordinances. If people without a disability living in a community have to observe "quiet hours" or rules to that effect, individuals living in CILA in that same community would be expected to similarly observe these rules. It's the opposite that isn't allowable - where individuals living in a CILA are required to observe quiet hours when people without a disability living in the same community are not.

36. How should a provider handle an individual's use of cannabis in the house?

Providers are subject to both state and federal law. In Illinois, the state and federal law are conflicting as both recreational and medical marijuana remain a Schedule 1 drug under the federal law but are permissible under State law. Until the conflict between state and federal law resolves, providers, after consulting with their own attorney, will need to assess all risk factors and make the best decision for their clients and business.

For your information:

Illinois State Law:

2014: Authorized Medical Cannabis Pilot program enacted. Statewide program that allows patients access to medical marijuana who meet one of the qualifying conditions.

2018: Enacted law to make the Medical Marijuana program permanent.

2020: Legalized recreational marijuana for consumers over the age of 21 who purchase from a licensed dispensary.

*Nothing in Illinois state law would prevent individuals in residential homes from using or possessing marijuana for either recreational or medical purposes. However, federal law does prohibit it.

Federal Law:

2009: Department of Justice (DOJ) advised federal prosecutors to focus on prosecution of significant traffickers of illegal drugs, including marijuana, and the disruption of illegal drug manufacturing and trafficking networks and should not be focused on individuals who are in compliance with existing state laws for the use of medical marijuana.

2013: DOJ advised, via memo, prosecutors to use discretion, but that there is no safe harbor, immunity or guarantee that federal authorities will not prosecute marijuana offenses even if the individual is in compliance with existing state laws. The memo included a list of priorities for federal prosecutors and the list did not include the use of medical marijuana under state law.

Community Integration and Engagement

37. What are ideas for ways to engage in the community?

Many individuals need more opportunities to be active community members who are included alongside their neighbors. Integration is important because it means that a person with disabilities has opportunities to be an included member of his or her community like someone who doesn't have disabilities.

HCBS settings must:

  • Be selected by a person from choices that include settings not solely limited to individuals who have similar or the same disabilities;
  • Be integrated into the larger community and support access to it; and
  • Offer individuals opportunities to work in integrated settings, control their personal resources and engage in life in their communities.

Engaging in the community may range from finding competitive employment to participating in activities in the community. Other examples include obtaining community services and going to place where other community members spend time, such as businesses, restaurants, the library or the gym. Individuals could also take a class or tour, go to a place of worship, attend a sporting event, go to a concert or play, see a movie, spend time shopping, get involved in a club or a hobby, visit a county fair or the beach or go to a party or dance. Providers can also look for volunteer opportunities with non-profit groups that align with individual's interests, help individuals to join committees/workgroups at church, provide supports to participate in neighborhood activities and facilitate opportunities for individuals to greet and get to know their neighbors.

38. Why is reverse integration considered insufficient?

CMS has been explicit that reverse integration does not meet the community integration mandate of the settings rule, which is focused on HCBS waiver funding supporting people with disabilities to have access to the broader community. The CMS Technical Advisors working with Illinois confirmed this. In order to demonstrate compliance with community integration, a setting must show what else they are doing to assist individual in accessing the broader community. The settings rule does not speak the benefit of reverse integration. The community integration requirement is not meant to deter sites from encouraging volunteers and other people not receiving services from participating in activities at the site, but it would not count as community integration.

39. What if you provide just dental services at our CDS to more than 50% of the individuals but not any other medical services?

This is no longer relevant as the pre-screen no longer includes dental in the question. However, the settings rule emphasizes choice in access to services that people without disabilities also use including medical and dental services in the community.