Sample Compliance Action Steps, Procedures and Activities

You have received a compliance action plan for your site, which requires you to identify activities, policies, processes, and systems that you will put into place to be able to show for future and ongoing compliance monitoring that your site is complying with components of the settings rule. Below are examples of possible steps you can implement to address the compliance issues identified. These are not comprehensive and are just suggestions and examples. You are welcome to identify other steps your organization will take to address the concerns.

Expectation Systems to Ensure compliance with HCBS Settings rule Ways to demonstrate

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

PROVIDER DOES NOT HAVE TO COMPLETE. DDD IS RESPONSIBLE FOR THIS EXPECTATION.
1b) Engage in Community Life
  • Individuals should have their own personal calendars.
  • Identify/consider looking at how the specific personal plan outcomes related to or can be addressed in the community/community life and write those into the implementation strategies.
  • Encourage natural supports in the community; ensure that individuals have access to contact information of natural supports
1c) Control Personal Resources
  • Ensure any financial management policies or practices do not restrict people's access to funds.
  • Encourage people to be their own payee with only support needed to manage finances.
  • Hold training courses for people you support about personal finance; utilize the ICDD funded Financial Wellness for Persons with Developmental Disabilities resources or make connections with people's banks.
  • Support informed choice in their bank and financial services
  • Support building relationships with their banker
  • Support people to access and utilize typical financial products such as banking apps and financial management apps and other online tools.
  • Hold training for staff regarding supporting people to better understand money/spending, to make financial decisions and avoid unintentional coercion based on value judgments
  • Consider debit cards for people so they can control access to their funds.
  • Pictures of people at the bank, pictures of people writing checks, voided personal checks
  • Track if anyone switches to become their own payee
  • Training attendance
  • Training agendas
  • Case notes that discuss individuals managing their finance or withdrawing money for an activity
  • Pictures of individual's debit cards
  • Data tracking of individuals learning to manage their own money
1d) Receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.
  • Support people to maintain a personal calendar
  • Identify/consider looking at how the specific personal plan outcomes related to or can be addressed in the community/community life and write those into the implementation strategies.
  • Support people to make an informed choice regarding all services. For example, interview prospective medical providers; read Google reviews to choose a pharmacy; use Trip Advisor to choose the best grocery store, restaurants, etc.
  • Identify how people who do not receive services engage in the local community and support people to identify community opportunities that might be of interest
  • Vehicles should be discrete and not advertise utilization of waiver services
  • Pictures of calendars
  • Show pictures that document how vehicles are not marked with agency names or logos or other markings that draw undue attention to the person being in the service system.
  • Photos of people doing activities such as shopping, going to the bank, getting their nails done, going to the doctor, in the community
  • Case notes showing that people are utilizing the community for activities, shopping, appointments
  • Photo of a public transportation card
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. PROVIDER DOES NOT HAVE TO COMPLETE. DDD IS RESPONSIBLE FOR THIS EXPECTATION.
2b) Setting options are based on the individual's needs, preferences PROVIDER DOES NOT HAVE TO COMPLETE. DDD IS RESPONSIBLE FOR THIS EXPECTATION.
3a) Ensures an individual's rights of privacy
  • Training for people in the house on privacy rights.
  • Training for staff members on how to support and uphold privacy.*
  • Monthly reporting notes documenting discussions and steps taken to ensure privacy in shared rooms.
  • Examples of changes made to reflect a person's privacy preference
  • Satisfaction surveys of people receiving services to garner opinions on privacy.
  • Competency (evaluation area) for DSP's
3b) Ensures an individual's rights of dignity and respect
  • Training for staff on dignity and respect and other rights.
  • Training for people receiving services on their rights.
  • Satisfaction surveys of people receiving services to garner opinions on dignity and respect.
  • Competency (evaluation area) for DSP's
3c) Ensures an individual's right of freedom from coercion
  • Training for staff on ANME
  • Training for staff on rights and restrictions.
  • Training for people about their rights and specifically their right to complain.
  • Advocacy training for people
  • Documentation in complaint/grievance logs that people receiving supports are included in complaint process
  • Competency (evaluation area) for DSP's
3d) Ensures an individual's right of freedom from restraint
  • Training for staff and people supported.
  • HRC policy, rights policy, positive behavior support policy, training curricula
  • Evidence of modifications (or commitment to follow new process).
  • HRC meeting minutes
  • Competency (evaluation area) for DSP's
4a) The setting optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to daily activities
  • Support people to create and maintain a calendar
  • Identify/consider looking at how the specific personal plan outcomes related to or can be addressed in choice of activity and write this into the implementation strategies.
  • Self-advocacy training
  • Training for DSPs about how to support choice/ informed choice
4b) Optimizes, but does not regiment individual autonomy, and independence in making life choices, including but not limited to physical environment
  • Self-advocacy training
  • Documentation of use of assistive technology and accommodations to address access.
  • Documentation about choice and education (if needed) about locking doors.
4c) Optimizes, but does not regiment individual autonomy, and independence in making life choices, including but not limited to with whom to interact
  • Training for people about sexual health education, internet safety.
  • Training on supporting people to develop and maintain relationships
  • Self advocacy training on rights to have visitors
  • Implementation strategies that are framed to encourage independence, autonomy, and personal connections.
  • Notes or discussions about creating and supporting relationship development of people with others outside the house/ organization.
  • Satisfaction surveys of people receiving services to garner opinions on friendships, relationships, and natural supports.
5) Facilitates individual choice regarding services and supports, and who provides them
  • Support people to maintain individualized schedules.
  • Demonstrate how people are involved in interviewing, selecting, and evaluating staff that support them
6a) Individuals have the freedom and support to control their own schedules and activities,
  • Support people to maintain individualized schedules.
  • Training and other strategies to ensure artificial barriers are not inadvertently placed upon people to control their schedules.
  • Individualized schedules
  • Internal organizational systems for tracking people's desires and choices to ensure they are addressed and ensure continuity between staff.
  • Satisfaction surveys of people receiving services to garner opinions on controlling schedules and activities.
6b) Individuals have access to food at any time
  • Training for staff
  • Self Advocacy/Rights training for people being supported on their rights
  • Take photos of available food.
  • Examples of modifications for those who must have modifications.
  • Examples of supporting people to shop for food and create their own menus.
  • Attendance sheet of rights trainings for people receiving services
7) Individuals can have visitors of their choosing at any time.
  • Track modifications of right to visitors at any time.
  • Policies that state visitors are allowed at any time
  • Rights policies and training for people
  • Implementation strategies that are framed to encourage visitors.
  • Implementation strategies with modifications to the right to have visitors showing you are following process
  • Attendance sheet of rights trainings for people receiving services
  • HRC meeting minutes
8)The Setting is physically accessible to the individual
  • Perform accessibility assessments.
  • Physical accessibility may not be modified at any time
  • Accessibility assessment and photos to show it was addressed
  • Documentation of home or vehicular modifications performed to make environment accessible.

 FOR RESIDENTIAL SITES ONLY (9-10)

Expectation Compliance issues identified
9) 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
  • Establish residency agreements.
  • Use of accessible residency agreements.
* Example of a residency agreement
10a) Each individual has privacy in their sleeping or living unit.
  • Training for staff and people receiving services on privacy rights and expectations of privacy.
  • Monthly reporting notes documenting discussions and steps taken to ensure privacy in shared rooms.
  • Attendance sheets from rights trainings
  • Satisfaction surveys of people receiving services to garner opinions on privacy.
  • Implementation strategy or case notes that reflects a discussion of privacy and any steps taken to address privacy issues
10b) Units have entrance doors lockable by the individual, with only APPROPRIATE staff having keys to door
  • Training for staff and people receiving services on right to privacy.
  • Accommodations made for people who may have difficulty with traditional locks.
  • Photos of locks and/or accommodations made
  • Documentation of how appropriate staff (to have keys) are determined
10c) Individuals sharing units have a choice of roommates in that setting
  • Self advocacy training.
  • Conflict resolution processes
  • Complaint processes
  • Examples of having potential housemates meeting with others in house prior to moving in.
  • Attendance sheets from self advocacy trainings
  • Satisfaction surveys of people receiving services to garner opinions on room/housemates.
10d) Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or agreement
  • Ensure residency agreements reflect people's rights to decorate their space
  • Training for people on their rights.
  • Residency agreement
  • Pictures of individualized decorating in rooms/homes

FOR BOTH CDS AND RESIDENTIAL (NEW)

Expectation Compliance issues identified
11. 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
  1. Identify a specific and individualized assessed need.
  2. Document the positive interventions and supports used prior to any modifications to the person-centered service plan
  3. Document less intrusive methods of meeting the need that have been tried and did not work
  4. Include a clear description of the condition that is directly proportionate to the specific assessed need
  5. Include regular collection and review of data to measure the ongoing effectiveness of the modification
  6. Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated
  7. Include the informed consent of the individual
  8. Include an assurance that interventions and supports will cause no harm to the individual
  • Confirmation that the organization will follow the settings/person centered planning process around modifications.
  • Human Rights Committee structure, training for members, meeting minutes.
  • Self-advocacy training.
  • Training on informed consent.
  • Training for staff on rights modifications processes.
  • Support for people to attend any meeting about them, including HRC meetings where a relevant modification is discussed.
  • Updated Implementation Strategies that reflect the modification process
  • Implementation Strategies and/or case notes actions taken to minimize or reduce the use of a modification