Risk Assessments for Participants in Home & Community-Based Waivers

Department of Human Services
Division of Developmental Disabilities
Information Bulletin

Risk Assessments for Participants in Home &
Community-Based Waivers
April 23, 2012


The Division of Developmental Disabilities has three waivers from the Centers for Medicare and Medicaid Services (CMS):

  1. Waiver for Adults with Developmental Disabilities
  2. Residential Waiver for Children and Young Adults with Developmental Disabilities
  3. Support Waiver for Children and Young Adults with Developmental Disabilities

All three CMS waivers require that potential risks to the health, safety and welfare of waiver participants be assessed annually (or more often, if indicated by the individual waiver participant's needs) and strategies to mitigate risk be incorporated into the individual service plan (ISP). While providers are free to select a commercially available assessment that includes an evaluation of risk or develop their own localized assessment, in order to ensure compliance with Medicaid waiver criteria and adequately plan participant services, this Information Bulletin presents the minimal components required to fulfill the Division's expectations.

During the Division's monitoring of a statistically valid sample of participants in each of the three waivers, the Division has found an overall 83% compliance rate for strategies to address risks identified by assessments for FY11 and 87% for FY12 through December 31, 2011. The Division has been working with providers through informal on-site technical assistance and plans of correction as non-compliance issues have been identified. Through these activities, the Division determined the need to issue this Information Bulletin describing minimal components of risk assessments and other aspects of the risk assessment process.

Note: This information regarding risk assessments will be incorporated into the Waiver Manual.

Minimal Components

Regardless of whether a provider purchases a commercially available assessment that includes an evaluation of risk or develops its own assessment, the following components are required. Providers may include other areas of risk and/or expand definitions of the various risk domains.

  1. Name of individual waiver participant receiving services
  2. Date of assessment
  3. Name of provider staff completing assessment
  4. Title of provider staff completing assessment
  5. Information sources for completion of assessment (methods and names of people contributing)
  6. Risk Domains. Each of the following Risk Domains must be included. Providers may include other areas of risk and/or expand definitions of the various risk domains. The examples of information that are included within each domain are intended to offer explanation of the types of issues that might be included. The examples are not a complete list and may be adjusted to include similar issues that are relevant to the person receiving services or to exclude issues which are not applicable to the individual's needs. 
    1. Health/Medical:includes issues such as risks associated with chronic medical conditions, compliance with physician recommendations, dietary needs, swallowing difficulties, medication side effects, mobility concerns (including ability to reposition self to reduce likelihood of pressure ulcers), sensory impairments, frequent falls, and other similar issues.
    2. Safety (Home):  includes issues such as risks associated with environmental hazards, personal safety, awareness of hazards, others in the home, emergency situation response, cooking, water temperatures, chemicals, cleaning products, and other similar issues.
    3. Safety (Community):includes issues such as risks associated with community access, traffic, strangers, navigation, supervision, and other similar issues.
    4. Safety (School/Workplace):includes issues such as conflict resolution with others, use of tools and equipment on the job, avoidance of dangers associated with tasks, dangers posed by other persons at the school or worksite, and other similar issues.
    5. Finances:includes issues such as risks of financial exploitation, income loss, insurance/benefit loss, and other similar issues.
    6. Behavioral:includes issues such as risks associated with display of inappropriate/maladaptive behaviors and interventions (including risks to self and risks to others), inappropriate sexual behaviors, and other similar issues.
    7. Supports:  includes issues such as presence and involvement of natural supports (family and friends, interpersonal skills, communication of needs (ability to ask for help), and other similar issues.
  7. Recommendations for supports that need to be in place if risk is a factor.

Assessment Process

When conducting risk assessments and making recommendations to mitigate risks, assessors should:

  1. Gather information from a variety of sources including the individual participant, guardian, family members, paid staff, record review, observation, and assessor direct knowledge of the individual.
  2. Recognize that some domains may not be applicable for all individuals. In such cases, the assessor should include a brief explanation of why the domain is not applicable and, therefore, no risks or potential risks are evident.
  3. Provide narrative information (including brief overview of current skills as well as potential and known risks) sufficient to guide the interdisciplinary team. Consideration should be given to both the risks associated with current activities of the individual as well as potential risks which inhibit the individual from pursuing his/her goals and fully participating in integrated settings.

Service Planning

All safeguards, supports, education and training necessary to mitigate identified risks should be addressed within the individual's service plan.

  1. Consider if the individual and his/her guardian, if applicable, are willing to accept some situations with risks to facilitate choice, independence, and community integration.
  2. Identify safeguards that are already in place to minimize identified risks and outline additional needed actions to reduce other risks which pose a real or potential threat to the individual's health, safety and/or welfare.
  3. Identify who will be responsible for each of the needed safeguards and actions.

Effective Date/Implementation

The requirements for risk assessments outlined in this Information Bulletin are effective for all waiver providers on July 1, 2012. As of that date, each provider must have a risk assessment plan which meets these requirements. Persons beginning services with a provider on or after July 1, 2012 will be expected to have a risk assessment (completed prior to the development of the individual service plan) that meets these requirements. For those persons served by the provider prior to July 1, 2012, a risk assessment that meets these requirements must be completed prior to the annual review and revision of the service plan occurring on or after July 1, 2012. No later than June 30, 2013, it is expected that all individuals served by the provider will have a risk assessment that meets the requirements outlined in this Information Bulletin.

When an individual is served by more than one provider, it is not necessary for each provider to complete a separate risk assessment. It is acceptable for providers to collaborate on the completion of the assessment and/or to share assessments with other providers as allowed under appropriate confidentiality rules and regulations. It is the responsibility of each provider to ensure a risk assessment is present within the individual's records maintained by the provider and to ensure that the risk assessment, regardless of which provider completed the risk assessment, is used to guide service planning.

Training Webinar Available

Webinar Available  for more information.  Providers and others are strongly encouraged to register and participate. A question and answer session will be included in each webinar.