HCBS Provider Self-Survey (Late Entries)

Background

The Centers for Medicare and Medicaid Services (CMS) requires states to review and evaluate current residential and non-residential settings funded through Home and Community-Based Services (HCBS), and to demonstrate compliance with the Federal HCBS Setting Rules that went into effect March 17, 2014. CMS developed these rules to ensure that individuals receiving services and supports through HCBS programs have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate.

This self-survey for HCBS residential (Intermittent CILA, 24-Hour CILA, Host Family CILA, Child Group Home, Community Living Facility (16 beds and under only)) and non-residential (Adult Day Care, Community Day Services, Group Supported Employment) settings for individuals with developmental disabilities will:

Indicate whether a site is: a) located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment; b) in a building on the grounds of, or immediately adjacent to, a public institution that provides inpatient institutional treatment; or c) any other setting that has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS. (42 CFR 441.301(c)(5)(v))
Note: Inpatient institutional treatment includes Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities (ICF/DD).

Resource Links

The following weblinks are included for your reference.

Instructions

Providers of HCBS residential and non-residential services must complete this survey for EACH RESIDENTIAL SITE and EACH NON-RESIDENTIAL in which they are serving individuals who are part of an HCBS waiver program. This includes Community Day Services sites located in Intermediate Care Facilities that serve HCBS waiver recipients.

It is expected the survey will take about 15 minutes to complete.

Please maintain a copy of any documentation provided along with your other provider files.

Failure to submit the provider self-survey in a timely manner will result in an automatic validation review.

Please email DHS.HCBS@illinois.gov with questions on this survey.

In addition to the HCBS Provider Self-Survey for Residential and Non-Residential Services, other efforts toward achieving compliance with the CMS Settings Rule will include:

Updated training webinars;
A HCBS Self-Advocate Survey - Residential & Non-Residential Services;
Policy guidance for HCBS residential and non-residential service providers on complying with the federal Settings Rule, as well as associated timeframes for submission of compliance documentation;
A review process for compliance documentation submitted as part of the self-survey or subsequent submissions;
Technical assistance for providers;
Validation reviews to confirm HCBS settings' compliance with the federal Settings Rule; and
Designation of sites for heightened scrutiny reviews in accordance with federal CMS criteria.

Definitions

"Community Integration" or" integration into the community." Ongoing participation in community life. For individuals in a HCBS Waiver, per 42 CFR 441.301(c)(4)(i), based on the needs of the individual as indicated in their Personal Plan, the State must ensure "the setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS."

"Factors that may isolate individuals receiving Medicaid HCBS from the broader community of individuals not receiving HCBS." (From Q&A #2, SMD # 19-001 - Home and Community-Based Settings Regulation - Heightened Scrutiny)

Due to the design or model of service provision in the setting, individuals have limited, if any, opportunities* for interaction in and with the broader community, including with individuals not receiving Medicaid-funded HCBS;
The setting restricts beneficiary choice to receive services or to engage in activities outside of the setting; or
The setting is physically located separate and apart from the broader community and does not facilitate beneficiary opportunity to access the broader community and participate.

*"Opportunities", as well as identified supports to provide access to and participation in the broader community, should be reflected in both individuals' person-centered service plans and the policies and practices of the setting in accordance with 42 CFR 441.301(c)(1)-(3) and (4)(vi)(F), 42 CFR 441.530(a)(1)(vi)(F) and 441.540, and 42 CFR 441.710(a)(1)(vi)(F) and 441.725.

"Heightened Scrutiny." The home and community-based services (HCBS) settings rule requirements define the qualities of settings that are eligible for reimbursement of Medicaid home and community-based services. The federal rule also assumes that certain settings are not home and community-based. These include:

Settings located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment
Settings in a building on the grounds of, or immediately adjacent to, a public institution.*
Settings that have the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS waiver services. (See "Factors" definition for more details regarding this criterion)

*The Centers for Medicare & Medicaid Services' (CMS) definition of public institution 42 C.F.R. § 435.1010: "Public institution" means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. For purposes of this regulation, a public institution is an inpatient facility that is financed and operated by a county, state, municipality, or other unit of government. A privately owned nursing facility is not a public institution.

If a residential or non-residential setting meets one of the above criteria, then the setting will require a heightened scrutiny review to overcome the assumption that it is not home and community-based. As part of this process, settings must submit compliance documentation to DHS in accordance with policy guidance. DHS will conduct a validation review. If DHS agrees the evidence indicates that the setting has the qualities of home and community-based settings, DHS will provide the evidence to CMS for review. CMS will consider evidence and issue a decision.

"Individual-owned or controlled." A setting in which the individual resides is a physical place that is owned, co-owned (but not directly or indirectly with a provider of Home and Community-Based Services) or rented by the individual. Examples:

An individual receiving Medicaid HCBS rents a home, for example, an apartment with roommates. A provider provides 24-hour supervision. If the individual can change providers without breaking the lease or other written agreement, then the setting is individual-controlled.
A parent wills her home through her estate to her son, who now is in his own home, but requires 24-hour supervision/supports. If he has chosen the providers who will work with him and can change providers as desired, then the setting is individual-owned.

"Provider-owned or controlled." A setting in which the individual resides is a physical place that is: a) owned, co-owned, leased or rented by a provider of Home and Community-Based Services; or b) owned, co-owned, leased or rented by a third party that has a direct or indirect financial relationship with a provider of Home and Community-Based Services. Examples:

The provider owns, co-owns, leases, rents or controls the home in which the individual receiving Medicaid HCBS resides.
Any setting where the individual must have a specific residential services provider in order to live in that setting.
A host family CILA which an unrelated caregiver owns and staffs the home.
An individual receiving Medicaid HCBS rents a setting, for example an apartment with roommates. A provider provides 24-hour supervision. If the individual cannot change providers without breaking the lease or other written agreement, then the setting is provider-controlled.
A parent wills her home through her estate to a provider, which agreed to serve her adult child in the home.

Thank you for your time and assistance with completing this survey!

Provider Information

Home/Facility Site

DDD Site ID:

Site Name:

Address:

City, State, ZIP:

Setting:

Type:

Ownership:

Respondent Name:

Respondent Email:

Respondent Phone:

Responsible Agency (as applicable)

Agency Name:

Agency Address:

City, State, ZIP:

Director Name:

Director Email:

Director Phone:

Institutional Setting

For the following questions, if you answer "Yes," your site will go through a heightened scrutiny process to determine whether it has the qualities of a home and community-based setting. If you answer "No," you will be required to provide documentation as indicated below.

1. The site is located in a building that is also a publicly or privately-operated facility that provides inpatient institutional treatment: a nursing facility, an intermediate care facility for individuals with intellectual disabilities, an institution for mental diseases, or a hospital:

2. The site is located in a building on the grounds of, or immediately adjacent to, a public institution that provides inpatient institutional treatment: a nursing facility, an intermediate care facility for individuals with intellectual disabilities, an institution for mental diseases, or a hospital:

3. The site has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving HCBS services:

After submitting this survey, please email documentation supporting your "No" answer(s) above to DHS.HCBS@Illinois.gov. Documentation may include:

Pictures of outside of building from all directions
Pictures of signage and entrances
Birds-eye-view images of site and surrounding area (from Google Maps or other source), with street and building labels
Floor plan/site plan

You will recieve a confirmation email at the Respondent Email you entered above.