HCBS Settings Rule: Confirmation of Provider Compliance with Residency Agreement Policy, Lockable Door Policy and Modification Process

As shared previously, due to the timeframe and requirements of HCBS Settings Rule validation process implementation, ALL organizations which operate provider-controlled sites are required to complete this survey to confirm that all of their provider-controlled locations are following the HCBS Settings Rule regarding residency agreements and lockable doors (where applicable) and the new modification process using the new Person Centered Planning templates as they are released.

Please note, your organization must still submit evidence of policy and site implementation evidence compliance and, where appropriate, submit to an onsite visit.

The survey response is due back by October 14,2022.

Provider Name:

Contact Name:

Email:

Phone:

By checking the boxes below, I confirm that all provider-controlled sites operated by this organization are in compliance with the following HCBS Settings Rule requirements:

• The organization has implemented the residency agreement requirements per the HCBS Settings Rule and the Residency Agreement for Provider Owned or Controlled Settings DDD Information Bulletin.
• The organization has implemented the lockable doors requirements per the HCBS Settings Rule and the Lockable Doors and Privacy in Provider Owned or Controlled Settings DDD Information Bulletin.
• The organization will follow the process for modifications of HCBS Settings Rule rights and utilize the updated Person Centered Planning process/template as it is released.

Name:

Date: