HCBS Settings Self-Assessment Tool

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This form must be completed to determine compliance with the HCBS Settings Rule. This form is for Providers who provide Residential services only or Residential services and Non-Residential services at the same setting.

The self-assessment tool is a set of questions that is geared to determine your compliance with the HCBS Settings rule. It will require you to submit evidence of compliance. The form will allow you to save along the way, so you do not need to complete it in one session. Please allow yourself ample time to complete. There are PDF versions of the questions available to view on our website so you can prepare ahead of time if you choose to.

Provider Name *

Provider Address *

Names and Roles of those Completing this Assessment: *

Setting Address *

# of Medicaid HCBS Individuals Served at this Location:
*

# of Total Individuals Served at this location:
*

HCBS Non-Residential Provider Type(s):

Select the Waiver Services you are Providing:
*

Yes

Employment Preparation Service (EPR)

Day Support Services (DSG, DSP, DSI)

Supported Employment (SEI, SED, SEC, SEE)

Select the Waivers you are Contracted to Provide Services for:
*

Yes

Acquired Brain Injury Waiver (ABI)

Community Supports Waiver (CSW)

Community Transition Waiver (CTW)

Physical Disabilities Waiver (PDW)

Limited Supports Waiver (LSW)

Is this form being completed for Residential Setting Self Assessment or Non-Residential Self Assessment *

Residential Setting Self Assessment

Non-Residential Self Assessment

RESPONSES TO THIS SELF-ASSESSMENT TOOL MUST NOT CONTAIN ANY CONFIDENTIAL OR PROTECTED HEALTH INFORMATION PERTAINING TO INDIVIDUALS SERVED. THIS INCLUDES IDENTIFIABLE DEMOGRAPHIC DATA, INFORMATION ABOUT THE PHYSICAL OR MENTAL HEALTH CONDITION(S) OF AN INDIVIDUAL, OR ANY INFORMATION REGARDING TREATMENT REGIMENS OR PAYMENT HISTORY FOR HEALTHCARE SERVICES PROVIDED TO AN INDIVIDUAL.

EXAMPLES OF EVIDENCE AND ANALYSIS ARE POLICIES, PROCEDURES, HANDBOOKS, TRAINING CURRICULUM AND MATERIALS, COMMUNICATION MATERIALS, ETC.

YOU CAN FIND ADDITIONAL INFORMATION ON OUR WEBSITE WITH UNDERSTANDING EXPECTATIONS OF COMPLIANCE.

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