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Thank you for your participation in this survey. One survey needs to be submitted for each designated HCBS site your agency operates. Questions should be answered specific to your site's operations and not specific to operations in response to the COVID pandemic. Please submit answers to ALL questions by December 31, 2020. 

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* 1. What is the name of the agency? 

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* 2. Please provide the address of the HCBS site for which you are completing this survey.

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* 3. Please provide contact information for the individual completing this survey.

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* 4. Please list all locations where the HCBS is provided.

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* 5. Which type(s) of HCBS programming does the agency provide? Please indicate approximately how many children/youth this site serves for each HCBS provided.

  Approximately how many children/youth receive this HCBS?
Community Habilitation
Day Habilitation
Caregiver/Family Supports and Services
Community Self Advocacy Training and Support
Prevocational Services
Respite Services (Planned and Crisis)
Palliative Care - Expressive Therapy
Palliative Care - Massage Therapy
Palliative Care - Bereavement Services
Palliative Care - Pain and Symptom Management
Supported Employment

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* 6. Is the provider located on the grounds of a publicly or privately-operated facility that provides inpatient institutional treatment? (Examples of “inpatient institutional treatment” include nursing facility, ICD/IID, IMD, or hospital)

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* 7. Is the program located on the grounds of a public institution? A public institution in this instance is defined by an institution meeting the criteria in the previous question and is funded and overseen by a governmental agency at the state, county, or local level.

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* 8. Is the provider located immediately adjacent (next) to a public institution?

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* 9. Please check any of the following setting(s) that may apply to your site.

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* 10. Is there public signage that would indicate the program is specifically for children or youth receiving HCBS?

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* 11. Is the program located in the community among private residences, retail businesses, banks, etc. to the same degree as other homes in the community?

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* 12. Is the program an environment that supports individual comfort, independence, and preferences and is not institutional in appearance or operation?

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* 13. Does the physical environment meet the needs of the children or youth requiring supports and handicap accessibility pursuant to local zoning requirements?

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* 14. Does the site provide opportunities for regular meaningful activities in community settings with others who do not receive services, for the amount of time desired by the child or youth?

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* 15. Is there sufficient transportation capacity (barring all public transportation limitations and issues) to support children or youth’s choice of activities and schedules?

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* 16. Do staff facilitate the use of public transportation to support children or youth’s choice of activities and schedules?

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* 17. Are bus and other public transportation schedules and telephone numbers posted in a convenient location?

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* 18. Do children or youth shop, attend religious services, schedule appointments, have lunch with family and friends, etc., in the community, as they so choose and as age appropriate?

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* 19. Do staff assist or provide resources to children or youth or their families/caregivers to become aware of activities occurring outside of the settings?

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* 20. Are children or youth able to have visitors of their choosing at any time, as age-appropriate, and not in conflict with their health and safety?

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* 21. Are children or youth only able to have visitors within a restricted visitor meeting area? (Please note that all visitors and visitation settings must be appropriate to the child/youth's Plan of Care)

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* 22. Are schedules individualized and identified in the child or youth’s Plan of Care, including when and how they are accessing community activities and events?

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* 23. Does a child or youth have a choice of whether or not to participate in extracurricular activities without being penalized?

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* 24. Are there restrictions to a child or youth’s food choice or choice of where/when mealtimes are?

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* 25. Are children or youth able to have a private cell phone, computer or other personal communication device or have access to a telephone or other technology device to use for personal communication in private at any time and as age-appropriate?

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* 26. Do youth have a checking or savings account or other means to control his/her funds and decide how to control their own funds, as age-appropriate?

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* 27. Does the site ensure a child or youth’s information (medical, diet information, etc.) is kept private/confidential?

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* 28. Are children or youth and/or their family/caregivers provided with information regarding their right to a person-centered planning process?

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* 29. Are children or youth or their family/caregivers provided information about their rights, including HCBS rights, in a manner that they understand and at their comprehension level?

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* 30. Do staff receive training on home and community-based services, including individual rights and how to support children and youth to exercise control and choice in their own lives?

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* 31. Is there continuous and updated documented evidence in the Plan of Care that staff supports individual input, choice, autonomy, and decision-making including choice of activities or meaningful community inclusion, relationships, freedom of association, religious/spiritual preferences, etc. as age appropriate?

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* 32. Are staffing schedules and operations (and their use of natural/peer supports) sufficient to support children or youth and their family/caregiver choice/participation in meaningful community activities according to the preferences/priorities in their Plan of Care?

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* 33. Does the person-centered planning process provide a method for the child or youth to request updates to their Plan of Care, as needed?

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* 34. Are all observed rights and limitation(s) documented in the Plan of Care and comply with HCBS? In addition, are steps taken to ensure other children/youth in the setting are not impacted by the restrictions within another child/youth's Plan of Care?

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* 35. Does the site allow a child or youth and their family/caregiver to choose which of the site’s employees provide his/her services? Example: A child or youth requests that all her personal care services to be conducted by female employees – is that request met?

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* 36. Does the site allow prospective HCBS recipients the opportunity to tour the site?

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* 37. Does the organizational culture reinforce and train staff to respect the cultural/ religious/other backgrounds of its children or youth and is it culturally competent?

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* 38. Does the provider have protocols in place to address children or youth or their family/caregiver’s dissatisfaction or complaints with the living environment?

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* 39. Are there gates and/or other physical barriers preventing children or youth’s entrance to or exit from certain areas of the setting?

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* 40. Are there restrictions when the child/youth needs to be in the setting? Would the child/youth otherwise be locked out of the location?

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* 41. Are there “house schedules” that require all children or youth to follow a particular schedule for waking up, going to bed, eating, leisure activities, community activities, etc.?

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* 42. Do children or youth have a key or other mechanism to open the front door (or main entrance) of the building, as age-appropriate?

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* 43. Do children or youth have a key and option to lock their own private living spaces and/or apartment, as age-appropriate?

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* 44. Can children or youth close and lock their bathroom door?

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* 45. Are surveillance cameras present inside a child or youth’s personal living space?

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* 46. Do staff knock and receive permission prior to entering a child or youth’s living space?

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* 47. Does only appropriate staff possess keys to private resident units?

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* 48. Do youth sharing residences have a choice of an appropriate roommate?

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* 49. For youth over 18, are married couples or partners able to share a room together?

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* 50. Are youth able to furnish and decorate their rooms/residences in the way that suits them?

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* 51. Please enter any comments to provide further information pertaining to above answers. 

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