HCBS Final Rule Provider Self-Assessment

Thank you for your participation in this survey. One survey needs to be submitted for each designated HCBS site your agency operates. Please submit answers to ALL questions within two weeks from receipt of the informational/reminder email sent from the State. Please note that previously designated providers adding a new site(s) do not need to complete this survey for previously designated sites.

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* 1. What is the name of your 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 select all locations where the HCBS is provided.

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

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* 6. Which type(s) of HCBS does the agency provide?

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* 7. 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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* 8. Is this site co-located with other facility types or located among private residences, retail businesses, banks, etc. to the same degree as other homes in the community?

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* 9. Is this site co-located with other facility types? If yes, does the program share office space, staff, or administration functions with that facility?

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* 10. Is the site located near public transportation?

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* 11. 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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* 12. 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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* 13. Does the site provide opportunities and resources to the children/youth to engage in activities in community settings with others outside of the settings who do not receive services, if desired by the child/youth?

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* 14. Does the provider assist in providing support with transportation if lack of transportation is a barrier to receipt of services?

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* 15. Are participants able to choose what services they want to receive?

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* 16. Are participants able to choose where they want to receive services?

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* 17. Does the site have person-centered policies to ensure individuals are supported in developing plans to support needs and preferences, including a method for the child/youth to request updates to their Individual Service Plan, as needed?

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* 18. Are children/youth and/or their family/caregivers provided information about their rights as an HCBS participant in a manner that they understand and at their comprehension level?

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* 19. Are all the participant’s rights and limitation(s) documented in the Individual Service Plan?

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* 20. Do staff receive training specific to HCBS and person-centered planning?

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