Provider Self-Assessment

In January 2014, the Centers for Medicare and Medicaid Services (CMS) announced a requirement for states to review and evaluate current Home and Community-Based Settings (HCBS), including residential and non-residential settings, and to demonstrate compliance with the new Federal HCBS Setting Rules that went into effect March 17, 2014. These federal guidelines were developed to ensure that members receiving long-term services and supports through HCBS programs under Medicaid waiver authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate.  For the purposes of this provider self-assessment, settings defined as institutions are: a nursing facility; institution for mental diseases; an intermediate care facility for individuals with intellectual disabilities; a hospital; or any location that have qualities of institutional setting.

The following self-assessment is the first step in the process to measure HCBS residential providers’ current level of compliance with these HCBS Setting rules.  Additional steps may include a member survey, request for documentation, and on site review. Failure to submit the provider self-assessment will result in an on-site review. There will be an opportunity for public input as the department continues to develop tools necessary to determine compliance.

CMS Regulatory Requirements:

  • 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. 42 CFR 441.301(c)(4)(i)/441.710(a)(1)(i)/441.530(a)(1)(i)
  • The setting is selected by the individual from among setting options including non-disability specific settings … The settings options are identified and documented in the person-centered plan and are based on the individual’s needs, preferences, … 42 CFR 441.301(c)(4)(ii)/ 441.710(a)(1)(ii)/441.530(a)(1)(ii)
  • The setting ensures an individual’s rights of privacy, dignity, and respect, and freedom from coercion and restraint. 42 CFR 441.301(c)(4)(iii)/ 441.710(a)(1)(iii)/441.530(a)(1)(iii)
  • The setting optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices including but not limited to daily activities, physical environment, and with whom to interact. 42 CFR 441.301(c)(4)(iv)/ 441.710(a)(1)(iv)/441.530(a)(1)(iv)
  • The setting facilitates individual choice regarding services and supports, and who provides them. 42 CFR 441.301(c)(4)(v) 441.710(a)(1)(v)/441.530(a)(1)(v)


Provider assessment process:

  1. The following self-assessment contains a set of questions designed to measure each provider’s level of compliance with federal HCBS guidelines. The following sections include a series of Yes/No questions.
  2. Providers of HCBS must complete one self-assessment for EACH license or setting that you own or lease where 2 or more people are receiving services.
  3. If you serve more than one HCBS population in your setting, select the DPHHS Division (Developmental Services, Senior and Long Term Care, or Addictive and Mental Disorders) that represents the largest percentage of your populations.
  4. The survey must be completed in its entirety before it can be submitted.  You cannot save your work and return to the survey. Survey is due by Friday, August 14, 2015.
  5. Please email with questions on this survey.