Current through Reg. 50, No. 13; March 28, 2025
(a) A home and community-based setting is a
setting in which an individual resides or receives HCS Program services or CFC
services. A home and community-based setting must have all of the following
qualities, based on the needs and preferences of an individual as documented in
the individual's PDP.
(1) The setting is
integrated in and supports the individual's access to the greater community to
the same degree as a person not enrolled in a Medicaid waiver program,
including opportunities for the individual to:
(A) seek employment and work in a competitive
integrated setting;
(B) engage in
community life;
(C) control
personal resources; and
(D) receive
services in the community.
(2) The setting is selected by the individual
from among setting options, including non-disability specific settings and an
option for a private unit in a setting in which residential support, supervised
living, or host home/companion care is provided. The setting options are
identified and documented in the PDP and are based on the individual's needs,
preferences, and, for settings in which residential support, supervised living,
or host home/companion care is provided, resources available for room and
board.
(3) The setting ensures an
individual's rights of privacy, dignity, and respect, and freedom from coercion
and restraint.
(4) The setting
optimizes, not regiments, individual initiative, autonomy, and independence in
making life choices, including choices regarding daily activities, physical
environment, and with whom to interact.
(5) The setting facilitates individual choice
regarding services and supports and the service providers who provide the
services and supports.
(b) Except as provided in subsection (c) of
this section, a program provider must ensure that HCS Program services and CFC
services are not provided in a setting that is presumed to have the qualities
of an institution. A setting is presumed to have the qualities of an
institution if the setting:
(1) is located in
a building in which a certified ICF/IID operated by a LIDDA or state supported
living center is located but is distinct from the ICF/IID;
(2) is located in a building on the grounds
of, or immediately adjacent to, a certified ICF/IID operated by a LIDDA or
state supported living center;
(3)
is located in a building in which a licensed private ICF/IID, a hospital, a
nursing facility, or other institution is located but is distinct from the
ICF/IID, hospital, nursing facility, or other institution;
(4) is located in a building on the grounds
of, or immediately adjacent to, a hospital, a nursing facility, or other
institution except for a licensed private ICF/IID; or
(5) has the effect of isolating individuals
from the broader community of persons not receiving Medicaid
HCBS.
(c) A program
provider may provide an HCS Program service or a CFC service to an individual
in a setting that is presumed to have the qualities of an institution as
described in subsection (b) of this section, if CMS determines through a
heightened scrutiny review that the setting:
(1) does not have the qualities of an
institution; and
(2) does have the
qualities of home and community-based settings.
(d) In addition to the requirements in
subsection (a) of this section, a program provider must ensure that a group
setting:
(1) allows an individual to:
(A) control the individual's schedule and
activities;
(B) have access to the
individual's food at any time; and
(C) receive visitors of the individual's
choosing at any time; and
(2) is physically accessible and free of
hazards to an individual.
(e) If a program provider becomes aware that
a modification to a requirement described in subsection (d)(1) of this section
is needed based on a specific assessed need of an individual, the program
provider must:
(1) notify the service
coordinator of the needed modification; and
(2) provide the service coordinator with the
information described in §
263.901(e)(21)
of this chapter relating to (LIDDA Requirements for Providing Service
Coordination in the HCS Program) as requested by the service
coordinator.
(f) If a
service coordinator receives a notification as described in subsection (e) of
this section, the service coordinator must convene a service planning team
meeting to update the PDP as described §
263.901(e)(21)
of this chapter.
(g) After the
service planning team updates the PDP as required by subsection (f) of this
section, the program provider may implement the modifications.
