O1: Is the setting in a publicly or privately operated facility that provides inpatient institutional treatment?

Standard: 42 CFR 441.530(a)(2)(v) – Based on location, the SADC is home and community based and not institutional in nature.

• Question Goal: Confirm the SADC is not located in a setting that provides inpatient care. If the SADC is in a publicly or privately operated setting that provides inpatient care, determine if the SADC is separate from the facility.
• Compliance Considerations:Outpatient medical providers are not "inpatient institutional treatment." If an SADC shares an entrance with a setting that provides inpatient care, it may still be separate and operate independently.
• Examples of What to Observe: If the SADC is in a facility providing inpatient institutional treatment, inquire about, and/or make observations to determine separation of the two programs. This may include investigating if the two programs have separate owners and staff, if the SADC is open to the public, and if the SADC has a clear location with a separate entrance.

O2: Is the setting in a building on the grounds of, or adjacent to, a public institution?

Standard: 42 CFR 441.530(a)(2)(v) – Based on location, the SADC is home and community based and not institutional in nature.

• Question Goal: Confirm the SADC is not on the grounds of or adjacent to a public institution. If the SADC is on the grounds of, or adjacent to a public institution, determine if the SADC is separate and not part of the public institution.
• Compliance Considerations:Outpatient medical providers are not "inpatient institutional treatment." If the SADC shares the same name or proximity to an institutional setting, it may not mean they are not "separate" and operate independently.
• Examples of What to Observe: If the SADC is on the grounds of or adjacent to a public institution, inquire about, and/or make observations to determine separation of the two programs. This may include investigating if the two programs have separate owners and staff, if the SADC is open to the public, and if the SADC has a clear location with a separate entrance.

O3: Does the SADC recognize the members' right to freedom to move about the setting, including the freedom to go outside as they choose, for those who are known to be safe and competent?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Ensure members are not restricted at the SADC and are free to move about the facility and access outdoor space.
• Compliance Considerations:Confirm the SADC does not restrict member’s ability to move about the space even if members have health or safety risks that may prevent them from independently moving about the setting or outside areas.
• Examples of What to Observe: Observe members moving about the SADC to ensure movement is not hindered. Inquire with the SADC representative if members, who are known to be safe and competent, can move freely within and outside of the setting.

O4: Does the SADC allow members to attend and participate in individualized community activities, for the amount of time desired by the members?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Confirm that the SADC allows community integration for the amount of time desired by the members, even if it overlaps with SADC hours of attendance.
• Compliance Considerations:Ensure the SADC does not have a restriction on community integration, such as the amount of time the member can engage in community activities, or how many hours a member must be at the SADC prior to leaving. For additional information, see SADC HCSB Community Integration.
• Examples of What to Observe:This information may be observed in posted signs that members can view and/or SADC policies and procedure documents.

O5: Does the SADC make members aware of their right to integrate into the greater community?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Confirm the SADC makes members aware they have the right to integrate with the greater community, by participating in activities and opportunities of their choosing.
• Compliance Considerations:Ensure the SADC has made members aware of their right to participate in any activity or opportunity of the members’ choosing in the community.
• Examples of What to Observe:This information may be observed in member rights documents.

O6: Does the SADC support members who seek opportunities and activities within the greater community??

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Confirm the SADC supports members to identify opportunities and activities within the greater community and make their interest known to the SADC for further support.
• Compliance Considerations:This question focuses solely on opportunities in the community.
  • SADC activities including group outings are not considered to be community integration.
  • Ensure the SADC supplies members with information on community opportunities or the resources needed to find opportunities with or without assistance.
• Examples of What to Observe:This information may be observed in posted calendars, or other documents that provide guidance and/or information on activities, events, or other opportunities within the greater community.

O7: Does the SADC make members aware of their right to seek competitive employment and work or volunteer opportunities?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Confirm the SADC makes members aware of their right to seek competitive employment and work or volunteer opportunities.
• Compliance Considerations:This question focuses solely on work or volunteer opportunities in the community.
  • Volunteering or working at the SADC or an affiliate is not considered "competitive employment and work or volunteer opportunities."
  • Ensure the SADC supplies members with information on work and volunteer opportunities in the community or the resources needed to find opportunities with or without assistance.
  • Confirm the SADC provides information on both work and volunteer opportunities.
• Examples of What to Observe:This information may be observed in posted documents that provide guidance and/or information on work and volunteer opportunities in the community.

O8: Does the SADC support members who wish to seek competitive employment and work or volunteer opportunities?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Confirm the SADC supports members to identify competitive employment and work or volunteer opportunities and make their interest known to the SADC for further support.
• Compliance Considerations:This question focuses solely on working and/or volunteering in the community.
  • Working or volunteering at the SADC or an affiliate is not considered "competitive employment and work or volunteer opportunities".
  • Ensure the SADC supplies members with information on work and volunteer opportunities in the community or the resources needed to find opportunities with or without assistance.
  • Support may include referring members to their MLTC plan care manager to inquire about services/support for obtaining work.
  • Confirm the SADC provides information on both work and volunteer opportunities.
• Examples of What to Observe:This information may be observed in posted documents that provide guidance and/or information on work and volunteer opportunities within the greater community.

O9: Does the SADC recognize the members' right to receive services or attend appointments in the community?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Confirm that the SADC allows members to receive services and/or attend appointments in the community while at the SADC.
• Compliance Considerations:Ensure the SADC makes members aware of their right to attend appointments in the community while at the SADC. Also ensure the SADC does not have restrictions on attending appointments such as a set amount of time members are allowed to be away from the SADC.
• Examples of What to Observe:This information may be observed in member rights documents or another posted document.

O10: Is information regarding public transportation available to members in a convenient manner?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Ensure the SADC supports members in identifying transportation methods by supplying local transportation information in a convenient manner.
• Compliance Considerations:Verify the SADC provides members with information on transportation options, including how to get to and from the SADC, and around the community.
  • If the SADC does not have public transportation options, and notifies the members of this, but provides information on transportation options available to the members, this could be considered compliant with exception.
• Examples of What to Observe:This information may be observed in the following documents:
  • Postings of route maps and schedules for buses, trains and/or subways.
  • Walking instructions/maps from the SADC to closest public transit stop(s).
  • Contact information for taxi companies, etc.

O11: Is the SADC free from barriers that restrict members' access or movement?

Standard: 42 CFR 441.530(a)(1)(iv) – 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.

• Question Goal: Confirm members are able to freely move about the SADC.
• Compliance Considerations:Ensure the SADC does not have any barriers that could hinder the member’s ability to move around the SADC. If the entrance locks for safety, consider if there are methods for the member to access the area. Ensure the SADC does not have restrictions for all members in their policies and procedures.
• Examples of What to Observe:Observe any locked doors, gates, fences, and any other barriers that would block the members from moving about freely in the SADC or entering/exiting the space.

O12: Does the SADC make members aware of the right to request an alternate meal option and how to request it?

Standard: 42 CFR 441.530(a)(1)(vi)(c) – Setting ensures individuals have the freedom and support to control their schedules and activities; and have access to food any time.

• Question Goal: Confirm alternative meal options exist.
• Compliance Considerations:Ensure the SADC offers alternative meal options to the members, and the members know how to request an alternative option.
• Examples of What to Observe:This information may be observed in posted documents for members advising that meal alternatives are available and how to request them.

O13: Are members given flexibility when they can have a meal?

• Standard: 42 CFR 441.530(a)(1)(vi)(c) – Setting ensures individuals have the freedom and support to control their schedules and activities; and have access to food any time.
• Question Goal: Verify members have flexible mealtimes.
• Compliance Considerations:Ensure the SADC informs members they have flexibility to decide when they have their meals. Confirm the SADC allows members to choose their mealtimes. Please note, the SADC may offer a time range, which is still compliant if the range offers sufficient time for flexibility.
• Examples of What to Observe:This information may be observed in posted member rights or other documents, that confirm flexibility in mealtimes.

O14: Are members given access to food and drinks throughout the day, at all times?

Standard: 42 CFR 441.530(a)(1)(vi)(c) – Setting ensures individuals have the freedom and support to control their schedules and activities; and have access to food any time.

• Question Goal: Confirm members have access to food and drinks at all times.
• Compliance Considerations:Ensure the SADC offers members food and drink options throughout the day. Members must be aware there is food and drinks available, and if the options are not readily available, information on how to request it.
• Examples of What to Observe:This information may be observed in posted member rights or other documents that confirm food and drinks are always available. The food drink station should be observed.

O15: Does the SADC provide members with flexibility in their daily schedule?

Standard: 42 CFR 441.530(a)(1)(vi)(c) – Setting ensures individuals have the freedom and support to control their schedules and activities; and have access to food any time.

• Question Goal: Confirm that the SADC does not regiment members’ schedules and that members have the right to determine what their time at the SADC looks like.
• Compliance Considerations:Ensure the SADC allows flexibility in the members’ schedule. Members must be free to choose the activities they wish to participate in.
• Examples of What to Observe:This information may be observed in posted member rights or other documents.

O16: Does the SADC afford opportunities for member activities that focus on the needs and desires of the members served?

Standard: 42 CFR 441.530(a)(1)(iv) – 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.

• Question Goal: Confirm the SADC provides activities for members based on their needs and desires and has a process to elicit feedback on activities from the members.
• Compliance Considerations: Determine how the SADC makes members aware of the right to provide feedback and suggestions on SADC activities, elicits suggestions from members, and ensures the SADC offers activities that meet the needs and desires of the members.
• Examples of What to Observe:This information may be observed in a posted member rights document, suggestion box, etc. advising members how they can contribute ideas for activities.

O17: Are SADC activities adapted to members' needs and preferences?

Standard: 42 CFR 441.530(a)(1)(vi)(c) – Setting ensures individuals have the freedom and support to control their schedules and activities; and have access to food any time.

• Question Goal: Confirm members can participate in all the activities they have chosen, and that accommodations are made whenever necessary.
• Compliance Considerations:Ensure the SADC adapts activities to meet the needs and/or preferences of the members and how members can request accommodation. For example, providing extra-large bingo cards for members with low vision.
• Examples of What to Observe:This information may be observed in member notices, activity calendar, member rights document, etc. informing the members that the SADC can adapt an activity and how to request it. Inquire how the SADC accommodates activities to fit the members’ needs/preferences.

O18: Does the SADC allow members to choose with whom they spend their time while at the setting?

Standard: 42 CFR 441.530(a)(1)(vi)(c) – Setting ensures individuals have the freedom and support to control their schedules and activities; and have access to food any time.

• Question Goal: Verify that members are free to socialize and spend time with other members of their choosing or choose not to do so.
• Compliance Considerations:Ensure the SADC does not restrict with whom the members spend their time.
• Examples of What to Observe:Observe members and note if the members appear to have chosen their seating and activities. Ensure there is not assigned seating, observe if members are communicating comfortably and freely. If members are not present at the time of the evaluation, documentation, such as a posted member rights document, must be used to determine compliance.

O19: Does the setting support members to access their money?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Confirm the SADC ensures the members have the right to access their own funds.
• Compliance Considerations:Ensure the SADC does not control the member’s finances or hold their money. Members must be aware of the right to control their own funds.
• Examples of What to Observe:This information may be observed in a posted member rights or other document that indicates members have the right to access their own funds.

O20: Does the SADC offer enough space for members to participate in a variety of activities?

Standard: 42 CFR 441.530(a)(1)(iv) – 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.

• Question Goal: Confirm there is sufficient space at the SADC for members to participate in a variety of activities.
• Compliance Considerations:Members need to be able to freely move about the setting and have room to engage in the activities of their choosing. All areas used by members should be spacious enough to accommodate the members and any mobility devices.
• Examples of What to Observe:Observe the layout of the SADC and whether there is sufficient space for engaging in activities, including physical activities. Determine if there is space for multiple activities to occur at the same time, and space for members to sit if they do not want to participate in an activity.

O21: Is there sufficient dining spaces for members that use a wheelchair?

Standard: 9 NYCRR 6654.20(c)(3) – The program shall comply with all applicable provisions of the Federal Americans with Disabilities Act.

• Question Goal: Confirm that dining space is accessible for members in a wheelchair or other mobility device.
• Compliance Considerations:Ensure the SADC has space for members in wheelchairs or with other mobility devices to access the dining area and eat comfortably.
• Examples of What to Observe:Observe the SADC dining space and ensure members with wheelchairs and other mobility devices can access the dining area and spaces at tables to comfortably sit and eat.

O22: Does the SADC provide a private dining space if requested by a member?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Confirm that a private dining space is available and members are aware of it.
• Compliance Considerations:The private space does not need to be in a separate room, but it must be away from other members. Members must be aware there is private dining space.
• Examples of What to Observe:Observe the layout of the SADC and ensure there is a space members can use to dine privately, including a table and chair. If it is not a clear space for members to access and use, inquire how members request to use the space and ensure members are aware it is available to them.

O23: Does SADC provide space for all members to do activities such as speaking on the telephone and visiting with others in private?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Confirm members have private space to make phone calls and visit with others.
• Compliance Considerations:Ensure the SADC has space for members to make phone calls or meet with visitors in private. Ensure members are aware space is available to them as well as how to request to use it. The space does not have to be a separate room, but it must provide privacy for the person using it.
• Examples of What to Observe:Observe the identified private space. Confirm the space provides adequate privacy for phone calls, and for a member and their visitor to speak in private. Observe if the space has a door that closes and/or other means of maintaining privacy.

O24: Is there a private space for members to have discussions on health or personal matters?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Confirm members have privacy when discussing personal matters.
• Compliance Considerations: Ensure the SADC has private space for members to have conversations about their health or other personal matters. The space does not have to be a separate room, but it must provide privacy for the person using it.
• Examples of What to Observe: Observe the identified private space. Confirm the space provides adequate privacy for members to discuss personal matters or health issues. Observe if the space has a door that closes and/or other means of maintaining privacy.

O25: Does the SADC ensure member records are kept in a secured location?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Ensure member information is kept private and confidential.
• Compliance Considerations: Confirm the SADC has a secure space to store member records. Verify it can be locked and confirm who has access to the location.
• Examples of What to Observe: Observe the space where member records are kept and the locking mechanism and confirm who has access to the member records.

O26: Is the number of members and staff present at the SADC at or below the maximum occupancy limit for the SADC?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm that the SADC is operating within the set occupancy level.
• Compliance Considerations: Ensure the total number of people in the SADC does not exceed the maximum occupancy level.
• Examples of What to Observe: Observe and confirm the number of people (members, staff, visitors, etc.) does not exceed the allowable amount, based on the Certificate of Occupancy or other municipal documentation.

O27: If the SADC is in NYC, is the certificate of occupancy (COO) posted?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm that all SADCs within the five boroughs of New York City have the COO document posted.
• Compliance Considerations: Ensure the COO has been visibly posted in SADC. If the SADC is located outside of the five boroughs of New York City, this question is compliant with exception.
• Examples of What to Observe: Observe that the COO is posted in a location visible to anyone who may enter the SADC.

O28: Is the SADC physically accessible to the members?

Standard: 42 CFR 441.530(a)(1)(vi)(E) – Setting is physically accessible to the individual.

• Question Goal: Ensure all members can access the entire SADC space.
• Compliance Considerations: Verify the SADC is physically accessible to all members. If an area is found to be not accessible, but the SADC is in the process of fixing it, gather and review documentation to confirm, and determine if the question should be compliant with exception. For example, an elevator is not working, and the SADC has a documentation of an upcoming appointment date for a contractor to fix the elevator.
• Examples of What to Observe: Observe all spaces, entrances, elevators, and rooms used by members and confirm the spaces are accessible for all members including those with mobility devices. Ensure members with mobility devices can enter and turn around inside the bathrooms.

O29: Are there secure handrails on both sides of all stairs and ramps leading into and within the SADC?

Standard: 9 NYCRR 6654.20(c)(3) – The program shall comply with all applicable provisions of the Federal Americans with Disabilities Act.

• Question Goal: Confirm that members have the ability to safely use the stairs and ramps at the SADC and the handrails are secure.
• Compliance Considerations: Ensure the SADC has handrails on both sides of any stairs and ramps. Confirm the handrails are appropriately secured for member use.
• Examples of What to Observe: Observe all stairs or ramps at the SADC, including entry and exits. Confirm there are secure handrails on both sides of stairs and ramps. Ensure the handrails are not loose.

O30: Is there a grab bar within easy reach of bathroom toilets?

Standard: 9 NYCRR 6654.20(c)(3) – The program shall comply with all applicable provisions of the Federal Americans with Disabilities Act.

• Question Goal: Confirm there is a grab bar in the bathroom, within reach of the toilet.
• Compliance Considerations: Ensure there are grab bars that are within reach of the toilet.
• Examples of What to Observe: Observe all bathrooms at the SADC and confirm there is an accessible bathroom with a grab bar near the toilet. If the bathroom has stalls, at least one stall must have a grab bar near the toilet.

O31: Is the grab bar near toilet secured and at a height of 36 inches from the floor?

Standard: 9 NYCRR 6654.20(c)(3) – The program shall comply with all applicable provisions of the Federal Americans with Disabilities Act.

• Question Goal: Confirm the grab bar in the bathroom is secure and appropriately installed.
• Compliance Considerations: Ensure the grab bar near the toilet is secure and attached to the wall.
• Examples of What to Observe: This information may be observed by confirming the grab bar is secured to the wall. The grab bar should be 36 inches (3 feet) from the floor, a visual estimate is acceptable for this observation.

O32: Is the flooring inside the SADC stable and firm?

Standard: 9 NYCRR 6654.20(c)(3) – The program shall comply with all applicable provisions of the Federal Americans with Disabilities Act.

• Question Goal: Verify the flooring inside the SADC is stable, firm, and free of any safety risk to the members.
• Compliance Considerations: Ensure the flooring, which includes tiles, carpeting, hardwood, floor mats, area rugs, etc. are secure. If the change in floor height is more than ¼ inches, this is considered a step and must have a ramp or another way for members to safely navigate this height change.
• Examples of What to Observe: Observe any carpeting and/or tiles to confirm they are secure and not a risk for members to slip or trip. Confirm that any area rug or entryway mats are flat on the floor and are not a tripping hazard to members.

O33: Are there visual and tactile signs for permanent rooms?

Standard: 9 NYCRR 6654.20(c)(3) – The program shall comply with all applicable provisions of the Federal Americans with Disabilities Act.

• Question Goal: Confirm visual and tactile signs are installed for permanent rooms in the SADC.
• Compliance Considerations: Ensure the SADC has signs posted on permanent rooms that are able to be seen and felt. The signs must have both raised letters and braille. Confirm members with or without mobility devices can touch the signs. Permanent rooms may include restrooms, kitchens, stairways, entries and exits.
• Examples of What to Observe: Observe signs outside of permanent rooms and confirm signs are clear and have raised letters and braille for visually impaired members. In addition, confirm the signs are accessible to members with mobility devices.

O34: Are appliances connected to electrical outlets in a safe manner?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the electrical outlets are in good working condition and there is no risk of fire by misuse of the outlets.
• Compliance Considerations: Ensure all appliances, including small appliances, are not plugged into extension cords that are not surge protected. Outlets must be undamaged and there must not be any exposed or frayed wires on cords that are plugged into the outlets. Multiple extension cords should never be connected.
• Examples of What to Observe: Observe the outlets in the SADC for any clear physical damage to the outlet. If there are extension cords at the SADC, confirm they are fully plugged into the outlet and appliance, and that connections are not near hazards (water, under carpets, etc.). Observe any small appliances (microwave, toaster, etc.) to ensure that they are not plugged into extension cords, unless surge protected. Confirm there are not frayed/exposed wired on cords that are plugged into the outlets.

O35: Is the fire detection system inside the SADC free from obstructions that would prevent it from fulfilling its function?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has an undamaged fire alarm and/or smoke detection system in place that is in working condition.
• Compliance Considerations: Ensure the fire detection system is free from obstructions. There should be 24 inches of clearance from the system and any objects. During the evaluation, confirm the fire detection system is working properly.
• Examples of What to Observe: Observe the fire detection system and confirm there are no obstructions or indications it is not in working order.

O36: Is the sprinkler system inside the SADC free from obstructions that would prevent them from fulfilling their function?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm if the SADC has a sprinkler system and if so, if it is in working order.
• Compliance Considerations: If the SADC has a sprinkler system, ensure the sprinkler is not damaged and has at least 18 inches of clearance. If the SADC does not have a sprinkler system, review the building and determine if the SADC is compliant with exception.
• Examples of What to Observe: If the SADC has one, observe the sprinkler system and confirm there is an acceptable amount of clearance, and the system is not visibly damaged.

O37: Are fire extinguishers undamaged, within inspection/expiration dates, and easily accessible?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has fire extinguishers that are not expired, easily accessible, and in working condition.
• Compliance Considerations: Verify the SADC has working fire extinguishers. Ensure the fire extinguisher is not damaged, has all required parts, and is not expired or has a recharge date that has passed.
• Examples of What to Observe: Observe all fire extinguishers in the SADC to confirm they are easily accessible and in working order. Check the expiration date or recharge date on the extinguisher and confirm it has not passed.

O38: Are fire extinguishers in all required locations throughout the SADC?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has fire extinguishers throughout the SADC.
• Compliance Considerations: Ensure the SADC has fire extinguishers throughout the SADC. Fire extinguishers should be in kitchens, near electrical panels, along all normal travel paths, and at each entrance/exit. If the SADC has a kitchen, ensure the fire extinguisher is ABC or Class K and is within 30 feet of the kitchen.
• Examples of What to Observe: Observe that fire extinguishers are in place in the required areas. Confirm the kitchen has an ABC or Class K fire extinguisher and it is within the required distance.

O39: Does the SADC possess and have posted a valid Food Service Establishment (FSE) permit?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm that all SADCs that prepare food on site have a valid Food Service Establishment (FSE) permit posted.
• Compliance Considerations: Ensure the SADC has a valid FSE permit. Confirm the name of the SADC/owner or the vendor is listed and that the permit is not expired. The FSE must be posted for view.
  • If the SADC uses a vendor or is part of a larger system’s food service department, confirm the vendor or system has a valid FSE.
  • If food is not prepared at the SADC, the SADC would not need an FSE. In this case, review the details to determine if the SADC is compliant with exception.
• Examples of What to Observe: Observe that an FSE with is posted for everyone to view. Confirm the expiration or renewal date has not passed and all information is accurate. If the SADC uses a vendor, confirm they have a valid FSE.

O40: Does the SADC recognize the members' right to have visitors of their choosing at any time?

Standard: 42 CFR 441.530(a)(1)(vi)(D) – Setting ensures individuals are able to have visitors of their choosing at any time.

• Question Goal: Verify that members are able to have visitors of their choosing at the SADC and that they are aware of this right.
• Compliance Considerations: Ensure the SADC allows members to have visitors, of their choosing, at any time, and for the amount of time they wish. Confirm members are aware of this right.
• Examples of What to Observe: This may be observed in posted member rights or other documents.

O41: Does the SADC have the member rights posted in a public area of the SADC which is clearly visible to members, families, and SADC staff?

Standard: 9 NYCRR 6654.20(e) – The program shall promote the rights of participants including providing copies and explanations of rights at admission and by posting the rights along with the addresses and telephone numbers of the area agency on aging and the office, in a public place which is clearly visible to participants, their families, and program staff.

• Question Goal: Verify the member rights document is posted in a public area for members, families and program staff to easily access.
• Compliance Considerations: Ensure the member rights document is posted in an area where everyone can see it and at least one copy is in English.
• Examples of What to Observe: Observe that the member rights are posted and that the location is accessible to members, families and program staff.

O42: Are the addresses and phone numbers for the AAA and NYSOFA posted in a public area which is clearly visible to members, families, and SADC staff?

Standard: 9 NYCRR 6654.20(e) – The program shall promote the rights of participants including providing copies and explanations of rights at admission and by posting the rights along with the addresses and telephone numbers of the area agency on aging and the office, in a public place which is clearly visible to participants, their families, and program staff.

• Question Goal: Verify the telephone number and address for the local area agency on aging (AAA) and the New York State Office of the Aging (NYSOFA) are posted in a public area for members to easily access.
• Compliance Considerations: Ensure the phone numbers and addresses for AAA and NYSOFA are posted in a public place, visible to everyone with or without a mobility device, and anyone entering the SADC.
• Examples of What to Observe: Observe and confirm that the SADC has the contact information for both the AAA and NYSOFA posted.

O43: Does the SADC have each member’s primary care physician and emergency contact information in an easily accessible location?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has members’ emergency contact and primary care physician's contact information readily available in the event of an emergency.
• Compliance Considerations: Ensure the SADC has the primary care physician and emergency contact for each member. The information must be in a place that is easily accessible in an emergency. The SADC can list the primary care physician’s office if the member does not see a specific physician.
• Examples of What to Observe: Observe that the SADC has the emergency and physician contact information in an easily accessible area in the event of an emergency. Confirm both emergency contact information and physician contact information is present for all members.

O44: Does the SADC have enough staff to support members as needed?

Standard: 42 CFR 441.530(a)(1)(v) – Setting facilitates individual choice regarding services and supports, and who provides them.

• Question Goal: Confirm the setting provides enough staff for members to maintain independence and assist as needed with daily activities.
• Compliance Considerations: Ensure the SADC has adequate staff to support and meet the needs of the members.
• Examples of What to Observe: Observe the members and staff present and determine if there is sufficient staff to meet the needs of the members. NYSOFA recommends a 1:7 staff to member ratio as best practice. If there are no members present at the time of the evaluation, verify the SADC policies and procedures indicate that the SADC has enough staff to meet the needs of the members.

O45: Does the SADC provide information to members about how to make a request to make changes to their SADC PCSP?

Standard: 42 CFR 441.725(a) – The person-centered planning process must be conducted appropriately, and in accordance with all applicable state and federal rules, regulations, and guidance.

• Question Goal: Verify that members are aware of how to make changes to their SADC PCSPs.
• Compliance Considerations: Ensure the SADC informs members that they have the right to make changes to their PCSP, at any time and for any reason, and how to request a change.
• Examples of What to Observe: This information may be observed in the posted member rights or other document informing members of their right to make changes to their PCSP and how to request a change.

O46: Do members have the right to be free from all abuse and harm, including but not limited to, physical or chemical restraints, seclusion, coercion, and neglect?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Verify that the members are free from all abuse, which could include but is not limited to restraints, coercion, physical or mental harm, neglect and seclusion, and that members aware of this right.
• Compliance Considerations: Ensure the SADC informs members they have the right to be free from all abuse and harm, including but not limited to, physical or chemical restraints, seclusion, coercion, and neglect.
• Examples of What to Observe: This information may be observed in the posted member rights or other documents informing members of this right. Confirm the document or posting includes all abuse, harm, restraints, seclusion, coercion, and neglect.

O47: Does the staff interact and communicate with members respectfully and in a manner in which the member would like to be addressed at all times?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Confirm that staff treat all members with respect and dignity.
• Compliance Considerations: Ensure the SADC staff interactions and communications with members are respectful during the evaluation.
• Examples of What to Observe: Observe how staff interact with members during the evaluation. If no members are present to observe interactions, review SADC policies and procedures to confirm there is a policy on staff treating members respectfully.

R1: Does the SADC have official municipal documentation that reflects the maximum occupancy allowance for the location?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has documentation indicating the maximum occupancy allowance for the location.
• Compliance Considerations: Ensure the SADC has the required occupancy documentation and is aware of the maximum allowable number of people for the SADC. The municipal documentation must be for the correct physical location and include the name of the SADC or building owner if the space is rented. If the document has an expiration date, confirm the date has not passed.
• Examples of Documentation to Review:
  • Certificate of Occupancy (COO).
  • FDNY Place of Assembly (PA) Permit (SADCs in NYC only).
  • Municipal Fire Department/Code Enforcement Max Occupancy Documentation.

R2: Does the SADC have official municipal documentation reflecting the appropriate usage description for the location?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has documentation indicating the appropriate usage for the space so that accurate information is available in the event of an emergency.
• Compliance Considerations: Ensure the SADC has the required documentation from the municipality reflecting the appropriate usage description for the location such as SADC or adult daycare. Confirm the document lists the physical address, name of the SADC or building owner, and permissible use description. This information is typically found in the same municipal documentation as the maximum occupancy.
• Examples of Documentation to Review:
  • Certificate of Occupancy (COO).
  • FDNY Place of Assembly (PA) Permit (SADCs in NYC only).
  • Municipal Fire Department/Code Enforcement Max Occupancy Documentation.

R3: Does the SADC maintain complete member attendance logs that, at minimum, indicate the member's full name, date, and time of attendance?

Standard: 9 NYCRR 6654.20(d)(2)(iii) – The program shall maintain and keep confidential administrative, financial, participant personal records, and services records, as detailed in the regulation.

• Question Goal: Verify the SADC documents member attendance.
• Compliance Considerations: Ensure the SADC maintains member attendance logs. Confirm the log includes the members’ full name, date, and time of attendance. For a new SADC that does not have members enrolled and attending, review the log the SADC will use and confirm it has space for the members to add their full name, date and time of attendance and determine if the SADC is compliant with exception.
• Examples of Documentation to Review: Completed attendance logs with member full name, date and time of attendance. Logs may be a physical or electronic log but must include full member name and date and time of attendance.

R4: Did the SADC complete the annual certification of their compliance with the standards and requirements set forth in 9 NYCRR 6654.20?

Standard: Administration – The SADC conducts all required administrative requirements, outside those identified in 9 NYCRR 6654.20.

• Question Goal: Verify that the SADC completed the annual certification to compliance with the standards and requirements set forth in 9 NYCRR §6654.20, in the Office of the Medicaid Inspector General (OMIG) portal.
• Compliance Considerations: Ensure the SADC has a valid certification completed within the last year.
• Examples of Documentation to Review: Completed OMIG certification.

R5: If the SADC is in NYC, did the SADC register with NYC Aging?

Standard: Administration – The SADC conducts all required administrative requirements, outside those identified in 9 NYCRR 6654.20.

• Question Goal: Verify that SADCs within the five boroughs of New York City have registered with the New York City Department for the Aging (NYC Aging).
• Compliance Considerations: Confirm the SADC name, address, and owner is accurate on the registration. This is a onetime registration but must be updated if the SADC moves, changes name, or changes ownership. If an SADC is not located within the five boroughs of New York City, this question is compliant with exception.
• Examples of Documentation to Review: Completed NYC Aging registration.

R6: Does the SADC possess valid personal and professional liability coverage for business operations?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has completed the requirement of obtaining valid professional and personal liability coverage.
• Compliance Considerations: Ensure the SADC has a valid personal and professional liability policy for their business operations. Confirm the policy lists the name and physical address of the SADC and has not expired. Professional Liability, sometimes called Errors and Omissions, covers negligence, mistakes, or failures to deliver professional services. Personal Liability, sometimes called Commercial Insurance, covers unintentional bodily injury, property damage, and sometimes third parties including medical bills, legal fees, and court-ordered settlements.
• Examples of Documentation to Review: The SADC’s insurance policy.

R7: Does the SADC and/or the SADC's hired vendor possess valid commercial auto insurance including liability coverage?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has obtained valid commercial auto insurance with appropriate liability coverage, or if the transportation is provided by a vendor, that the SADC has a copy of the transportation vendor's insurance.
• Compliance Considerations: Ensure the SADC has valid commercial auto insurance or has a copy of their transportation vendors insurance. Confirm the policy lists the physical address of the SADC (or vendor) and is not expired. If the SADC does not provide transportation, review the SADC and the detailed reason to determine if the SADC is compliant with exception.
• Examples of Documentation to Review: The SADC’s auto insurance policy or the SADC’s transportation vendor’s auto insurance.

R8: Does the SADC have a policy for retaining documentation of service delivery that include, at minimum, member name and date and duration of service?

Standard: 9 NYCRR 6654.20(d)(2)(i) – The program shall establish, follow, and have on file for review written policies and procedures regarding the operation of the program.

• Question Goal: Confirm the SADC policy includes a process to document service delivery for all members.
• Compliance Considerations: Ensure the SADC policy details how the SADC documents and retains service delivery records. The policy must indicate that at minimum the SADC documents member name and date and duration of the service.
• Examples of Documentation to Review: SADC policy documents, etc.

R9: Does the SADC have a policy indicating how the annual self-evaluation of the program will be conducted?

Standard: 9 NYCRR 6654.20(d)(2)(ii) – The program shall conduct and maintain on file a self-evaluation of its administrative, fiscal, and program operations, including feedback from participants and caregivers, at least annually.

• Question Goal: Confirm the SADC has policy on how and when to complete a self-evaluation of the program.
• Compliance Considerations: Ensure the SADC has a policy describing how the annual self-evaluation will be conducted. Confirm the self-evaluation includes evaluations of the administrative, fiscal, and program operations.
• Examples of Documentation to Review: SADC policy documents, etc.

R10: Does the SADC have a policy that defines the criteria for member eligibility?

Standard: 9 NYCRR 6654.20(d)(2)(i) – The program shall establish, follow, and have on file for review written policies and procedures regarding the operation of the program.

• Question Goal: Confirm the SADC policy defines the criteria for member eligibility.
• Compliance Considerations: Ensure the SADC has a policy defining the eligibility requirements for members, including that the SADC serves members who are functionally impaired and will benefit from the program.
• Examples of Documentation to Review: SADC policy documents, etc.

R11: Does the SADC have a policy that describes the procedure for member admission?

Standard: 9 NYCRR 6654.20(d)(2)(i) – The program shall establish, follow, and have on file for review written policies and procedures regarding the operation of the program.

• Question Goal: Confirm the SADC has a procedure for members admission into the program that includes ensuring the program only serves members whose needs can be met by the SADC.
• Compliance Considerations: Ensure the SADC has a documented procedure for the admission of members. It must include that the SADC will only admit a member after an assessment of the member's functional capacities and impairments has been completed, which confirms their needs can be met by the SADC.
• Examples of Documentation to Review: SADC policy documents, admission policy, admission procedure documents, etc.

R12: Does the SADC have a policy that describes the procedure and rationale for discharge?

Standard: 9 NYCRR 6654.20(d)(2)(i) – The program shall establish, follow, and have on file for review written policies and procedures regarding the operation of the program.

• Question Goal: Confirm the SADC has a documented procedure for member discharge from the program.
• Compliance Considerations: Ensure the SADC has a policy describing the rationale and process for discharging a member. Confirm the policy clearly defines the discharge procedure and rationale for why members get discharged including if the SADC can no longer safely or adequately serve the member.
• Examples of Documentation to Review: SADC policy documents, discharge policy, discharge procedure documents, etc.

R13: Does the SADC have a policy on providing activities which include social, intellectual, cultural, education, and physical group activities?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that confirms that the SADC offers activities which include social, intellectual, cultural, education, and physical group activities.
• Compliance Considerations: Ensure the SADC has a written policy to offer activities which include social, intellectual, cultural, education, and physical group activities.
• social, intellectual, cultural, education, and physical group activities.
• Examples of Documentation to Review: SADC policy documents, etc.

R14: Does the SADC have a policy confirming supervision and monitoring are provided which includes observation and awareness of the member’s whereabouts, activities and current needs during attendance at the program, and protects the safety and welfare of the member?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that confirms supervision and monitoring are provided and protects the safety and welfare of the members.
• Compliance Considerations: Ensure the SADC has a policy confirming the program provides supervision and monitoring. The policy must include that the SADC provides observation and awareness of the members’ whereabouts, awareness of activities and current needs during attendance at the program and protects the safety and welfare of the members.
• Examples of Documentation to Review: SADC policy documents, etc.

R15: Does the SADC have a policy confirming personal care is provided including some or total assistance with the following: toileting, mobility, transfer, eating, dressing, bathing, grooming, routine skin care, changing simple dressings, and using supplies and adaptive and assistance equipment?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that confirms personal care is provided to members based on their needs, including some or total assistance with the following: toileting, mobility, transfer, eating, dressing, bathing, grooming, routine skin care, changing simple dressings, and using supplies and adaptive and assistance equipment.
• Compliance Considerations: Ensure the SADC has a policy confirming personal care assistance is provided by the SADC based on the needs of the members. The policy must include that personal care services include some or total assistance with the following: toileting, mobility, transfer, eating, dressing, bathing, grooming, routine skin care, changing simple dressings, and using supplies and adaptive and assistance equipment.
• Examples of Documentation to Review: SADC policy documents, etc.

R16: Does the SADC have a policy confirming support is provided to the member with self-administration of medication, which includes prompting, identification of medication, bringing the medication and any necessary supplies to the member, opening the container, positioning the member for medication and administration, and disposing of used supplies and materials?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy confirming support is provided to the member with self-administration of medication.
• Compliance Considerations: Ensure the SADC has a policy explaining that support is provided to members with self-administration of medication. The policy must confirm that assistance includes prompting, identification of medication, bringing the medication and any necessary supplies to the member, opening the container, positioning the member for medication and administration, and disposing of used supplies and materials.
• Examples of Documentation to Review: SADC policy documents, etc.

R17: Does the SADC have a policy addressing how to identify a need for home delivered meals and handle referrals for members to home delivered meal services as needed?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy to identify members who would benefit from a home delivered meal service and handle referrals as needed.
• Compliance Considerations: Ensure the SADC has a policy to identify members’ needs for home delivered meals. Verify the SADC has a process on how to refer members for this service, which could include informing the MLTC plan care manager of the identified need.
• Examples of Documentation to Review: SADC policy documents, etc.

R18: Did the SADC notify the local fire jurisdiction of the SADC's physical location and current hours of operation in writing?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC has completed the requirement of notifying the local fire jurisdiction of the location of the SADC and hours of operation.
• Compliance Considerations: Ensure the SADC has notified the local fire jurisdiction of their physical location and current operating hours. While this is a onetime notification, the information must be accurate.
• Examples of Documentation to Review: A copy of the written notification to the local fire jurisdiction of the location and hours of operation of the SADC.

R19: Does the SADC have fire drills twice yearly?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm that the SADC has completed at least two fire drills in the past 12 months.
• Compliance Considerations: Ensure the SADC has completed two fire drills in the last 12 months. Confirm the documentation includes the dates and times of the drills and the SADC name is included. If the SADC has not been open for 12 months and has not completed two fire drills in the past 12 months, determine if this is compliant with exception.
• Examples of Documentation to Review: SADC fire drill documentation, SADC fire drill log, etc.

R20: Does the SADC have a procedure for handling environmental and member emergencies?

Standard: 9 NYCRR 6654.20(d)(2)(vi)-(viii) – The program shall maintain all physical environment and safety regulations, have all required elements of emergency preparedness, and have sufficient liability coverage, as detailed in the regulation.

• Question Goal: Confirm the SADC is prepared for an emergency and has a process for both environmental and member emergencies.
• Compliance Considerations: Ensure the SADC has policy that addresses how to handle environmental and member emergencies. Examples of environmental emergencies includes flooding or fires, while member emergencies may include injuries or medical events. Confirm the policy documents the SADC process when handling emergencies.
• Examples of Documentation to Review: SADC policy documents, SADC emergency procedure documents, etc.

R21: Does the setting ensure staff are knowledgeable about the capabilities, interests, preferences, and needs of members?

Standard: 42 CFR 441.530(a)(1)(v) – Setting facilitates individual choice regarding services and supports, and who provides them.

• Question Goal: Verify that staff are kept aware of each member's capabilities, interests, preferences, and needs.
• Compliance Considerations: Ensure the SADC staff are kept informed about the capabilities, interests, preferences, and needs of members, including any changes in the members’ care needs.
• Examples of Documentation to Review: SADC policy documents, staff meeting agendas and/or minutes, etc.

R22: Does the SADC ensure that a member's behavior does not impede on the rights of other members?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Verify that all members' rights are not impeded upon based on behavioral issues of another member.
• Compliance Considerations: Confirm that the SADC ensures that a member’s behavior does not hinder the rights of another member and ensures staff are trained in behavioral supports.
• Examples of Documentation to Review: SADC policy documents, such as a behavior management and conflict resolution, etc.

R23: Does the SADC have a policy to ensure the member rights are explained to the member and/or caregiver?

Standard: 9 NYCRR 6654.20(e) – The program shall promote the rights of participants including providing copies and explanations of rights at admission and by posting the rights along with the addresses and telephone numbers of the area agency on aging and the office, in a public place which is clearly visible to participants, their families, and program staff.

• Question Goal: Confirm the SADC ensures members' rights are explained to members and/or caregiver upon admission.
• Compliance Considerations: Ensure the SADC has a policy that the member rights are explained to each member and/or caregiver.
• Examples of Documentation to Review: SADC policy documents, SADC admission policy, etc.

R24: Does the SADC have policies to ensure that copies of the member rights are provided to the member and/or caregiver?

Standard: 9 NYCRR 6654.20(e) – The program shall promote the rights of participants including providing copies and explanations of rights at admission and by posting the rights along with the addresses and telephone numbers of the area agency on aging and the office, in a public place which is clearly visible to participants, their families, and program staff.

• Question Goal: Confirm the SADC ensures members rights are provided to the member and/or caregiver.
• Compliance Considerations: Ensure the SADC has a process for distributing a copy of the member rights document to each member and/or caregiver.
• Examples of Documentation to Review: SADC policy documents, SADC admission policy, etc.

R25: Does the SADC have a policy or procedure on the person-centered planning process?

Standard: 9 NYCRR 6654.20(d)(1)(iii) – The program must develop and maintain a service plan for each participant, as detailed in the regulation.

• Question Goal: Confirm that the SADC has a policy on the person-centered planning process.
• Compliance Considerations: Ensure the SADC has a policy on person-centered planning process.
• Examples of Documentation to Review: SADC policy documents, etc.

R26: Does the SADC have a policy stating the development of a PCSP is required within 30 days of admission?

Standard: 9 NYCRR 6654.20(d)(1)(iii) – The program must develop and maintain a service plan for each participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy about the creation of the member's initial PCSP within 30 days of enrollment.
• Compliance Considerations: Ensure the SADC policy clearly states all members’ initial PCSP is developed within the first 30 days of admission into the program.
• Examples of Documentation to Review: SADC policy documents, etc.

R27: Does the SADC have a policy or procedure to ensure the PCSP is reviewed and updated at least annually?

Standard: 9 NYCRR 6654.20(d)(1)(iii) – The program must develop and maintain a service plan for each participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that the member's PCSP is reviewed and updated annually, at minimum.
• Compliance Considerations: Ensure the SADC policy explains that the PCSP is reviewed and updated at least annually.
• Examples of Documentation to Review: SADC policy documents, etc.

R28: Does the SADC have a policy or procedure to review the PCSP when there is a change in condition?

Standard: 9 NYCRR 6654.20(d)(1)(iii) – The program must develop and maintain a service plan for each participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that the member's PCSP is updated when there is a change in condition.
• Compliance Considerations: Ensure the SADC policy supports the members to update their PCSP when there is a change in condition.
• Examples of Documentation to Review: SADC policy documents, etc.

R29: Do all documents indicate the member leads or directs the person-centered planning process?

Standard: 42 CFR 441.530(a)(1)(iv) – 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.

• Question Goal: Verify members lead and direct their person-centered planning process.
• Compliance Considerations: Ensure all SADC documents and policies indicate the member leads or directs the person-centered planning process. Confirm the documents do not use “participate in,” “a part of,” or “in conjunction with” as this would indicate the member did not lead the process.
• Examples of Documentation to Review: SADC policy documents, posted member rights documents, other posted notifications.

R30: Are SADC menus reviewed and approved by a registered dietitian and certified with a signature and date?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm all menus are reviewed and approved by a registered dietitian as indicated with a signature and date.
• Compliance Considerations: Ensure a registered dietitian certifies and signs off on SADC menus and confirm the full name of the dietitian and license number is present.
• If the SADC participates in the United States Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP), the SADC is exempt from this requirement. In this case, collect and review documentation to confirm CACFP participation and consider if the SADC is compliant with exception.
• Examples of Documentation to Review: SADC menus, meal plans, etc.

R31: Does the SADC plan menus that are based on a minimum four-week cycle?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has meal options that rotate to give members a variety on a four-week schedule.
• Compliance Considerations: Ensure the SADC menu rotates on a four-week cycle and confirm no menu options repeat. While some dishes may repeat, ensure the same exact meal (main and side dishes) does not repeat within the four-week period.
• If the SADC participates in the United States Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP), the SADC is exempt from this requirement. In this case, collect and review documentation to confirm CACFP participation and consider if the SADC is compliant with exception.
• Examples of Documentation to Review: SADC menus, meal plans, etc.

R32: Does the SADC have a policy detailing the security and maintenance of food and equipment?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy detailing security and maintenance of food and food preparation equipment.
• Compliance Considerations: Ensure the SADC has a policy describing how they secure and maintain food and equipment. The policy needs to contain information about providing meal service, storing/maintaining food, cleaning, and maintaining and/or securing food preparation equipment. If the SADC does not prepare food and has a third-party vendor/caterer who supplies and prepares all food, determine if the SADC is compliant with exception.
  • If the SADC participates in the United States Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP), the SADC is exempt from this requirement. In this case, collect and review documentation to confirm CACFP participation and consider if the SADC is compliant with exception.
• Examples of Documentation to Review: SADC policy documents, etc.

R33: Does the SADC have current records of the amount and cost of meals served?

Standard: 9 NYCRR 6654.20(d)(1)(iv) – The program must provide services consistent with the needs of the participant, as detailed in the regulation.

• Question Goal: Confirm the SADC is keeping appropriate records of the amount and cost meals served at the SADC by reviewing the most recent records.
• Compliance Considerations: Ensure the SADC maintains current records detailing the amount and cost of meals served. If the SADC does not have any members enrolled, confirm that the SADC has a process to document this information, and determine if the SADC is compliant with exception.
  • If the SADC participates in the United States Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP), the SADC is exempt from this requirement. In this case, collect and review documentation to confirm CACFP participation and consider if the SADC is compliant with exception.
• Examples of Documentation to Review: SADC records of amount and cost of meals served.

R34: Does the SADC have policies on staffing plans including ensuring adequate staffing?

Standard: 9 NYCRR 6654.20(d)(2)(i) – The program shall establish, follow, and have on file for review written policies and procedures regarding the operation of the program.

• Question Goal: Confirm that SADC has a policy to ensure adequate staffing to serve members.
• Compliance Considerations: Ensure there is a policy in place on staffing plans to guarantee adequate staff to meet the needs of members. NYSOFA recommends a ratio of 1:7 staff to members.
• Examples of Documentation to Review: SADC policy documents, etc.

R35: Does the SADC have a policy requiring staff to have a health assessment conducted prior to contact with members?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for staff to have a health assessment conducted prior to contact with members.
• Compliance Considerations: Ensure the SADC policy requires staff to complete a health assessment prior to contact with members.
• Examples of Documentation to Review: SADC policy documents, etc.

R36: Does the SADC have a policy requiring staff to have a health assessment conducted annually?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for staff to have a health assessment conducted annually.
• Compliance Considerations: Ensure the SADC has a policy requiring staff to complete a health assessment annually.
• Examples of Documentation to Review: SADC policy documents, etc.

R37: Does the SADC have a policy requiring staff to have a TB screening conducted prior to contact with members?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for staff to have tuberculosis (TB) screening conducted prior to contact with members.
• Compliance Considerations: Ensure the SADC has a policy requiring all staff have a TB screening completed prior to contact with members. TB screenings are sometimes called TB tests, Purified Protein Derivative (PPD) tests, or Mantoux tests.
• Examples of Documentation to Review: SADC policy documents, etc.

R38: Does the SADC have a policy requiring staff to have a TB screening conducted bi-annually?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for staff to have a tuberculosis (TB) screening conducted bi-annually.
• Compliance Considerations: Ensure the SADC has a policy requiring all staff complete a TB screening every two years. TB screenings are sometimes called Purified Protein Derivative (PPD) tests or Mantoux tests.
• Examples of Documentation to Review: SADC policy documents, etc.

R39: Does the SADC have a policy requiring new hire training regarding the organization?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for new hires to complete orientation training on the organization or SADC itself.
• Compliance Considerations: Ensure the SADC has a policy requiring new hire training on the SADC organization. This may include the mission or vision of the organization. This training may be referred to as orientation to "the provider" and included with orientation to “the program and the community.”
• Examples of Documentation to Review: SADC policy documents, etc.

R40: Does the SADC have a policy requiring new hire training regarding the SADC's policies, procedures, and operations?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for new hires to complete orientation training on the SADC's policies, procedures, and operations.
• Compliance Considerations: Ensure the SADC has a policy for new hire training on the SADC's policies, procedures, and operations. This training may be referred to as orientation to "the program" and included with orientation to “the provider and the community.”
• Examples of Documentation to Review: SADC policy documents, etc.

R41: Does the SADC have a policy requiring new hire training regarding the local community and external resources?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for new hires to complete orientation training on the community and external resources.
• Compliance Considerations: Ensure the SADC has a policy for new hire training on the local community and the resources available to members. Examples could be emergency services, community agencies, transportation, local resources for LDSS participants, etc. This training may be referred to as orientation to "the community" and included with orientation to “the provider and the program.”
• Examples of Documentation to Review: SADC policy documents, etc.

R42: Does the SADC have a policy requiring staff receive new hire orientation training regarding working with the elderly, members' rights, safety, and accident prevention?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for new hires to complete orientation training on the working with the elderly, member's rights, safety, and accident prevention.
• Compliance Considerations: Ensure the SADC has a policy for new hire training on working with the elderly, member's rights, safety, and accident prevention.
• Examples of Documentation to Review: SADC policy documents, etc.

R43: Does the SADC have a policy requiring staff and volunteers receive training on personal care skills, body mechanics, behavior management, family and relationships, mental health, and HIPAA privacy and security?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for staff and volunteers to complete orientation training on basic social day care services regarding personal care skills, body mechanics, behavior management, family and relationships, mental health, and HIPAA privacy and security.
• Compliance Considerations: Ensure the SADC has a policy confirming staff and volunteers receive training on personal care skills, body mechanics, behavior management, family and relationships, mental health, and HIPAA privacy and security.
• Examples of Documentation to Review: SADC policy documents, etc.

R44: Does the SADC have a policy that all staff and volunteers must have annual safety training regarding the use of fire extinguishers?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that staff receive annual safety training on use of the fire extinguishers.
• Compliance Considerations: Ensure the SADC has a policy confirming that staff and volunteers receive annual safety training on how to use fire extinguishers.
• Examples of Documentation to Review: SADC policy documents, etc.

R45: Does the SADC have a policy that all staff must have annual safety training on evacuation procedures, emergency situations, and accessing emergency phone numbers?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the details of staff annual safety regarding evacuation procedures, emergency situations, and accessing emergency phone numbers.
• Compliance Considerations: Ensure the SADC has a policy confirming staff receive annual safety training regarding evacuation procedures, emergency situations, and accessing emergency phone numbers.
• Examples of Documentation to Review: SADC policy documents, etc.

R46: Does the SADC have a policy requiring all staff receive at least 6 hours of in-service training annually?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for staff to receive at least 6 hours of in-service training annually.
• Compliance Considerations: Ensure the SADC has a policy confirming staff receive at least 6 hours of in-service training annually. Training topics may vary but should be relevant to the role of the staff member.
• Examples of Documentation to Review: SADC policy documents, etc.

R47: Does the SADC have a policy that all staff and volunteers receive role/task appropriate training?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has appropriate in service training for volunteers.
• Compliance Considerations: Ensure the SADC has a policy confirming staff and volunteers receive task specific training. For example, if a volunteer is only working to cook and serve food, training on food safety would be appropriate.
• Examples of Documentation to Review: SADC policy documents, etc.

R48: Does the SADC have a policy requiring service staff receive at minimum 20 hours of group, individual, or on-the-job training within 3 months of hire?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm the SADC has a policy that includes the requirement for service staff and volunteers to receive at least 20 hours of relevant training within the first three months of providing services to members at the SADC.
• Compliance Considerations: Ensure the SADC has a policy confirming staff receive at least 20 hours of training within the first 3 months of hire. The policy must include that training cover the following topics: socialization skills and activities; supervision and monitoring; personal care skills, taught by a registered nurse; the family and family relationships; mental illness and mental health; and cardiopulmonary resuscitation (CPR). Additionally, the policy must require that an assessment of the services staff knowledge be conducted.
• Examples of Documentation to Review: SADC policy documents, etc.

R49: Does the SADC have a policy requiring all staff receive CMS HCBS Final Rule and person-centered planning, practice and thinking training?

Standard: Training – The SADC ensures staff receive all required training, outside requirements identified in 9 NYCRR 6654.20.

• Question Goal: Ensure all staff and volunteers receive training and are aware of the requirements of the CMS HCBS Final Rule, and person-centered planning, practice and thinking.
• Compliance Considerations: Confirm the SADC has a policy for staff training on the CMS HCBS Final Rule specific policies and person-centered planning, practice and thinking. Confirm this is an operationalized process.
• Examples of Documentation to Review: SADC policy documents, etc.

M1: Does the member file contain at least the initial assessment of the member’s functional capacities and impairments?

Standard: 9 NYCRR 6654.20(d)(1)(ii) – The program shall serve only individuals whose needs can be met and managed and shall admit an individual only after an assessment of the individual's functional capacities and impairments has been completed.

• Question Goal: Verify member(s) file contains the initial assessment which indicates the member’s functional capacities and impairments.
• Compliance Considerations: Confirm member file includes the member’s initial assessment which indicates the member’s functional capacities and impairments.
• Examples of Documentation to Review: The member’s initial assessment.

M2: Does the PCSP document the full name of the person who completed it?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP documents who completed it.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the first and last name of the person who completed the document.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M3: Does the PCSP document the date it was completed??

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the date the PCSP was completed is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP documents the month, day, and year the PCSP was completed with the member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M4: Has the PCSP been updated within the past year?

Standard: 9 NYCRR 6654.20(d)(1)(iii) – The program must develop and maintain a service plan for each participant, as detailed in the regulation.

• Question Goal: Verify that the PCSP was updated at least annually.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP has been updated within the past year.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M5: Does the PCSP document the member's full legal name?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's full legal name is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP includes the member’s full name.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M6: Does the PCSP document the member's date of birth?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's date of birth is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP lists the member’s month, day and year of birth.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M7: Does the PCSP document the member's physical address?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's physical address is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by the SADC PCSP documents the member’s address.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M8: Does the PCSP document the member's phone number?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's phone number is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s phone number.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M9: Does the PCSP document the member's email address?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's email address is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s email address and confirm it is in a valid email format. If the PCSP indicates the member does not have an email address, review the PCSP and determine if this response is compliant with exception.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M10: Does the PCSP document the member's preferred language?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member’s preferred language is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s preferred language.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M11: Does the PCSP document the member's gender?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member’s gender is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s gender.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M12: Does the PCSP document the member's gender identity?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member’s gender identity is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s gender identity, which could include male, female, transgender, non-binary, none, etc.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M13: Does the PCSP document whether the member lives with someone who supports their care, including the person’s name and relationship to the member, if applicable?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify if the member's living circumstances are documented on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member lives with someone and if that person is involved in their care. If the PCSP indicates that the member lives with someone involved in their care, it must include the name of the person and their relationship to the member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M14: Does the PCSP document the member's MLTC plan?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's MLTC plan is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s MLTC plan.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M15: Does the PCSP document the member's Medicaid ID?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's Medicaid ID is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s Medicaid ID. Medicaid IDs have two letters, five numbers, and one letter.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M16: Does the PCSP document the member's care manager?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's care manager is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the members’ care manager’s full name.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M17: Does the PCSP document member’s care manager’s phone number and email address?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the contact information for the member's care manager is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the care manager’s phone number and email address.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M18: Does the PCSP document the member's primary care physician?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's primary care physician is listed on the PCSP.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s primary care physician.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M19: Does the PCSP document at minimum the member’s primary care physician’s phone number?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the phone number for the member's primary care physician is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the primary care physician’s phone number.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M20: Does the PCSP document the days and times the member attends the SADC?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the schedule of when the member attends the SADC is listed on the PCSP.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the days and times the member attends the SADC.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M21: Does the PCSP document how the member gets to and from the SADC and their home?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates how the member gets to/from the SADC.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates how the member gets to and from the SADC.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M22: Does the PCSP document a contact person for the member?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify there is a contact person for the member listed on the PCSP.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates a contact person for the member. Confirm the contact person’s name, contact type, and relationship to the member is listed on the PCSP.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M23: Does the PCSP document the phone number and email address for all of the listed contact persons?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the phone number and email address for the member's contact person is listed on the PCSP.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the phone number and email address for the member’s contact person. If the PCSP documents that the contact person does not have an email address, review the PCSP and determine if this response is compliant with exception.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M24: Does the PCSP document pertinent diagnoses, health issues, and/or conditions for the member?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the member's pertinent diagnoses, health issues, and/or conditions are listed on the PCSP.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s pertinent diagnoses or health issues/conditions of the member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M25: Does the PCSP document whether the member needs assistance with medication while attending the SADC and if applicable the level of assistance needed?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates whether the member needs assistance with medication and if so, the level of assistance needed.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates whether the member requires assistance and if so, the level of assistance required to self-administer their medications while at the SADC.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M26: Does the PCSP document any medications, over the counter, herbal supplements, etc. that the participant is taking and the condition/diagnoses it is being taken for?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates any medications, supplements, etc. that are being taken and the condition/diagnoses they are being taken for.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the medications the member is taking and condition or diagnoses it is being taken for. If the PCSP indicates a medication list is attached, verify that it is attached and includes the condition/diagnosis for each medication.
• Examples of Documentation to Review: This information must be found in, or affixed to, the SADC PCSP.

M27: Does the PCSP document any allergies, the member's severity of allergic response, and required emergency response?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates any known allergies the member has along with the severity of the allergy and the emergency response that should be taken.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates all allergies of the member and severity of the allergy and the emergency response must be included.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M28: Does the PCSP document any dietary restrictions/requirements and the reasoning/justification?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates any dietary restrictions or requirements and the reasoning/justification for that restriction or requirement.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying that the SADC PCSP documents the dietary restrictions/requirements and the reason for them.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M29: Does the PCSP document any nutritional preferences or special diet?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates any nutritional preferences or a special diet the member maintains.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the members’ nutritional preferences and/or special diets for example, vegetarian, kosher, halal, etc.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M30: If the member has a dietary preference, does the PCSP document if the SADC can accommodate this, and if so, what was implemented or if not, what alternative option was implemented?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates that the member has a nutritional preference/special diet, and how the SADC will accommodate this.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the SADC can accommodate the member’s nutritional preferences/special diet. If an SADC can accommodate the preference, it must indicate how, for example, the SADC has a kosher kitchen and prepares kosher meals. If the SADC cannot accommodate the preference an alternative option must be implemented, for example, the SADC cannot provide kosher food so the SADC orders kosher meals.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M31: Does the PCSP document whether the member is able to communicate their needs and if not the reason the member is unable to do so?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates whether the member can communicate their needs and if they are unable to do so, the reason why they are not able to do this.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member is able to communicate their needs. If a member is unable to communicate their needs, confirm the SADC PCSP documents the reason why.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M32: Does the PCSP document whether the member appears to be able to make their own decisions and if not the reason the member is unable to do so?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates whether the member can make their own decisions and if they are unable to do so, the reason why they are not able to do this.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member is able to make their own decisions. If the member is unable to make their own decisions, confirm the SADC PCSP documents the reason why.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M33: Does the PCSP document whether the member can be left alone and unsupervised and if not the reason why?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates whether the member can be left alone and unsupervised and if they are not able to be left alone, the reason why.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member is able to be left alone and unsupervised. If the member is unable to be left alone and unsupervised, confirm the SADC PCSP documents the reason why.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M34: Does the PCSP document any pain and/or sensory needs the member has including the assistance to be provided if applicable?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates whether the member has any pain and/or sensory needs and if they do, what the need is and the assistance to be provided.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member has any pain and/or sensory needs. If the member has any pain or sensory needs, confirm the SADC PCSP documents what the need is and how the SADC will address those needs.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M35: Does the PCSP document the level of care and any assistive technology/device for the activities of daily living (ADLs)?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates the level of care and the assistive technology/device, if applicable, for the ADLs.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the member’s level of care for the ADLs of mobility, transfers, toileting, continence, and eating and if the member requires assistive technology/device for each. All ADLs require a level of care: independent, supervision only, minimal hands on assistance, moderate hands on assistance, and total hands on assistance and a response for assistive technology/device.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M36: Does the PCSP document the member's preference in regards to who provides their personal care assistance?

Standard: 42 CFR 441.530(a)(1)(iii) – Setting ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

• Question Goal: Verify the PCSP indicates the member's preference in who provides their personal care assistance.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member has a preference in regard to who provides their personal care assistance.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M37: Does the PCSP document if the SADC was able to meet the member's preference regarding who provides their personal care assistance and if not, was the member given the opportunity to choose to receive services elsewhere?

Standard: 42 CFR 441.530(a)(1)(v) – Setting facilitates individual choice regarding services and supports, and who provides them.

• Question Goal: Verify the PCSP indicates whether the SADC can meet the member's preference in who provides their personal care assistance and if not, confirm that the member was told this preference could not be met and given the opportunity to choose to receive services elsewhere.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying if the SADC PCSP indicates if the SADC can meet the member’s preference for personal care needs. If the member indicates they do not have a preference, review the PCSP and determine if this response is compliant with exception.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M38: Does the PCSP document any risks to the member’s health/wellbeing, potential trigger(s), previous responses to triggers, measures in place to minimize risks, and safeguards?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates any risks to the member’s health/wellbeing, potential trigger(s), previous responses to triggers, measures in place to minimize risks, and safeguards.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates any risks to the member’s health and wellbeing, the potential triggers, previous responses to these triggers, measures the SADC has put in place to reduce the risk, and any safeguards implemented. Confirm all areas of in this section have been addressed.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M39: Does the PCSP document the member's preferences (likes or dislikes)?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates the member's preferences.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP documents the member’s preferences.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M40: Are the preferences indicated on the PCSP personalized to the member?

Standard: 42 CFR 441.725(a) – The person-centered planning process must be conducted appropriately, and in accordance with all applicable state and federal rules, regulations, and guidance.

• Question Goal: Verify the member preferences indicated are personalized to the member.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP documents preferences that are personalized to the specific member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M41: Does the PCSP document the member's strengths?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates the member’s strengths.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP documents the member’s strengths.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M42: Are the strengths indicated on the PCSP personalized to the member?

Standard: 42 CFR 441.725(a) – The person-centered planning process must be conducted appropriately, and in accordance with all applicable state and federal rules, regulations, and guidance.

• Question Goal: Verify the member strengths indicated are personalized to the member.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP documents strengths that are personalized to the specific member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M43: Does the PCSP document the member's needs?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates the member’s needs.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the members’ needs. Needs will likely include why the member attends the SADC, such as assistance with ADLs or socialization.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M44: Are the needs indicated on the PCSP personalized to the member?

Standard: 42 CFR 441.725(a) – The person-centered planning process must be conducted appropriately, and in accordance with all applicable state and federal rules, regulations, and guidance.

• Question Goal: Verify the members’ needs indicated are personalized to the member.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP documents needs that are personalized to the specific member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M45: Does the PCSP document the member's goal(s)?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates the member's goal(s).
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates goals for the members.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M46: Are the goals indicated on the PCSP personalized to the member?

Standard: 42 CFR 441.725(a) – The person-centered planning process must be conducted appropriately, and in accordance with all applicable state and federal rules, regulations, and guidance.

• Question Goal: Verify the member goals indicated are personalized to the member.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates goals that are personalized to the member. At least one goal is required for a member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M47: Are the goals indicated on the PCSP measurable and include the outcome criteria, actions and/or steps to reach the goal, and related activity(s)?

Standard: 42 CFR 441.725(a) – The person-centered planning process must be conducted appropriately, and in accordance with all applicable state and federal rules, regulations, and guidance.

• Question Goal: Verify the member goals indicated are measurable and fully defined.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the outcome criteria, actions and/or the steps needed to reach the goal, and related activities. Confirm the goal is measurable and that all fields in this section are completed.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M48: Does the PCSP document the SADC Activity(s) the member is interested in?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the PCSP indicates the SADC activity(s) the member is interested in.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the SADC activities the member is interested in.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M49: Are the SADC Activity(s) indicated on the PCSP personalized to the member?

Standard: 42 CFR 441.530(a)(1)(iv) – 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.

• Question Goal: Verify the SADC activities the member is interested in are personalized to the member and therefore, the member's right to autonomy and independence was maintained.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP documents SADC activities that are personalized to the specific member.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M50: Does the PCSP document the supports needed for the member to participate in SADC activities of their choosing?

Standard: 42 CFR 441.530(a)(1)(vi)(C) – Setting ensures individuals have the freedom and support to control their schedules and activities; and have access to food any time.

• Question Goal: Verify the SADC is supporting members to participate in SADC activities and confirm these supports are documented in the PCSP.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the support needed for the member to participate in the activities listed.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M51: Does the PCSP document the community integration activities the member is interested in?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Verify the PCSP indicates the community integration activities the member is interested in.
• Compliance Considerations: Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the individual community integration activities the member is interested in. Group outings with the SADC are not community integration activities. If the member was offered and declined activities, confirm the SADC indicated the activities that were offered. At a minimum, the SADC must help to coordinate the community activities for members.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M52: Are the community integration activities indicated on the PCSP personalized to the member?

Standard: 42 CFR 441.530(a)(1)(iv) – 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.

• Question Goal: Verify the community integration activities the member is interested in are personalized to the member and therefore, the member's right to autonomy and independence was maintained.
• Compliance Considerations: Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates personalized community integration activities. SADC group outings are set by the SADC and therefore not personalized. Additionally, group outings are not community integration activities.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M53: Does the PCSP document the details of the community integration activity including the location, day, time, frequency, materials needed and transportation method?

Standard: 42 CFR 441.725(b) – The SADC PCSP must be completed correctly and totally, and in accordance with all applicable state and federal rules, regulations and guidance.

• Question Goal: Verify the details of the community integration activities are documented in the PCSP.
• Compliance Considerations:Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the details of the community integration activity. Confirm all fields in this section are completed.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M54: Does the PCSP document the supports needed for the member to attend community activities?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Verify that the SADC is supporting members to participate in community integration activities and confirm these supports are documented in the PCSP.
• Compliance Considerations:Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates the support needed for the members to attend the community integration activity. Support could include coordinating the activity, transporting or coordinating transportation to the activity, reminding the member of the activity when the date or time approaches. At a minimum, the SADC must help to coordinate the community activities for members.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M55: Does the SADC support the integration of the member with the community, even if there are health/safety risks which need personalized support for the member?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Ensure the SADC is not restricting members from participation in community integration opportunities based on health and/or safety needs which would require personalized support. All members should have the same opportunities regardless of their health/ safety needs.
• Compliance Considerations:Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the SADC supports the member’s right to integrate into the community even if the member has health/safety risks.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M56: Does the PCSP document if the member is interested in working and/or volunteering?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Verify the PCSP indicates if the member is interested in working and/or volunteering.
• Compliance Considerations:Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member is interested in working and/or volunteering in the community. If the member is unable to work/volunteer, confirm the SADC indicates why the member is unable to do so and ensure the reason is appropriate.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M57: If the member is interested in working and/or volunteering, does the PCSP document the details of the work and/or volunteer opportunity(s) the member is pursuing including frequency, day/time, and the support provided by the SADC?

Standard: 42 CFR 441.530(a)(1)(i) – 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, to the same degree of access as individuals not receiving Medicaid HCBS.

• Question Goal: Verify the PCSP indicates the details of the work/volunteer opportunities the member is pursuing, if the member indicates they are interested.
• Compliance Considerations:Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP documents the details of the work and/or volunteer opportunity(s) the member is pursuing including frequency, day/time, and the support provided by the SADC for members interested in working or volunteering. If the member is not interested in working, review the PCSP and determine if this response is compliant with exception.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M58: Does the SADC PCSP document and include justification for any modification to the freedoms allotted to the member via the CMS HCBS Final Rule 441.301(c)(4)(vi)(A) through (D)?

Standard: 42 CFR 441.530(a)(1)(vi)(F) – Any modifications of the additional conditions under 441.301(c)(4)(vi)(A) through (D) for provider-owned and controlled settings must be supported by a specific assessed need and justified in the person-centered service plan.

• Question Goal: Verify whether there are any modifications of the additional conditions under 441.301(c)(4)(vi)(A) through (D) for provider-owned and controlled settings which must be supported by a specific assessed need and justified in the PCSP.
• Compliance Considerations:Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member requires a modification to the freedom to support and control their schedules, have visitors of their choosing at any time, have access to food at all times. If the member requires a modification, ensure the SADC documents all required information.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M59: Does the SADC PCSP document and include justification for any modification to the other freedoms allotted to the member via the CMS HCBS Final Rule?

Standard: 42 CFR 441.530(a)(1)(iv) – 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.

• Question Goal: Verify whether there are any modifications of the additional conditions under 42 CFR 441.530(a)(1)(iv) for provider-owned and controlled settings which must be supported by a specific assessed need and justified in the PCSP.
• Compliance Considerations:Ensure the person-centered planning process was completed correctly by verifying the SADC PCSP indicates if the member requires a modification to the freedom to control their own funds and the independence to interact with whom they choose. If the member requires a modification, ensure the SADC documents all required information.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

M60: Was the PCSP Acknowledgement signed by the member or their designated representative, indicating the rights under the person-centered planning process were conducted appropriately?

Standard: 42 CFR 441.725(a) – The person-centered planning process must be conducted appropriately, and in accordance with all applicable state and federal rules, regulations, and guidance.

• Question Goal: Verify that the member or their representative acknowledged that the person-centered planning process was conducted appropriately and they are aware of their rights in this process and agree to the PCSP as it was created, by signing.
• Compliance Considerations:Confirm the person-centered planning process was completed correctly by verifying the SADC PCSP is signed by the member or their designated representative and includes the rights under the person-centered planning process were conducted appropriately. Signatures may be electronic or wet signatures.
• Examples of Documentation to Review: This information must be found in the SADC PCSP.

S1: Does the staff file contain evidence that the SADC verified the staff/volunteer member has a valid medical/clinical license, if applicable?

Standard: 9 NYCRR 6654.20(d)(2)(iii) – The program shall maintain and keep confidential administrative, financial, participant personal records, and services records, as detailed in the regulation.

• Question Goal: Confirm that the SADC obtained evidence that clinical staff was licensed at the time of hire.
• Compliance Considerations:Ensure the staff/volunteer files document the SADC verified the clinical staff have a valid medical and/or clinical license. Clinical staff are not required for SADCs and therefore, not all SADCs have clinical staff. If the staff file being reviewed is not that of a licensed clinical provider, this question may be compliant with exception.
• Examples of Documentation to Review: Confirmation of the validity of the license such as, a screenshot of the NYSED website showing the individual’s license.

S2: Does the staff file contain evidence that the SADC verified that the staff/volunteer is not on the OMIG Exclusion List?

Standard: 9 NYCRR 6654.20(d)(2)(iii) – The program shall maintain and keep confidential administrative, financial, participant personal records, and services records, as detailed in the regulation.

• Question Goal: Confirm that the SADC obtained evidence that the staff/volunteer was free from the OMIG exclusion list.
• Compliance Considerations:Ensure the staff/volunteer files document the SADC confirmed the staff/volunteer was not on the OMIG exclusion list at the time of hire.
• Examples of Documentation to Review: Confirmation that the staff/volunteer is not on the OMIG exclusion list such as, search results from OMIG indicating the staff/volunteer’s name was searched and returned 0 results.

S3: Does the staff file contain evidence that the SADC verified that the staff/volunteer is not a risk to the members at the SADC?

Standard: 9 NYCRR 6654.20(d)(2)(iii) – The program shall maintain and keep confidential administrative, financial, participant personal records, and services records, as detailed in the regulation.

• Question Goal: Confirm that the SADC obtained evidence that all staff and volunteers were not a risk to members at the SADC.
• Compliance Considerations:Ensure the staff/volunteer files document, the SADC collected evidence that staff and volunteers are not a risk to members at the SADC.
• Examples of Documentation to Review: Background check of staff/volunteer, Motor Vehicle Record (MVR) check for staff who transport members, etc.

S4: Does the staff/volunteer file contain a completed initial health assessment prior to employment for staff/volunteers hired within the last year?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm the staff file contains the staff/volunteer completed initial health assessment dated prior to the start of employment.
• Compliance Considerations:Ensure the staff/volunteer files contain the initial health assessment, completed prior to employment, for the staff /volunteer if they were hired within the last year. If the staff/volunteer was hired over one year ago, this may be compliant with exception.
• Examples of Documentation to Review: Staff/ volunteer health assessment.

S5: Does the staff/volunteer file contain proof that an annual health assessment was completed within the last 12 months?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm that staff/volunteer file contains proof that an annual health assessment was completed within the last 12 months.
• Compliance Considerations:Ensure the staff/volunteer files contain proof that an annual health assessment was completed within the last 12 months.
• Examples of Documentation to Review: Staff/volunteer health assessment.

S6: Does the staff/volunteer file contain a negative PPD skin test/CXR/Q dated prior to employment, for staff/volunteers hired within the last two years?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm the staff file contains a negative PPD skin test/CXR/Q dated prior to employment.
• Compliance Considerations:Ensure the staff/volunteer files contain a negative skin test for tuberculosis, dated prior to employment for any staff/volunteer hired within the last two years. If the staff/volunteer was hired over two years ago, this may be compliant with exception
• Examples of Documentation to Review: Staff/volunteer TB skin test result.

S7: Does the staff/volunteer file contain a negative PPD skin test/CXR/Q dated within the past 24 months?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(a) – The program shall meet all staffing requirements, including ensuring the health status of each staff person who may or will have contact with participants, as detailed in the regulation.

• Question Goal: Confirm that staff/volunteer file contain a negative PPD skin test/CXR/Q dated within the past 24 months.
• Compliance Considerations:Ensure the staff/volunteer files contain a negative PPD skin test/CXR/Q dated within the past 24 months.
• Examples of Documentation to Review: Staff/volunteer TB skin test result.

S8: Does the staff/volunteer file contain proof of annual training on the use of fire extinguishers?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm that staff/volunteer file contains proof of annual training on the use of fire extinguishers.
• Compliance Considerations:Ensure the staff/volunteer file contains proof of annual training on the use of fire extinguishers. Verify the date of the training is within the last 12 months.
• Examples of Documentation to Review: Staff/volunteer training certificate, training sign in sheets with date of training and staff/volunteer sign in signature, etc.

S9: Does the staff/volunteer file contain proof of annual training on emergency and evacuation procedures?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm that staff/volunteer file contains proof of annual training on emergency and evacuation procedures.
• Compliance Considerations:Ensure the staff/volunteer file contains proof of annual training on emergency and evacuation procedures.
• Examples of Documentation to Review: Staff/volunteer training certificate, training sign in sheets with date of training and staff/volunteer sign in signature, etc.

S10: Does the staff/volunteer file contain evidence that at least 6-hours of annual training to develop, review, or expand skills or knowledge, was completed within the last 12 months?

Standard: 9 NYCRR 6654.20(d)(2)(iv)(c) – The program shall ensure all staff training requirements are met, as detailed in the regulation.

• Question Goal: Confirm that staff/volunteer file contain proof that at least 6 hours of annual training was completed to develop, review or expand skills or knowledge.
• Compliance Considerations:Ensure the staff/volunteer file contains proof annual training was completed to develop, review or expand skills or knowledge. This training may cover any relevant topics based on the staff/volunteer role.
• Examples of Documentation to Review: Staff/volunteer training certificate, training sign in sheets with date of training and staff/volunteer sign in signature, etc.

S11: Does the staff/volunteer file contain valid proof of training on CPR/AED?

Standard: Training – The SADC ensures staff receive all required training, outside requirements identified in 9 NYCRR 6654.20.

• Question Goal: Confirm that staff/volunteer file contains valid proof that training on CPR/AED procedures.
• Compliance Considerations:Ensure the staff/volunteer file contains proof the staff/volunteer completed CPR/AED training. Confirm the training/certification has not expired at the time of the evaluation.
• Examples of Documentation to Review: Staff/volunteer training certificate, etc.