Mark NO if the Provider does not have a policy or if any of the criteria above Non-Scored were not satisfied. Mark NA if the Provider does not provide IHCS or Supported Living. 14. The IHCS or Supported Living Provider D This question applies to IHCS and Supported Living Providers only. Exploratory has a policy which ensures that all The reviewer determines if the Provider’s policy regarding individual schedules and individuals receiving this service are activities exists and includes documentation of the IHCS or Supported Living service afforded the opportunity to regularly that demonstrates that individuals can update their activities. update their activities, consistent with Mark YES if the Provider has a policy that addresses all criteria. non-Medicaid recipients in a similar or Mark NO if the Provider does not have a policy or if any of the criteria above same setting. were not satisfied. Mark NA if the Provider does not provide IHCS or Supported Living. Non-Scored 15. If independent living technology or D This question applies to Supporting Living Providers only. Exploratory remote monitoring is used at any The reviewer determines if the Provider’s policy regarding individual rights exists service location, the Provider has a and includes evidence that a consent form is obtained and on for each impacted policy which ensures that a consent individual where independent living technology or remote monitoring is used at a form to use independent living service location. technology was obtained from each If independent living technology or remote monitoring is used at any service impacted individual and is on file. location, staff informed all impacted individuals and anyone identified by the individuals of what impact the independent living technology will have on the Non-Scored individual’s privacy. Assistive technology is an item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve a participant’s functioning or increase a participant’s ability to exercise choice and control. Examples of equipment and services covered as independent living technology include: medication dispensers, door sensors, window sensors, stove sensors, water sensors, pressure pads, GPS Tracking
Non-Scored Mark NO if the Provider does not have a policy or if any of the criteria above were not satisfied. Mark NA if the Provider does not provide IHCS or Supported Living. 14. The IHCS or Supported Living Provider has a policy which ensures that all individuals receiving this service are afforded the opportunity to regularly update their activities, consistent with non-Medicaid recipients in a similar or same setting. Non-Scored D This question applies to IHCS and Supported Living Providers only. The reviewer determines if the Provider’s policy regarding individual schedules and activities exists and includes documentation of the IHCS or Supported Living service that demonstrates that individuals can update their activities. Mark YES if the Provider has a policy that addresses all criteria. Mark NO if the Provider does not have a policy or if any of the criteria above were not satisfied. Mark NA if the Provider does not provide IHCS or Supported Living. Exploratory 15. If independent living technology or remote monitoring is used at any service location, the Provider has a policy which ensures that a consent form to use independent living technology was obtained from each impacted individual and is on file. Non-Scored D This question applies to Supporting Living Providers only. The reviewer determines if the Provider’s policy regarding individual rights exists and includes evidence that a consent form is obtained and on for each impacted individual where independent living technology or remote monitoring is used at a service location. If independent living technology or remote monitoring is used at any service location, staff informed all impacted individuals and anyone identified by the individuals of what impact the independent living technology will have on the individual’s privacy. Assistive technology is an item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve a participant’s functioning or increase a participant’s ability to exercise choice and control. Examples of equipment and services covered as independent living technology include: medication dispensers, door sensors, window sensors, stove sensors, water sensors, pressure pads, GPS Tracking Exploratory
Provider+C1Y2+Tool.docx