If the first choice is selected, does the State provide specific methods to detect unauthorized use of restraints and specify the state agency (or agencies) responsible for conducting this oversight? No Yes Note: In cases where the waiver serves a population (e.g., MR/DD or TBI, children with serious emotional disturbance) for whom the use of restraints and restrictive interventions is common and the state indicates that the Appendix does not apply, the reviewer is advised to confirm with the state that such interventions are prohibited. The state must complete Item G-2-c.ii. to describe how the state detects unauthorized use. For permitted, has the state identified safeguards that G-2-a-i Safeguards each type of restraint address: Concerning the Use of The use of alternative methods to avoid the use of restraints? Yes No Restraints Methods for detecting the unauthorized use of restraints? Yes No The protocols that must be followed when restraints are employed (including (Complete only when the the circumstances when their use is permitted) and how their use is authorized? use of restraints and/or Yes No restrictive interventions is The practices that must be employed to ensure the health and safety of permitted during the individuals? Yes No course of the provision of Required documentation concerning the use of restraints? waiver services regardless Yes No of setting.) Education and training requirements that personnel who are involved in the administration of restraints must meet? Yes No Does the state’s response specify: G-2-a-ii Oversight Responsibility The state agency (or agencies) responsible for overseeing the use of restraints and ensuring that the state’s safeguards are followed? Yes No When oversight is not performed by the Medicaid agency or the operating agency (if applicable), the process for the oversight agency to communicate information and findings to the Medicaid agency and/or operating agency? Yes No
If the first choice is selected, does the State provide specific methods to detect unauthorized use of restraints and specify the state agency (or agencies) responsible for conducting this oversight? No Yes Note: In cases where the waiver serves a population (e.g., MR/DD or TBI, children with serious emotional disturbance) for whom the use of restraints and restrictive interventions is common and the state indicates that the Appendix does not apply, the reviewer is advised to confirm with the state that such interventions are prohibited. The state must complete Item G-2-c.ii. to describe how the state detects unauthorized use. G-2-a-i Safeguards Concerning the Use of Restraints (Complete only when the use of restraints and/or restrictive interventions is permitted during the course of the provision of waiver services regardless of setting.) For each type of restraint permitted, has the state identified safeguards that address: The use of alternative methods to avoid the use of restraints? Yes No Methods for detecting the unauthorized use of restraints? Yes No The protocols that must be followed when restraints are employed (including the circumstances when their use is permitted) and how their use is authorized? Yes No The practices that must be employed to ensure the health and safety of individuals? Yes No Required documentation concerning the use of restraints? Yes No Education and training requirements that personnel who are involved in the administration of restraints must meet? Yes No G-2-a-ii Oversight Responsibility Does the state’s response specify: The state agency (or agencies) responsible for overseeing the use of restraints and ensuring that the state’s safeguards are followed? Yes No When oversight is not performed by the Medicaid agency or the operating agency (if applicable), the process for the oversight agency to communicate information and findings to the Medicaid agency and/or operating agency? Yes No
CMSInstrumentforReviewingHCBSWaiverApplications-January2015.docx