ALL

C1.  The provider collects data regarding program quality including, but not limited to, incidents, restraints, investigations and medication occurrences.

	Regulations 7.04 (2) (b): The provider shall regularly evaluate the level of quality of its supports and services through a process that is utilized to implement service improvements consistent with the outcomes delineated in the provider’s mission statement and the Department’s certification regulations and standards.

Guidelines:
The first step in a provider’s ability to implement an effective quality management and improvement system is the commitment to the collection of data regarding program quality from a variety of both internal and external stakeholders and sources.  Providers cannot measure and evaluate services unless they collect the needed information.  While providers may be very effective in remedying individual situations, service improvement activities involve moving to the next level and gathering information that sets the stage for broader organizational improvement initiatives.  Information collected should directly relate to the outcomes the agency strives to achieve both organizationally, for each discrete service type and for the individuals it supports.  Agencies need to demonstrate a variety of ways in which they collect aggregate data regarding program quality including utilization of HCSIS management reports, results of consumer and family satisfaction surveys, feedback from state agencies with whom they contract (performance based contracting), as well as any internal evaluation processes they may utilize.

While there are no specific requirements concerning what information is collected, it is important that providers collect data on other measures of quality separate and apart from incident management.

HCSIS
Annual Contract reviews
Performance Based Objectives

Management reports, 
QA reports, HRC minutes, other summary documentation -  
administrative  office
  	The provider’s method of collecting data is reviewed to determine what information is gathered and how this is aggregated in order to facilitate review and analysis by service type as well as location.  

	Provider has data process in place to capture information in all of the identified areas for each of their service types and agency-wide on a regular basis.  Data collection includes information regarding program quality.

	Data collection is not occurring for each service type as well as agency wide and/or is not occurring on a regular basis, and/or does not include information regarding program quality. 
	
ALL

C2.  The provider analyzes information gathered from all sources and identifies patterns and trends.

	Regulations 7.04 (2) (b): The provider shall regularly evaluate the level of quality of its supports and services through a process that is utilized to implement service improvements consistent with the outcomes delineated in the provider’s mission statement and the Department’s certification regulations and standards.

Guidelines:
While collecting data regarding service quality is important, it is only constructive if the information gathered is carefully reviewed and analyzed with an eye towards identifying any patterns and trends that may emerge.  Doing so is particularly helpful if the information is reviewed by a variety of individuals within the agency who can bring different perspectives to the review of the information.  The agency needs to have a mechanism to review service quality information on an on-going basis that involves broad representation from both agency staff and individuals/families.  The identification of patterns and trends is a key step in guiding the agency towards identifying areas it may want to prioritize for service improvement initiatives.	Agency documentation and administrator interview – administrative office	Review the agency’s system for analyzing information and identifying patterns and trends within each service type and for the organization as a whole. 

Review what processes are in place and who in the agency reviews and analyzes information.

	Agency is analyzing information gathered from all sources and is identifying patterns and trends for each service type as appropriate and individuals, families, and provider staff are involved in review of information and in the provision of feedback.
	Agency does not analyze the information gathered and/or is not identifying patterns and trends for each service type as appropriate and/or involvement of individuals, families and provider staff in review and analysis of information is limited or non-existent. 	
ALL

C3. The provider actively solicits and utilizes input from individuals and families regarding satisfaction with services. 
	Regulations 7.04 (2) (a): The provider shall regularly evaluate the level of quality of its supports and services through a process that actively involves individuals and families and must include, but need not be limited to, an assessment of the individual’s satisfaction with the services provided;

Guidelines:
Individuals and families are the primary “customers” of the agency’s services and supports.  Their opinions and suggestions regarding both positive practices and areas of concern should be taken very seriously and should inform and assist in prioritizing service improvement activities.  A provider may gather feedback from individuals and families in a variety of ways.  Whether accomplished through formal or informal mechanisms, agencies need to be able to demonstrate that they actively seek out and integrate the opinions of individuals and consumers, in ways that assure the confidentiality, integrity and utilization of the feedback.
	Satisfaction surveys or other processes such as focus groups– administrative office

Administrative interview	Review for the presence of completed annual satisfaction surveys, or evidence of other processes that demonstrate how individual and family input is gathered.

Review the agency’s system for making service improvements in each type of service based on information gleaned from satisfaction surveys. 	Information regarding satisfaction with services has been obtained and documented from families and individuals and there is evidence that input has been utilized to inform service improvement efforts in each service type. 
	Information regarding satisfaction with services has not been obtained and documented from families and individuals and/or there is little or no evidence that input from families and individuals is utilized to inform service improvement efforts in each service type. 	
ALL

C4. The provider receives and utilizes input received from internal systems, DDS and other stakeholders to inform service improvement efforts.

(Strengthened guidelines)	Regulations 7.04 (2) (b): The provider shall regularly evaluate the level of quality of its supports and services through a process that is utilized to implement service improvements consistent with the outcomes delineated in the provider’s mission statement and the Department’s certification regulations and standards.

Guidelines:
Providers receive feedback on their performance in a variety of formats from DDS and other stakeholders as well as their own internal reviews.  Information may include internal data gathered concerning program quality, information received from individuals and families, annual standard contract reviews, performance based objectives and feedback from site visits.  As the primary purchaser of services, it is important that agencies incorporate feedback received into their on-going service improvement efforts.  It is also essential that feedback received be reviewed promptly so that service improvement efforts can be designed and/or adjusted in response to this feedback in a timely manner.  

Stakeholders include the Centers for Medicare and Medicaid Services, which regulates home and community based waivers. Regulations, known as the Community Rule, require Massachusetts and its providers to ensure community settings meet certain standards with respect to community access and integration, choice and control, and rights and dignity. Providers should consider CMS requirements as a part of the service improvement efforts.
	Agency documentation and administrator interview – administrative office

	The agency’s system for evaluating information from all major stakeholders including data garnered on program quality is reviewed to determine the process for utilizing this information in service improvement efforts.

	The agency responds to input received from internal data collection, DDS, CMS and other major stakeholders and incorporates the information in the design of service improvement efforts in a timely manner.  

	The agency does not respond to input from all major stakeholders and/or does not incorporate the information in the design of service improvement efforts in a timely manner.	
ALL

C5. The provider has a process to measure progress towards achieving service improvement goals.	Regulations 7.04 (2) (b): The provider shall regularly evaluate the level of quality of its supports and services through a process that is utilized to implement service improvements consistent with the outcomes delineated in the provider’s mission statement and the Department’s certification regulations and standards.

Guidelines:
The provider needs to establish clear service improvement goals based on the analysis of patterns and trends performed above.  The provider needs to review the results of their analyses and prioritize areas for service improvement, establishing a set of improvement targets that should lead to enhanced quality of supports.   An agency need not address all areas at once, but needs to focus their effort on those they consider to be priorities.  There should be a process in place to target areas upon which to work and a consensus within the agency regarding the importance of these service improvement targets.

The process of service improvement is a continuous one.  To complete the loop, the provider needs to establish quantifiable targets against which it can measure its progress in reaching its desired goal(s), a process for measuring and monitoring progress, and an ability to make “mid-course” corrections if necessary.  It needs to also have mechanisms to assure that individuals and families receive information regarding the achievement of targeted service improvements.	Agency documentation e.g. strategic plan 

Administrator interview – administrative office.

Agency documentation such as periodic reports on progress- administrative office

on site review	Review the process for implementing strategies to make specific service improvements.  

Review provider system for collecting data pre and post implementation of strategies to make specific service improvements.  

Review if identified program improvements have occurred at programs, as appropriate.

Review the provider’s system for making “mid-course” corrections if necessary.  	Service improvement goals have been developed, benchmarks have been established based on the data and actions are implemented with data collected to measure service improvements.  Mid-course corrections are made if necessary.

	Service improvement goals have not been developed and/or actions have not been implemented and/or data are not being collected to measure service improvements and/or mid-course corrections are not made when necessary.

ALL

C6. The provider has mechanisms to plan for future directions in service delivery, and implements strategies to actualize these plans.
	Regulations 7.04 (2) (b): The provider shall regularly evaluate the level of quality of its supports and services through a process that is utilized to implement service improvements consistent with the outcomes delineated in the provider’s mission statement and the Department’s certification regulations and standards.

Guidelines:
Strategic planning enables a provider to establish a process to review its mission and purpose and set long range goals for the direction in which the agency will proceed.  Strategic thinking and planning includes a critical look at where the agency wants to be in the future, and both the opportunities and challenges that are present within the agency.  Strategic planning enables an agency to translate its current strengths and challenges into operational directions.  An effective strategic planning process should actively involve individuals, family, staff and other stakeholders.

An effective strategic planning process results in specific action steps that move the agency towards its stated goals.  The plan outlines the resources that are needed to accomplish the goals as well as the parties involved in implementation.  The provider also has a mechanism to evaluate and review progress to meet its strategic objectives.
	Agency documentation including strategic planning information and administrator interview – administrative office	Review whether the agency has any process (formal or informal) that enables it to do long range planning, set broad organizational goals, and/or re-think its overall mission.  Review if individuals’ current and future needs are incorporated into the agency’s planning process.

Review how provider utilizes its planning process to implement strategies and actualize plans.  
	There are documented mechanisms in place to plan for future directions in service delivery and strategies are in place to actualize plans.	Documented mechanisms are not in place to plan for future directions in service delivery and/or strategies are not in place to actualize these plans.	
ALL

C7. Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.

(Revised indicator and strengthened guidelines)  	Regulations 7.06 (d) (1): Comments from individuals, families or guardians of individuals….shall be included in the evaluation of staff performance. 

Guidelines:
The relationship between individuals and staff who support them is a key factor in successful outcomes for individuals served.  It is important, therefore, that providers have a way in which they can gather the opinions of individuals served as one component of  staff performance assessment.  This could includes input into evaluations of staff performance, participation in prospective staff interviews, group input to gather opinions of all who share the same staff, and/or other less formal mechanisms to assure that the voices of individuals are heard. Through whatever process gets determined, it is important for agencies to gather and reflect feedback from individuals about prospective staff at the time of hire and about current staff on a regular and ongoing basis, including input into the staff who provide services and supports daily.

At the time of hire, when prospective staff are interviewed, individuals should be afforded the opportunity to participate on the interview selection committee and/or to be able to meet with all potential candidates being considered.  One member of the household/ service recipient can serve as the individual representative on the committee.  The provider may have a process which factors in observation of interactions with individuals, into the hiring decision process.  While observation of prospective staff interactions is important, it is preferable to engage individuals directly in the hiring process utilizing any unique communication modes necessary.

Feedback from individuals regarding their opinions on staff performance is important for providers to capture and utilize within a full and effective employee performance evaluation system.  This includes gathering input from all/ some who share the same staff on staff performance prior to evaluation, and/or checking in with individuals on the performance of new staff and/or periodic less formal ways of observing staff interactions to assure that the individuals’ behaviors, comments, reactions and feedback are noted and are used in the context of staff evaluations to improve staff performance. Through whatever process gets determined, it is important for agencies to gather and reflect feedback from individuals and to use this feedback.  

Strategies for seeking input need to take into account and be consistent with each individual’s style and method of communication.

	Agency documentation and administrative interview (e.g. hiring process; system for obtaining feedback) – administrative office

Individual interview – on site	Review how provider gives individuals opportunities to offer feedback on staff performance (either individually or within a group discussion), and how this information is utilized or shared in the evaluation of staff.  

Review if individual involvement in feedback occurs as one component of staff performance evaluations and on a regular and ongoing basis including input into the staff who provide services and supports.

Review how individual input is sought in the hiring process.
	Provider has a process to obtain individual feedback on staff performance and feedback is occurring regularly at the time of hire and on an ongoing basis and feedback is shared with staff for evaluation and training purposes.

	Provider does not have a process to obtain individual feedback on staff performance and/or feedback is not occurring regularly at the time of hire and on an ongoing basis and/or feedback is not shared with staff for evaluation or training purposes.

ALL

C8. There are opportunities for communication between guardians, family members, and staff on a regular and timely basis.

	No specific regulatory reference 

Guidelines:
Guardians and family members have a key stake in the health, safety and quality of life of their family member.  They are in almost all instances, a key partner with the provider.  Communication with guardians and family members, therefore, can go a long way in assuring their trust and constructive participation in the lives of their family members.  

Communication needs to include reporting of incidents in a timely manner, as well as other on-going issues that impact on the lives of individuals served. In addition, communication where at all possible should be in the family’s primary language.  

In addition, ongoing communication with guardians and families and staff who support them facilitates successful outcomes for individuals served.  It is important, therefore, that providers have a way in which they can keep the lines of communication open, regularly sharing information on the individual, gathering the opinions of guardians/ families, responding to any concerns, and communicating the resolution of any concerns.   Guardians may offer observations or comments on staff performance to managers.  This information can be utilized to promote better communication and staff performance.

Guardians are very often an integral part of the individuals’ lives, have in-depth knowledge of the individuals’ strengths, needs, and interests, and are able to share preferred styles of interactions and methods of working with the individuals.  As a valuable resource, guardians may be invited to provide input on prospective staff at time of hire, and feedback on staff performance.  

Providers need to have mechanism for soliciting/determining  each family’s and/or guardian’s preference for frequency of contact and types of situations they wish to be informed of, and for establishing mutually agreeable patterns of communication in line with these preferences.  For communication with families, providers need to speak to the individuals, as competent adults, to solicit their opinion on the type and frequency of contact that they prefer to have with their family, as well as what contact they want the provider to have with their family member.   Therefore, when assessing communication between the provider and the family, it is important to talk to the individual first.  
	Staff interview – on site

HCSIS reports – off site 

Guardian notification – off site

Individual Record – on site

Guardian/family member interview – off site
	Review staff knowledge of importance of regular contact with guardians and family members and how they insure this happens.  Review provider’s mechanisms for determining family/ guardian preference for frequency of contact and types of situations that they wish to be informed of, and whether communication is consistent with preferences.

Review through records and interviews if communication occurs when incidents, restraints and/or investigations occur as well as at the time of the ISP in addition to regular communication on what is happening for the individual.  
	Communication with guardians and family members regularly occurs when incidents, restraints and/or investigations occur and at the time of the ISP and regularly on what is happening for the individual consistent with family/guardian wishes and in a timely manner.

	Communication with guardians and family members does not regularly occur when incidents, restraints and/or investigations occur and/or at the time of the ISP and/or regularly on what is happening for the individual consistent with family/guardian wishes and/or does not occur in a timely manner and/or communication is not consistent with mutually agreeable patterns.
	
RES

C9. Staff /home providers provide opportunities to develop and/or increase personal relationships and social contacts.

(Revised indicator and strengthened guidelines)  	Regulations 5.03 (2) (f) 1: Services and supports are to be provided in a manner that promotes…
(f) The opportunity to engage in activities and styles of living which encourage and maintain the integration of the individual in the community including:
1.  Social interactions in integrated settings typical of the community which maximize the individual’s contact with other citizens who live or work in that community

Regulations 7.03 (d): Relationships: Support to develop and sustain varied and meaningful relationships with family, friends, neighbors and co-workers …

CMS § 441.530 Home and Community-Based Setting.(a) (1) (iv): Optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to, … with whom to interact.

Guidelines:
A first step in the support to develop, and increase relationships is a familiarity with the individual’s interests in this area.  Staff (home provider) needs to have knowledge of whom the individual likes/ dislikes/ would like to spend time with.  This includes having a sense of who among their current friends as well as new contacts the individual wants to increase contact with and what type of friendships and frequency of contact is desired.  

In accordance with their desires, individuals need to be provided with opportunities to developand increase relationships with friends including fostering opportunities for ongoing planned and spontaneous communication, activities, and visits with friends. While individuals and staff may be social and friendly with each other, opportunities for developing personal relationships with people other than paid staff and family should be supported and encouraged by staff. 

Part of bridge-building means assisting the individuals to reach out to, talk to/communicate with and to promote and advance their connections with others.  In addition to having a richer connection with other people who share their interests during an event or club, staff can facilitate the individual to have additional contact with others consistent with their desires.  In addition, individuals should be supported to increase personal relationships by encouraging them to make arrangements to see people and to engage in activities that promote the development of relationships like invitations to the home and entertaining.  

Staff should assist individuals in being “good friends”.  Good friends call each other on their birthday, check in on them with they are sick and show interest in what interests them. 

If the individual does not directly communicate any particular interests in relationships, provision of general new opportunities to develop/ increase social contacts still needs to occur.  Staff /home provider need to consider information gathered from various sources (e.g. their knowledge of the individual; communication with the day service and the family) and encourage and support new opportunities for contact.  For example, if staff (home provider) knows that the individual enjoys spending time with someone who attends the same place of worship with them they could suggest getting together with that person at another time and facilitating this to occur.

The staff /home provider needs to fully understand an individual’s interests in this area to determine the development of new relationships and deeper social contacts which would be desirable, and the individual’s needs for support to expand his/her circle of friends.	Staff Interview – on site
Relevant documentation

Individual interview – on site	Review if staff have knowledge of individuals’ interests in friendship or social contacts with specific individuals.  Assess how they are supporting individuals to develop and/or increase opportunities for social contact.  

Review if individuals report they receive needed support.	Staff have knowledge of individuals’ interests in friendship or social contacts with specific individuals and are consistently supporting individuals to develop and/or increase opportunities for social contact.  Staff can articulate strategies and identify specific steps being taken towards this goal. 

.	Staff do not have knowledge of individuals’ interests in friendship or social contacts with specific individuals and/or are not supporting individuals to develop and increase opportunities for social contact and/or opportunities are not provided consistently.  
	
RES

C10. Staff (Home Providers) support individuals to develop appropriate social skills

	Regulations 7.03 (1) (d): Relationships: Support to develop and sustain varied and meaningful relationships with family, friends, neighbors and co-workers …

Guidelines:
While individuals may express a desire for increased friendships, they may also need support to develop appropriate social skills to enhance the likelihood for this to happen.  The provider needs to assess the need for support in the area of social skills development, and then design and implement actions to support individuals.  

If individuals have an identified ISP objective relative to social skills, the provider must develop and implement support strategies to teach appropriate social skills.

For others, while an annual objective may not be necessary, individuals may still require ongoing support and education.  One way to do this is to continue to model appropriate skills on a regular basis, while another is to utilize day to day interactions as “teachable moments”.   For example, day to day interactions such as greetings, manners, interactions with neighbors, the conduct of commercial transactions and interface with the public are all opportunities that should be used to prompt utilization of appropriate skills.

Fostering the development of social skills goes beyond daily teachable moments.  For example, how to initiate and hold conversations and engage in dialogue on a one to one basis and in groups, how one expresses oneself in public and appropriate boundaries, are some of the topics for which guidance and education may be necessary. 
	Staff Log/Individual Record – on site

Staff Interview – on site

Observation – on site

	Review individual record and staff log to identify needs in this area, which should then be reviewed with staff during staff interview.  

Review how staff become familiar with the strengths and needs of individual’s social skills and how they are supporting growth in this area; e.g. using teachable moments such as supporting an individual to interact appropriately.  

	The provider has evaluated individuals’ need for support in the area of social skills.  Staff have a clear understanding about the strengths and needs of individuals with respect to social skills, and actions are taken to support these needs and growth in this area.

	The provider has not evaluated the need for support in the area of social skills and/or staff do not have a full understanding about the strengths and needs of individuals with respect to social skills and/or actions are not taken and/or provider is not fully supporting growth in this area.

RES

C11.  Staff (home providers) support individuals to get together with family and friends 
(Revised indicator and strengthened guidelines)  	Regulations 5.04 (3): … The right to be visited and to visit others under circumstances that are conducive to friendships and relationships, in accordance with the following requirements:  An individual shall be permitted to receive visitors, unless ill or incapacitated to the degree that a visit would cause serious physical or emotional harm; provided that the individual’s attorney, guardian, legal or designated representative, personal physician, clergy or family members shall be permitted to visit at all times, unless the individual objects, and shall be provided with a suitable place to confer on a confidential basis; 
Reasonable restrictions may be placed on the time and place of the visit in order to protect the welfare of the individual or the privacy of other individuals and to avoid serious disruptions in the normal functioning of the provider.  Arrangements shall be made for private visitation to the maximum extent possible;  Denial of visitation or restrictions for any reason other than those stated in 115 CMR 5.04(3) (b), shall be treated as a modification of the ISP, and requires compliance with the regulations governing ISP modifications.  The human rights committee shall be notified of the intention to deny or restrict visitation. 

CMS § 441.530 Home and Community-Based Setting. (a) (D): Individuals are able to have visitors of their choosing at any time.

Guidelines:
The first step in supporting individuals is to gather information about the individual’s desires relative to ongoing contact with family and friends. In addition, providers need to gather information about the desires of the family. Unless clinically contra-indicated or agreed upon, family contacts need to be maintained and encouraged through facilitation of communication (e.g. phone calls, letters, cards and email) and visits both at the individual’s home, as well as at other locations including but not limited to other people’s homes and community locations.   

It is important to provide opportunities for social exchanges and visits to the greatest extent possible. Staff (home providers) need to then offer support in this area.  This includes assistance in establishing the times and places for getting together and in private as desired, coordinating visits, and arranging transportation for visits outside the home.  Many providers have developed proactive schedules that outline the frequency and location of visits, and how the provider is supporting these activities. 

Staff (home providers) must work with all individuals to ensure that individuals are able to visit friends and family (inside and outside of the home), that individuals’ needs are addressed and that the needs of individuals for privacy are met.  The staff /home provider will work with each individual to determine who the individual wants to spend time with, and encourage and support individuals to have visitors in accordance with their desires including what works best for him/her in terms of visits; whenever possible, the staff (home provider) needs to facilitate individual’s inviting their family and friends to visit and making the family and friends feel welcome in the individual’s home. This might include for example, invitations to former staff with whom individuals wants to stay in contact.  

The provider must have a strategy that encourages and promotes family contact/visit, while balancing the needs of all members of the household and assuring the regular routines of the household.  Staff facilitate and mediate discussions between housemates about visitation, assisting individuals living  in 24 hour residential settings to jointly agree to visitors, balancing all housemates’ choices and needs. 
If there is a plan for the limitation on visits (e.g. Risk Management Plan, Behavioral Plan, restraining order against a family member) there is documentation the ISP and supporting records, as appropriate to support this modification.  	Individual Interview – on site

Staff Interview – on site

Documentation – on site (any documentation that reflects visitation) e.g. ISP; restrictions) 

Individual record/staff log – on site
	Review if staff are knowledgeable and supportive of individual’s preferences for seeing family and friends.  Review whether staff are assisting in the actualization of these visits.  

Review if individual gets together with family and friends at the frequency desired.  

If there is a difference between what an individual desires and opportunities provided is this something outside of the provider’s control (e.g. family doesn’t visit as often as the individual would like)?  

If this is a desire that would negatively impact other individuals in the home (e.g. having guests over very late at night), review whether the provider has a strategy to balance these various needs.

Review documentation to determine if there are any limitations on visits that have not been addressed. 

	Staff support contact with family and friends unless there is an approved and documented plan for limited contact describing the limitation and rationale. 

 	Staff do not support contact with family and friends and/or limit contact without an approved plan describing the limitation and rationale.  
	
RES

C12. Individuals are supported to explore, define, and express their need for intimacy and companionship.

(Revised indicator and strengthened guidelines)  	Regulations 7.03 (1) (d): Relationships … Included is support and education to individuals in expressing intimacy and sexuality in an appropriate and safe manner. 

Guidelines:
The perspective is that all adults are sexual beings, and while not always verbally expressing a specific need, often need support in this area. The provider must review the individual’s interest and need for support in the area of intimacy and companionship, and then design and implement actions to support these identified interests and needs.  As needs are expressed to have specific close relationships (such as romantic/companionship relationships) including the need and desire for privacy to conduct relationships, staff /home providers should support individuals relative to these needs.

If individuals have an identified ISP objective or an identified training need relative to intimacy, the provider must develop and implement support strategies and/or provide training.

For others while an annual objective or formal training may not be necessary, individuals may still require ongoing support and education on some aspect of the very broad topic of intimacy.  This could include guidance, support and/or education on matters related to recognizing and preventing sexual abuse, gender identity, health, safety, self-expression, physical and romantic relationships, and appropriate boundaries.  For example, as necessary, education/training/skills and support may be needed related to how to proceed when an individual wishes to take a relationship to a different level, to formally pursue or date another individual or when an individual wishes to embark on a more romantic relationship with a person who is a friend.  Any education/ training must be geared to the learning style and needs of the individual.  
While not required, having a Sexuality Educator(s) on staff or being familiar with one that is available to consult can assist the provider to promote training to individuals and staff (home providers) in this area.  In addition, there are a number of curriculums available that can be utilized to train staff (home providers) and individuals in this topic.
At a minimum, basic education needs to be offered to staff/ home providers to ensure that staff / home providers are supporting and recognizing individuals as sexual beings who have a basic human right to engage in relationships of their own choosing.  Staff/ home providers need to be able to evaluate and articulate each individual’s needs and interests in this area and not merely automatically conclude that the individual is “not interested”.   
	Staff Interview – on site

Staff log/individual record – on site

Individual Interview 

Sexuality curriculum for staff and individuals; documentation regarding training to both staff and individuals.  (if present)	Review staff knowledge in this area and how individuals needs/desires are being explored and/or supported.  

Review individual record and staff log to identify needs in this area, which must then be reviewed with staff during staff interview.  

Review if individual feels that s/he is being supported by staff in this area.  Inquire as to whether there are concerns/ questions/ interest in this area that are/are not being addressed.

Review of organizational systems including curriculum, resources utilized, and support in the area of intimacy.  
	There is evidence that the needs and/or desires of the individual in the area of sexuality/ romantic relationship development have been reviewed (formal or informal evaluation process), that staff are aware of and can describe individual’s needs and interests, in the areas noted above, that support is given to the individual, and that support and education is geared to the individual’s learning style.  The provider utilizes a curriculum and has appropriately trained staff or has access to resources that supports learning in this area.
	There is no evidence that an individual’s needs and/or desires in the area of sexuality/ romantic relationship development have been reviewed and/or there is an identified need in this area with no support provided and/or that support and education geared to the individual’s learning style has not been provided.  The provider does not have a preferred curriculum or access to resources that it utilizes.

RES + DAY

C13.  Staff (home providers) provide support for individuals to develop skills to enable them to maximize independence and participation in typical home activities and routines.

(Strengthened guidelines)  	Regulations 5.03 (1): Services and supports are to be designed to provide meaningful assistance to the individual in acquiring and maintaining those physical, mental, and social skills which enable the individual to cope most effectively with the demands of his or her own person and environment. 

CMS § 441.530 Home and Community-Based Setting.(a) (1) (iv): Optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities...

Guidelines:
The staff (home provider) must encourage, teach and foster maximum independence in home routines and activities.  Even individuals living on their own may benefit from further supports to engage in and manage their household activities and routines.  For example, staff can provide mentoring, support and assistance to increase their independence even further.

The staff (home provider) must first gather information about the individuals’ desires and skills relative to home life, including both personal care as well as home care through a variety of mechanisms such as familiarity with the individual, interview, observation, picture books and/or other communication assistive technology. The staff (home provider) need to support, as needed,  the individuals’ development of skills on a routine and ongoing basis so that individuals can do things for themselves as opposed to having staff do things for them.  For example, daily and weekly activities such as dressing, tooth-brushing, laundry, meal preparation, shopping, managing money, cleaning, traveling/transportation, yard work and regular medical appointments are all activities that should be used to teach, guide, encourage and prompt greater independence and further skill development and participation.  Any education/ training must be geared to the learning style and needs of the individual; education and training may occur in the home or the community (such as an adult education cooking class). 

If the individual cannot perform all aspects of the task, they must be supported to participate in several steps in the process.  For example, an individual may not be immediately able to learn to do laundry, but s/he can be supported to put laundered items away in the drawers.  Additionally, staff should encourage and support individuals to continue to attempt tasks that they have not been able to do in the past. For some individuals’, due to their health care status, for example, this indicator may be less applicable.  However there are very few circumstances in which the promotion of greater independence and the development of home skills (or personal care skills), should not occur. 

Home providers and their families function autonomously and are uniquely different from one another, yet the individuals living within these settings must be supported to participate in these routines to the fullest extent of their capabilities and interests.  
	Documentation – on site

Staff Interview and Individual Interview – on site

ISP goals and assessments 

Observation	Review staff understanding of individual needs and subsequent support to enhance individual growth and  independence in completing daily/ weekly routines and activities; e.g. completing laundry tasks, meal preparation and clean-up, shopping, and other typical home activities.

Review how staff support individual’s interests and needs in these areas to ensure that  individuals can do things for themselves as opposed to having staff do things for them.

	Staff are knowledgeable about support needs to maximize independence and participation in typical home activities and routines and are providing that support.  Individuals are actively participating in typical home activities (to the fullest extent possible).
	Staff are not knowledgeable about support needs to maximize independence and participation in typical home activities and routines and/or are not providing that support and/or individuals are not actively participating in household activities (if able to do so).	
RES 

C14.  Staff (home providers) support individuals to make choices regarding daily household routines and schedules.

(Strengthened guidelines)  	Regulations 5.03 (2) ( c): Services and supports are to be provided in a manner that promotes:  self determination and freedom of choice to the individuals’ fullest capability.

Regulations 7.03 (1) (b): Individual Control:  Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously.

CMS § 441.530 Home and Community-Based Setting.(a) (1) (iv): Optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities...

Guidelines:
Imbedded in the definition of home and home life is the recognition that individuals should be able to exercise choice and control over completion of household and personal activities such as when to wake up, when to go to sleep, when to complete household chores such as laundry, and when to shower/bathe. For individuals living independently, these choices may include whether to clean their apartment or to hire a cleaning service.  The staff (home provider) must facilitate the exercise of personal choices.  Individuals may also need to be supported in making choices balanced with other needs, such as getting enough sleep so that they can wake up for work the next day. 

In 24 hour residential supports as well as individual supports, household routines, schedules and activities must be determined by the individuals living in the home and not for the convenience of staff.  Individuals have a voice and a choice in daily household routines and schedules. Choices do not necessarily have to be the same for all housemates at the same time. This includes that individuals’ bedtimes are dictated by the individual preference and not determined by staff.

In placement services the home care provider must ensure that individuals living in the home have a voice and choices when it comes to routines, schedules and activities.  

Individuals need to be presented with options and be allowed to make choices consistent with each individual’s style of decision-making and communication (e.g. verbal, pictorial, visual); so staff may need to use a variety of mechanisms such as familiarity with the individual, interview, observation, picture books and/or other communication assistive technology to ensure choice and control.   

Individual choices must be balanced with the needs and desires of other individuals with whom the individual lives.  The staff  (home provider) need to encourage the balance of choices among and between the individuals within a household.  For example, encouraging someone who likes loud music to use headphones so as not to disturb their housemates.
In the event that individual choices lead to incompatibility between housemates, the staff (home provider) must make every effort to make accommodations within the location.  For example, one accommodation could be rearranging who shares bedrooms to enhance compatibility.  Conversations, for instance between housemates, can be coordinated as one mechanism to resolve issues.  
	Staff Interview – on site

Individual Interview – on site

Observation	Review staff knowledge of individual preferences in everyday home activities, such as what to wear, eat, when to get up or go to bed, etc, and how these preferences are supported.  Determine how staff are supporting individuals to make choices as well as consider how their choices impact on other individuals in the home. 

Review the individual’s preferences and their perception of support in daily choices.

If choices might negatively impact other individuals in the home, review whether the provider has a strategy to balance these various needs.
	Staff are knowledgeable about individual choices and support those choices taking into account the balance between the individual’s choices and the others within the household and household routines, activities and schedules are determined by the individuals 
	Staff are not knowledgeable about individual choices and/or do not support those choices and/or staff do not assist an individual to make choices taking into account the balance between the individual’s choices and the others within the household; and/or household routines, activities and schedules are not determined by the individuals 	
RES

C15. Staff (home providers) support individuals to personalize and decorate their rooms/homes and personalize common areas according to their tastes and preferences.

(Revised indicator and strengthened guidelines)  	Regulations 5.03 (2) (7): Possessions which are appropriate to the individual’s age and practices of the local community and consistent with the individual’s interests.

CMS § 441.530 Home and Community-Based Setting. (a) (1) (vi) (B) (3): Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement.

Guidelines:
The staff (home provider) must gather information about the tastes and preferences of individuals.  The staff (home provider) need to support the individuals’ development and fulfillment of choices on an ongoing basis, not just upon moving into the home.  In addition, while many people take pride in personalizing and decorating their bedrooms, in 24 hour residential supports, individuals do not always contribute to the personalization of the common areas.  The staff should invite the individuals to participate in decorating the common areas in accordance with their collective likes and interests. The house, its common areas and bedrooms should reflect the individuality of the individuals who live there, with signs/items throughout the house of the hobbies, interests and people they care about. These signs include but are not limited to photos, posters/paintings/wall hangings, hobby items, books, paint color, linens, collections and other personal items in their bedrooms and in common areas as determined by the individuals in the house. 

In placement services, individuals decorate and personalize their bedrooms and work with the home care provider to participate in decorating common areas in accordance with their collective likes, dislikes, needs and choices.  

Individuals living independently may need greater assistance working within the community to personalize and decorate their space, such as assistance with the purchase and/or rearrangement of furniture.  
	Staff Interview – on site

Individual Interview – on site

Site review/ observation	Review staff’s knowledge of individual preferences in decorating their individual space and personalizing common space, and whether these preferences are honored. 

Note how people’s bedrooms/common spaces are decorated and personalized and whether this matches people’s interests and desires. 
	Staff are knowledgeable about how individuals wish to decorate their rooms and support the individuals to personalize their room, and there is evidence of individuals’ participation in decoration of the common areas of their homes according to their personal tastes.	Staff are not knowledgeable about how individuals wish to decorate their rooms and/or do not support the individuals to personalize their room and/or there is no evidence of individuals’ participation in decoration of the common areas of their homes.	
RES

(Access and Integration)

C16. Staff (home providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities. 

(Revised indicator and strengthened guidelines)  	Regulations 5.03 (2) (f) 5: Recreation and leisure time activities appropriate to the individual’s age and the practices of the surrounding community and which are consistent with the individual’s interests and capabilities; ...

Regulations 7.03 (1) (c) (1): … assist individuals to participate in integrated recreational, social, and leisure activities outside of the home in culturally typical settings and with other members of the community, consistent with the needs, desires, and choices of each individual;

Guidelines:
Staff (home providers) must pro-actively make efforts to support integrated activities in the community where the individuals are living.  Typically, the community at large offers a wide variety of options for cultural, recreational and spiritual activities and should be encouraged. Staff (home providers) must have knowledge of the individuals’ likes/ dislikes relative to cultural, social, recreational and spiritual activities, and what they like to spend time doing.  Staff need to fully assess individual’s interests through a variety of mechanisms such as familiarity with the individual, interview, observation, picture books, and exploratory trips.  Staff need to drill down to what the individual wants to do, how frequently and to which establishments.  Technology, communication tools, and other assessments and discussions (with the individual and the individual’s family, as available) should be utilized to assess the interests of individuals who cannot readily communicate their interests.  

Staff (home providers) must also have knowledge of where in the community these interests can be explored.  For example, if an individual expresses a desire to go to religious services, the individual must be supported to select from those in their denomination located nearby. 

Staff need to fully assess people’s interests through a variety of mechanisms such as familiarity with the individual, interview, observation, picture books, and exploratory trips.  Staff need to drill down to what the individual wants to do, how frequently and to which establishments.  Technology, communication tools, and other assessments and discussions (with the individual and with the individual’s family, as available) should be utilized to assess the interests of individuals who cannot readily communicate their interests.  

When the individuals’ specific interests are not known, staff need to observe, evaluate, and document individual’s interests.  Taking note of individual’s interests can be done through a variety of methods such as by conducting interest inventories, brain-storming with the individual and people who know the individual well, and / or frequent community trips to explore various types of activities.  Staff should also take the type of environment that the individual prefers into consideration when determining individuals’ interests.  For example, it would helpful to know whether the individual is drawn to loud, festive events with crowds or prefers quiet activities such as nature walks.  

Staff’s, home providers and volunteers’ own interests and community involvement may also provide entry into different activities that individuals wish to explore. Providers can develop an inventory of potential community activities to introduce individuals to through "mapping" what exists locally and by collecting information from others as to what their connections are to community organizations. This information can then be used to match individuals to activities based on interest and/or for exposure.

In accordance with their desires, individuals need to be provided with opportunities to develop and increase these activities and have opportunities for ongoing participation in those that are of interest.  

Some individuals may not have had many opportunities and would benefit from exposure to different activities as a first step in identifying and then fostering their particular interests.  In these instances, staff must offer opportunities for individuals to explore a variety of new activities. It may be beneficial to offer a new activity several times before drawing a conclusion about whether the activity is something the individual likes or dislikes. 

Individuals may be interested in engaging in activities with familiar people, for example attending a provider operated dance or sports club. Staff (home providers) must support these opportunities in line with the individuals’ interests.  

	Individual Interview – on site

Staff Interview – on site

Documentation - interest inventories; personal profiles; community resource documentation; calendars of events attended – on site	Review how staff support exploration, discovery and participation in varied cultural, social, recreational and spiritual activities to potentially broaden each individual’s knowledge and potentially broaden interests.

	Staff determine what is of interest to the individual by supporting exploration, discovery and encouraging participation of integrated cultural, social, recreational and spiritual activities on a consistent and sustained basis. 	Staff do not determine what is of interest to the individual and/or do not support exploration, discovery or participation of integrated cultural, social, recreational and spiritual activities on a consistent and sustained basis.
.	
RES

(Access and Integration)

C 17.  Community activities are based on the individual’s preferences and interests.

(Revised indicator and strengthened guidelines)  	Regulations 7.03 (1) (c) 1, 2: Community Membership:  Opportunities for individuals to participate in and contribute to the life of their community.  Included are requirements that the provider shall: 1. assist individuals to participate in integrated recreational, social, and leisure activities outside of the home in culturally typical settings and with other member of the community, consistent with the needs, desires, and choices of each individual; 2. assure that individuals have access to the same community services and resources used by other people;

Guidelines:
Once individuals’ preferences and interests in community activities have been assessed and discovered, staff must support individuals in realizing these preferences and interests. 

Individuals in 24 hour residential supports and placement services will generally need more support and guidance to fully engage in activities in the community.  Community activities beyond simple commercial transactions such as shopping, picking up an item or, running an errand must be promoted.  For instance based on the individual’s preferences the use of the community for cultural, social, recreational and spiritual activities must be encouraged e.g. Adult education classes; neighborhood meetings and gatherings; seminars; social / recreational clubs and groups.  

Typically individuals living independently and receiving individual supports are directly communicating their particular interests, and the expectation is that staff will assist them in finding venues and opportunities to engage in these community activities. Many individuals living alone are supported to engage in their preferred activities on an individualized basis, while others convey an interest in joining friends for community activities; this must be supported.  

Activities that occur on an individualized basis must be done as much as possible.  This allows for the greater possibility that activities are based on individuals’ expressed interests rather than the group’s. Also, activities may occur outside of a typical weekday timeframe, such as night time and weekend activities.  

There are few to no circumstances in which participation in community life on some level would be considered not applicable.
	Documentation such as calendars, receipts, activity logs, newspapers – on site

Staff Interview – on site

Individual interview – on site	Review the frequency, variety, and the individualization of community activities.

Interview staff to review their knowledge of local events and activities as well as their knowledge of the individual’s interests and preferences.

Interview individuals to determine the match between the community activities that participate in and their preferences and interests.

	Staff are knowledgeable about local events and activities and provide frequent opportunities for community activities that are in line with the individual’s preferences and interests and staff can articulate an individualized strategy or plan to promote community involvement and are implementing such plan.
	Staff are not knowledgeable about local events and activities and/or do not provide frequent opportunities for community activities that are in line with the individual’s preferences and interests and/or staff cannot articulate an individualized strategy or plan to promote community involvement and/or are not implementing such plan.

RES

C 18.  Staff (home providers) assist individuals to purchase personal belongings. 

(Strengthened guidelines)  
	Regulations 7.03 (1) (b): Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously.  

7.03 (1) (f) 9: support each individual to obtain personal possessions, including an adequate supply of fashionable, seasonal clothing as necessary for the individual’s health and comfort and consistent with the individual’s choice and preferences, and assist each individual to maintain his or her clothing in a clean and well kept manner.

Guidelines:
The purchase of personal belongings, however small, can hold much meaning for individuals.  Personal care items, clothing, music, videos, and games are among some of the many items that the individuals’ must be encouraged to select and purchase, in accordance with their interests and the needs related to what they want in their home and their room(s). Stores should be selected based on choice of the individual, not staff convenience. Shopping trips may need to occur on an individual basis, rather than as a group activity.

Staff (home providers) can play an important role in supporting individuals to make choices in how to use their personal funds to make desired purchases, as independently as possible.
	Staff Interview – on site

Relevant documentation – on site

Individual Interview – on site	Review how staff support individuals to purchase their personal belongings of their choosing at stores of their own choosing.

Review if staff provide the support needed for individuals to purchase items they want.  	Staff assist individuals to purchase personal belongings of their choosing at stores of their own choosing.	Staff do not fully assist individuals to purchase personal belongings of their choosing at stores of their own choosing.	
RES

C19.  The provider assists 
individuals to make 
knowledgeable decisions. 

(Strengthened guidelines)  

 	Regulations 7.03 (1) (b):  Individual Control:  Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously.

CMS § 441.530 Home and Community-Based Setting. (a) (1) (iv): Optimizes but does not regiment individual initiative, autonomy, and independence in making life choices.

Guidelines:
The ability to make informed decisions requires an individual to consider both the advantages and the disadvantages and risks involved.  Individuals living with less than 24 hour supports may need guidance in weighing the risks and benefits of both small and large choices and decisions.  

Staff (home providers) must be knowledgeable about the capabilities of an individual in this area and be able to provide necessary support to enable an individual to make informed decisions.  Support could include brainstorming, discussing, and guiding the individual to analyze their decision by weighing the positives and negatives and determining what the trade-offs and options might be.  The role of the staff (home provider) is to assist the individual to understand the pros and cons, so that he/she may be more likely to act responsibly. 

However, even with support and training, individuals may ultimately make a decision with which staff do not agree. Individuals should be allowed to make decisions which may present an element of reasonable risk and failure, as failure is something that all individuals experience and learn from.  However, barring a documented modification of a restriction in decision-making, individuals must be allowed to make decisions.
	Staff interview - on site

Individual interview - on site

Relevant documentation – on site
	Review staff understanding of individual’s capability to make decisions based on the information shared as well as what staff do when individuals make a decision with which staff do not agree. 

Review if individuals are given support to weight pros and cons, risks, benefits, and options and then to make knowledgeable decisions in both small and significant areas of their lives.

Review the support received by the individual to make decisions.

Interview individuals to determine what type of decisions that they are able to make with support.	Staff understand the individual’s capability to make knowledgeable decisions and provide needed support to enhance individual knowledge to make decisions.

	Staff do not understand the individual’s capability to make knowledgeable decisions and/ or provide needed support to enhance individual knowledge to make decisions.

RES

C20. The provider has emergency back-up plans to assist the individual to plan for emergencies and/or disasters.	Regulations 7.03 (1) (f) 4:… assure safety and well-being in both home and work environments…

Guidelines
The provider has an emergency back-up plan or has assisted the individual to develop his/her own back up plan.  The provider is aware of what this plan is and assists the individual to be knowledgeable about the plan and to know who to call in an emergency.

Emergency back up plans can consist of a provider on-call system, an on-call system to the area office/service coordinator; and/or use of generic resources such as 911.

The provider must periodically check to assure that the individual is knowledgeable about plans for emergencies and/or disasters.  Review of individual needs and of the adequacy of the emergency plan(s) must occur periodically.
	Documentation, including search plans; on-call procedures – on site

Staff interview – on site	Review the emergency back-up plans, and staff’s knowledge of the plans.	Provider has emergency back-up plans and staff are aware of them.	Provider does not have  emergency back-up plans and/or staff are unaware of them.	
IHS

C21. Staff helps to coordinate outreach efforts to other agencies, groups, community resources and natural supports when necessary to assist individuals to manage and maintain their independence.	No specific regulatory reference
Guidelines

Individuals living independently or semi-independently often interface with a variety of different organizations.  They may need assistance from staff to coordinate and navigate through what can be complex processes.  

The individual may need assistance to navigate through the systems including but not limited to welfare system, the landlord, housing authority, court system, mental health services, and substance abuse programs. 

The provider must determine what assistance an individual requires and staff must provide necessary support, facilitation, coordination and assistance.
	Staff Interview – on site

Relevant documentation – on site

Individual Interview – on site	Review staff’s knowledge of agencies and supports available to assist an individual.  Review if they explore and effectively utilize other agencies when possible to support the individual.  Review if staff are aware of the people and relationships the individual has in the community and whether these relationships are nurtured and supported, when appropriate, to assist the individual to manage and thrive in the community in which they live.

Review if individuals have been given information about the resources available to them in the community.  When possible, have staff provided support for other relationships that can provide support?	Staff are knowledgeable about local resources, agencies with whom the individual interacts, and important relationships to provide natural support and staff provide the needed assistance to support these connections. 	Staff have not explored local resources, agencies with whom the individual interacts and/or important relationships to provide natural support and/or staff have not provided when possible the needed assistance to support these connections. 	
EMP

C 22. Staff have effective methods to assist individuals to explore their job interests.	Regulations 7.03 (1) (b) and (e):  Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously;

Training, education, supports and services necessary to meet the goals articulated in the individual’s ISP.  Included in the requirements that the provider shall assure the assessment, training, and supports to assist the individual to acquire skills that increase self-reliance and that are necessary for desired and valued outcomes.  This include but is not limited to paid employment in integrated settings in the community and the ability to maintain and control one’s home. 

Guidelines
Providers must use a variety of means to explore job interests including interest inventories, job tours, informational interviews, job shadows, etc.  Situational assessment/job try-out is one way to determine if options being considered make sense and to expand employment options of interest.    Methods for exploration must be customized to the specific needs of the individual, such as communication style and preferences.  A wide array of jobs and careers must be explored, especially for those with limited or no work experience.  Individuals in employment supports, for instance must have opportunities to see what duties different jobs entail through mechanisms such as job tours and informational interviews.  Situational assessment/job try-out is one way to determine if options being considered make sense and to expand employment options of interest. Many of these same processes must be used for those in Center Based work.   Assessment tools and gathering of information on individuals interests for those in Center Based work must not be restricted to only those jobs readily available “in house”.  

Work must start initially with the individual’s interests and job goals and simultaneously be used to expand the individual’s frame of reference regarding job interests.  Career exploration must not only identify work skills and interests but also settings that the individual is comfortable in and that would be a good work culture match.

There must be a discovery process to determine an individual’s strengths and abilities as well as for the person to get to know herself/himself in terms of job interests and goals.   Information gathered from activities such as interest assessments, community visits, observations in a variety of settings, input from family and friends, job trials, etc., are used in working with the individual to determine his/her job goal.  The discovery process must also identify settings that the individual is comfortable in and are a good work culture match, provide work hours and pay of choice, etc.
	Employment documentation including:
Interest inventories, vocational assessments, to determine individuals’ interests and corresponding job exploration activities such as job tours, shadowing, informational interviews, and job trials  - on site

Staff interview – on site

Individual interview – on site	Individuals’ and service related information on employment processes and activities are reviewed to determine whether individuals’ employment interests have been assessed and explored.

Discussions about obstacles and potential solutions.

	Staff have regularly assessed the individual’s job interests, and staff have explored those interests identified with the individual. 
	Staff have not recently assessed the individual’s job interests, and /or staff have not explored those interests identified with the individual.

EMP

C23.  Staff utilize a variety of methods to assess an individual’s skills and training needs in employment.  

	Regulations 7.03 (e): Training, education, supports and services necessary to meet the goals articulated in the individual’s ISP.  Included in the requirements that the provider shall assure the assessment, training, and supports to assist the individual to acquire skills that increase self-reliance and that are necessary for desired and valued outcomes.  This include but is not limited to paid employment in integrated settings in the community and the ability to maintain and control one’s home. 

Guidelines:
Job skills assessments must emphasize what an individual can do rather than merely noting what they cannot do, and/or what/where the deficits are.  Staff must assess an individual’s skills, interests, career goals and employment support needs. 

Methods used could include vocational assessments, discussions with the individual, behavioral observations, results of any testing, previous performance history, any assistive technology information, etc.
 
Assessments must be conducted to accommodate person’s unique learning and communication styles, and those providing support in employment must be knowledgeable in the outcome of assessments and have received training in how the assessments are conducted.

Exploration of job skills and talents must be done in an expansive, positive way; i.e. intent is to identify job options, not eliminate them.  Skills assessment must not be based solely upon what provider has currently available; e.g.   janitorial crew, recycling, etc

The provider must identify work skills as well as identify settings that the individual is more competent in and therefore be settings that would further promote learning and skill development.
	Employment documentation including:
vocational skills assessments,
performance reviews, on  job trials, assessment of the independence of the individual and the type/ number of staff support needed to perform the job – on site

Staff interview – on site

Individual interview	Individuals’ and service related information on employment processes and activities are reviewed to identify whether individuals’ employment skills and training needs have been assessed.  A review of general skills assessments as well as specific skills and training needs for particular jobs, are reviewed.

Whenever possible the agency conducts assessments in natural settings.

 	Staff have assessed the individual’s job skills and training needs using a variety of methods that focus on individual strengths and career interests and skills related to assessment reflect both overall job skills that are necessary for any job, as well as proficiencies relevant to the person’s identified field of interest.

	Staff have not assessed the individual’s job skills and training needs and/or have not used a variety of methods in that assessment that focus on individual strengths and skills related to career interests and/or assessment does not reflect overall job skills or proficiencies relative to individuals' field of interest. 

.

EMP

C24. There is a plan developed to identify job goals and support needs.	Proposed Regulation 7.09 (2) (b): Career planning is provided through the development of an individualized plan that identifies specific job goals and support needs.

Guidelines:
A well thought out, detailed plan is a foundation to success in finding and obtaining employment. The plan must be individualized and use a person-centered process so the individual can build an awareness and understanding of job possibilities and make informed choices.  

Although individuals in employment supports are generally further along in the community employment continuum than their center based work colleagues, both need to be working to identify job goals and support needs.  Center based options must not be based solely upon what the provider has currently available, such as janitorial crew and recycling. The provider must identify work skills as well as identify settings that the individual is more competent in and therefore be settings that would be a good match.   

It is important that the plan be tailored to the skill set of the job/career interest; the appropriate educational and training opportunities are identified.

Employment goals are addressed both within the individual’s ISP as well as within the service setting; e.g. a long term goal might be a specific type of employment with a shorter term goal of acquiring necessary work skills specifically for that particular job. Support strategies must complement the job goal.

Another necessary adjustment that must be considered to better support individuals to obtain employment and work experiences is transportation.  The provider must work with the individual to pursue and obtain employment in a location that they can access.  While the provider does not necessarily have a role in directly transporting the individual, the provider must assist in finding jobs that are conveniently located, as well as facilitating the coordination of transportation and/or guidance on use of public transportation. 
	ISP – job objectives or specific employment plan developed through work program 

Other employment information and objectives – on site

Support Strategies  - on site

Staff interview – on site

Individual interview	Individuals and service related information on employment processes and activities are reviewed to determine whether goals have been identified by the individual based on a person centered process, and there is a plan to support the individual in achieving these goals.	Job goals and support needs have been identified based on the individual’s current interests, strengths and needs and there is a detailed written plan in place that addresses the individual’s goals and support needs. 
	Job goals and support needs have not been identified based on the individual’s current interests, strengths and needs; and/or there is not a detailed written plan in place that addresses the individual’s goals and support needs. 

EMP

C25.  Staff assist individuals to work on skill development for job attainment and success.	Guidelines:
Based on assessments and job interests, staff must develop and implement a plan to support individuals in developing skills that will enhance successful job attainment.   

This includes guidance and education to learn, master, and refine job skills  – both general and specific.

Skill development however, should not automatically be seen as a requirement for successful employment.  Although some skills would be helpful, the lack of some skills should not always be an impediment to obtaining a job; e.g. some individuals may have difficulty with interview skills but the job developer could facilitate a job placement by representing the individual to an employer, and/or by facilitating accommodations within the job, while involving the individual as much as possible in the process.   Skill development could occur concurrently with looking for employment.

There needs to be a connection between the overall employment plan developed and the acquisition of skills consistent with the individual’s specific vocational interests.

In addition, external resources can be utilized to support job development.  Resources such as community based classes, One Stop Career Centers, must be explored and these resources incorporated, as appropriate, into skill development strategies.
	Individual record, staff log, and any documentation of skill building activities – on site

Staff Interview – on site

Individual Interview 

Observe skill development activities – on site	Individual information is reviewed to determine if staff are building on identified skill strengths and addressing skills needed to enhance job attainment and success.  Review whether the lack of some skills are an automatic impediment to job exploration.

	Staff are using information about individual strengths and needs to enhance specific skills needed for job attainment and success related to desired identified individual employment goals and skill development is available on an ongoing basis.

	Staff are not fully using information about individual strengths and needs to enhance specific skills needed for job attainment and success and/or information is not related to desired identified individual employment goals and/or the frequency of skill development opportunities is limited (e.g. due to staff availability or expertise).

	
EMP

C26. Career planning includes an analysis of how an individual’s benefits/ entitlements can be managed in a way that allows them to work successfully in the community.

	Regulations 7.03  (1) (f): … individual is assisted in securing adequate economic resources to meet his or her needs;

Guidelines:
A careful benefits analysis must be completed so that concerns about the impact of employment on disability benefits can be addressed. 

It is important that this analysis be completed intermittently, at certain junctures for instance, when seeking new employment and when the number of hours or the wages increases. 

There are resources in the community that can assist the individuals to learn and weigh the short and long term implications of working.  For example, “bene-plan” information is available.   
	Documentation of benefits analysis – yearly or in ISP cycle – on site

Staff Interview – on site

	Documentation is reviewed to identify if an analysis has been completed of how future earnings will affect individual entitlements.

Review if there is a staff person who is knowledgeable about and can explain the relationships between employment and benefits.	An analysis has been completed of how future earnings will affect individual entitlements and the impact has been clearly explained to the individual and/or family.

	An analysis has not been completed of how future earnings will affect individual entitlements and/or the impact has not been communicated to the individual and/or family. 

EMP

C27. Individuals and families are encouraged and supported to understand the benefits (advantages) of integrated employment.

(Strengthened guidelines)  	CMS § 441.530 Home and Community-Based Setting.(a) (1) (i): The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings...

Guidelines
Individuals and families must be educated about the benefits of integrated employment.  A variety of means could be utilized.  If there is familial or individual concern about integrated employment, a variety of methods for discussing the benefits of employment must be utilized, such as ongoing conversations, presentation of written information, family forums, conferences, and discussions with individuals who have successfully moved into integrated employment, etc.

Staff need to present, as needed,  information to individuals, families, and guardians regarding the benefits and advantages of supported and/or competitive employment, including options for benefit protection.  Staff should work with individuals to resolve their concerns and misconceptions about integrated employment.

Issues of concern raised by individuals and families must be constructively addressed.

Individuals can be encouraged to speak/communicate with other individuals who have found success in integrated employment. Families are often a resource for individual employment.  Connecting families who have concerns about employment with families who fully understand the benefits of employment and have seen the success can make sure that families and individuals fully understand community employment advantages.
	Staff Interview – on site

Guardian interview – off site

Individual Interview

Individual Record
Other documentation (pamphlets, brochures) – on site	Review whether staff have made concerted efforts to outline the benefits of integrated employment to individuals and families.

Review the individual’s understanding of the benefits of integrated employment.  

Review contact with the guardians on the advantages of integrated employment.  

Review all documentation outlining efforts to present the benefits of integrated employment including connecting families/guardians.
	Staff have presented information to families and individuals on the benefits of supported employment.  If efforts are not at first successful, then further efforts are made to impart this information using a variety of means; e.g. conversations, written information, discussions with individuals/ families who are successfully working.

	Staff have not presented information to families and individuals on the benefits of supported employment.  If information has been presented but efforts are not at first successful, staff have not made additional efforts to present the information using a variety of means; e.g. conversations, written information, discussions with individuals/ families who are successfully working

EMP

C28.  Staff maintain and develop relationships with local businesses in order to facilitate job development opportunities.

(Strengthened guidelines)  	No specific regulatory reference 

Guidelines
The agency must utilize a variety of means to connect and network with local businesses, such as joining local business groups, participating in community job fairs to become better known, and directing contact with businesses to highlight the strengths of the available workforce.

Agencies facilitate business contacts in a variety of different ways, and through various models of service delivery.  For instance, some agencies expect all staff to be trained, knowledgeable and have demonstrated abilities in areas such as: job seeking, networking, and marketing to promote positive perceptions of how individuals’ can be an asset to potential employers.

Some providers assign job developers to conduct informational interviews with perspective businesses, promote job tours, engage in correspondence with local businesses, and make efforts to expand volunteer opportunities to bridge individuals with local businesses.

Providers should cultivate a group/base of local businesses that they are working with, at any given moment, that are willing to hire interested individuals.  

Providers also need to work with local businesses to directly hire individuals who have proven successful in group and individual supported employment ventures.  

Some providers have developed their own community businesses, increasing employment opportunities for individuals.  For example, coffee shops, retail stores, and landscaping companies are among the various types of businesses that have been developed.  It is important, though, for providers to ensure that individual choice of job placement remains the goal.
	Staff Interview/Exec Director interview

Job developer(s) interview – on site

Relevant documentation
such as membership and attendance at chamber of commerce; attendance at local job fairs; partnerships with local businesses – on site
	Review whether staff have worked in a variety of ways to develop relationships with local businesses to facilitate job development opportunities; e.g. joining local business groups, contacting local businesses to make them aware of the potential workforce. 

Review the amount of staff time dedicated to relationships with business and job development activities.

Review available documentation to further determine efforts to connect and network with local businesses.	Staff have worked in a variety of ways with a sustained effort to develop relationships with local businesses in order to facilitate job development opportunities.

Provider has fostered relationships with several businesses to hire individuals.
	Staff have not worked or worked only in limited ways to develop relationships with local businesses in order to facilitate job development opportunities.
 
Provider does not have sufficient relationships with other businesses to hire individuals.	
EMP

C29.  Individuals are supported to obtain employment that matches their skills and interests.

.	Regulations 7.03 (1) (b): Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously;

Guidelines:
Once interests and skills are identified, the provider must support the individual to pursue acquisition of a job.  This includes support such as assistance to attend a job interview, job trials, distributing resumes and applications to potential leads, and making phone calls to follow-up on a potential position.

In addition to follow-up phone calls in pursuit of a job opening, the provider needs to explore other avenues to employment.  For example, informal networking by various staff and broadening the individuals’ involvement in the job search can assist the individual to obtain employment.   The provider is encouraged to support the individual with the optimal level of support needed to achieve the goal of employment.

It is important that providers strike a balance between attempting to fill a niche with community employment and finding ideal employment for each individual.  For instance, facilitating community employment for individuals in areas that community employers have difficulty finding employees such as within “generic positions” such as janitorial, housekeeping, and kitchen help, is important and allows for movement of more individuals into community employment.  In addition, providers need to support placement in community positions in line with each individuals’ interest and talents. 
	Staff Interview – on site

Relevant documentation – on site

Individual Interview	Review whether staff are knowledgeable about individual skills and interests and whether they use this information to assist in obtaining employment of choice.  Review the frequency and duration of actions to obtain jobs such as calls, submission of applications, job interviews, and job contacts made. 

	Staff are demonstrating sustained ongoing efforts to obtain employment, within a reasonable time frame, which match the individual’s preferences by implementing and modifying support strategies to address obstacles as necessary. 	Staff are not demonstrating sustained ongoing efforts to obtain employment within a reasonable amount of time which match an individual’s preferences by implementing and/or modifying support strategies to address obstacles.

EMP

C30.  Individuals are supported to work in integrated job settings.

(Strengthened guidelines)  	CMS § 441.530 Home and Community-Based Setting.(a) (1) (i): The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings...

Guidelines:
There must be evidence of a strong effort to support work in integrated work settings.  Integrated work settings should be absent of a congregation of workers with disabilities, and include regular contact with co-workers who are not disabled as well as social interactions with co-workers at the work site such as at breaks, lunch or after-hours gatherings of co-workers.  

To be part of an integrated employment situation means that the physical environment has to promote using the same facilities as others without disabilities.   Individuals should be supported to utilize the same work space as others including bathrooms, break rooms, and office/ work space. Access in and out of the work setting needs to afford individuals with the ability to enter/exit the work place in a manner that is as convenient as other employees.  
	Staff Interview – on site

Individual Interview

Record Review Opportunities for work in integrated settings are provided – on site 

Documentation e.g. enclave information – on site  

Observation of employment settings	Review if staff are providing opportunities for work in integrated job settings.

Review of schedules, routines.

Review that job settings are integrated.	Opportunities for work in integrated settings are provided. 
	Opportunities for work in integrated settings are not provided on a regular basis and/or there is no plan to provide integrated opportunities to individuals.
	
EMP

C31. Accommodations and adjustments are made to enable an individual to perform his/her job functions.

	Regulations – no specific regulatory reference  

Guidelines:
Necessary and appropriate accommodations, assistive technology, etc. based on an individual’s needs must be in place to enhance success.

The provider must be familiar and/or knowledgeable about this information or know where to go for resources that address individuals’ rights and workplace accommodation(s) such as the Americans With Disabilities Act (ADA) and Architectural Access Board (AAB).  Individuals are supported, as needed, to request and receive accommodations.

In addition, other generic resources and funding sources exist that might assist individuals to obtain adaptive equipment and/or assistive technology that is designed to accommodate their unique needs and enhance their employability. (i.e. MassMatch, Massachusetts Rehabilitation Commission, Easter Seals Assistive Technology assessment and loan program, PASS, ERWE).
	Individual Record/Staff Log
Staff Interview

	Review if there is a need for reasonable accommodation and whether it is being provided.

The agency is able to explain how this is taken into consideration during the job exploration process.

This is also part of the assessment process.	Assessment of accommodations needs has been conducted and accommodations have been provided as applicable.  	Assessment of accommodation needs has not been conducted and/or accommodations have not been provided as per the assessment. 	
EMP

C32.  Wages earned are in accordance with at least the minimum or prevailing wage rate.	Regulations 7.03 (1) (f) 8: comply with state and federal wage-hour requirements when individuals engage in any work which must be compensated.

Guidelines:
The individual should be or have a goal to be paid directly by the employer and not by the agency at a rate commensurate with others in the position.  Individuals who are in competitive employment must be paid consistent with others performing similar work, which must be at least the minimum wage or prevailing wage rate.  

Any volunteer activities that the individual participates in must meet the criteria for volunteering outlined in the Department of Labor (D.O.L.) guidelines.
	Documentation on wages and jobs performed within the past year – on site	Review if wages are in accordance with the minimum or prevailing wage rate.	Wages are paid in accordance with the minimum or prevailing wage rate.

.
	Wages are not paid in accordance with the minimum or prevailing wage rate.

.	
EMP

C33.  Employee benefits and rights are clearly explained to the individual.

	Regulations - no specific regulatory reference

Guidelines:
Employee rights and benefits are explained through a variety of means, which could include discussion, use of examples, practice and written information.

Benefits must be explained by the employer if the individual is employed outside of the agency with support from the agency as appropriate and necessary.  General rights of employees and processes can be explained by the agency, while the specifics should be explained by the employer of record.

When the provider is the actual employer, they need to explain the rights and benefits to the individuals.  Written information that is helpful in outlining rights and benefits could include a handbook or policies or specific strategies of the employee to review regarding employee rights and expectations.  

When the provider is the actual employer, it is important providers work to ensure that the individual is receiving the same benefits as other employees (i.e. paid time off, union membership, breaks and meal times).

If the individual loses their job, staff need to provide necessary support to review whether unemployment benefits are available.
  	Staff Interview – on site

Individual Interview

Documentation – on site

	Review whether and how employee benefits are explained to the individual.

Review the individual’s understanding of their employee benefits.

Review any documentation to see what information is given to the individual.	Employee benefits and rights have been presented to the individual in a way to enhance understanding, and there is information available that outlines benefits and rights.  

	Employee benefits and rights have not been presented to the individual and/or have not been presented in a way to enhance understanding and/or there is no information available outlining rights and benefits.
	
EMP

C34. The agency provides the optimal level of support to promote success with a specific plan for minimizing supports.

(Strengthened guidelines)  	No specific regulatory reference 

Guidelines:
Job support strategies must match the learning style of the individual and the culture of the job site.  

Job supports must include the use of natural supports supplemented as necessary by agency supports.

There must be a well thought out plan for fading job supports to the minimal but sufficient support needed that is developed from the beginning of the employment. Plans may include specific skills training, encouragement to resolve issues at work with employers and co-workers directly and other strategies to minimize supports over time. 

The individual is a partner in all aspects of the plan for support.

Assessments of individual’s performance must be done routinely, with discussion of the plan for reduction of those supports over time.  The level of support must be adjusted and consistent with the individual’s current performance assessment.
	Staff Interview – on site

Relevant documentation – on site

	Review how the agency plans for and provides on-the-job support and how it determines when support can be faded without jeopardizing success.	Staff provide needed support for success and have a well thought out plan for fading support.

	Staff are not providing adequate support for success and/or do not have a clear plan for fading support.

	
EMP

C35. Individuals are given feedback on job performance by their employer.

	No specific regulatory reference 

Guidelines:
Feedback must be provided by the employer with facilitation and reinforcement from the agency as appropriate and necessary. It is important that there is documentation e.g. in the form of progress notes, that feedback was given.  Regarding specific feedback given from the employer,(if the employer is not the provider) to the individual, the individual should understand and agree that this will be shared with the provider, and the provider must utilize such information to assist the individual to improve job performance.  

Staff must maintain on-going contact with the employer regarding issues that arise and performance evaluation results.  Evaluations must occur on a schedule as that of other employees working for the employer.  

	Staff Interview – on site

Evaluation documentation or summary of evaluation e.g. progress notes.   – on site

Individual Interview	Inquire if individuals are given feedback on job performance on a schedule commensurate with other employees.  Determine if agency staff facilitate and reinforce evaluation results when needed.

Consult with the agency concerning their actions to inform and assist the individual on their job performance based on employer feedback.	Individuals are given feedback on their job performance on a schedule and a manner commensurate with other employees and staff facilitate and reinforce evaluation results when needed. (Depending on the job they hold; e.g. competitive or enclave, either the employer or supervisor)
	Individuals are not given feedback on their job performance on a schedule and/ or a manner commensurate with other employees and/or staff do not facilitate and reinforce evaluation results when needed.

	
EMP

C36. Ongoing supports are provided to enhance job retention and advancement	No specific regulatory reference 

Guidelines:
The agency must maintain a schedule of on-going check-ins with the employer (if the employer is not the provider) and individual to monitor status and pro-actively address issues.  Staff must provide and assist the employee with any short term on-the-job retraining based on changing job requirements and/or any performance issues identified.  Staff must monitor the individual’s satisfaction with employment and determine the level of interest and opportunities available for career advancement within the current company or other companies.  Staff must also maintain contact with the employer regarding career advancement opportunities and to address and resolve issues that arise.  

As supports are faded, staff ensure that an employer knows how to contact the agency to ask for additional or renewed supports, as needed, to preserve an individual’s job.
	Staff Interview – on site

Individual Interview

Individual record and agency documentation – on site	Review how staff conclude what supports are needed to enhance job retention and advancement and then how that support is provided.  Review if support is provided when needs develop.

Review if individual believes they are receiving support they need.

Review record and any documentation to determine if needs have developed and if they have been addressed by staff.	The need for ongoing supports has been determined and is being provided in a manner to enhance job retention and advancement. 
	The need for ongoing supports has either not been determined and/or is not being provided in a manner to enhance job retention and advancement.	
EMP
DAY

C37. There is support to develop appropriate work related interpersonal skills.

	Regulations 7.03 (1) (d): Relationships: Support to develop and sustain varied and meaningful relationships with family, friends, neighbors and co-workers.  

Guidelines:
Individuals’ current interpersonal skills must be assessed to identify areas requiring further skill development.  Staff need to then design and implement actions to support assessed needs.  

If individuals have an identified ISP objective relative to social skills, the provider must develop and implement support strategies to teach appropriate social skills.

For others, while an annual objective may not be necessary, individuals may still require ongoing support and education.  Staff must support the development of social skills on a routine and ongoing basis for those who can benefit from this support.  For example, day to day interactions such as greetings, manners, interactions with others at the day site, the conduct of commercial transactions and interface with the public are all opportunities that must be used as “teachable moments” to prompt appropriate skills.

Fostering the development of social skills goes beyond daily teachable moments.  For example, how to initiate and hold conversations and engage in dialogue on a one to one basis and in groups, how one expresses oneself in public and appropriate boundaries, are some of the topics for which guidance and education may be necessary. 

For individuals in employment or center based work supports, supports must focus on the development of work related interpersonal skills,  understanding of work relationships, understanding of the employer chain of command, facilitation of typical co-worker relationships and problem solving of interpersonal issues on the job.

When feedback from the employer has indicated difficulties in interpersonal interactions it is important that staff are supporting individual to develop positive skills.

The agency must assist individuals to receive training, as needed, to enhance their knowledge in areas such as: professional dress, interpersonal skills with co-workers / supervisors, discrimination, and sexual harassment.

	Staff Interview – on site

Observation

Individual interview	Review if staff have an understanding of social skill development and whether they understand the individual’s needs and are providing the necessary supports.	Staff are providing support to develop appropriate job social skills. 
	Staff are not fully providing support to develop appropriate job social skills.
	
EMP

C38.  Specific habilitative and behavioral goals necessary to prepare individuals for work are identified.
	Regulations - no specific regulatory reference

Guidelines:
Assessments must be completed to determine general goals to prepare an individual for work such as increasing attention span, completing assigned tasks, and addressing needs such as interfering behaviors than could impact employment, Support strategies must be developed to address habilitative goals.

Assessment of support needs must also identify obstacles to employment. Additionally strategies to overcome obstacles must be identified and implemented.  

	Staff Interview – on site

Individual record – on site

Individual Interview	Review how goals were developed and whether they are based on the myriad of information gathered about the individual.

Review if documentation supports appropriate habilitative and behavioral goal development.

Review if individual is satisfied with the identified goals.	Habilitative and behavioral goals have been developed based on all of the information obtained that will help prepare the individual for work.

	Habilitative and behavioral goals have not been developed and/or are not based on all of the information obtained that will help prepare the individual for work and/or strategies to overcome obstacles are not identified and/or not being implemented.

.  	
EMP

C39. There is a plan developed to identify job goals and support needs that would lead to movement into supported employment.  	Regulations - no specific regulatory reference

Guidelines:
Plans must be individualized with a person-centered process so the individual can build an awareness and understanding of pursuing job possibilities as distinct from other goals and interests.  

The plan includes individually tailored strategies to enhance a person’s skill set for a job/career interest including the appropriate educational and training opportunities are identified.
	ISP – job objectives
Other employment information and objectives

Support Strategies – on site

Staff interview – on site

Individual interview	Individual and service related information on processes and activities are reviewed to identify whether employment has been discussed, goals have been identified by the individual based on a person centered process, and there is a plan to support the individual in achieving these goals.	Support needs have been identified based on the individual’s current interests, strengths and needs and there is a detailed written plan in place that addresses the individual’s goals and support needs and the individual has been presented with employment as an option.  
	Job goals and support needs have not been identified based on the individual’s current interests, strengths and needs; and/or there is not a detailed written plan in place that addresses the individual’s goals and support needs and/or the individual has not been presented with employment as an option.

DAY

C40. Individuals are supported to explore, discover and connect with their personal interest and options for community involvement, personal interest and hobbies.

Revised

Strengthen guidelines  	Regulations 7.03 (1) (b): Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously;

Guidelines:
Staff must assess individual likes and dislikes to begin determining what the individual wants to do during the day.  Staff must also expose individuals to other options so that they might broaden their interests and make more informed choices about what to do during the day.  It may be beneficial to offer a new activity several times before drawing a conclusion about whether the activity is something the individual likes or dislikes. 

Providers use a variety of means to explore interests including interest inventories, volunteer opportunity trials, offering of hobbies or access community based activities to identify interests etc. Exploration includes a broad spectrum of possibilities and methods for exploration are customized to the specific needs of the individual, such as communication and learning style and preferences.   

Staff need to fully assess people’s interests through a variety of mechanisms such as familiarity with the individual, interview, observation, picture books, and exploratory trips.  Staff need to drill down to what the individual wants to do, how frequently and to which establishments.  Technology, communication tools, and other assessments and discussions (with the individual and with the individual’s family, as available) should be utilized to assess the interests of individuals who cannot readily communicate their interests.  
Individuals’ interests and hobbies should be identified, and then explored on a frequent and individualized basis.  
	Staff Interview – on site

Individual interview and observation

Documentation – on site
	Review how staff support individuals in exploration, discovery and participation in varied cultural, social, recreational and spiritual activities to potentially broaden each individual’s knowledge and potentially broaden interests.
so they can make a more informed choice about what to do during the day.

Review any documentation that outlines/ explains individual interests.	Staff support individuals to determine what is of interest to the individual and support exploration, discovery and participation in  activities related to community involvement, personal interest and hobbies on a consistent and sustained basis. 

 	Staff do not support individuals to determine what is of interest to the individual and/or do not support exploration, discovery  or participation in  activities related to community involvement, personal interest and hobbies on a consistent and sustained basis.

	
DAY

C41  Individuals participate in activities, including those in the community, that reflect their interests and preferences.

Revised 

Strengthen guidelines	Regulations 7.03 (1) (b): Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously;

Guidelines:
Once individuals’ preferences and interests in community activities have been assessed and discovered, staff must support individuals in realizing these preferences and interests. 

Activities that occur on an individualized basis must be done as much as possible.  This allows for the greater possibility that activities are based on individuals’ expressed interests rather than the group’s.

Individuals in day services will generally need support and guidance to fully engage in activities in the community.  Community activities beyond simple commercial transactions such as shopping, picking up an item or, running an errand must be promoted.  	Staff Interview – on site

Individual Interview – on site

Individual Record, staff log, any activity documentation – on site
	Review if staff are knowledgeable about individual interests and are providing activities (including those in the community) based on the individual’s interest and choice.

Interview individuals to determine the match between the activities (including those in the community) that participate in and their preferences and interests.

Review any interests identified in the individual’s record or staff log and whether activities reflect that interest and are based on individual choice.

Review the frequency, variety, and the individualization of activities (including those in the community).	Staff provide frequent opportunities for activities (including those in the community) that are in line with the individual’s preferences and interests and staff can articulate a specific strategy or plan to promote community involvement and are implementing such plan.
	Staff do not provide frequent opportunities for activities (including those in the community) that are in line with the individual’s preferences and interests and/or staff cannot articulate a specific strategy or plan to promote community involvement and/or are not implementing such plan.	
DAY

 (Access and Integration) 

C42.  Individuals are involved in activities that connect them to other people in the community.

Strengthen guidelines
	Regulations 7.03 (1) (c) 1,2,4:  Community Membership: Opportunities for individuals to participate in and contribute to the life of their community.  Included are requirements that the provider shall: 1. assist individuals to participate in integrated recreational, social and leisure activities outside of the home in culturally typical settings and with other members of the community, consistent with the needs, desires, and choices of each individual; 2. assure that individuals have access to the same community services and resources used by other people; 4. locate work supports in an employment setting whose general design features do not emphasize the supports’ separateness or difference.

Guidelines
Staff must provide frequent opportunities for individuals to participate in activities that bring them into contact with the community at large.  This could include going out to lunch, going to the senior center or going to a community activity.  These activities need to provide opportunities for interactions with others in the community.Activities within the community are offered based on a person’s interests and at a frequency based on their preference.  Activities utilizing generic resources, and which are used by other community members should be promoted.   

When the individuals’ specific interests are not known, staff’s, home providers and volunteers’ own interests and community involvement may also provide entry into different activities that individuals wish to explore. Providers can develop an inventory of potential community activities to introduce individuals to through "mapping" what exists locally and by collecting information from others as to what their connections are to community organizations. This information can then be used to match individuals to activities based on interest and/or for exposure.

	Staff Interview – on site

Individual Record, Staff Log, other activity documentation – on site	Review what activities individuals do in the broader community and how frequently these occur.  Review if these activities provide opportunities to interact with others in the community.  

Review staff log, individual record, and any other documentation of activities afforded to the individual to determine if they occur at least 2 times per week and provide and opportunity for interaction with others in the community.	Community activities are provided on a regular basis and provide opportunity for natural interactions with others in the community.	Community activities are not provided on a regular and frequent basis and/or do not provide opportunities for natural interactions with others in the community are limited.
	
DAY

C43  Staff act as bridge builders to support individuals to develop, sustain and enhance relationships with others. 

Revised

Strengthen guidelines  	Regulations 7.03 (1) (d):  Relationships:  Support to develop and sustain varied and meaningful relationships with family, friends, neighbors and co-workers …

Guidelines
A first step in the support to develop, sustain and increase relationships is a familiarity with the individual’s interests in this area.  Staff must have knowledge of whom the individual likes/dislikes/would like to spend more time with.  Staff must use moments during the day, such as during social activities or lunch, to foster ongoing, reciprocal communication and relationship building.  For example, staff could support individuals to do an activity of mutual interest together.  

Opportunities to develop personal relationships can be supported through regular contact with people that share common interests, with people that the individual has identified as being friends, with people the individual works with,  and through time with people in the community through events and other activities (i.e., going to a restaurant/club, attending church).  

While individuals and staff may be social and friendly with each other, opportunities, as noted above, for developing personal relationships with people other than paid staff and family should be supported and encouraged by staff. 

In addition, individuals should be supported to increase personal relationships through such actions as supporting individuals to make arrangement to see people and to engage in activities that promote the development of relationships such as through invitations to the home and entertaining.

If problems are noted, staff must develop ways to address them, such as working with two individuals who are having difficulties with each other.  

Part of bridge-building means assisting the individuals to reach out to, talk/communicate with  `and to promote and advance their connections with others.  In addition to having a richer connection with other people who share their interests during the event or club, staff can facilitate the individual to have additional contact with others consistent with their desires, which may include exchanging information with other service providers to support desires.  For instance, staff could communicate to the residential provider about people that the individual has connected with as part of the day service to encourage friendship outside of day service hours.
	Staff Interview – on site

Individual Record/Staff Log – on site

Individual Interview – on site	Review staff knowledge of an individual’s needs in this area and how they support developing stronger relationships.

Review individual record and staff log to determine if there are issues in this area that are not being addressed.

Review if the individual has any friends at work.  Are there people he/she enjoys spending time with?  Review if the individual has opportunities to spend time with others.  Review if staff help in solving problems that develop.	Staff have knowledge of individuals’ interests in friendship or social contacts with specific individuals and are consistently supporting individuals to develop, sustain and/or increase opportunities for social contact.  Staff can articulate strategies and identify specific steps being taken towards this goal. 
	Staff do not have knowledge of individuals’ interests in friendship or social contacts with specific individuals and/or are not supporting individuals to develop, sustain and increase opportunities for social contact and/or opportunities are not provided consistently.  
	
DAY

C44  Staff have effective methods to assist individuals to explore their job interests if appropriate.	Regulations 7.03 (1) (b): Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously.

Guidelines
Agencies must utilize different means to explore individuals’ possible job interests.  While employment may not be a primary focus, job interests must be explored with the individuals.  This must include different vehicles to expose individuals to employment, and must be customized based on the individual’s learning style and needs.  These may include interest inventories, visiting different types of employment or volunteering at a place of interest.	Staff Interview – on site

Individual Record/Site Information– on site

Individual Interview – on site	Review if staff assist individuals to explore their job interest and if they customize that exploration based on the individual. 

Review process for exploring job interests and determine if it is based on the individual’s learning style, needs and preferences. 

Review if individual is interested in work and the type of work interest.  Review if staff revisit individual interests and any efforts to explore possible work goals.
	Staff have regularly assessed the individual’s job interests, and staff have explored with the individual those interests identified, and this is revisited at least annually.. 
	Staff have not regularly assessed the individual’s job interests, and /or staff have not explored with the individual those interests identified at least annually..

DAY

C45  Individual’s decisions of what to do during the day are revisited on a regular basis.

Strengthen guidelines  	Regulations 7.03 (1) (b): Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously.

Guidelines
Individual interests, including an interest in employment, must be revisited on a regular basis.  This must involve more than just asking the individual.  Efforts must be made to expose individuals to different options to consider before discussing their interest. Individuals must be supported to make choices in how they spend their time at the CBDS.

Individuals’ decisions of what to do during the day must be revisited periodically.  In addition, these daily choices must dove-tail with longer range interests and goals.  
	Staff Interview – on site

Individual interview – on site	Review how the staff support day to day choices by individual and what interests are encouraged and pursued  

Review with individual what they like to do during the day.  

Review whether this is revisited on a regular basis.	Staff on a regular basis (at least quarterly) revisit an individual’s interest in work or non-work activities, considering the individual’s learning style in presentation.

 	Staff do not revisit what an individual does during the day and/or do not expose the individual to different options for consideration on a regular basis considering the individual’s learning style in presentation.	
ALL BUT EMP

C46.  Staff support individuals to learn about and use generic community resources.	ACCESS AND INTEGRATION

CMS § 441.530 Home and Community-Based Setting.(a) (1) (i): The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.

Guidelines
In order to support individuals to learn about and use community resources, staff need to have a thorough understanding of local community resources such as where the (local) store(s), bank(s), restaurants, theatres, gyms, libraries, post offices, places of worship, and other community businesses are located.  Staff need to be knowledgeable about the driving, public transportation and walking routes to these community resources.  Staff need to be familiar and aware of upcoming community events.  In addition, staff need to be familiar with the specific places and events that are of interest to the individuals.

Engagement in commercial transactions such as shopping, picking up items, running errands, going to the bank, library and post office, must be promoted on a frequent and individualized basis.  Commercial transactions that do not promote community involvement, such as on-line shopping, or using the drive-through of a local coffee shop, should be limited, and replaced with community transactions and errands that more fully support community utilization.  

Full use of community resources means that while engaging in commercial transactions, staff should support the individual to use these resources in as independent and typical ways possible such as by taking the lead in greeting the cashier, making the purchase, checking in and out, and other exchanges. In addition, each individual’s preferences for where they want to shop, or engage in community activities need to be supported.

Staff support to use community resources includes support to individuals to maximize access to the same community resources as other people use.
	Staff Interview – on site

Documentation, including local newspapers, receipts, community calendars, library cards, and menus

Individual interview – on site	Review staff knowledge of community resources, community transportation, and events.

Determine frequency, type and variety of community transactions.

Review how individuals use community resources.	Staff support individuals to use varied community resources on a frequent and ongoing basis. 	Staff do not support individuals to use varied community resources  on a frequent and ongoing basis.	
ALL

C47. Individuals have full access to the community through transportation available and/or provided. 	CMS § 441.530 Home and Community-Based Setting.(a) (1) (i): The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.

Guidelines
Transportation to and from community resources and activities including work sites in the community, and transportation within the community is a key component in assuring community access and integration.  Individuals living in urban, rural, and suburban settings need to be provided with routine and ongoing ways to travel to activities and access the community.  This might include utilizing a provider vehicle, which is unmarked and indistinguishable from other vehicles typical in the community.  However, staff support in transportation is not limited to direct provision of transportation in provider vehicles.  Individuals need to have various mechanisms to get to community resources at the frequency and to the places desired.  Staff must facilitate the use of transportation, such as with friends, other natural supports, staff private vehicles, cabs, private cars, and public transportation (as available) including The Ride.  

Staff support individuals to become more independent in safely traveling within their community, such as by learning about and using public transportation or cabs, and supporting individuals to walk to and from resources and activities within the community, including work sites in the community.  Cell phones and other tools can be provided to ensure that individuals can independently travel to community activities, yet have a way to contact staff should the need arise.  	Staff Interview – on site

Individual interview – on site

Transportation / community logs and documentation such as vehicle information, bus passes, receipts for cabs	Assess what methods of transportation are utilized routinely to support individuals to travel to activities and access the community.  (provider vehicle; public transportation)

Assess what actions and measures staff take and at what frequency, to facilitate the use of transportation (eg supporting individual to travel by public transportation; familiarizing individual / supporting individuals to learn transportation routes; calling a cab).  
	Transportation is available and/or provided and/or arranged on a regular and frequent basis.	Transportation is not available and/or not provided and/or not arranged on a regular and frequent basis.	
RES

C48. Individuals are a part of the neighborhood.	CMS § 441.530 Home and Community-Based Setting.(a) (1) (i): The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.

Guidelines
To engage in community life, the first step is naturally to be a part of a neighborhood that is comprised of both people with and without disabilities. Staff must support individuals to interact informally with neighbors and other regular community visitors including mail carriers, delivery persons and sales people. Interaction should be in keeping with the neighborhood traditions and customs.

Individuals should be encouraged and supported to take part in events and activities that connect them to neighbors including people without disabilities. These activities may include formal activities such as block parties, clean up days or yard sales and more spontaneous opportunities to interact like walking/exercising, giving out candy at Halloween and doing yard work/chores. Individuals are supported to spend time outside of their home, weather permitting.

Staff should take opportunities to encourage individuals to meet and greet their neighbors, introducing themselves and waving.

Individuals should be supported to contribute to their neighborhood by offering to help neighbors (i.e, raking leaves, shoveling snow, walking pets, taking mail in). 

Neighborhoods are not always urban or walkable.  Support to individuals to be part of town and country neighborhoods might include such elements as attending the town beach; participating in block parties; familiarization and utilization of the town offices and polling places; hanging out at the local neighborhood/ community center or general store.  
	Observation

Staff interview

Individual Interview

	Assess routines and opportunities to interact with neighbors outside  throughout the year (eg during mail delivery or when getting home, in/ out of cars; during yard work, gardening, or shoveling; during walks) 

Assess staff supports to individuals to greet and interact informally with neighbors through the above routines and experiences. 
	Staff support individuals to develop connections with neighbors through regular opportunities.	Staff are not fully providing support to develop connections with neighbors.
	
RES

C49. The physical setting blends in with and is a natural part of the neighborhood and community. 	CMS § 441.530 Home and Community-Based Setting.(a) (1) (i): The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.

Guidelines
The home itself should be located in a neighborhood that is comprised of similar housing stock for people with and without disabilities. The home should have the appearance of any other home in the immediate neighborhood on the exterior.  There should be no features that distinguish it from other homes including fireboxes, exit/entrance signs, signs for the provider or lines painted in the driveway like a parking lot.

The home should not be isolated from other homes typical of the neighborhood.  The only fences should be in keeping with other homes in the immediate neighborhood.  

The home should not be located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment. Ideally, the home should not be located in a building on the grounds of, or immediately adjacent to, an operating public institution.  	Site review	Determine if setting is physically part of the neighborhood and broader community. 	Setting is in a neighborhood with similar housing stock and there are no features that distinguish it from other houses in the neighborhood and setting is not isolated from neighborhood.	Setting is not in a neighborhood with similar housing stock and/or there are features that distinguish it from other houses in the neighborhood and/or setting is isolated from neighborhood.	
EMP

C50. Individuals are supported to understand and become a part of the culture of the workplace (including workplace social activities and events).	CMS § 441.530 Home and Community-Based Setting.(a) (1) (i): The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings...

Guidelines

Creating a linkage between the individual and other employees of the work setting is an essential function of staff.  Staff need to support individuals to meet, get to know, talk with and work alongside fellow employees.  Individuals should be introduced to and known and respected by colleagues.  Staff must be knowledgeable of the specific social culture and climate of the industry in which a person works (e.g. formal, casual, personal, autonomous).  The provider can then assist the individual to understand the professional, social, and cultural expectations of their workplace.

Individuals should be encouraged and supported to connect and interact with other employees with and without disabilities, to the extent the individual chooses.  Staff must support individuals to interact with colleagues in keeping with the employment culture, through support to socialize with others during the conduct of business, taking breaks together, and eating meals together.  

Employment supports should be delivered in the least restrictive, most non-stigmatizing manner as possible in order to support the individual to blend in.  For example, consideration should be given to how job coach supports are delivered, as the level of support received from the job coach or the number of individuals served together, should not be a deterrent to contact with other employees.  

Staff need to support individuals to fit into the work culture, understand the work place dynamics, and to dress and act in accordance with the workplace norms.  

Individuals need to be supported to take part in workplace social activities and events consistent with their interests and preferences.  Staff need to work with employers to ensure that all employees are welcome/ invited to attend any after-hours company events, picnics, company sponsored sports events or parties. Staff need to facilitate an individual’s participation in events and activities that occur during non-employment hours, through working with the individual, family, residential staff, the company, and others to ensure actualization.   

Staff should ensure that individuals are supported to make and maintain relationships/friendships with co-workers outside of the workplace, as the individuals choose.  Staff need to assist individuals to identify their interests and preferences in social contact, and to make and actualize plans to see co-workers for such activities as movies, dinners out, or personal celebratory events such as weddings, showers, or parties.  
	Individual Interview

Staff Interview

Relevant documentation, if present, such as employee handbook, invitations	Determine the work place culture including the typical pattern of socializing during breaks and lunches and the frequency and types of social activities and events which occur. 

Assess staff’s familiarity with the workplace culture and what support they are providing to the individual to connect with and interact with other employees without disabilities.  	Staff are knowledgeable concerning the rhythms and culture of the work place, the individuals’ support needs in this regard, and are supporting individuals to understand and become part of this workplace culture.  	Staff are not knowledgeable concerning the rhythms and culture of the work place, and/or not familiar with the individuals’ support needs in this regard, and /or are not fully supporting individuals to understand and become part of this workplace culture.  	
ALL

(Choice, Control and Growth)

C51. Staff (Home Providers) are knowledgeable about individuals’ satisfaction with services and supports and support individuals to make changes as desired.
	CMS § 441.530 Home and Community-Based Setting.(a) (1) (v): Facilitates individual choice regarding services and supports, and who provides them.

Providers and staff regularly check in with individuals regarding their satisfaction with services and supports currently received through formal evaluation activities, ISP and other meetings and more informal discussions that may occur during the course of the day.  In addition, providers and staff provide information to individuals about who, at any time, they can talk to about satisfaction with or issues about their services and supports.

As providers and staff become aware of concerns, they respond quickly and appropriately to these concerns regarding staff, services or supports. Staff should make efforts to resolve such issues as arguments with housemates, dissatisfaction with choice of activities or preferences for staff assignments, informally through discussions with the individual.  Specifically, providers and staff support people to make changes within provider services. Providers and staff advocate for and support people to seek alternative placement or services including a different model of support if concerns cannot be resolved after efforts have been made.	Staff interview – on site

Individual interview – on site

Documentation such as house meeting minutes; house logs; progress notes; satisfaction information; interest information

	Determine individuals’ preferences and satisfaction with activities, services, housemates, staff assignments and supports.

Determine staff’s knowledge and familiarity with  the individuals’ satisfaction with  above. ,. 

Review how staff supports the individual to increase satisfaction within the home.  

Assess whether the staff communicates / advocates for / supports the  individual to make a change in services or supports as needed or desired. 
	Staff are familiar with and knowledgeable concerning individuals satisfaction and staff support the individual by making changes  to improve satisfaction and staff supports the individual to make a change if desired.	Staff are not familiar with and knowledgeable concerning individuals satisfaction and /or staff do not support the individual by making changes to improve satisfaction and/or staff do not support the individual to make a change if desired.	
RES

 (Choice, Control and Growth)

C52. Individuals have choice and control over their leisure and non-scheduled activities.	CMS § 441.530 Home and Community-Based Setting. (a) (1) (vi) (C) Individuals have the freedom and support to control their own schedules and activities...

Imbedded in the definition of home and home life is the recognition that individuals should be able to exercise choice and control over not only household activities but also leisure and non-scheduled activities. Individuals must be supported to make choices in how they spend free time at home, such as what craft or hobby the individual would like to engage in or to learn. 

This choice and control is evidenced in many ways. Individuals can go into any common area of the setting when they want to. Individuals can pick what they want to watch on television or listen to on the radio. Staff are not watching the shows that they prefer. Staff are able to accommodate spontaneous requests for trips or make provisions to be responsive within a reasonable period of time. Schedules for trips and outings as well as leisure activities in general are determined by individuals, not for or by the convenience of staff.   

For settings in which a group of individuals live, staff should facilitate decision making around shared activities both inside and outside of the setting.	Staff Interview – on site

Individual Interview – on site

Observation and site review	Determine individuals’ preferences of leisure and non-scheduled activities. 

Review staff knowledge of individual preferences in leisure and non-scheduled activities in and out- side of the home and how these preferences are supported.  

Determine how staff are supporting individuals to make choices leisure and non-scheduled activities individually and as shared group activities.	Staff are knowledgeable about individual choices related to leisure and non-scheduled activities and support those choices and leisure and non-scheduled activities are determined by the individuals,  including individual activities and shared activities.
	Staff are not knowledgeable about individual choices related to leisure and non-scheduled activities and/or staff do not support those choices and/or leisure and non-scheduled activities are not determined by the individuals,  including individual activities and shared activities.
	
RES

 (Choice, Control and Growth)

C53. Individuals are supported to have choice and control over what, when, where and with whom they want to eat.	CMS § 441.530 Home and Community-Based Setting. (a) (1) (vi) (C): (C) Individuals … and have access to food at any time.

Staff support individuals to make choices and have control around food and dining.  Food preferences are honored. Individuals do not have to eat a certain meal because it was the meal prepared. Alternatives are readily available should an individual choose to eat something else. Food is available at all times.

Individuals are involved with food shopping, either by going on shopping trips and/or making requests of others going shopping, and meal preparation as they choose. Food choices are not guided by staff preferences, but are individual controlled.  Cultural, religious and ethnic traditions and customs related to food and dining are embraced. 

While there is no fixed mealtime schedule to which everyone must adhere, individuals may jointly decide a dining schedule that works for them.  Individuals do not have to ask if they can have a snack.  In terms of choosing where to eat, there is no assigned seating in the house and individuals are not required to eat in the dining room.

Individuals with specific clinical dietary requirements (documented in the person-centered plan) have choice and control within those requirements. For individuals with no such clinical restrictions, while education/training must be provided related to healthy eating, less healthy choices can be made by individuals.  Staff support individuals to balance dietary risks and make informed food choices.
	Observation

Individual interview

Staff interview

Documentation review

	Determine the individuals’ food preferences and preferred dining times, the people to dine with, and location for eating.  

Determine staff’s knowledge of individual’s preferences and the support given to actualize these preferences.

Assess what current practices are and how choices over what, when and with whom one eats are made.  	Staff are knowledgeable concerning individuals choices and preferences over what, when, where and with whom they want to eat and staff support these preferences and decisions are individually driven rather than staff controlled.	Staff are not knowledgeable concerning individuals choices and preferences over what, when, where and with whom they want to eat and /or staff do not fully support these preferences and/ or  decisions are not individually driven.	
ALL

(Choice, Control and Growth)

C54. Individuals have the assistive technology and/or modifications to maximize independence.	CMS § 441.530 Home and Community-Based Setting. (a) (1) (vi) (E): The setting is physically accessible to the individual.

CMS § 441.530 Home and Community-Based Setting. (a) (1) (iv): Optimizes but does not regiment individual initiative, autonomy, and independence in making life choices.

There are many occasions in which use of technology or assistive device can aid in fostering someone’s independence.  Assistive technology is a great equalizer and includes not only computers and high tech devices, but every day technology and low tech items such as smart phones, cameras, day planners, highlighters.  For example, an individual who receives hand over hand assistance to shave may be able to independently shave with an electric razor.  The provider should review and assess the individual’s needs to determine whether the individual would benefit from any assistive tools and devices.  Targeting a particular area in which the individual desires increased independence, and then exploring AT technology options, can assist in overcoming limitations.  
Assistive technology and modifications are provided to encourage, teach, communicate and foster maximum independence in home routines and activities. With the use of any necessary assistive technology, staff support individuals’ development of skills on a routine and ongoing basis. Examples of assistive technology include but are not limited to computers, electric toothbrushes, and alarm clocks.  

Even given health issues, there are very few circumstances in which the promotion of greater independence and the development of home/personal care skills cannot occur. 	Observation

Site review

Individual interview

Staff interview	Review whether  staff have fully assessed the individual’s needs and identified the need or benefit of any assistive technology.  
	Individuals have been assessed to identify any assistive technology that may be of benefit and assistive technology and modifications to maximize independence are provided when needed.	Individuals have not been assessed to identify any assistive technology that may be of benefit and/or assistive technology and modifications to maximize independence are not provided when needed.