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HCB Settings Review

Home and Community-Based (HCB) Settings Quality Review 

An overview of the process can be found here.

The Home and Community-Based (HCB) Settings Quality Review, referred to by the Centers for Medicare and Medicaid Services (CMS) as "Heightened Scrutiny", is the process of identifying home and community-based (waiver) settings that are presumed to have the characteristics of an institution. This is for day (non-residential) and residential settings. If institutional characteristics are present, the setting is subject to more intense review (scrutiny) by the state.

Using the criteria in 42 CFR 441.301(c)(5), South Carolina Department of Health and Human Services (SCDHHS) will gather data on settings to determine whether the settings have home and community-based qualities.  If SCDHHS determines that any of the settings are presumed institutional, but have home and community-based qualities, those settings will be submitted to the Center for Medicare and Medicaid Services (CMS) for final heightened scrutiny review.

Institutional characteristics of settings as defined by 42 CFR 441.301(c)(5)(v) include:

  • Settings located in a building that is also a publicly or privately operated facility that provides inpatient insitutional treatment; OR
  • Settings in a building on the grounds of, or immediately next to, a public institution*; OR
  • Settings that have the effect of isolating individuals receiving Medicaid HCBS (waiver services) from the broader community of individuals not receiving Medicaid HCBS.

*A public institution is defined as an inpatient facility that is financed and operated by a county, state, municipality, or other unit of government.

For any setting that SCDHHS determines is subject to heightened scrutiny, SCDHHS will request that the provider produce evidence that the setting does not have institutional qualities and either does meet or could meet, with corrective action, the HCB settings requirements.

Providers should not submit evidence that focuses on the aspects and/or severity of the disabilities of the individuals served in the setting (from: CMS Webinar (Oct. 23, 2015). Home and Community Based Settings, Excluded Settings, and the Heightened Scrutiny Process).

SCDHHS will notify providers in advance that they will be subject to the heightened scrutiny process so the provider may prepare evidence that supports the specified setting as being home and community-based.

Suggested Documentation and Information to Provide as Evidence for HCB Settings Quality Review by SCDHHS

Specific Residential Setting Requirements

Other evidence that will be utilized includes:

  • Provider self-assessment
  • Site visit documentation
  • Interviews with waiver participants who utilize the setting/live in the home
  • Information received through the public input process

SCDHHS will review all evidence submitted regarding a setting's quality (heightened scrutiny) review.  Based upon this evidence, SCDHHS will determine one of the following:

  1. The setting is institutional and will not be allowed to continue as an HCBS (waiver) provider.
  2. The setting is not institutional, but needs corrective action to come into compliance with the new HCBS requirements.  Settings in this category will not be submitted to CMS for final heightened scrutiny review.
  3. The setting must be submitted to CMS for final heightened scrutiny review.  Settings that SCDHHS submits to CMS for their review are settings that are presumed institutional, but SCDHHS has determined they have home and community-based qualities.  These settings will need final review by CMS to be allowed to continue as a HCBS provider.  These settings may also need corrective action to come into compliance with the new HCBS requirements.  CMS will make the final determination of whether the setting can continue to be a HCBS provider.

The evidence for settings submitted to CMS for final heightened scrutiny review will be made available for public comment per CMS requirements.  This evidence will be included in the amended Statewide Transition Plan.  The amended Statewide Transition Plan will include SCDHHS' final categorization of settings (day and residential) for HCBS compliance into the following categories:

  • Fully comply with federal requirements
  • Do not comply - will require modifications
  • Cannot meet requirements - will require removal from the program/relocation of individuals
  • Subject to Heightened Scrutiny

Providers can submit materials to SCDHHS in two ways:

South Carolina Department of Health and Human Services
Attn: Kelly Eifert, Ph.D.
1801 Main Street
PO Box 8206
Columbia, SC 29202-8206
Providers can contact Kelly Eifert or Cassidy Evans for any questions related to this process at HCBSAssessments@scdhhs.gov 

 

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