2. Is the facility in one of the following locations?
SPECIAL NOTE FOR SECTION II AND SECTION III:
All elements for each characteristic must be met for the response to be Yes. Evidence of support should be maintained, by the provider, in circumstances where element(s) of a characteristic is/are met, but a plan of action/correction is required for any element(s) that is/are not met. This will ensure monitoring only occurs for the area(s) that is/are out of compliance.
Section II: General HCBS Criteria
I certify that the above information is true and correct. I further understand that any false or misleading information may be cause for denial or termination of participation as a Medicaid Provider.
The following special characters are permitted within the assessment: , . : ( ) - & / ; \
Any use of additional special characters will result in an assessment error preventing submission.