Instructions:

As a provider of NC Innovations – Residential Supports, Day Supports, and Supported Employment or CAP/DA/CAP CHOICE – Adult Day Health Services and Coordinated Caregiving, an HCBS provider self-assessment must be completed as follows:

• One per site for Residential, Day Supports, Adult Day Health, Coordinated Caregiving, (b)(3) services (Residential and Day Supports), and (b)(3) DI Services (Residential and Day supports).
• One per corporate site and a minimum of 10 work site assessments or 10% (whichever is greater) during the initial provider self-assessment process (July 15, 2015 – September 15, 2015) for NC Innovations Supported Employment, (b)(3) Supported Employment, and (b)(3) DI Supported Employment.
• One per Corporate Site for new or acquired providers needing to submit a Supported Employment Corporate Site assessment

*Note, providers are no longer required to submit a provider self-assessment for any new Supported Employment work sites. Supported Employment should only be provided in competitive, integrated settings and therefore, new Supported Employment work sites should meet such requirements.

Assessments must be submitted, to the appropriate LME-MCO/Local Lead Agency electronically.

The assessment, unless otherwise noted by responses to Section I - Question 1, must be completed in detail and entirety.

Please Note:

• Day Supports, Adult Day Health and Supported Employment providers must complete Demographic information, Section I and Section II – General HCBS Criteria, but are not required to complete Section III.
• Residential and Coordinated Caregiving Providers are required to complete Demographic information, Sections I, II and III of the assessment.
• Evidence of a provider’s ability to meet an individual characteristic must be clearly described and must include noted examples by the corresponding characteristic/number.
• Each provider must maintain examples of evidence for each of the characteristics, for review by the designated authority, but is not required to submit the information upon completion of the assessment.
• If an individual characteristic is not presently met in its entirety, a plan of action/improvement must be included by the corresponding characteristic/number.
• It is recommended that the Companion Document (PDF) be utilized as a point of reference in the completion of the self-assessment.

NO ePHI is to be entered on this form. This is a site assessment only and questions should be answered specific to the site and not the individual(s) served.