District of Columbia Personal Experience Assessment for Day and Vocational Services Regarding Compliance with the CMS HCBS Settings Rules

Introduction

This is survey that people with intellectual disabilities who receive waiver supports, their families, and their advocates can use to help provide DDS with information about your experience with receiving day and vocational/ employment services and supports. DDS will also be asking people these questions through our Service Coordination monitoring. However, people and their families may also want to fill these out on their own. You may give a completed copy of the survey to your service coordinator.

Preliminary Information
Person’s Name: Person’s Contact Information:
Person's Phone Number: Person's Email Address:
Service Type: (e.g. Residential Habilitation, Supported Living) Service Coordinator:
Please provide a list of people who participated in the assessment process (Max 3000 characters)

Question DescriptionHow Important is this to the Person? (1-5 or N/A)How Often does
the Person Get to Experience This?
(1-5 or N/A)Comments & Feedback
(Max 2000 characters)
(a)   The home ensures a person’s rights of privacy, dignity, respect and freedom from coercion and restraint.
1You are comfortable discussing your concerns with staff at your day or vocational program.

2People help you with your personal needs in private.

3You know how to file an anonymous complaint (without telling your name).

4Your health information and other personal information (mealtime protocols, therapy schedules) are kept private.

5Staff do not talk about your private information in front of other people.

6Staff at the day program or vocational program calls you by your name or a nickname that you like.
(b)  The home optimizes a person’s initiative, autonomy, and independence in making life choices.
7You make your own schedule and can decide what activities you want to participate in.

8You have opportunities to learn about and participate in self-advocacy groups (such as Project Action!)
(c)   The home facilitates individual choice regarding services and supports, and who provides them.
9Staff knows what is important to you and what is important for you so that they can help you get what you need and want.

10You have the information you need to choose your own providers, including your doctors.
(d)  The home provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources.
11Your program helps you to look for a job in the community, if you want one.

12You know about and are able to participate in activities that are important to you in the community.
(e)   The home is integrated and supports access to the greater community.
13Your program is located among local shops, businesses and recreational areas.

14You can get training on how to use public transportation, if you would like it.
(f)   The home provides opportunities to engage in community life.
15You do volunteer work, go to classes, have lunch with friends and family schedule appointments, etc. in the community as you choose.
(g)  The home provides opportunities to control personal resources.
16If you are working, you can take your paycheck to the bank to be cashed or deposited, if you want.
(h)  The home provides opportunities to receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS.
17You have the help you need to go and do activities that you would like to do in the community such as going to parks, recreation centers, etc.
(i)    The home is selected by the person from among options including non-disability specific homes and a private unit in a residential setting.
18You know how to choose what kind of day or vocational supports you receive and change them if you want to.
(j)    If provider-owned or controlled, the home provides a specific unit or dwelling that is owned, rented, or occupied under a legally enforceable agreement.
19You can use the phone or computer privately, with or without support, if you want to during breaks or lunch time.
(m) If provider-owned or controlled, the home provides that each person has privacy in their sleeping or living space.
20Staff always knocks before entering if you are in a bathroom or a room where you are changing your clothes.
(n)  If provider-owned or controlled, the home provides units with lockable entrance doors, with appropriate staff having keys to doors as needed.
21You have a secure place to lock your personal belongings during the day.
(q)  If provider-owned or controlled, the home provides people with the freedom and support to control their schedules and activities and have access to food any time.
22You are able to have a meal at the time and place of your choosing.

23You are able to make your own schedule that focuses on what you need and what you want to accomplish in your life.

24You are able to choose to participate in activities that you like doing.

25You can have a snack if you want, unless you have a medical condition that may require restrictions.
(r)   If provider-owned or controlled, the home allows people to have visitors at any time.
26Your day program or vocational program allows visitors.
(s)   If provider-owned or controlled, the home is physically accessible to the person.
27You have full access to all common areas of the day or vocational program.

28The program location is fully accessible to you (bathrooms, break rooms) and meets your needs including having supports as needed, such as grab bars and ramps.