District of Columbia Personal Experience Assessment for Residential Services Regarding Compliance with the CMS HCBS Settings Rules
Introduction

This is survey that people with intellectual disabilities who receive residential waiver supports, their families, and their advocates can use to help provide DDS with information about your experience with receiving 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.
1People help you in private, when appropriate.

2You know how to file an anonymous complaint (without telling your name)

4Staff does not talk about your private information in front of other people.

5Staff in your home calls you by your name or a nickname that you like.

3Your health information or other personal information (mealtime protocols, therapy schedules) is kept private.
(b)  The home optimizes a person’s initiative, autonomy, and independence in making life choices.
6You make your own schedule and can decide when to get up, take a bath or shower, and what activities you want to participate in.

7You 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.
8Staff in your home knows what is important to you and what is important for you so that they can help you get what you need and want.

9You 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.
10You have the help you need to get a job, if you want one.

11You know about and are able to participate in activities that are important to you and your community.
(e)   The home is integrated and supports access to the greater community.
12You receive the support you need to see your family and friends and spend time doing what you’d like to do in the community.

13You can get training on how to use public transportation, if you would like it.
(f)   The home provides opportunities to engage in community life.
14You get to do things like go shopping, go to church or temple, or go out to lunch with friends and family.
(g)  The home provides opportunities to control personal resources.
15You are able to get your money whenever you want to and do not have to ask in advance when you need to get your money.
(h)  The home provides opportunities to receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS.
16You 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.
17You get to choose where you live and know how to ask for a change in where you live if you want to.

18You know how to request a private bedroom, if you want one.
(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 have a lease or written agreement for your home that explains eviction and your appeal rights.
(k)  If provider-owned or controlled, the home provides the same responsibilities and protections from eviction as all tenants under landlord tenant law of state, county, city or other designated entity.
20You know your housing rights and when you might be required to move and what your rights are should you be asked to leave your home.
(l)    If the home is provider-owned or controlled  and the tenant laws do not apply, the state ensures that a lease, residency agreement or other written agreement is in place providing protections to address eviction processes and appeals comparable to those provided under the jurisdiction’s landlord tenant law.
21You know how to ask for a new place to live.
(m) If provider-owned or controlled, the home provides that each person has privacy in their sleeping or living space.
22You can have private phone calls or send emails privately, if you want to.

23People knock before coming into your room.
(n)  If provider-owned or controlled, the home provides units with lockable entrance doors, with appropriate staff having keys to doors as needed.
24You can close and lock your bedroom and bathroom doors.
(o)  If provider-owned or controlled, the home provides people who are sharing a place to live with a choice of roommates.
25You can choose a roommate and know how to ask for a new or different roommate if you want one.
(p)  If provider-owned or controlled, the setting provides people with the freedom to furnish and decorate their sleeping or living space within the lease or other agreement.
26You can decorate your room if you want and can change the decorations whenever you want.
(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.
27You can eat what you want and decide when and where you would like to eat.

28You are able to make your own schedule and can come and go as you want to.

29You can ask for something else to eat, if you do not like what is served for lunch.

30You 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.
31You can have visitors whenever you would like them.
(s)   If provider-owned or controlled, the home is physically accessible to the person.
32You have full access to the kitchen, dining area, living room, laundry, and all other common areas of your home.

33You are able to move around your home whenever you need to because you have all of the supports you need to do that, such as grab bars and ramps.