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Home and Community-Based (HCB) Settings Quality Review

The Home and Community-Based (HCB) Settings Quality Review 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.  This process is the precursor to Centers for Medicare and Medicaid Services (CMS) process of "Heightened Scrutiny." CMS resources on Heightened Scrutiny:

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. Please read the additional Updated Frequently Asked Questions (FAQ) on the Heightened Scrutiny process from CMS , questions 4 and 8, on how the state must submit that information.

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 institutional 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.

Please see the Updated Frequently Asked Questions (FAQ) on the Heightened Scrutiny process from CMS, Question 2, on how CMS defines settings that isolate.

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.

DDSN Providers: an overview of the process can be found here.

Stakeholder feedback process - link to webinar and transcript

New Guidance issued by CMS March 22, 2019

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

DDSN Providers, refer to the charts below for guidance on evidence to compile for settings in the HCB Settings Quality Review Process:

  • Residential Settings
  • Non-Residential Settings
    • The "Promising Practices" is information for providers looking for new ways to reimagine their service delivery and operations to achieve HCBS compliance and individualize services for waiver participants
    • The CMS Exploratory Questions are there to guide providers on ways to shift or change their settings and programs toward HCBS compliance

Specific Residential Setting Requirements

Other evidence that will be utilized includes:

  • HCBS Compliance Action Plans (CAPs)
  • Current compliance/contract 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 HCB Quality Review.  Based on 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 must be submitted to CMS for final heightened scrutiny review, per the new requirements as listed in the Updated Frequently Asked Questions on the Heightened Scrutiny Process . 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 list of settings submitted to CMS for heightened scrutiny review will be made available for public comment per CMS requirements.  CMS will select a random sample of settings to review from the full list of settings submitted for heightened scrutiny.  The state must provide an evidence package to CMS for each of those settings they selected to review. This evidence will be included in the amended Statewide Transition Plan as appendices.

Please see all updates and public notice information on the Statewide Transition Plan.