HCBS Requirements Modification Addendum to the Person-Centered Plan (PCP) Applicability: Sections 21 and 29 Waivers

Background Information

Case Managers use this form:

When a person is receiving or will start receiving HCBS Section 21 or Section 29 services in a residential setting; AND

The person needs a modification to an HCBS requirement when they are receiving services in the residential setting; AND

The HCBS Modification(s) do not relate to a “Challenging Behavior”.

Important: Modifications related to a “Challenging Behavior” require compliance with 14-197 CMR ch.5.

For ALL Provider-Owned or Controlled RESIDENTIAL Settings, HCBS requirements that may be modified include a Member’s:

freedom to have an individualized schedule and activities, selected by the person and supported by the provider. Global Settings Rule § 6.04(B)(3).

access to food at any time. § 6.04(B)(3).

ability to choose his/her own visitors and times when visits occur. § 6.04(B)(4).

choice of housemate(s) and roommate if sharing a living unit and/or a bedroom. § 6.04(B)(2)(b).

freedom to furnish and decorate their living unit and bedroom as they choose. § 6.04(B)(2)(c).

ability to have lockable entrance door(s) to the person’s living unit (and bedroom if the person shares a living unit with unrelated individuals), and only the individual and appropriate staff have keys to door(s). § 6.04(B)(2)(a).

The HCBS Modification must:

Be based on specific and individualized assessed needs identified in an assessment of the individual.

Be necessary to ensure the health, safety, and well-being of the person.

Be properly documented with supporting information in the Person-Centered Service Plan.

Be approved by the person and/or legal guardian through informed consent.

Assure that the interventions and supports will not cause any harm to the Member.

An HCBS modification may additionally require the use of an approved Safety Device (e.g., a locked cupboard/refrigerator for the purpose of keeping a person with uncontrollable eating impulses from dangerous eating habits, and supported by a medical diagnosis of a related disability, such as pica or Prader-Willi syndrome), which requires a written recommendation from a physician and a Safety Device Plan approved by the Planning Team and the Review Team.

This Addendum must be completed and retained in Person’s paper file

which thereby makes it an attachment to the Person-Centered Plan.

Which Residential Settings Are Provider Owned or Controlled?
Setting Type	Section 21/29 Waiver
Residential: Provider Owned or Controlled	Group Home Provider-Owned Residence Provider-Leased Residence Shared Living-Unrelated Provider Family-Centered Home
Residential: Not Provider Owned or Controlled	Member(s) own home Relative owns home Member/relative rents from third party (not provider) Shared Living-Related Caregiver

Part A. Basic Information [Completed by Case Manager]

Person
Last Name:	Enter Value	First Name:	Enter Value
EIS #:	Enter Value	Effective Date of Modification(s):	Enter Value
Case Manager
Agency Name:	Enter Value
Last Name:	Enter Value	First Name:	Enter Value

Part B. HCBS Modification [Completed by Case Manager]

Then forwarded to Provider via secure email. If necessary, can be delivered via fax, regular mail, or hand delivery.

The Case Manager documents required HCBS modifications here. (The modification must be based on an assessed need, and necessary to ensure the health, safety, and well-being of the person.)

Identify each HCBS modification based on a Member’s assessed needs. (Check all that apply):

During the delivery of HCBS in any type of Provider Owned or Controlled Residential Setting:

☐ A.	Freedom to have an individualized schedule and activities, selected by the person and supported by the provider.

☐ B.	Access to food at any time.

☐ C.	Freedom to choose his/her own visitors and times when visits occur.

☐ D.	Choice of housemate(s) and roommate if sharing a living unit and/or a bedroom.

☐ E.	Freedom to furnish and decorate their living unit and bedroom as they choose.

☐ F.	Ability to have lockable entrance door(s) to the person’s living unit (and bedroom if the person shares a living unit with unrelated individuals), and only the individual and appropriate staff have keys to door(s).

(Part B is continued on the next page.)

(Part B is continued below.)

Identify why the HCBS modification(s) is required—Detail how the assessed need for each modification has been identified. (The modification must be based on the person’s health and/or safety need(s) identified in a current assessment. This may be an initial assessment or reassessment by the Case Manager, an assessment by an HCBS Provider or a Specialist Provider involved with the person.)

Modification (Fill in row below if letter checked in Question 1 above.)	Assessed Need What is the specific assessed health and/or safety need(s) Who completed the assessment that identified the need(s) When was the assessment completed that identified the need(s) Include diagnosis/condition, if applicable
Example: B. Access to food at any time	Matt has Prader-Willi syndrome, a condition that causes him to ingest large quantities of food. Matt’s physician, Dr. Smith confirmed his diagnosis in his annual physical exam on 6/20/2020.
Freedom to have an individualized schedule of activities, selected by person and supported by provider	Enter Value
Access to food at any time	Enter Value
Freedom to choose visitors and times when visits occur	Enter Value
Choice of housemate(s) and roommate if sharing a living unit and/or bedroom	Enter Value
Freedom to furnish and decorate living unit and bedroom as the person chooses	Enter Value
Ability to have lockable entrance door(s) to living unit (and bedroom if person shares unit with unrelated individuals); and only the individual and appropriate staff have key(s).	Enter Value
Residential Setting and HCBS Waiver Provider
Describe Setting where modification(s) will be used:	Provider Name (Organization, if applicable):
Enter Value	Enter Value
Provider contact to receive this form (First & Last Name):	Primary contact email:
Enter Value	Enter Value

Part C. HCBS Provider Responsibility [Completed by the Residential Waiver Service Provider]

Then this Addendum is returned to the Case Manager via secure email. If necessary, can be delivered via fax,
regular mail, or hand delivery.

The Residential Service Provider must complete this section. The person (and legal guardian if applicable) and Case Manager will review the modification plan proposed by the Service Provider and consider its approval. The provider plan must:

Ensure the HCBS modification is implemented in the least restrictive manner necessary to protect the person, as described in this Plan.

Provide support to reduce or eliminate the need for the modification as soon as feasible.

Provide updates on the implementation and effectiveness of this Plan to the person and Case Manager when requested.

Residential Setting and HCBS Waiver Provider
SETTING ADDRESS WHERE MODIFICATION WILL BE USED:	PROVIDER NAME (ORGANIZATION IF APPLICABLE):
Enter Value	Enter Value
PRIMARY CONTACT FIRST NAME:	PRIMARY CONTACT LAST NAME:
Enter Value	Enter Value

Service Provider should select (click on) the HCBS modification(s) listed below that are selected in Part B.1 above as needing modification. Complete the six required questions to create the plan for implementation of the HCBS Modification.

A.	Freedom to have an individualized schedule and activities, selected by the person and supported by the provider

B.	Access to food at any time

Freedom to choose his/her own visitors and times when visits occur

Choice of housemate(s) and roommate if sharing a living unit and/or a bedroom

Freedom to furnish and decorate their living unit and bedroom as they choose

Ability to have lockable entrance door(s) to the person’s living unit (and bedroom if the person shares a living unit with unrelated individuals), and only the individual and appropriate staff have keys to door)

Part D. Person’s Informed Consent

Your signature (or mark) shows that you participated in and understand the HCBS Modification(s) that your Case Manager and Provider documented in this form. You decide whether to agree to or not agree to each of these HCBS Modification(s). If you agree, you can change your mind at any time. You also can ask your Case Manager for a review discussion on a Modification at any time.

The reason for the HCBS Modification(s) has been explained to me in a way that I understand. I also understand how my Provider will provide the Modification to ensure my health, safety, and well-being.

Your options:

☐ I approve of the HCBS Modification(s) identified in this Plan, which is part of my PCP.

or

☐ I refuse any HCBS Modifications.

Person	Date
Legal Guardian (Legally Appointed Decision-Maker)	Date

Challenging Behavior is defined as behavior that: A. presents an imminent risk to the health and safety of the person or the community; or B. presents serious and imminent risk of damage to property of the community; or C. seriously interferes with a Person’s ability to have positive life experiences and maintain relationships. 14-197 CMR ch.5.02-9.

Provider-owned or Controlled Residential Setting is defined as “[a] specific physical place in which a Member resides that is owned, co-owned, and/or operated by a provider of home and community-based services. MBM, Ch. 101, Ch. I, Sec. 6, § 6.02(F).

The Global Settings Rule is codified at 10-144 C.M.R. ch. 101, ch. I, Section 6.

Safety Device is defined as an implement, garment, gate, barrier, lock or locking apparatus, video monitoring or video alarm device, helmet, mask, glove, strap, belt, protective glove, limited to the person in question whose effect is to reduce or inhibit the person’s movement in any way with the sole purpose of maintaining the safety of the person. 14-197 CMR ch.5.02-46.