Appendix VI: NF-based LOC System Heightened Scrutiny ...€¦ · NF-based LOC System Heightened...

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Appendix VI:

NF-based LOC System Heightened Scrutiny Evidence Packages: Non-Residential

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Ohio Department of Medicaid HEIGHTENED SCRUTINY EVIDENCE PACKAGE

Setting Information Provider’s Name Daybreak Adult Day Care and Transportation Location of the Setting McArthur, Ohio

Type of Setting Adult Day Center

Number of Individuals Served at the Setting 4 Waiver

Waiver Services Being Provided at the Setting Adult Day Service

Heightened Scrutiny Prong

Recommendation As required by 42 CFR 441.301 (c) (5), the State of Ohio submits this request for heightened scrutiny review for the setting identified above. The State has compiled evidence that the setting is integrated and supports full access of individuals to the greater community, is selected by the individual from among disability and non- disability-specific settings, ensures individual rights, and promotes individual initiative, autonomy, choice, and independence.

Section One On Site Visit Observation Date(s) Conducted 1.27.2017

State Agency that Conducted the On-Site Visit Ohio Department of Aging

Description of the Setting

Bryan L. Casey DBA Daybreak Adult Day Care and Transportation is a privately-owned limited liability company in McArthur, Ohio. The setting is in the rural area just north of downtown McArthur. Daybreak Adult Day Care, hereafter ADC or setting, is co-located with a nursing facility (NF), which is owned by Continuing Healthcare Solutions, a separate entity leasing to the ADC. The ADC had a census of four waiver individuals when state staff conducted their onsite observational review. Individuals on PASSPORT attend one to five times a week from four to eight hours at a time, depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

There is not an exterior sign identifying the setting or the NF from the main road. The setting is in a two-story brick building located off the main road and is about two miles from shopping, restaurants, and entertainment. The setting is located among a few private homes and businesses with woodlands around the setting. Once one enters the driveway, there is an exterior sign identifying the NF, not the ADC.

There is a blacktop driveway leading to the NF parking lot with a small walkway leading to the main entrance of the NF. Once inside the main entrance, there are hallways leading to the NF and an elevator individuals, staff, and visitors take to the ADC on the second floor.

✔Prong 1: Setting is in a publicly or privately operated facility that provides inpatient institutional treatment.

Prong 2: Setting is in a building on the grounds of, or adjacent to, a public institution.

Prong 3: Setting has the effect of isolating individuals from the broader community.

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Once exiting the elevator on the second floor, the setting is through a separate unlocked door. Once through the setting door, there are tables, chairs, a TV, a few recliners, and a small kitchen area. There are a few games, puzzles, and books nearby on bookshelves. Located at back of the room is a large bathroom for individuals attending the ADC. The setting offers a phone for individuals to use in private, if needed.

The ADC serves snacks and meals during the morning and afternoon. Individuals can request something to eat at any time of the day. Daily meals for individuals are prepared in the NF kitchen and brought to the ADS for individuals. There are alternatives meals available, if requested.

There are materials posted throughout the setting which describe community and planned activities and events for individuals. The setting plans at least 2-3 outings a month in the community. Outings include trips to the movies, restaurants, shopping, parks, lakes, and to Old Man’s Cave. There is a small downtown, with a Dollar Store, which individuals enjoy visiting-. The setting offers several daily activities such as arts and crafts, card games, exercise time, traditional jigsaw puzzles and word puzzles. During the on-site visit, some individuals were observed playing cards with friends and staff and others were watching TV, reading, and relaxing.

The setting offers transportation to individuals during outings and other local events. Family members and friends are also available to assist with transportation needs as well. The setting helps facilitate transportation of individuals when needed. There is no public transportation in the area, but individuals may use providers such as Vinton County Senior Citizens, AHOY Transport, Jackson-Vinton Community Action, and other transportations providers. There is a list of transportation providers posted on a bulletin for individuals to view in the ADS.

ADC staff are separate from NF staff and receive training in several areas depending on staff and position. Some of the training includes Resident Rights, Person Centered Care, Food Handling, and Freedom from Coercion and Restraint. Staff training takes place semi-annually and in person.

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Section Two Community Integration Observations and Input from Individuals, Family Members/Guardians, and Staff

Three individuals were interviewed during the on-site visit. They were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. All three indicated they had been attending the setting for quite a while and enjoy it. One individual mentioned he liked the setting and everyone likes him too. Another stated if he needed anything the staff will get it. The three individuals stated they felt comfortable addressing staff with any concerns or issues and if they need anything, staff are always available when needed. They were all in agreement the staff respect their privacy and always shuts curtains and doors, when applicable, and talk to individuals in private. They each stated the food is good and snacks are available anytime. One individual stated she can make phone calls in private when she wants and all agreed they can have visitors anytime. The individuals enjoy the outings provided by the setting. One individual stated, the setting takes them to the movies, to the park, to lakes, Old Man’s Cave, and shopping downtown at the Dollar Store. Another mentioned they sometimes go to Logan, Jackson, or Athens where there is a Kmart, Walmart, and Golden Corral.

Three employees were interviewed during the on-site visit. An employee interviewed stated she always knocks before entering the bathroom area, and closes doors and curtains during an individual’s shower at the ADC. The interviewer noted, showers are provided to individuals, wishing to shower at the ADC, three times a week. The employees reported the setting offers outings in the community at least a couple times a month. The activity director explained more about the outings indicating ADC staff take individuals out two to three times a month to the movies, out to eat, shopping, the park, lakes, and Old Man’s Cave. Staff are with individuals during outings and see the individuals’ interaction with the community. The staff also mentioned there is a small downtown with a Dollar Store, the individuals like shopping. The activity director also mentioned trips to Logan, Jackson, or Athens Counties where there is a Kmart, Walmart, and Golden Corral for individuals and their family to shop and eat out. She added family will assist with the outings. Another staff person confirmed individuals enjoy doing arts and crafts, exercise, puzzles, card games, and individuals may choose what activities they participate in. If an individual wants a snack, they can contact staff at any time. Staff also stated, when individuals have a special celebration the staff will prepare a luncheon for individuals and their family and friends, in addition to the regular lunch. The employee expressed how the individuals enjoy spending time at the setting. The activities director also noted individuals can make calls, in private by stepping outside the room or use an office. Individuals are also afforded privacy by using the family room downstairs, according to the activities director.

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Section Three Additional Evidence

The following evidence has been compiled that demonstrates the setting is integrated in and supports full access of individuals receiving HCBS into the greater community.

The state has considered all the following to demonstrate the setting is integrated and supports full access of individuals receiving Home and Community Based Services into the greater community: • Abuse policy• Client Agreement• Compliance policies• Consumer Interviews• Employment policy• Emails from provider• Floor Plan• Grievance policy• Menu• Photos• Residential Rights • Staff Interviews• Staff Training• Structural Compliance Review Letter• Transportation List

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Section Four Public Comments Summary Public Comment Period

Summary of Public Comments Received

Summary of the State’s Response to the Public Comment Received

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Setting Information Provider’s Name DayBreak Adult Day Services and Nutrition Services Location of the Setting Sydney, Ohio


Number of Individuals Served at the Setting 15

Waiver Services Being Provided at the Setting Adult Day Service



Section One On Site Visit Observation Date(s) Conducted December 20, 2016


Description of the Setting ADS and Nutrition Services of Shelby County DBA DayBreak Adult Day Services and Nutrition Services (hereafter ADC or setting) is owned and under the direction of the Shelby County Board of Commissioners Office in the city of Sydney, Ohio. The setting is on the grounds of a public institution and co-located with a nursing facility (NF). The ADC had a census of 15 waiver individuals when state staff conducted their onsite observational review. Individuals attending the setting through the PASSPORT waiver attend one to five times a week from four to eight hours at a time depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

The setting is a two-story building and is visible from Fair Road, the county road where the setting is located. There is an exterior sign identifying the ADC from the road and is less than two miles from a convenience store and about four miles to downtown Sydney and local businesses. There are several residences located next to the county property and across the street. Individuals living in private residences have the same experience as the ADC individuals attending the setting: they must drive at least four miles to get to major retail stores, restaurants, and entertainment.

The ADC entrance is located off a long driveway, which is entered from Fair Road. The setting is in a rural area about 1.5 miles from I-75 in Western Ohio. The setting itself is not visible from the street; however, there are additional signs for both the ADC and the NFwhen approaching the building. Additionally, there are several signs with directional arrows along a long driveway directing visitorsto the ADC. The ADC is in the lower level and at the back of the same building as the NF and has a separate entrance. Upon enteringthe ADC, there is office space to the left and to the right.


✔Prong 2: Setting is in a building on the grounds of, or adjacent to, a public institution.


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Once past the office space there is a large room with a full kitchen to the right with dining space furnished with tables and chairs. To the left of the dining space is another open area with tables, chairs, sofas and room dividers to facilitate more than one activity being scheduled at the same time. Past the activity area, there are rooms for individuals to receive personal care or rest. There are also restrooms in the same area. At the back of the ADC there is an exit door, which leads to a small area with an elevator. There is also an activity area past the elevator with exercise equipment and an emergency exit.

To access the NF from the ADC, a visitor would have to either exit out of the main entrance of the ADC and walk or drive to the front of the NF, or exit out of the back of the ADC and access the elevator to the first floor of the building.

At the time of the state observational review, the setting was going through a rebranding to further differentiate themselves from the Fairhaven NF. The setting provides meals and snacks to individuals attending the ADC. There is a menu posted on the bulletin board for individuals to view., Sometimes meals are prepared in the kitchen as a group activity, with individuals choosing the day and the meal. Snacks are available by request and during snack time. They also have snack bingo, where individuals can win snacks and take them home. If an attendee misses a meal, a request may be made for a snack or for a tray to be prepared and provided to the individual. There is food insecurity for some of individuals, and as a result, staff often send extra food home with i n d i v i d u a l s .

During the site visit, state staff had the opportunity to observe individual staff at the ADC. State staff observed individuals participating in two different group activities and a couple socializing in the kitchen area. ADC staff were familiar with everyone’s needs, personalities, and behaviors and they adjusted conversations and interaction accordingly.

Individuals attending the setting have their own personal interests, which the setting accommodates in a variety of ways with an assortment of activities during the week: exercises, easy listening music, card games, ball toss, Family Feud WII, outdoor walks and social time, trips to the library, and shopping trips to different stores. During the time the Shelby County Fair is running, individuals have the option of attending with the ADC. They also have outings to local parks and the US Air Force Museum. Individuals have the autonomy to participate or sit out of an activity at the setting or in the community.

The setting provides daily transportation for individuals to and from the setting, as well as twice monthly shopping trips. The setting also plans at least one offsite activity each month. Individual’s may access transportation through family and friends providing transportation as well as public transportation through Shelby Public Transit. A few individuals can drive themselves to and from the ADS. Staff assist in arranging transportation for those having to leave for appointments or other engagements, as necessary.

Individuals have the freedom to leave the setting during the day to attend appointments, activities with family or friends and then return or come back the next day. There were no key codes, locks or alarms on the doors at the time of the observational review.

ADC staff are separate from NF staff. ADC staff receive specific training in several areas depending on staff and position, annually. Some of the topics are Breaking the Chain of Infection, Customer Service Strategies, Hand Hygiene, HIPAA/HITECH: What All Employees Need to Know, Understanding Dementia and a Review of the ADS Personnel Policy and Procedure Manual. If a shift on the ADC side needs to be covered, a NF employee may assist, if necessary. They are trained in the topics above, as well as others. Additionally, the director of the ADC provides social work support to the NF

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Section TwoCommunity Integration Observations and Input from Individuals, Family Members/Guardians, and Staff

Three individuals were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. The experiences of the individuals were unique to each one’s needs. One individual at the end of the interview, indicated she was happy with the setting. Two others indicated they attended the setting for socialization. All like the staff and confirmed they had privacy when needed. All individuals indicated they felt comfortable talking to staff at the setting, asking for a different meal if they did not like what was served, and could have visitors. They like the activities in and outside the setting. One individual stated she participates in the activities she liked, when she is at the setting. She went onto confirm there are offsite activities twice a month. Additionally, she discussed her home life and expressed she needed assistance with transportation during her time in the community. She stated the staff were helping her with setting up non-medical transportation. Another individual stated staff helped him get rid of bedbugs at his home, along with assisting him in getting his cellphone straightened out. He mentioned every year he gives the prayer at the annual Christmas Dinner at the ADC. He also stated he sets his personal care up to meet his schedule, so there are times when he receives care at the setting and other times at home. He transports himself to the setting and mentioned one of the volunteers at the setting invited him to the men’s group at his church, which the individual now attends on a regular basis. He agreed he enjoys the ADC and is bored at home on the days he does not attend.

Three employees were also interviewed without the presence of administrative staff. Staff indicated some individuals attending the setting would be isolated from the greater community if they did not have the ability to attend the setting due to the rural nature of the county. They also stated there were some individuals attending who were very active in the community, but liked the ADC for socialization. One staff person mentioned individuals had their confidence boosted from attending the ADC and seemed to be more comfortable communicating to others, during outings and other activities outside the ADC, such as church. All staff indicated individuals could use the telephones or have private conversations in the administrative offices. Staff reported individuals leave the setting regularly, whether on their own, with friends, family, or for a scheduled outing. Staff confirmed most individuals enjoy the community integration. Staff confirmed individuals have the flexibility to receive services and supports during the time and place of their choosing. In addition to individuals being able to request a snack at any time, if an individual missed a meal, they could request cereal or a sandwich from staff. They can also a request a food tray to be brought to them from the NF. Lastly, they can review the menu during an earlier session and bring their lunch, if they choose. A staff person mentioned individuals will plan a meal each month and fix it themselves at the ADC. The staff indicated food insecurity is an issue in their county, so they ensure individuals have food at home when they leave the ADC, especially on the weekends. To ensure individuals are not embarrassed by needing assistance with lack of food, they play snack bingo, so individuals win their food they take home with them. Staff mentioned, if individuals wish, they can access the NF barber and beauty shop.

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Section ThreeAdditional Evidence


The state has considered all of the following to demonstrate the setting is integrated and supports full access of individuals receiving Home and Community Based Services into the greater community: • Accidents and Incident Investigating and Recording Policy• Activity Calendar• Admissions policy• Client belongings Policy• Client Bill of Rights• Client Complaint and Suggestion Information and Policy• Client Surveys• CMS Post Certification Revisit Report• Floor Plan• Grievance policy• Hair Services• HIPAA Policy • Individual Interviews• Medical Acknowledgement form• Medication Regimen policy• Menu• Mission Statement• Organization Chart• Personnel Policies and Orientation Checklist• Photos• Residential Handbook• Residential Rights• RN Availability policy• Satellite Map• Staff Interviews• Staffing Schedule• Staff Training

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Section FourPublic Comments Summary Public Comment Period


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Setting Information Provider’s Name Easter Seals Adult Day of Springfield Location of the Setting Springfield, Ohio



Waiver Services Being Provided at the Setting Adult Day Services





Description of the Setting Easter Seals Adult Day of Springfield, hereafter ADC or setting, is part of Goodwill Easter Seals Miami Valley, a private, non-profit, corporation in Springfield, Ohio. The ADC shares a building with the Developmental Disabilities of Clark County Business Operations and is adjacent to the FF Mueller Center, an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). The business operations and FF Mueller Center are county operated and are separate entities and organizations from the ADC. The ADC has no access to the Developmental Disabilities of Clark County space in either the business operations or the ICF/IID. The ADC is located near residential homes, apartment buildings, and private retail businesses. The ADC had a census of 19 PASSPORT individuals when the onsite observational review was conducted. Individuals on PASSPORT attend one to five times a week from four to eight hours at a time, depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

The ADC is a multi-level building located off a residential road and there is an exterior sign identifying the ADC from the main road. As one enters the main driveway to the setting, there is a small drive off to the right, leading to the entrance and drop off point to the ADC. Directly ahead, off the main driveway and to the left, is parking for visitors, staff, and individuals attending the ADC. There are several buildings owned by the county on the grounds in addition to the ICF/IID and Developmental Disabilities of Clark County, each have a separate address, shared driveway, and parking. There is a separate sign identifying the Developmental Disabilities of Clark County Business Operations entrance.

There is a drop area for individuals attending the ADC, near the main entrance of the ADC. A canopy covers both the drop off area and the main entrance, so individuals are protected from the elements. Once inside the entrance, there is a second set of doors leading to the main common area. The main common area is used for activities and events at the ADC. There is a staff office and additional common areas located nearby.




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As one moves through the setting, there are several activity and private rooms with chairs, tables, couches, games, books, puzzles and TVs for use by individuals attending the ADC. There is a kitchen, dining room, laundry room, administrative offices, therapy rooms, several bathrooms with walk-in showers, and a nursing office. The ADC also has an outdoor patio with seating for individuals to access at any time. During the observational review, the reviewer noted there are telephones in private rooms for individuals to use. There is only one direct way in and out. There is an exit onto the patio, but it is secured. The main door is never locked but the setting has a Wander Guard system in place. Participants attending the center are provided name badges, which have a sensor on them. It sets off an alarm if the participant walks or passes through the front door. The ADC offers a morning snack, full hot lunch, and an afternoon snack. The daily menu is posted for individuals to view in the ADC. There are alternative meals, if requested. There is open seating during meal times, and snacks are always available upon request.

A monthly calendar is prepared and posted on a bulletin board for individuals to view. There are outings at least once a month including trips to Walmart, country fairs, local parks, scenic bus rides in the country, an ice cream shop, the casino, volunteer projects at the setting, and many more. If an individual chooses not to participate in an activity in the community, they have activities to choose from at the ADC including Bingo, board games, Karaoke, movies, golf and putting, dancing, crossword puzzles, adult coloring, and other activities. On the day the reviewers visited, several individuals were playing games, exercising, relaxing in the lounge area watching television, reading the daily newspaper, and working on puzzles. The ADC utilizes volunteers who assist with games. The volunteers each help once or twice a week.

Individuals may leave the ADC on their own, if case planned in their person-centered plan. Additionally, the setting will assist individual employed to get to their respective jobs on time, by queuing and arrange transportation. For those who wish to gain employment they offer referrals and other assistance to gain employment.

The ADC provides medical and non-medical transportation. Individuals may access transportation with or without assistance of ADC staff to medical appointments and other requested destinations. In addition, transportation is available for outings and local events sponsored by the setting. Individuals may also access public transportation which is available by the Springfield City Area Transit, United Senior Services of Clark Co, if they qualify, ride sharing, and local taxis. Also, family members may assist individuals with their transportation needs

ADC staff are trained monthly and annually in addition to keeping their First Aid, CPR, D.R.I.V.E. Training, and defensive driving training current. The ADC also performs monthly safety drills. An annual group training on incident reporting, major unusual incidents, and food safety is provided for ADC staff. The ADC uses an on-line training service, for some of the standard training such as HIPAA, Supporting Everyday Lives for People with Disabilities, Principles and Practices of Effective Direct Supports, Positive Culture in Developmental Disabilities, Dementia Care, Alzheimer’s Disease & Related Disorders for Homecare Workers, and Personal Centered Planning for Individuals with Developmental Disabilities.

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Three individuals were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. The individuals stated they really enjoyed their time at the ADC, and the staff treats them nice. One individual mentioned everything is exciting from internal activities to outings. Another mentioned they enjoy outings to the casino, restaurants, and the local park. They confirmed staff respect their privacy by shutting doors, conducting conversations in private, and allowing them choice of which services they want to receive and which staff may provide them. They are not assigned seats in the dining room or during activities. The individuals stated they have access to snacks, and choice of food during meals, and upon request. They mentioned they are not required to participate in activities and they may have visitors at their leisure.

Three employees were interviewed without the presence of administrative staff. All three stated they support privacy and dignity of individuals by keeping individual’s doors closed, when they are receiving services and talking to them in private about personal issues. They reported individuals leave the ADC regularly on scheduled outings to go into the community for activities including shopping, dining out, and other activities. Per an employee, individuals can come and goes as they please, but some may need a little help. Staff confirmed individuals have the flexibility to receive services and supports during the time and place of their choosing. If an individual wants a snack they can contact staff at any time.

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• Abuse policy• Activity Calendar• Adult Day Agreement• Floor Plan• Grievance policy• Individual Interviews• Menu• Outings for the month• Photos• Photo policy• Signage• Staff Interviews• Staffing Schedule• Staff Training• Structural Compliance Review• Visitor log

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Setting Information Provider’s Name Acacia Place Adult Day Center Location of the Setting Cleveland, Ohio







State Agency that Conducted the On-Site Visit Ohio Department of Medicaid

Description of the Setting Eliza Jennings DBA Acacia Place Adult Day Center is a private, non-profit, corporation in Cleveland, Ohio. Acacia Place Adult Day Center, hereafter ADC or setting, is co-located with a nursing facility (NF). The ADC had a no waiver individuals when the onsite observational review was conducted. Individuals attending the setting, through the PASSPORT waiver, attend one to five times a week from four to eight hours at a time, depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

The ADC is a multi-story setting, which is located off a main street. It is located among other residential buildings, private businesses, retail businesses, and restaurants which allows for easy community integration. There is a main sign identifying the Eliza Jennings Health Campus and a driveway located at the first entrance. There is an additional driveway to and signage identifying the ADC on the grounds, which is also accessible from the road. There are parking lots for visitors, staff, and individuals located off both drives. The ADC has its own entrance and door, which requires a keypad code to access. There is a keypad positioned by the door at each end of the ADC, exiting through the door at the end of the ADC leads to the NF; exiting through the door at the other end of the ADC leads to the maintenance area and administrative office. Only the staff has the keypad codes due to safety concerns for the individuals.

Outside of the main entrance, there is a drop area with a canopy and doors leading to a foyer and the main doors of the setting. As one proceeds through the main doors, there is a common area, which is used for activities and events. There is an administrative office and social areas located nearby.




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The entrance opens to the main dining room. Right off the main dining room is the food preparation area and the kitchen. Off the kitchen is a hallway leading to the common areas and activities area and a sitting room. Individuals can go to the sitting room to have private or social time. The room has chairs, tables, and computers for individuals too. There is an additional room nearby where Saido Learning takes place. This is a non-pharmaceutical intervention program, which has been shown to reduce and even reverse symptoms of dementia. There is artwork posted in the area to prompt discussions and to assist with memory improvement for the individuals. There is a private room with a telephone, which individuals can use for personal phone calls.

The setting offers a morning snack, full hot lunch, and an afternoon snack. The daily menu is posted for individuals to view in the setting. There are alternatives meals available, if requested. Individuals can request something to eat at any time of the day and there is open seating during meals times.

There are materials posted throughout the setting which describe community and planned activities and events for individuals. The setting plans at least one outing a month in the community. Outings include trips to Walmart, country fairs, local parks, country rides, ice cream parlors, the bowling alley, and more. If an individual chooses not to go into the community on an outing, there are activities to choose from at the ADC: Bingo, board games, Karaoke, movies, corn hole, crosswords, adult coloring, and other activities. On the day the reviewers were visiting, several individuals were playing games and performing exercises. Some chose to sit and relax in the lounge area and were watching TV, reading the daily newspaper, and working on puzzles.

The setting offers transportation to individuals during outings and other local events. Family members and friends are also available to assist with transportation needs, as well. The setting helps facilitate transportation of individuals when needed to access other transportation options: public transportation, Cleveland’s Senior Transportation Connection, taxis or ride sharing services.

ADS staff are separate from NF staff and receive training in areas depending on their position. Some of the training includes First Aid and CPR, About Mental Health Impairment, Understanding Alzheimer’s Disease/Dementia, HIPAA, and Understanding Communications in Persons with Dementia. There is annual training on incident reporting, Major Unusual Incidents, and Food Safety. Staff training takes place in person, and online.

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Three individuals were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. All three individuals stated they really enjoyed their time at the setting, and the staff is nice. One individual mentioned everything is exciting from internal activities to outings. The individuals reported they choose their own daily schedules and they can decide who and what services they want provided. They confirmed staff respect their privacy by shutting doors, conducting conversations in private, and allowing them choice of what staff may help them. They mentioned they are not assigned seats in the dining room or during activities. The individuals stated they have access to food. They confirmed they are not required to participate in activities. The all reported they may have visitors at their leisure during their stay at the setting.

Employees were interviewed without the presence of administrative staff. The three stated they support privacy and dignity of individuals by keeping individual’s doors closed and by talking to them in private about personal issues. They reported individuals leave the setting on scheduled outings at least once a month to go into the community for shopping, dining out, and other leisure activities. Staff confirmed individuals have the flexibility to receive services and supports during the time and place of their choosing. If an individual wants a snack they can request it at any time.

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The state has considered all of the following to demonstrate the setting is integrated and supports full access of individuals receiving Home and Community Based Services into the greater community: • Abuse policy• Activity Calendar• Advocate listings• Disclosure form• Provider emails• Fee policy• Floor Plan• Google Maps• Grievance policy• Individual Employment policy• Individuals Interviews• Participant Forms• Participant Handbook• Photos• Menu• Outings permission slip• Structural Compliance Review• Staff Interviews• Staffing Schedule• Staff Training• Table of Organization

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Setting Information Provider’s Name Forest Hills Center Location of the Setting Columbus, Ohio









Forest Hills Center is a part of Embassy Healthcare Management, Inc. a privately-owned corporation. Forest Hills Center is an Adult Day Center (ADC) setting co-located with a nursing facility (NF) in Columbus, Ohio. There were two waiver individuals attending the ADC, when state staff conducted their onsite observational review. Individuals on PASSPORT attend one to five times a week from four to eight hours at a time, depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

The ADC is in a single-story building off a major interstate and is situated among private residences and businesses. The setting is surrounded by trees and there is a service road leading to the main entrance of the setting. At the entrance to the ADC is a sign identifying Forest Hills Center.

There is a parking lot for individuals and visitors with a walkway, leading to an entrance with two double doors. There is a sign identifying the setting on the main entrance doors. Outside of the main entrance there are a few chairs for individuals to use for relaxation and socialization. Inside the main entrance, there is a lobby with a reception and seating area, a conference room, and administrative offices. Off the lobby, there is a hallway to the right leading to the ADC. At the entrance of the ADC there is a sign identifying the setting. There is another long hallway perpendicular to the entrance of the ADC. Off this hallway there are physical therapy, laundry, and conference rooms and a nursing office at the very end, before the entry to the NF. The entry to the NF was closed at the time of the observation review.




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Once inside the ADC, there is a kitchen area with a sink, cupboards, a large table and chairs, refrigerator, toaster oven, and a water dispenser. There is an activity area with a table and chairs, and a large common area with recliners and a TV. The entrance door to the ADC, off the hallway described earlier, is never locked and individuals can come and go as they please, as documented in their person-centered plan. There is an additional double door entry way at the side of the setting, which is a private, secured entrance for the ADC. The setting offers a telephone for individuals to use in private if needed.

The setting serves snacks and meals during the morning and afternoon. Individuals have access to snacks any time. Meals are prepared by a chef with different options for individuals to choose from for their meal. During the on-site visit, individuals were observed sitting around a table socializing while enjoying an early morning snack, others watched TV, read, and played games with staff. Staff were observed assisting individuals from the table to the activity area for exercises. Individuals engaged in activities of their choice at the setting and others chose to go with groups in planned and unplanned activities into the community or with family and friends.

There are materials throughout the setting describing community and planned activities for individuals. The activity calendar describes daily activities offered at the setting. The setting plans at least two activities in the community every month. Outings include shopping, trips to public parks, dining at local restaurants, and many other activities. The setting has an informal partnership with the Columbus Parks and Recreation Department and information is shared with staff regarding programs and events for individuals to attend. If an individual chooses not to participate in an activity in the community, they have many activities to choose from at the setting: Bingo, tongue twisters, trivia games, card games, Jeopardy, movies, Wheel of Fortune, and other entertainment in the recreation and common areas. There are books, newspapers, movies, magazines, movies, and puzzles available for individuals to use in a group setting or in the private areas if they do not wish to participate in group activities. There are also walking paths on the grounds of the setting for individuals to use, if they choose.

Individuals may access transportation, with or without assistance of ADC staff. Transportation services are arranged for all scheduled outings, with no extra charge. Other available options include Project Mainstream, Senior Options, and public transportation (Central Ohio Transportation Authority) and ride sharing for non-medical transportation, to name a few. Family and friends also assist individuals with transportation needs. Transportation is also available for individuals who live within 15 miles of the setting who need transportation to and from the setting.

There are separate staff for the ADC and NF. Annual in-service trainings are offered throughout the year along with any additional training. Some of the trainings include: Abuse and Neglect, Resident Rights, Elopement, Approaching Alzheimer, Fall Prevention, and Protecting our Individuals.

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Three individuals were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. All three individuals interviewed spoke well of their experience at the setting. One individual mentioned she loved this setting compared to the one she attended while residing in Michigan. Individuals reported staff are always willing to help them. The individuals confirmed they choose their own daily schedules and activities and have flexibility in receiving services and supports during the time of their choosing. Another individual described her experience receiving services as good and she shared she chooses how to spend her time at the setting. Each individual agreed they feel comfortable talking and interacting with staff. They confirmed privacy is not an issue and there are no assigned seats during meal or activity times. All three are active in the community during outings and two of the individuals assist with bus runs and volunteer as chaperones during outings. They particularly like the outings to the Columbus Metro Parks. They are not required to participate in activities and come and go as they please, along with having visitors when and where they want. Another individual said his daughter and grandchildren visit him and they meet in the activity area or can go to a private room to visit. The individuals enjoy the food and they all know how to ask for an alternate meal, if wanted. One individual stated there are options available when the ADC serves things she did not like. The individuals also confirmed snacks and drinks are always available.

The employees were also interviewed without the presence of administrative staff. All three staff members interviewed stated they let individuals direct the help they need. Staff reported they try not to talk about private issues in front of other clients and shut doors for privacy. During the interview, when asked about privacy issues and confidentiality, one staff person mentioned they are discreet and private about individual’s incontinence issues and other personal matters and do not make a big deal about things. Staff also noted individuals leave the setting one to two times per month to go into the community for activities including shopping, dining out, visiting the local metro parks, and other local events. One employee mentioned individuals are happy to go out in the community and really enjoy the outings. The employee added individuals interact with staff and each other during outings. An employee confirmed the snack policy, mentioning individuals can grab a snack whenever they want.

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• Abuse policy• Activity Calendar• Adult Day Agreement• Floor Plan• Grievance policy• Individual Interviews• Menu• Outings for the month• Photos• Photo policy• Signage• Staff Interviews• Staffing Schedule• Staff Training• Structural Compliance Review• Visitor log

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Setting InformationProvider’s Name Heritage Manor Adult Day Care Center of the Youngstown Area Jewish Federation Location of the Setting Youngstown, Ohio






Section OneOn Site Visit Observation Date(s) Conducted 2.6.2017

State Agency that Conducted the On-Site Visit Ohio Department of Medicaid

Description of the Setting Heritage Manor Adult Day Care Center of the Youngstown Area Jewish Federation is a non-profit corporation in Youngstown, Ohio. The setting is just north of Youngstown State University. Heritage Manor Day Care, hereafter ADC or setting, is co-located with a nursing facility (NF). The ADC had a census of seven waiver individuals when state staff conducted their onsite observational review. Individuals on PASSPORT attend one to five times a week from four to eight hours at a time, depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

There is a sign identifying the community from the main road, but not the ADC. The ADC is a single-story building and is about less than a mile from shopping, restaurants, and entertainment. The setting is among residential buildings and private retail businesses with woodlands surrounding the setting.

As one approaches the setting, there is a driveway leading to the NF and ADC parking lots for visitors, staff, and individuals. The setting is visible from the ADC parking lot and has its own entrance. There is a sign identifying the setting located at the front entrance of the NF.

The entrance to the ADC is in the rear of building. The door is secured by a key pad. The keycode is provided to some individuals at the ADC (depending on care plan), family members, and staff. Staff indicated this was for security purposes in case an individual had wandering tendencies. Once inside the main entrance, there is a common area. There are two other doors leading to the program areas, where individuals can freely move around the ADC at their leisure.




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As one proceeds through the other doors, there are Arts and Crafts and Multipurpose rooms which are used for activities and events. Located nearby is an administrative office and social area. There is a telephone in the administrative office for individuals to use in private, if needed. Is there anything standing out, you want the reader to know about the setting? If not, describe just the dining experience, and food availability.

The setting serves two meals a day and afternoon snacks. The daily menu is posted for individuals to view in the setting. There are alternative meals available by request. Individuals can request a snack at any time of the day and there is open seating during meal and activity times.

There are materials posted throughout the setting which describe community and planned activities and events for individuals. The setting does not offer outings in the community. The setting offers a secured outdoor area for individuals to access during outdoor activities. There are several daily activities such as word games, kick ball, arts and crafts, painting, trivia, exercise, coloring, ball toss bowling, and Bingo. On the day the reviewers were visiting, several individuals were playing games, some were sitting and relaxing in the lounge area watching TV, reading the daily newspaper, doing chair exercises, and working on puzzles.

The setting provides medical and non-medical transportation. Family members and friends are also available to assist with transportation needs as well. The setting helps facilitates transportation of individuals when needed. The setting utilizes Angel Carriers for their additional transportation needs. Individuals may also have access to public transportation, Easter Seals, taxis, or ride sharing services.

ADS staff are separate from NF staff. Staff are trained upon hire, annually, and in person. There is training in several areas depending on staff and position. Some of the training includes Abuse, Neglect, Exploitation and Misappropriation. Some examples of in-services are Dealing with Difficult Families, Depression, Stress, Burnout, and Dementia.

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Three individuals were interviewed during the state’s onsite observational review. They were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. All three individuals stated they really enjoyed their time at the setting, and the staff is nice. The individuals reported they choose their own daily schedules. They confirmed the staff respect their privacy by shutting doors, conducting conversations in private, and allowing them choice of what staff may help them. They confirmed they are not assigned seats in the dining room or during activities. The individuals stated they have access to and choice of food. They confirmed they are not required to participate in activities. The individuals report they may have visitors at their leisure during their stay at the setting.

Three employees were interviewed without the presence of administrative staff. They all stated they support privacy and dignity of individuals by talking to them in private about personal issues, and covering them up if needed. They reported individuals participate in joint activities and events with the NF residents and ADC individuals on the campus. They added all the individuals get along with the residents during these outings. Staff confirmed food is always available for individuals to access. One employee mentioned there is plenty of food and it never an issue. If an individual wants a snack, they can contact staff any time.

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The state has considered all of the following to demonstrate the setting is integrated and supports full access of individuals receiving Home and Community Based Services into the greater community: • Abuse policy• Activity Calendar• Advocate listings• Disclosure form• Provider emails• Fee policy• Floor Plan• Google Maps• Grievance policy• Individual Employment policy• Individuals Interviews• Participant Forms• Participant Handbook• Photos• Menu• Outings permission slip• Structural Compliance Review• Staff Interviews• Staffing Schedule• Staff Training• Table of Organization

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Section FourPublic Comments Summary Public Comment Period


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Setting Information Provider’s Name Ottawa County Riverview DayBreak Location of the Setting Oak Harbor, Ohio






Section OneOn Site Visit Observation Date(s) Conducted 6.5.2017



Ottawa County Commissioners-Senior Resources doing business as Ottawa County Riverview DayBreak is a setting owned by and under the direction of the Ottawa County Board of Commissioners, in rural Oak Harbor, Ohio. DayBreak is an Adult Day Center, hereafter ADC or setting, located on the Ottawa County Riverview Health campus. The setting is on the grounds of a public institution and co-located with a nursing facility (NF). The ADC had a census of one waiver individual when state staff conducted their onsite observational review. Individuals attending the setting, through the PASSPORT waiver, attend one to five times a week from four to eight hours at a time, depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

When one approaches the main driveway from the state route, there is a sign located near the road in front of the building identifying the setting and the NF. The setting is in a single-story building with the main entrance located at the rear of building. The ADC is located among a few private homes, private and retail businesses, farmlands and behind the setting is the Portage river.

There is a driveway off the state route leading to the parking lots around the building and to other areas on the campus. In the back of the building, where the ADC is located, there is a shared main entrance for the ADC and the Ottawa County Senior Resources. There is a canopy covering the walkway to the entrance. Once inside the entrance, straight ahead, is a hallway leading to the setting. A sign identifying the setting, is outside of the setting entrance.




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Once through the door of the setting, there is a full kitchen area with a stove, cabinetry, sink, microwave, and refrigerator. Off the kitchen is an activity room with recliners, a table and chairs, TV, books and bookshelves, DVDs, and games for individuals to access. There is a bulletin board in the area, which has an activity calendar and dining menu posted for individuals to view. Outside the room and down a hallway is the NF, which has its own external entrance. The setting has a telephone for individuals in the ADC’s office for use in private, if needed.

The ADC serves lunch and dinner with several options. Snacks and beverages are available upon request. Individuals may also bring their own lunch, if they prefer. Individuals attending the setting are free to sit with whom and where they choose, at any time.

There are materials posted throughout the setting describing community events and planned activities for individuals. The setting plans at least 2-3 outings a month in the community. Outings include bus trips to community events, shopping trips, movies, parks, sporting events, trips to the zoo, restaurants, and the African Wildlife Safari to name a few. There are luncheons twice a week at the Oak Harbor Senior Center to facilitate integration with the community.

The setting offers several daily activities such as puzzles, exercise, and ball toss, arts and crafts, Tick Tack Toss, coffee and daily chronicle, card games, a matching game, Hangman, table b, chair yoga, and many more. During the on-site visit, some individuals were observed working on puzzles, drawing and participating in activities with staff, friends, and family. Others were participating in activities of their choice such as watching TV, reading, and relaxing.

The setting offers transportation to individuals during outings and local events. The setting staff help facilitate transportation for individuals, through the public transportation system, Ottawa County Transit Agency and through LogistiCare, a transportation company available for individuals with medical appointments. Individual’s family and friends also assist with their transportation needs.

ADC staff are separate from NF staff. ADC staff receive training in several areas depending on their position. Staff training takes place upon hire, quarterly, and as needed. The setting offers an in-service education program, which takes place face to face. Some of courses include History and Definition of Adult Day, PASSPORT guidelines, Dementia Care, and Resident Rights.

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Individuals were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. All three individuals stated they really enjoy their experience at the setting. One individual mentioned enjoying the setting and noted the staff were nice. All three individuals feel comfortable addressing staff with any concerns or issues and if they need anything, staff are available. Another individual mentioned staff are easy to talk with and are understanding. The individuals agreed staff respect their privacy and always shut doors and talk to them in private. They all agreed the food is good and snacks are accessible anytime. An individual discussed the food being good and one could not ask for anything better. The individuals really enjoy the outings provided by the setting. They all like dining at the local Frisch’s Big Boy restaurant and agree this is the best outing.

Employees were interviewed without the presence of administrative staff. The employees interviewed stated they are always discrete if an individual has a personal issue, and they make sure individuals have a change of clothes at the setting and during outings. The employees reported the setting offers outings all the time. One employee confirmed individuals do quite a bit in the community and they interact well during outings. They go out two to three times a week to various places such as sporting events, the zoo, shopping trips, and to restaurants. They confirmed individuals may choose what activities they participate in daily. If an individual wants a snack, they can contact staff at any time and get something off the breakfast menu, which is always available. The employee expressed how the individuals enjoy spending time at the setting, mentioning one individual liked to color and felt they were learning a lot there. She shared individuals can make private calls in the office if needed.

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The state has considered all the following to demonstrate the setting is integrated and supports full access of individuals receiving Home and Community Based Services into the greater community: • Abuse policy• Activity Calendar• Client policy• Consent Form• Consumer Interviews• Employment policy• Floor Plan• Grievance policy• Google Maps• Menu• Photos• Provider Consumer List• Residential Rights • Staff Interviews• Staff Training• Structural Compliance Review Letter• Transportation

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Setting Information Provider’s Name Today Center for Adults Location of the Setting Xenia, Ohio






Section One On Site Visit Observation Date(s) Conducted 12/1/16


Description of the Setting Today Center for Adults is owned and under the direction of the Greene County Board of Commissioners in Xenia, Ohio. Today Center for Adults, setting is an Adult Day Center, hereafter ADC or setting, on the grounds of a public institution and co-located with a nursing facility (NF). The ADC Waiver Provider had a census of one waiver individual when state staff conducted their onsite observational review. Individuals on PASSPORT attend one to five times a week from four to eight hours at a time, depending on their individual care plan. During the remainder of the week and weekends, they participate in other activities outside the ADC and reside in the community with friends and family.

There is an exterior sign identifying both the NF and the ADC from the main road. The ADC is visible from the street and is a single-story setting located off a main service road and is about a mile from shopping, restaurants, and entertainment. The setting is surrounded by woodlands and farmland. There are private homes and a county park across the street and more residential apartments and private homes are within a mile of the setting.

As one drives up to the setting, there is a drive, leading to a parking lot on the left side off the setting for individuals, staff and visitors. There is a drop-off spot, covered by a roof, located in the front of the setting and entrance. The reviewers observed from the outside, the ADC and NF appear to be attached by a long hallway with the ADC in the front and the NF in the rear of the building. The setting resides in a rectangular shaped building with a large courtyard in the middle. The front left of the rectangle, facing the street, is where the ADC is located. There is a main entrance located in the back of the building for the NF, with a side entrance for staff to use. State staff confirmed this was not an entrance way for the ADC. On the inside, the setting is separated from each side of the NF by double doors, a breezeway, and another set of double doors. The doors to the NF on both sides of the setting were closed during the observational onsite review.




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Once inside the main entrance of the setting, there is a lobby with chairs and tables. Off the lobby, there is a lounge and business offices on the left and another business office on the right. Directly ahead is the reception desk and copy room. Further up from the offices on the left of the lobby there is a hallway, leading to a closet, conference room, public restroom, and the NF double doors. Off the lobby to the right of the reception desk is a hallway leading to the ADC, anyone can enter the setting, however to leave one must ask a staff person to enter a code into the secured keypad to exit the doors. Staff indicated this was for security purposes in case an individual had wandering tendencies.

Inside the ADC, the room opens to large common/recreation area with chairs, couches, tables, and a TV. Off this area are offices, another common area, clinic office, laundry room, men’s and women’s bathrooms. Toward the back of the setting are meeting rooms/lounges with chairs and couches, books, games, magazines, DVD’s and DVD player, and a TV. There are additional common/recreation rooms and a full kitchen toward the back of the space. Meals are prepared in the NF and brought to the ADC kitchen to be served. There is a dining room located at the rear of the room for individuals and visitors to use. Off the dining room is a door, leading to a small entryway and double doors to the NF. The door was secured and closed during observational onsite review. A public telephone is available in one of the offices for individuals to make private telephone calls, if needed.

The setting provides a morning snack, hot lunch, and an afternoon snack. Individuals have the option to eat when, where, and with whom they choose. There are special meals provided to those who have special dietary restrictions. Snacks and drinks are always available upon request. Visitors are always welcome and encouraged to join during meal times. Menus are combined with the activities calendar and posted for individuals to review. Individuals are welcome to bring their own lunch on days they did not like the menu items.

There are materials posted on a bulletin board in the setting describing community and planned activities for individuals. During the observational onsite review, the reviewers noticed flyers and other community activity materials located at the front reception desk. Family members and friends assist with outings in the community. The reviewers observed family members taking their daughter out to lunch; according the administrator, the individual leaves weekly with her parents. Activities in the community are not regularly planned, as most individuals have regular access to community activities and events by way of family members and friends.

While there, the reviewers observed individuals engaging in different activities at different times, the individuals could participate in exercises, a group art craft and other individual or smaller group activities of choice (e.g. watching TV, painting and drawing, puzzles, listening to iPods, playing Uno etc.). There are books, newspapers, magazines, DVDs, and TVs available for individuals to use in a group setting or in a common room if they do not wish to participate in group activities, as well. One individual chose to associate with himself, and other individuals were observed approaching him and trying to engage him in conversation. During the site visit, there were a few visitors present.

Transportation is available for individuals, and they may access it with or without assistance of AL staff. The setting utilizes transportation services for transporting individuals to and from the setting. The transportation services include Greene Transport, Xenia Adult Recreation and Services Center or Green County Council on Aging. The Today Center for Adults has handicap accessible vans available for transportation to and from the setting, as well. The setting has parking available for those individuals with their own vehicles.

ADC staff are separate from NF staff. ADS staff receive specific training in several areas depending on staff and position, upon hire, semi-annually, and as needed. Training takes place face to face and online. The trainings include: Cognitive Disorders, The Aging Process, Non-Violent Crisis Intervention, Clean-up Procedures, Crisis Prevention, PASSPORT requirements, Incident Reporting, Alzheimer and Dementia, Food Safety Education, to name a few.

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Three individuals were interviewed without the presence of administrative staff. The questions are a set of standard questions used in a conversational tone with individuals to ensure they are at ease during the interviews. All three individuals stated they really enjoy their experience at the setting. One mentioned she enjoys the staff and other individuals as well at the center. All three feel comfortable addressing staff with any concerns or issues and if they need anything, staff are always available. One individual confirmed she has the freedom to do whatever she wants, when she wants and stated she goes out to dinner with friends, who come and get her. The individuals agreed staff respect their privacy and always shut doors during personal care or other medical activities or when an individual wants to talk to a staff person in private. Two agreed the food is good and snacks are accessible anytime. The other individual packs her lunch, but she did state, if she does not want the lunch she brought, she can eat at the setting. Two of the individuals stated they attend a few activities outside the setting, the other does not really like to leave or participate in activities. The two individuals enjoy the activities, and one mentioned, she enjoyed the activities at the setting and occasionally her daughter leads an arts and crafts session and assists other individuals.

Three employees were interviewed without the presence of administrative staff. All three staff interviewed stated they support privacy and dignity of individuals by keeping doors closed while and individual is changing, knocking before entering, and asking if they need help. This is also addressed during in-service trainings. All three employees confirmed they enjoy their job and one stated, she enjoys working with the individuals and families, regarding tours, visits, and the financial piece of the business. Staff mentioned the setting provides health and social services to all individuals. The activities calendar and menu are posted on a bulletin board in the recreation area for individuals to view. Staff confirmed, they will read the menu and activities to individuals daily. One individual mentioned she assists with various activities around the center like reading the menu and activities calendar to individuals. Two employees confirmed the individuals enjoy the activities and they always have help. Another staff person agreed with the above, and added they have several volunteers and some family members who help with activities and serving meals.

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Section Three Additional Evidence


The state has considered all of the following to demonstrate the setting is integrated and supports full access of individuals receiving Home and Community Based Services into the greater community:

• Abuse policy• Activity Calendar• Agreement for Today Center• Complaint/Suggestion Form• Consumer Interviews• Floor Plan• Google Maps• Grievance policy• HIPPA policies• Letters of Support• Menu• New Participant and Visitor Info• Pamphlet• Participant Rights• Photos• Policies• Provider Consumer List• Release of Information• Satisfaction Survey Results• Staffing Schedule• Staff Training

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Appendix VI: NF-based LOC System Heightened Scrutiny ...€¦ · NF-based LOC System Heightened...

Documents

Transcript of Appendix VI: NF-based LOC System Heightened Scrutiny ...€¦ · NF-based LOC System Heightened...