house design for disabled person

all right. it's 1:00. it's time to start the webinar. welcome, everyone, to "the new hcbs rule - how does it affect housing for people with disabilities?" this

is the second of five webinars that are hosted by the autistic self advocacy network, collaboration to promote self-determination, association of university centers on disabilities, the national disability rights network and the national association of councils on developmental disabilities.

i'm samantha crane, the director of public policy at the autistic self advocacy network, and i'll be acting as your monitor today. the webinar will be recorded. slides are available to all registrants at the end of the webinar. the autistic self advocacy network is an organization dedicated to

promoting self-advocacy among people with autism spectrum disorders and making sure that self-advocate voices are heard in public policy discussions. we and the other participating organizations are collaborating on this webinar series in order to make sure that advocates, policymakers, and anyone else with an interest is aware of

the new home and community-based services rule and how it's going to impact people with disabilities and how advocates can make sure that it is implemented in a way that really improves services for people across the spectrum of disability. today's webinar is going to focus on housing. we are joined by esme grant,

the director of public policy at the national association of councils on developmental disabilities, and katherine berland, director of government relations at ancor. i am going to turn this over to esme in order to start this off. thank you so much. samantha, i

think my screen might have gone down. i've made you the presenter. sorry. technical difficulties. i am going to make myself the presenter again, show my screen. i accidentallyï¿½-- i was supposed to give you control of

my keyboard instead. here you go, esme. sorry about that. i'll start off by introducing myself. my name is esme grant, director of the public policy for the national association of councils on developmental disabilities.

i spoke a little bit on the introductory webinar that we did last week talking about the dd network and the different organizations we work with. our work on the hcbs rule has been in conjunction with the national disability rights network which represents the protection advocacy group as well as

the association of university centers on disabilities, which represents the ucedds in various states. we're excited to expand that work with other folks like katherine berland who will join in the second half of this webinar. next slide, samantha. we'll just jump ahead one more.

what i really want to go over with you all today -- as i mentioned, my colleague katherine will be joining us for the second half of this webinar. i want to provide the background of what this rule is really about. i want to talk to you a little bit aboutï¿½ -- when we talk about the hcbs rule,

what are we really talking about and what's sort of the big picture of what's going on in terms of home and community-based services and how does this rule fit into that. as you can see from this overview, i want to provide a little background on where home and community-based services comes from as well as the

olmstead connection to the new rule. i know we talked a bit about olmstead in the introductory webinar but i'm going to dive into it in a different way in order to create that foundation. i'm going to discuss the federal housing policy and how it connects to the new rule, how do we talk about services in terms of residents and

where one lives if we don't connect that with existing federal housing policies. so i want to talk a little about how all the agencies, the federal government, are working together and how they will play a role in how policies are put into play. then i'm

going to pass it off to the real expert of the hour, katherine berland from ancor, who's going to dig into the new rule in terms of how it applies to housing and gives examination of specific guidance from the centers for medicaid and medicare services on how to implement the rule. so, again, today is about housing.

just to give you a preview of some of the upcoming webinars, next week, octoberï¿½14 will be on stakeholder engagement, so really talking about how to play a role in making sure that we're all impacting as a community how this rule plays out. octoberï¿½21, going to talk about employment day

guidance. i know we're all very excited that the rule will have an impact on employment in day settings and we're excited to see how that plays out but today is really about so i just want to give people a heads up that if they have employment questions that

should be reserved for the octoberï¿½21. and then our final webinar, octoberï¿½ 28, is going to be enforcement and monitoring. we're going to talk about a lot of exciting things today and the direction that we're heading, but what's really the purpose of this if we don't enforce and

implement it? so the final webinar of the series will talk about that. so jumping back to today, i want to start off just bare bones. so next slide, samantha. we're going to talk a little bit about where home and community-based

services came from. i don't want to spend too much time on social security, but this is really what we're talking about today. the hcbs rule is a change to the social security act regulation. so just diving a little bit back

into time and where all of this medicaid and everything came from, i want to talk about social security. it all started with social security which was created by what we call the social security act of 1935. social security generally, as many of you know, is a system that creates a foundation of economic

security for certain qualified recipients. back when it was originally started, it really was for folks of lower economic strata as well as people who were blind but other disabilities really didn't come into play until a little bit later down the line.

there were two systems created under social security to assist people with disabilities and a wide range of disabilities. the first was created in 1956. it was the social security disability insurance program.

interestingly, it used to only cover workers that were 50 and adult children acquiring a disability before the age of 18. that's changed. but this is a system where a worker must work for a certain amount of time to qualify in order to receive

payout should they acquire a disability. and now it also qualifies their spouses and children as well. so it's paid for by a trust fund of payroll contributions. ssi is a little different,

supplemental security income. you don't have to pay into it. it was created in 1972. it's paid for by general tax revenues. so when you go out into the workforce and you work, part of your taxes go into

general tax revenue which, in part, helps to pay for these systems are really created in order to make sure that people have the most basic things in life, housing, food, and are able to not fall into deep poverty and become homeless and live outside of just the general

expectations that folks should be able to have in life. so why this is important is that medicaid was actually created under social security. with initial social security, we're talking about housing, food, and just the

general pieces of daily life. medicaid was created as a social healthcare program in order to help families and individuals with low income and resources or for particular categories; so people with disabilities, to receive supplemental security income, for example.

really, medicaid was addressing a lot of the health concerns that the greaterï¿½-- that folks had in terms of folks who were in this lower economic strata. it was created with the social security amendments act of 1965. it's a

system which matches federal funds to state funds to help supplement health and medical assistance to recipients. if we think about when this was originally created, it was helpful for folks who had children with disabilities or were people with disabilities

and couldn't afford the resources to provide either for their children or for themselves. so we think in terms of really health-based, medical-based models and institutions, and institutional placement, and really not a lot in terms of community involvement or community placement.

if you still want to see sort of a very common model of this, you can look at some developing countries around the world where their social welfare system is very much like ours was of yesteryear where a lot of people with disabilities are placed in institutions and that's where the

resources are put. what happens, though, for the united states was that in 1981 this changed with waivers. and waivers, as many of you know, are like exceptions to the rule. part of what was enacted,

section 1915(c). so many of you know the terminology 1915(c) waivers. it's because it's from 1915(c) of the social security act. and really it allows for states to administer these resources in different ways in terms of home and community-based

services; so outside of the institutional model and into home and community-based services. so the trend really started in 1981 and went from there. we'll talk about some other things that have changed along the way but i wanted to give you a framework for when

we talk about hcbs rule what are we talking about. well, we're talking about regulation that are changing sections 1915(c), (i), (k), of the social security act. and then at the bottom you can see that hcbs has grown

significantly from 1991, 14% folks were using hcbs services; 2004 36%, and current day we're going to see much more folks using home next slide, please. so let's also look at where are people with disabilities living. in terms of this graph that you're seeing before you, this is really

just addressing intellectual and developmental disabilities but it gives you an idea of where people with idd at least are living and a framework of people who are receiving home and community services. the dark bars are 1982. this is when the medicaid waivers really

began. you can see that the majority of people lived in residences that had 16 or more residents within them; so typically an institutional setting. and very few, less than 16,000, about 15,702, living withï¿½-- in residences

with one to three residents. you can tell by the bars here, the light bar which represents 2011, this is really dramatically shifted. but now we're seeing even more people serviced and even more in-home and community services with one to three residents. 224,000ï¿½-- 224,947 now being served

in one-to-three resident facilities whereas about 55,000 in those 16 or less residents. so we've seen a real shift here. another thing i want to mention is on the next slide, in terms of costs. this is taken from figures

based on a national council on disability report from 2012 really looking at every state and the average cost of community-based services versus institutional care services. what we did was we created a chart that took the lowest average of a state and the highest average

of a state for each. as you can see, the lowest average of community care per year in a state is $22,467 whereas the highest average within a state wasï¿½ $107,453 for community care, on the institutional end, however, the lowest range average for a

state wasï¿½$104,025 whereas the highest range for a state wasï¿½$375,950. so the reason i want to mention this is that when we talk about home and community-based services, there's a number of reasons why this is a better option for individuals.

however, there's also a cost implication here. we're based in washington, d.c. there's a lot of discussion around budgets and what can be afforded and what can't. there's a real argument for moving policies towards home and community-based services whereas

you can provide more services to more people. that's a real issue that people are focusing on. so as we look at how policies are transforming in order to cater more towards community care options, keep in mind that there's a cost component there as well that can

make these policies much more efficient. now, i have had questions from members on the employment side in terms of the costs of things like supported employment and so forth. i'll sort of boot that to our later webinar on employment services.

but for the most part, for housing, we're really seeing a lower cost in terms of the community care range. i don't want to spendï¿½-- and i could spend, but i don't want to spend a whole day with you all on the americans with disabilities act and olmstead, but it's reallyï¿½--

i know we've talked a little about it in our introductory webinar last week, but it really is the essence of what we're talking about here. i wanted to go over the legislation as well as the results of the supreme court decision just a little bit to

show you how it's shaping a lot of federal policies that we're now seeing emerging and taking place, including the hcbs rule. some folks say that the americans with disabilities act has not been as effective as it could be. a lot of people have criticisms of it.

but in my opinion it's been rather phenomenal in the changes that it's made. and one of the things that the americans with disabilities act has done is the emergence of making sure that people are not unjustifiably segregated. a lot of folks hear about the

olmstead decision. but not a lot of folks necessarily know that that comes from the americans with disabilities act. i think that we all sort of see it as its own sort of existence, but it really is enacting the ada.

it's based on an ada case brought by two women, lois curtis and elaine wilson, who had developmental disabilities and lived in a hospital in georgia. mental health professionals at that hospital in georgia found they were ready to move to community-based services but they remained confined

in the institution. so they filed a case based on the americans with disabilities act title ii, which applies to states and local governments, and ended up going all the way to the supreme court who made its decision in june of 1999. their

holding was that unjustified segregation of persons with disabilities constitutes discrimination and violation of title ii of the americans with the court held that public entities must provide community-based services to persons with disabilities when such services are appropriate.

affected persons do not oppose community-based treatment, and community-based services can be reasonably accommodated taking into account the resources available to the public entity and the needs of others who are receiving disability services from the entity. so it

really provided a platform for folks to use the americans with disabilities act to move more services into home and community services and arguing that people with disabilities should not be now, just taking one quick step back, now i'm going to throw you into constitutional law, but the

was able to be enacted because of the 14th amendment of the constitution, the equal protection law. so if you're really thinking about all of the themes here, it's really about equal protection of the law that people with disabilities should not be treated any differently

than any other citizen is treated, which then brought us the ada and then the interpretation under olmstead. so really powerful themes to move us forward. next slide. so in 2009, president obama, as you can see in the lower photo there, was with lois curtis from the olmstead

decision and declared 2010 the year of community living. this really set forth a theme of community integration and community living for all agencies that fall under the federal government. and just an example of some of the things that happened. well, for one,

you had the creation of the administration of community living under the department of health and human services. you also had the department of housing and urban development, which we'll talk about in a little bit, also called hud, issue an olmstead compliance document

in restructuring their section 811 program to provide grants to those only with integrated housing. you had d.o.j., the department of justice, pursuing several olmstead settlements, and also recently breaking new ground was recent rhode island settlements on sheltered workshops.

and then, of course, you had the centers for medicaid and medicare services issuing a new home and community-based services rule. so really, i want everyone to be able to view this rule in terms of a holistic approach that federal policy is taking, looking at really moving towards more community integration.

we're going to talk aboutï¿½-- a little bit about hud, diving into a little bit of what hud has done. while this rule falls under the centers for medicaid and medicare services, hud is going to play a very important role. hud is in charge of all public housing that receives federal funding.

right there. perfect. it's really important that they're aware of and involved with the rule and also are moving their own policies in line with olmstead and aligning them with the rule in order to provide the housing that will be needed as we move more towards community-integrated settings.

a few of the things that hud has recognized is issued for people with disabilities in finding housing is, one, that there's a short supply of affordable housing. it's not very affordable on an ssi level income. there's long waiting lists for hud rental assistance programs, and

there's lack of integrated options. a lot of the disability programs are targeted and mandated to serve exclusively people with disabilities. and then there's also a non-compliance with olmstead in a lot of housing developments that receive federal funding. so what they did, and this was really

miraculous -- next slide -- they issued in 2013 the hud olmstead guidance. now, this didn't necessarily change anything in terms of their own olmstead compliance. instead it really just laid out for housing providers what they were expected to

do in order to come in line with olmstead. but it gave them really great guidance and information to the wider world of housing on olmstead and the trends and where hud is planning on going next. so the purpose was to provide information about olmstead to clarify

how recipients of financial assistance from hud can assist state and local efforts through, for example, instituting olmstead preferences and then encourage housing providers to support olmstead implementation by increasing affordable housing options. you can see on this slide -- and actually if you just even google hud

olmstead guidance, you'll come up with the document. it's not very long. it's 11 pages. half of that is the actual guidance and then the other half are frequently asked questions. but it's just a really wonderful document.

i suggest for any of you that can google this after, or on your ride home from work if you're taking transportation, just read it quickly. it will really be enlightening and help you understand the trend that hud is moving forward in. on the next slide i'm going to give you a little sample of what's in

that guidance. for one, it talks about integrated settings compared to segregated settings. it says integrated settings are those that provide individuals with disabilities opportunities to live, work, and receive services in the

greater community, like individuals without disabilities. it's located in mainstream society. and with housing, it allows individuals with disabilities to live like individuals without disabilities without rules that limit activities or immediate ability

to interact with greater society. some examples are scattered site apartments, tenant-based rental assistance and integrated developments. and then they talk about what segregated settings are. they are occupied exclusively or primarily by individuals with disabilities.

they sometimes have the qualities of institutional care including lack of privacy, regimented activities, and limiting visitors. so when you dive into this document a little bit more, if you look on the bottom of page 8, i'm going to read you a little bit of how hud's connecting with the cms rule.

bear with me. it's a short paragraph. as states and local entities increasingly provide healthcare and support services to individuals with disabilities and integrated community-based housing because of olmstead and efforts to rebalance delivery of healthcare services, hud

encourages housing developers and providers to explore state-specific conditions to assess the continued viability of different housing models as they relate to future referral and future availability of medicaid and other funding for services. so really, hud is triggering a lot of folks to really assess how they can

continue to provide the same models in light of the future availability of medicaid and other funding for services. and that's what we're going to dive into with this rule. they go on to actually talk about hud reviewing its own housing programs to determine how it can facilitate greater housing choice by increasing integrated

housing options for people with disabilities. there's real change happening. they are very well aware of the cms rule. i actually had the opportunity after the issuance of the new hcbs rule in january to speak with then hud secretary donovan about the rule. they see a real alignment with their policies and this new rule.

and, in fact, it's important to know that hud staff actually worked on the new hcbs rule. so although this is coming out of cms, you have a lot of folks that were able to work on this from department of justice to hud. so i

really want to give you all just a very big picture of how all the federal policies are coming together and all the federal agencies are coming together to move forward towards more community-based integration and how to create systems change in order to make that happen.

so katherine will dive intoï¿½-- i'll do one more slide. that's hud resource slide. katherine is really going to dive into the highlights of this rule, but i really want to say that some of the highlights from our perspective is that it defines and describes what home and community-based

services are. this is really never done before. so this is very exciting to see this now in this social security act, defining what these are. settings are selected based on a person-centered process. a lot of

the hud guidance and a lot of what you'll see within the rules about person-centered, self-determination, choice, it's really about the individual. in line with that, ensures the individual's dignity, respect, and freedom from coercion and restraint and maximizes

opportunities for individuals to have access to home and community-based services. so i'll just wrap up here on the next slide by saying that we at nacdd have hopes and concerns about this new rule. i'll start with our concerns and end on a

more positive note with you, our hopes. but our concerns is that -- on the right-hand side you can see the infamous schoolhouse of henry's turkey service where a number of men with intellectual and developmental disabilities were kept for a decade in just real

dire circumstances. these are dire but real circumstances that a lot of people with disabilities live in. so our concern is that as a community, we don't do enough to help implement the rule and make sure it's maintained.

this is a really exciting opportunity, but it's going to take the whole community to make sure that it's integrated, that the education is out there, and that people are able to really have a say in how this rule moves forward. the hopes, on the other hand, on the picture on the left-hand side, are

two sisters, one of whom lived much of her life, most of her life, in rosewood, which was an institution in maryland. this is taken from the maryland dd council who followed the stories of these individuals when they moved into the community after the closure of that institution.

it really reminds me of a story when i was younger. i have a younger sibling with a developmental disability who's lived with me my entire life. but i had a friend at the time who said she had a younger sister as well. i was over

at her house and i said, ï¿½really, i didn't know you had a younger sister.ï¿½ and her younger sister actually lived in an institution, and she didn't have contact with her after the parents had made that decision. so this story of this picture represents to me these sisters coming back together and really

being able to live in the community together. i think that that is really the hope of this rule; that we do move away from institutionalization and more into community integration so that people can really all have access to the community; that we can really move forward the spirit of this

rule and move forward into this next generation where those sorts of situations do not occur. with that i'm going to pass this off to samantha to then pass to katherine to wrap this up. hi. this is samantha again. katherine, i'm trying to share the

controls with you so that you can control the slides yourself. let me know if that doesn't work. fire away. and thank you, esme, for that great summary of where we are, setting the context. my name is katherine berland.

i'm the director of government relations for the american network of community options and resources, abbreviated ancor. we are aï¿½-- ancor is a national trade association representing private providers of services to people with significant disabilities, primarily

intellectual and developmental disabilities. we have over 800 members nationwide and they provide a range of services: residential, employment, and other services. we are very interested in this rule and how it applies and how it's going to

work to help in more than half a million people that we serve. that's my introduction. what i'm going to do today -- and, again, thank you, esme, for putting it in context. before we launch into the nitty-gritty of the rule, i do want

to just restate the purpose behind it. as esme said, this rule came about as part of cms's intent to support the olmstead mandate and ensure that hcbs funding is being used to support settings that truly are home and community-based. with olmstead mandate, which is part

of the americans with disabilities act, it's somethingï¿½-- it is a different entity than the centers for medicaid and medicare services which administers medicaid programs and the waivers that hcbs are delivered under. important to understand that distinction. it has been possible to have something that cms would approve.

so what this rule is really about, it's about cms telling states, providers, and stakeholders that they want to make sure that the criteria that they have out there for approving waivers is going to be consistent with and support the olmstead mandate. and we're seeing a lot of real

cooperation between various government agencies that all provide a piece of the puzzle, as esme mentioned. we have housing and urban development, we have the department of labor. they're all making their own rules.

and they all have their own authorities. it reallyï¿½-- really what this as a rule about is about ensuring that cms's piece of it really supports the olmstead mandate within the ada. cms found the need to have firm guidelines and definitions surrounding so that standards are

applied uniformly across the program. i want to step back. people to panic thinking that this rule means that settings are going to close tomorrow. that's not what this rule is about. the last thing cms wants is for people to be

displaced or have their services interrupted or be at risk of institutionalization. we just want to ensure that if funding is being used so that people can live and be served in a community; that people are really living and being served in the community.

this rule does mean that the providers are going to have to make some changes. but cms has the understanding of the amount of work that will need to be done to transition services and settings, which is why there is a transition period of up to five years.

first i'll give a very brief recap of the provision. the rule was released januaryï¿½10 of this year and went into effect on march 17, 2014. the rule defines and describes home and community-based settings under section 1915(c) waivers,

1915(i) and 1915(k) options. it also intends to use in this criteria laid out in the rule to [indiscernible] all authorities going forward, including the waiver demonstrations. the rule says to be eligible for hcbs funding, the services and settings have to conform to the criterias set

forward. they would have to pay for it another way. so as pointed out, states have to be very aware of the olmstead implications from designing their systems to make sure that they have settings available to provide services in the least restrictive

settings appropriate to the individual. the other thing i want to point out here is that the standards included in the rule are a floor, not a ceiling. what i mean by that is the federal government has set certain minimum requirements that individual states can set additional criteria for their own program that they'll require and

still be consistent with the rule. additionally, the rule sets forth requirements through the person-centered planning process and the person-centered plan. and finally, the rule lays out transition timeframe and requirements for states to submit transition plans. note that the transition plan and provisions in the rule only apply to

the transitioning of settings. everything else in the rule went into effect on march 17 of this year, including the provisions for person-centered planning. there is no additional timeframe for transitioning the services because they should already be happening.

there are some settings excluded. these are nursing facilities, institutions for mental diseases, intermediate care facilities for individuals with intellectual disabilities, icfs. hospitals that provide long-term care services, and any other location that has the

qualities of an institution as determined by the secretary. now, this is a somewhat subjective term and allows discretion on part of the secretary to make determinations that are not based on what a setting is called but rather than how it operates. if it functions as an

institutional setting it will be excluded. the settings always excluded, in addition, certain settings will receive a higher level of scrutiny in determining whether they meet the hcbs criteria. these are settings that share a building with an inpatient facility,

that share space with or are next to a public institution, any other setting that has the effect of isolating individuals receiving medicaid hcbs from the broader community. cms issued settings which i'll be going into in some detail in a few minutes. these are settings

that are subject to higher scrutiny but are not automatically disallowed. if the setting makes a compelï¿½-- i'm sorry. if the state makes the compelling argument these settings facilitate the individuals living full lives in the community, they may still be included in the home

and community-based settings in the state. this is going to be very fact specific. circumstance by circumstance determination. it's challenging to say definitively what exactly will or won't be included for these settings.

i'm going to touch briefly on criteria before moving into the settings guidance. the main thing to keep in mind through all of this is that a person's life experience in these has to be on par with that of a person who is not receiving medicaid hcbs funding.

it's not what type [inaudible]. the setting can be selected from the setting options. the state has an obligation to provide an array of setting options, including non-disability specific settings and the option for private unit. this does

not mean that the state has an onus to fully fund all options for all people, but it has to ensure that the options is within the program. this also doesn't mean each provider has to provide every setting option, which options are available for a person will be limited by her individual circumstances

and resources. additionally, privacy rights must be respected. this includes things like not posting in common areas, individual meal restrictions, not distributing medication to everyone in front of everyone else, and respecting the person's preferences about who

to spend time with. there's a specific [inaudible] against coercion and restraint. and finally, the setting must optimize independence and autonomy. more about how the person spends their time where they spend it and who they spend it with. as i mentioned, there is some

additional criteria that applies to provider controlled settings. so in addition to the settings i just laid out for all settings, if it's provider controlled, there must also be a written lease or residency agreement. it doesn't have to be a formal lease but it

does have to be in writing. the most important characteristic of this is that it sets forth all the same protections and responsibility that other people within that jurisdiction have. so this will include processes that must be followed prior to eviction

proceedings, for example. additionallyï¿½-- i think i just lost my ability to control it. are you able to go to the next bullet? i was clicking on something on the questions that might have stopped you. ok. turning it back to you right now.

by the way, i'm hearing that some people are having a hard time hearing you, katherine. so maybe you want to talk a little closer to the mic. i will try to do that. thank you. i'm still not able to

advance the bullets. there we go. good. there are some additional privacy requirements. one is that units have entrance doors lockable by the individual with only appropriate staff having keys.

individuals who are sharing units must have a choice of roommates. and, again this doesn't mean that a person will always get to have their first choice. it just means that a person has to have input into decisions and their preferences respected whenever possible among

available options. along those lines, a person has to be able to decorate their space the way they want to, within their lease agreement. as an example, i've lived in apartments where i couldnï¿½t paint the walls or would have to get permission before doing

certain improvements. that's how life works. this rule doesn't create additional rights beyond what other tenants in the jurisdiction have, but it does mean that someone should be able to put up pictures of their family in their room or pick

their own bedspread. so things like that, you know, understanding examples like that i think will help you understand what this rule is getting at. and finally, an individualï¿½-- i went too far. an individual has to be able to control his or her own

schedule, have access to food and access to visitors. i've gotten a lot of questions about the food and visitors requirement. this doesn't mean a person has to have access to a full kitchen 24/7 or even that there can't be scheduled meal time.

what it means is that if somebody misses a meal, they don't go hungry until the next one. maybe they can keep snacks in their room or be able to fix their own food in the kitchen. there has to be a way for someone to be able to eat

what they choose, when they choose. additionally, the visitorsï¿½ requirement says you can't limit access of visitors. for example, you can't say that visitors can only come through a window between 3:00ï¿½and 7:00ï¿½each day. practically it will be important to work with the people sharing the space to make sure

that everyone's rights and preferences are respected. i think most of us have at some point lived with a roommate who maybe isn't very considerate, like having visitors over at midnight when i have to get up early the next morning to go to work. most roommates just

have to work that out between themselves by talking about respecting each other's schedules. it's the same here. people may need additional support in order to work out those informal arrangements. but it can't be forbidden to allow someone to visit at any time.

and then finally, the final requirement is the setting must be physically accessible by the individual at all times. this rule does not change any accessibility requirements from the americans with disabilities so if a setting does not need to be ada compliant before the rule,

it still doesn't as long as the individual can physically move in and out and around the settings either on his own or with support available. any of these criteria for provider-controlled settings may be modified except for the physically accessible requirements.

a requirement can only be modified in response to a specific assessed need included in the person-centered plan. it can't be based on just the diagnosis. it has to be particular to that individual. plan has to none straight modification

is necessary for health or safety concerns and document less restrictive alternatives have been attempted. it has to be reviewed frequently to ensure that the modification is still necessary. cms issued several pieces of guidance on the rule focusing mostly on residential settings

and transition planning. guidance i find most helpful is the summary and the guidance on settings that isolate. i'll go more into that in a minute. this page has all the current cms guidance document hyperlinks. understand you'll have these slides

available you after this presentation. all right. it's 1:00. it's time to start the webinar. welcome, people with disabilities?" this housing. we are joined by esme grant, thank you so much. samantha, i i've made you the presenter. sorry. technical difficulties. i am going show my screen. i accidentallyï¿½-- i

my keyboard instead. here you go, esme. sorry about that. developmental disabilities. i spoke ucedds in various states. we're what this rule is really about. i policies. so i want to talk a little policies are put into play. then i'm how this rule plays out. octoberï¿½21, guidance. i know we're all very

housing. so i just want to give monitoring. we're going to talk implement it? so the final webinar to start off just bare bones. so services came from. i don't want we're talking about today. the recipients. back when it was of disabilities. the first was created in 1956. it was the social

program. interestingly, it used that's changed. but this is a disability. and now it also children as well. so it's it was created in 1972. it's revenues. so when you go out be able to have in life. so why social security. with initial lower economic strata. it was

amendments act of 1965. it's a resources are put. what happens, waivers. and waivers, as many of the rule. part of what was enacted, section 1915(c). so many of you the social security act. and really and went from there. we'll talk we talking about. well, we're act. and then at the bottom you

the dark bars are 1982. this is began. you can see that the an institutional setting. and with one to three residents. so one to three residents. so or less residents. so we've seen costs. this is taken from figures of a state for each. as you can individuals. however, there's

afforded and what can't. and to more people. that's a real employment and so forth. i'll sort on employment services. but for about here. i wanted to go over as effective as it could be. a made. and one of the things that olmstead decision. but not a lot of disabilities act. i think that we

enacting the ada. it's based on in the institution. so they filed a decision in june of 1999. their such services are appropriate. the services from the entity. so it the equal protection law. so if of community living. this really set things that happened. well, for one, human services. you also had the

only with integrated housing. you sheltered workshops. and then, of bit of what hud has done. while this right there. perfect. affordable housing. it's not very guidance. now, this didn't necessarily own olmstead compliance. instead olmstead. but it gave them really the document. it's not very long.

it's 11 pages. half of that is the document. i suggest for any of you that guidance. for one, it talks to segregated settings. it says without disabilities. it's located in mainstream society. and with to interact with greater society. so segregated settings are. they are individuals with disabilities. and

connecting with the cms rule. so bear with me. it's a short paragraph. there's real change happening. and policies and this new rule. and, in rule. so although this is coming out department of justice to hud. so i i'll do one more slide. sorry. services are. this is really never done before. so this is very exciting

act, defining what these are. the person-centered process. a lot of individual. in line with that, about this new rule. i'll start hopes. but our concerns is that -- dire circumstances. these are live in. so our concern is that in maryland. this is taken from with me my entire life. but i had a

a younger sister as well. i was over together. i think that that is hi. this is samantha again. control the slides yourself. let me know if that doesn't work. fire away. thank you so much. and thank you, my name is katherine berland. i'm ancor. we are aï¿½-- ancor is a national disabilities. we have over 800

employment, and other services. we that's my introduction. what i'm context. before we launch into the it. as esme said, this rule came hcbs are delivered under. it's that cms would approve. so what as esme mentioned. we have housing department of labor. they're all making their own rules. and they

i want to step back. i don't want to close tomorrow. that's not what this rule is about. the last thing of institutionalization. we just to make some changes. but cms has of the provision. the rule was 2014. the rule defines and describes forward. they would have to pay for it another way. so as pointed out,

person-centered planning. there is disabilities, icfs. hospitals that operates. if it functions as an excluded. the settings always few minutes. these are settings i'm sorry. if the state makes the the state. this is going to be very fact specific. circumstance by circumstance determination. so

settings guidance. the main thing medicaid hcbs funding. it's not what type [inaudible]. the setting the option for private unit. this does is within the program. this also respected. this includes things like independence and autonomy. this is residency agreement. it doesn't that jurisdiction have. so this

i'm sorry. i was clicking on hearing you, katherine. so maybe ok. i will try to do that. thank you. i'm still not able to advance the bullets. there we go. good. thank you. ok. there are some additional privacy requirements. one is that their first choice. it just means

lease agreement. as an example, certain improvements. that's how life works. this rule doesn't create their own bedspread. so things like too far. ok. an individual has to access to visitors. i've gotten a visitors requirement. this doesn't until the next one. maybe they the kitchen. there has to be a

3:00ï¿½and 7:00ï¿½each day. practically it are respected. i think most of us have to go to work. most roommates just schedules. it's the same here. people all times. this rule does not act. so if a setting does not need plan. it can't be based on just the diagnosis. it has to be particular to that individual. the

and transition planning. the settings that isolate. i'll go guidance document hyperlinks. i you'll notice that there isnï¿½t a link to any non-residential settings guidance which because right now it doesn't exist. there will be another webinar specifically on non-residential settings coming

up in a couple of weeks. so i won't go into it today, but i will say providers and stakeholders shouldn't be waiting on that guidance to move forward. if and when that guidance comes out, it's not going to be inconsistent with the requirements through residential settings.

things cms will be looking for will be how much and the quality of interactions that people within a non-residential setting have with people outside of it. i don't think we're getting anything like percentages of time spent or ratios of people with disabilities to people without

disabilities. it's really going to be more about the quality of the total life experience the individual has. as i promised, i'm going to talk to you about the guidance on settings that isolate. cms issued guidance on settings that isolate several months ago. it identifies two characteristics that often tend to

be present in settings that isolate. one indicator is that the setting is designed specifically for people with disabilities, especially for people with one type of disability. the second characteristic is if most of the people there have disabilities and individuals don't go out to receive services but

rather have people come to them. now, neither of these characteristics is determinative in and of itself. you do have to take a fuller look at the situation and circumstances. you'll have to be able to show the settings does not isolate individuals and are considered a home and community setting.

the guidance includes other things to consider in evaluating a setting as isolative if the setting is designed to provide multiple types of services and activities on site. what we're talking about hereï¿½-- here we're talking not just about services and supports the person needs related to their disability,

but also things like getting their haircut, going to church, social activities. is it all on site or do people go out into the community? and when people do go out into the community, is it a car trip out and they still spend all of their time with the same people as in the setting or do they have

opportunity and ability to really interact with other people? remember that the standards that we've talked about before in connection with in this rule is asking do people have access to the community at the same level as people that are not receiving hcbs funding? we're

really looking at the total life experience rather than a checklist where if you check off enough boxes it qualifies. people's lives don't work that way. and then the last major point of this guidance is that hcbs settings don't include the use of sets and restrictions used in institutional

settings. some interventions are allowed in institutional sets and some aren't. either category [inaudible] an hcbs setting. the rule also includes a specific prohibition against the use of restraint and [inaudible]. the guidance includes some specific examples of settings that will

typically isolate individuals. these are farmstead or disability-specific farm communities. these are usually in rural areas, on large properties with little access to the broader community. remember that the rule says the standard is that people have to have the same access to the community as people not receiving hcbs funding.

so rural settings are ok as long as the people living in them have the same access as everyone else. for example, someone who lives in a very rural area might only go into town once a week to buy groceries or run errands. that's ok. the guidance separates out farming communities that typically include

all services being brought in with the people living there rarely never going out. gated or security communities for people with disabilities, the guidance points out that much like disability-specific farming communities, gated communities tend to bring services in rather than having

people going out which has the effect of isolating individuals. residential schools. these are settings that have residential services and educational programs in the same building or in very close proximity to each other. what it means for individuals is they don't have to travel into a

community to live or to attend school. and, again, the reason these settings tend to isolate people is that the people living there tend to only interact with other people in the settings rather than with the general public. and finally, multiple settings co-located and operationally related. these are settings to congregate a

large number of people with disabilities together and provide for significant shared programming and staff. like the others, the critical factor here is whether people in the setting have the opportunity to act as a larger community. this one is interesting in that the guidance says continuing care retirement communities do not raise the same concerns as

settings that serve people with disabilities. most retirement communities include residents that live independently as well as those receiving hcbs. to follow these settings, it's going to depend on the detail of the situation whether each individual setting is isolative. the guidance does mean people living in these settings should

expect that additional scrutiny will be applied. as i mentioned, the rule includes a timeframe for transition. again, the intent to cms is not to disrupt people receiving services or create a higher risk for reinstitutionalization but there are changes that have to be made. recognizing that changes take time,

cms has set forth a transition planning process for states to follow. states will have up to five years to fully transition into compliance. cms has said repeatedly that states will have different amounts of work to do. five years is the maximum timeframe but states that can do the transitioning in a shorter period of time will

be expected to. the state has to evaluate its settings and identify those that are statutorily excluded from hcbs. remember, these are nursing homes, icf and hospitals. it also has to identify those that are presumed to have the qualities of an institution and either accept that

they will be excluded or provide reasons why they do have the qualities of hcbs settings. if those settings do not currently comply, the state would like to transition them into compliance, it would have to describe its plan to bring them into compliance. finally, the state has to identify settings that are currently compliant

with the requirements of the rules. ok. so timing for submission of transition plans. any state that operates the 1915(c) waiver or 1915(i) plan has to submit a transition plan for that waiver or plan when it comes up for renewal or amendment. remember, the rule also applies to 1915(k) state plans.

those are the new community first choice options. the reason the 1915(k) isn't included here is that those have to come in fully compliant with the rule when they originate. once the state submits the plan for that waiver or state plan, the clock starts ticking and they have 120 days

to submit a statewide transition plan that includes all hcbs authorities within the state. now, states that didn't have any renewals or amendments that would trigger that 120-day clock have to submit their statewide transition plan within a year of the effective date of the

rule which puts their deadline at march 16, 2015. by then, all states under 1915(c) or 1915(i) will need to have submitted a transition plan for the stage. at least 30 days prior to submitting the plan to cms, states propose the exact transition plan publicly for comments. when they submit the

plan, they have to include a summary of comments received and also include changes made based on comments or justification for not making changes as suggested. i'm going to go into a little more detail on this aspect of it on the next slide. now, remember, even though the

rule only applies to 1915(c), (i), and (k), cms has said that it expects all hcbs authorities, including 1115 waiver demonstrations to comply with the rule's criteria. so there are some states that operate 1115's rather than 1915. they will need to ensure that their programs are in compliance. and my

advice would be to be proactive in addressing any changes that need to be made rather than waiting until a renewal is necessary. the intent of this rule is not to allow 1115 to act as a shield against making changes to a state's hcbs system. now, the last piece that i'm going to talk about before we move on to

questions is how stakeholders can be most effective during the transition process. the partner organizations on this webinar have created an hcbs worksheet for assessing services and settings helpful in working through the transition plans states are putting out. this hyperlink here, also available

on the hcbs advocacy website. the hcbs advocacy site [indiscernible] you can find out where your state is in process and access the state's draft transition plan once it's been posted. some states have already posted plans and some are still working on them. we've seen a lot of plan-to-plan,

which will list areas that need to be addressed that are kind of sketchy on the details of how they'll get there. mostly why it's important for advocates to be involved now during the planning stage to make sure that your voices get heard and the right things make it into the final plan. states have to consider your comments and they take

it very seriously. your input will carry the most weight if you have clearï¿½-- if points are clear, concise and well organized. the worksheet takes you through steps to think about as you work the points you want to comment on. step 1, the first thing you'll look at is whether the state has properly

identified settings that are not home and community-based under the rule. you'll want to look closely at the evaluation to see if there are appropriate conclusions regarding these settings. next, we'll determine if the state has properly identified settings that are presumed to not be home

and community-based. this is where you'll use that guidance about settings that isolate to see if the state has included in this list those settings that tend to isolate. step three is about how to evaluate the state's person-centered planning process to come up with a person-centered service plan or plan of care. i

won't get too much into that. it will be covered in an upcoming webinar. but because the person-centered planning requirements are already in effect now, they won't generally be referred to in transition plans. there's no transition period provided for those requirements. but it is helpful to keep in mind what your

state's program looks like to make sure that person-centered planning is central to it. if you uncover any areas that can be improved, you can include that with your comments. step four is to determine if the state's settings and services that they have identified as hcbs do meet the new rule's requirements.

there is a list of criteria to consider which goes back to that first list i went over about optimizing independents and autonomy and ensuring that a person has the same level of access to the community as do people not receiving the hcbs. there are also criteria about ways to ensure that a person is supported

in making informed decisions about their life. and finally, step five is to determine if provider-owned settings meet the criteria and rule. the worksheet includes criteria to think about when looking at particular settings. once you have gathered your information, using the worksheet as

a tool, you should weigh into your state agency. as i mentioned, they are in the draft plans and give the public, the community, to comment on them. each state will have its own system set up to receive comments. we have links to the state agencies on the hcbs advocacy site to help you find the

ones for your state. states have to consider your commentsï¿½-- i already said that part. again, states have to consider your comments and assess if you can be fair, concise, and well organized. here are some additional resources to have available to help you understand the rules and your

stateï¿½s transitioning. cms used to have a very easy to remember website but that link isn't work anymore so here's the full website. you can also just google cms hcbs rule and find it pretty easily. of course, the hcbs advocacy website which i mentioned before, that's where you find links to all the

states to get information on where they are with their transition planning process along with a lot of other resources. and the final thing that i want to leave you with is that we're still pretty early in the implementation of this rule. there's still a lot of opportunity

for people to be involved in the changes that are being made in your state. the changes being made aren't sudden, overnight changes. there will be transitioning that happens. and the more proactive you can be to work your state agencies, the more you'll be able to ensure

that the changes being made are beneficial for the services. that is the end of my presentation. i'll give it back to samantha. thank you, both esme and katherine, for this great presentation. the thing that caused you, katherine, to lose control was me trying to look through all of the questions to see

which questions i was going to ask first. because i had to let go of that, i'm trying to go through the questions right now and figure out which ones we need to ask. we have a question from paul eckland saying: under the olmstead decision is there not an obligation of the government to help develop affordable

and accessible housing since if there isn't enough affordable and accessible housing, how can people use hcbs services? esme, would you like to take that question? sure. and i would say that that's exactly what i think the government is trying to attempt to do right now. hud has beenï¿½-- has very much recognized that that's a big issue, affordable

housing component. they're looking at new models of providing affordable housing as we move into home and community-based services. and they've extended some of their programs. i know their section 811 program they've been shifting a little bit. i think that it's going to take some time and some more creativity. i'm

not quite sureï¿½-- we have a new secretary of hud, secretary julian castro, who was brought in, in part, because of his unique approach to housing and development of housing and creativity. so i haven't met with him yet or been able to talk to some of the lead folks at hud under his leadership since he came

into office, but i think in these remaining years that we have in the administration under president obama that there will be some very unique developments coming about. there's also a really great staff person at hud who works on all of these issues. his name is brendon mctaggart. i'm happy to share his

information. he's very happy to be accessible to you all. so if you contact me, i can share that with you. but he can give you really more details on what hud is doing to address the issue of the supply of there's also some legislation in congress that's looking to address this as well. so we can give more

information about that, but certainly there is the connection. but i would say that the government has been making tremendous strides on meeting olmstead. the americans with disabilities act is not in full compliance, but i'd say that this administration has done a very good job of moving us in the right direction. whoever we have in 2016, i hope will

continue that trend. thanks, esme. i've got another question from richard stinson asking: what does this rule mean for very large residential settings? one setting he was worried about was two 13-person residences side-by-side and connected by a walkway so it's basically making them one building.

and the other concern was some groups in florida that are in the process of developing very large communities that are similar to communities for seniors. it's unclear whether they're all going to beï¿½-- from the question, whether they're all going to be people on hcbs or if some people on hcbs and some people who don't have disabilities.

but let's assume for the purpose of this question that they are going to be large communities in which everyone or nearly every resident has a disability. and will these be allowed under the new rule? i'll pass that off to katherine who i think will have a good perspective on this but a couple of points i

want to make. for one, if you're aware of residential settings that tend to isolateï¿½-- and katherine went over what some of these settings are. if you're aware of a specific one within your state, then when you do have that opportunity for stakeholder input, do name it as somewhere that you have concerns about and make sure that you

provide that name. we're noticing in a lot of plans that they're not identifying some of the settings that may no longer qualify for hcbs funding, but we'd like to see more specificity, at least within the public comments, of identifying this. i think that's really important for cms. and states do have to provide a summary of public

comments to cms. so it's really important that you get your voice out there. however, i also want to make another point. cms is not going to just shut down funding immediately. that's not the point of this rule. and my concern has been that as we've seen in a lot of states, sort of this rampant fear that all of a sudden services are just

going to be shut down because they're not in compliance with this rule. i really want folks to focus on the word transition. it's about transitioning services that may currently receive hcbs funding and transitioning into this new model. so you won't see a number of these [indiscernible] no longer receiving funding, just cut them off.

that's not the point. i don't think that the federal government aims to just cut people off and have them not have anything at all in thoseï¿½ -- and no services at all. rather, it's a transition. so i just want to make sure i drive home that point. but, at the same time, if they want to continue receiving

funding for the years to come, they're going to have to transition and the state's going to have to have a real plan on how to do that. cms will work with them. the states will work with providers. and this is really about a plan of people working together to make this transition occur. so in some states we're seeing where

they recognize that there are settings that are, for example, like those 13-person settings connected to another that creates this large setting. and they've realized that they need to transition. they're coming up with solutions to do that. i think the important message to drive home is really that this is

about transitionï¿½-- i'm sure every state will be able to identify something that might not be in current line with the rule but it's about moving towards the direction of what the rule holds. katherine, do you have more insight on that? i do. i want to speak to what the rule itself says about larger settings,

congregate settings. the rule itself actually does not specify a maximum number. it doesn't specify that settings can't be congregates. it does say that larger settings might tend to isolate. so you really have to look at the details. and this is where that determination really matters. so you have to

look at what is the life experience of the people living in that setting. now, that saidï¿½-- so those settings would not, by default, run afoul of the rule. they could still be permissible depending on the circumstances, but, as i mentioned before we do live in a federal system. we have the federal government and

then we have individual states, jurisdictions. states can set limits on size. they can go above and beyond what the rule says. so a state could decide that any settings with more than four people would the not be eligible for hcbs funding in that state, which, again, is why it's really important for

everyone to really be working with their state agencies to talk to them about the programs that they have to make the case -- in a setting like you described to make the case why it still qualifies for hcbs funding or if the state's going to say that it doesn't, then, you know, work on how to transition

those people to more appropriate settings. the last point that i'll make is that this really does talk about what hcbs funding will pay for. there are other funding streams available. when we're talking about how these rules work, again, we're talking about federal law and we're talking about state

administration of their medicaid program. so states can decide based on a fair amount of flexibility in terms of how they want to allocate their dollars. the key consideration is howï¿½-- what the federal government is going to be willing to pay for and out of what bucket. so, you know, when we're talking about

back to the last question, about developing housing stock, olmstead in some ways is a bit of an unfunded mandate meaning there's this mandate for states to serve people in the most appropriate settings but there's not always the funding to back that up. funding doesn't come from the executive branch. funding comes from

the legislative branch. hud can only do so much if they don't have the money to implement the programs they want to implement, which is why, you know, it's really important to understand how funding structures work and then go to where the money is to get the appropriate funding allocated for the programs that you want to encourage.

with this rule, again, what cms is sayingï¿½-- all they're saying is we're going to fund programs under hcbs that really do result in people living out in the community. if a program as available as it is for the people that live there haven't accomplishing that goal of community integration, it's going to have to be funded another way

and the state would have to make the determination that they want to fund it, using another source of funding. does that clarify? i hope. i thinkï¿½-- i understood that pretty clearly. i'd like to move on to another question. we had a couple of questions about what needs to be in the lease and whether the provider

can still be the owner of a building in which people who receive their services can live. i can take that one as well. the rule ï¿½-- i'll tell you, this rule was a long time coming and it went through several revisions. one is the earlier proposed versions of the rule would have mandated a separation between

housing providers and service provider. the final rule doesn't make that change. the final rule says that the provider can provide both residential and also other services. and when a person chooses that setting, they are choosing to have the services provided by that provider. so if they want to quit the provider, theyï¿½-- they couldn't

bring another provider in, they would have to move to a more appropriate setting. that said, what has to go into the lease agreement, again, the standard is that it has to have the same protection that other people within the jurisdiction have. residential law, it is all over the place. you have state jurisdictions. you have

local jurisdictions. so really it's very specific to where you are, what has to be included in it. there's no single answer. but it does have to carry the same, you know, rights and responsibilities, details in the agreement that other people in the jurisdiction have. we were talking about a provider-controlled

setting. yes, the provider can own it. the lease agreement would have to spell out the process for eviction and any appropriate appeals process just like anyone else in the jurisdiction would have. what aboutï¿½-- i actually find this interesting. so someone asked about restricting food. and this is a common question that we see a lot.

let's say you've got a couple of people living in a setting and one person has prader-willi syndrome or pica or some other condition that really means that for their individual reasons they can't have a unlimited access to food. now, the rule says that there can be modifications based on a single

person's individual needs, but it also says that you can't modify the requirements for one person simply based on the needs of another person. so how would we expect a provider to accommodate one person's right to have access to food anytime while at the same time another resident cannot have access to food at any time?

i can take this one. this is where you need to be creative in your thinking. and you need to find solutions that are going to be the least restrictive. for example, the person who it would be unsafe, unhealthy, for them to have unlimited access to food, you know, you modify the criteria for them. and you go through the person-centered

planning process and it's documented in the planning, do all of that. for the other people in the setting, you have creative means. for example, maybe you work with them to find solutions such as maybe they could have a locked cabinet that they have the key to, the person who is not restricted in their access. so they understand that

it's necessary because of the person that they live with, you know, hopefully they get along and everyone is representing everyone else's rights and needs. that would be a possible solution. the same thing i always go back to, what would i do if i was in that setting without any type of disability? if i had a roommate that's drinking all

of my milk, i would label it. and if that doesn't work, i would put it someplace that they couldn't have access to it. we can work out these solutions and we can be a little bit creative. it does take a little bit of thinking outside of the box and understanding that the people that we serve, they have a lot of the same

capabilities; they just need a little bit more support and a little bit of help in coming up with these creative solutions. i see a lot of these things that really are not insurmountable problems, like they are things that with a little bit of creativity we can come up with solutions that work for people and

still respect everyone's rights. i have a question of my own for katherine. it's following up on one of the things she was saying about how many options does the state have to offer to people. and do all options need to be offered to all people? can you clarify what you meant by that statement? the rule does say

that everyone needs an option of a non-disability-specific setting. so what might be an example of a circumstance in which, you know, a person might not necessarily need to have access to a specific residential option? again, in this comes back to funding and resources. the best

way i can explain it is, again, to take disability out of it completely. the example that i used when talking to my membersï¿½-- i have a son who's in college. as much as he would love to have his own apartment, we can't afford it so he has to live with a roommate. his first year he lived with someone

and they really didn't get along. they had to live with each other for about six months until one of them was able to transfer. but because of both of their life circumstances, you know, us as parents we weren't able to afford to get them private rooms. they had to stick it out until they could move to a more

appropriate setting. so it's the same thing here. the options have to exist. there are options. there were options available to my son to have a private room, but because of his individual resources and circumstances wasn't able to afford that option. so that's why he ended up with the roommate. it's

the same here. so states have to ensure that a variety and an array of options are available. but they don't actually have toï¿½-- they're not responsible for ensuring that the funding is there to make sure that everyone has their top choice. many people would prefer to live on their own, you know, both in

the disability community and in the non-disability community. lots of us would prefer to have our own place, but at various times depend depending on where we are in our lives, we don't have the resources to make that happen. it doesn't mean that the options aren't available. so that's what i meant when i said that.

states do have to ensure that options exist, but people are still going to be limited by the resources that are available. and unfortunately funding being what it is, not everyone's going to be able to have their first choice available to them. it is going to depend on their own circumstance. so, i mean, if i am in my 20s and i'm

moving out on my own and i'm a person with a disability, my ssi check really doesn't give me enough money to rent a one bedroom of my own but i still should be able to go in on a lease with another person, letï¿½s say, for a two bedroom of my choice and receive funding and receive services in that non-disability setting, specific setting.

yeah. ok. i just wanted to clarify that. we want to make sure that states don't sort of say, well, you know, we're only going to offer services in a non-disability-specific setting to, like, first 50 comers. and just because the option is there, then we're complying and we're not necessarily going to offer

it to everyone, even if they can afford to pay rent for that apartment. i'm looking through some more questions. they keep coming in. this is a follow-up comment, said, ï¿½well what if someone getting hcbs services wants to move in with someone not receiving hcbs services?ï¿½ i would guess that this is really just about, you know, what the rent is on

that apartment. so if i have a romantic partner who's not disabled and i move in with them, i can payï¿½-- i can afford my share of the rent. can i bring my hcbs service provider with me into that setting? i would say yes. katherine, do you agree? it wouldï¿½-- you know it would depend a little bit more on the details. because

states do still have their waivers and what services are covered under the waivers. so it is going to depend a little bit on what the state says. but there's nothing in the rule that would prohibit that. it's still going to beï¿½-- it's up to the state to determine whether it's going to pay for it under its waiver. yeah,

there's nothing in the rule that would prevent that. but if it'sï¿½-- they do need to be able to provide services in non-disability-specific if the person can afford live in those settings. i would certainly make that argument. i will confess that i need to think about this one a little bit more.

on the face of it, that seems right. and if anyone wants to follow up with either me or katherine on that issue when we've had more time to think about it, please feel free to do so. what aboutï¿½-- someone asked if someone would be able toï¿½-- let's say a three-person setting. let's

say the staff in that setting isn't able to accompany them on each person's schedule because they only have one person to serve those three people and so they can't necessarily go in three different directions. does anyone have comments on that? esme, do you want to take that one?

so the questionï¿½-- sorry. can you repeat that? if there's only staff to? to accompany people like on one trip outside the setting at a time, let's say. so three people, each one wants to go to a different place at 1:00ï¿½in the afternoon and they aren't able to due to limited staffing,

would that be acceptable under the rule? well, this is another issue we'll have to look into. but i'll say that this is really the crux of what katherine was saying, that we're really at the beginning of the implementation of this rule and how it will exactly play out. we're still seeingï¿½-- i mean, we had our first guidance, the cms

guidance which katherine previewed to you was releasedï¿½-- i think june, around that time. i think so. and we're still waiting on the employment guidance and some deeper employment guidance. and there's still guidance being released as of this month. so it's really difficult

to give you a precise answer to specific questions like that. but also, we're watching from the national level how cms is looking at just the transition plans at large because that will give us a preview of the decisions that they'll be making. my understanding is as of right now, none of the plans has been

officially accepted. some might need some changes before they're really looking like the transition plans. i just say thatï¿½-- and i apologize for not having the exact answer. i just don't think we're at that point yet. we're really at the point where we're in the transition plan period. that's

up until march of next year. and then states have within the five-year period time to really put these specifics into play. so i don't know that we're going to see those precise answers except for in the next five years. i'm going to add that this is one thing that asan has expressed

concern about that really the larger the setting is the harder it's going to be to maintain adequate, flexible staffing to make sure that people really can exercise maximum flexibility in terms of how they spend their day in order to meet the requirements of the rule. so this is something

that people are really going to have to think hard about. if we're going toï¿½-- if the state is committed to maintaining multi-person settings, small multi-person settings, it's going to have to really think very hard about how to maintain adequate staffing and flexible staffing to

make sure that people actually get the benefit of these protections of the rule. i think we have about two minutes left. we have time for one more question but there are so many people who have questions. one short question that someone said is: what if a provider can't safely support someone and they want the person to leave the provider-owned home? if there's a

tenant protection, you know, that the person has to get a certain amount of notice before eviction, how is that going to interact with the provider's desire to control who's in the setting on a day-to-day basis? the rule does address emergency situations. so in emergency situations, action can be taken immediately if there is a health or

safety risk and then, you know, while you're determining the more appropriate long-term action. what i would say from the provider perspective, because this is an issue that does come up, you know, yes, you do have to provide the same protection that other people in the jurisdiction have but you can write into the lease agreement, you know, what

the eviction process is, how much time is required. again, if there's an emergency circumstance, you are permitted to deal with that circumstance to ensure that everyone is safe and protected. what i would advise for providers and other stakeholders on the call to do is to work within their states to ensure that they're able to have

protectionsï¿½-- i mean basically landlord protections that would provide alternative, acceptable, legal remedies for if a person needs to be removed from a premises immediately. you know, provide an alternative that still respects the person's rights and dignity. also, protect the provider in the instance if they're not able to adequately support

that person in a manner that's safe for everyone involved to provide them some coverage so that there is an alternative that a person can go to. so, you know, it is tricky. it is some complicated, kind of in the weeds legal stuff that we have to work through with this. i don't want anyone to think that this isn't going to be a challenge. it

is going to be challenging. the best advice i can give is to be proactive and to work with your states and ensure that you are able to have protections that will protect not only the people served but also the people providing services. great. we are about to lose cart so i'm going to have to wrap this up. thanks, everyone, for joining. our next webinar

is next week, octoberï¿½14, at 1:00. we'll be focusing on stakeholder engagement and from state and local perspectives. thanks to esme and katherine. i hope you all have a great day. bye. subtitles by the amara.org community

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