Frequently Asked Questions

Person-centered planning is at the core of all promising practices. That said, there are staff, activity, and environmental design approaches, as described below, which could be part of an individual's person-centered plan in response to unsafe wandering and exit-seeking. These promising practices have been compiled from industry and governmental sources and are offered as suggestions as they do not constitute requirements for HCBS services or providers.

Staffing:

• Ensure that staff have adequate training in person-centered planning and unsafe wandering or exit-seeking, including how to effectively engage and participate with individuals in both planned and spontaneous activities as well as strategies for addressing the underlying needs and preferences that may motivate wandering or exit seeking.
• Support individuals to move about freely with staff who help individuals walk or leave the room safely (e.g., providing a walking companion).
• Ensure adequate staffing for activities outside the facility.
• Ensure staff regularly escorts individuals to locations and activities outside of the setting as outlined in the person-centered services plan.
• Provide flexible supervision to assure adequate support from resident to resident and from time to time for the same resident dependent upon need.

Activities:

• Prevent under-stimulation by offering activities that engage the beneficiary's interest. Activities could include music, art, physical exercise, mental stimulation, therapeutic touch, pets, or gardening.
• Provide a wellness program to help people exercise, have a healthy diet, manage stress, improve balance and gait, and stimulate cognition.
• Support mobility through engaging activities, such as dog walking, gardening, yoga, and dance.
• Develop daily meaningful activities and minimize passive entertainment, such as television watching.
• Make available easily accessible activities, such as playing cards, reading books and magazines.
• Encourage interaction with others.
• Ensure that family and friends have unrestricted access to the individual if she or he wants this, and to the setting itself.

Environmental design:

• Eliminate overstimulation, such as visible doors that people use frequently; noise; and clutter.
• Create pictures on walls that can be sensory in nature to give individuals a place to stop and experience through sight or touch.
• Manage shift changes so that individuals do not see significant numbers of staff coming and going through the exit/entrance door at the same time.
• Use signage to orient the individual to the environment, such as indicating where toilets and bedrooms are, and assuring that there are places for individuals to sit and rest in large spaces within a setting that allow for safe wandering.
• Disguise exit doors using murals or covering door handles as safety codes permit.
• Use unobtrusive technological solutions, such as installing electronic coding lock systems on all building exits, or having individuals who wander or exit-seek unsafely wear electronic accessories that monitor their location.
• Include lockable doors on each individual's room unless the resident's person-centered plan documents that such an arrangement is unsafe, following the requirements of the rule on individual modifications. Alternative features designed for safety, such as doors on living units that are not lockable or secure exits, should be used only when they are part of the resident's person-centered plan, after less intrusive methods have been tried and did not work, as provided in the rule.
• Ensure unrestricted access to secured outdoor spaces and a safe, uncluttered path for people to wander, which has points of interest and places to rest.
• Identify quiet, public spaces for individuals to sit, observe and rest while simultaneously being part of the community, and may include items that are used to soften the senses or help with removing sensory stimulation.
• Enable people to leave the premises when they are not at risk of doing so unsafely. For example, wearable technologies can give people the ability to leave the setting or can limit the unsafe exiting of residents whose person-centered plans document that they are at risk of doing so.
• Using tools and technology to monitor an individual's activities to promote optimal independence and personal autonomy, but assuring that such resources are not used in place of adequate supervision.
• Ensure that Medicaid beneficiaries who may wander or exit-seek unsafely carry identification with their name and the service provider's location and contact information,
• Create a back-up plan or lost-person plan that describes roles and responsibilities when an individual has exited in an unsafe manner.
• Evaluate each lost-person incident to make revisions to person-centered care plans or to environmental design as necessary.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 144.19 KB)

FAQ ID:94981

All settings must facilitate and optimize Medicaid beneficiaries to live according to their daily routines and rituals, pursue their interests, and maximize opportunities for their engagement with the broader community in a self-determined manner, as outlined in the individual's person-centered service plan. The plan must reflect clinical and support needs as identified through an assessment of functional need, and document the individual's preferences for community integration and how these preferences will be addressed in the setting they have chosen.

Settings can support community integration, in accordance with each individual's person-centered plan by strategies and practices such as:

• Finding out during initial assessments what individuals desire in terms of community engagement and educate them about how the setting's capabilities will meet the individual's needs and preferences. This should be done before the individual makes a decision about services and settings to allow the best fit between the person and place.
• Documenting the factors the person identifies as important in a community such as proximity to and involvement of family, connections to communities of faith, specific cultural resources and activities, and others.
• Recording individual preferences for community integration in the person-centered plan and how the setting will support those preferences (e.g., participating in their faith community, attending a favorite club, Sunday breakfast at the local diner, interests in volunteering or in working, etc.) as well as the transportation needed to achieve desired outcomes, recognizing that many of these activities are leveraged through natural supports and thus would not require Medicaid-funded resources.
• Providing individuals with opportunities to engage others in their settings through activities, outings, and socialization opportunities.
• Providing sufficient staff and transportation to enable individuals' participation in their activities of choice in the broader community. These could include opportunities for work, cultural enjoyment, worship, or volunteering. The person-centered service plan may also include provider-facilitated opportunities to engage in desired activities in the broader community.
• Ensuring that visitors are not restricted, and individuals can connect to their virtual communities of choice through social media noting that this alone does not substitute for community activities and integration.
• Ensuring that individuals have opportunities to visit with and go out with family members and friends, when they want this. Providing an inviting environment and flexible schedules and service times (e.g., meals, medication administration) can encourage family and friends' participation in the life of the residential setting and support their efforts to maintain individuals' connections to the external community.
• Reviewing at least annually whether any parts of the person-centered plan need change. It is important to note that the modifications requirement within the regulations defining home and community-based settings also applies to anyone in a residential or nonresidential setting, and thus the person-centered plan needs to document what services and supports should be made available to allow people to live where they want and do what they want during the day to assure maximum integration with the broader community. For more information on the HCBS rule requirements on person-centered planning, please refer to CMS' previous FAQs on this topic.

All settings, including those in rural communities and those in low density suburban areas, are encouraged to provide adequate transportation opportunities to meet beneficiaries' desires for meaningful community engagement and participation in typical community activities.

Note that visits by community members have value but do not substitute for community access for Medicaid beneficiaries receiving services in residential and adult day settings.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 144.19 KB)

FAQ ID:94986