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Review Activities

This evaluation process uses a comprehensive, multiple-method approach, much of which is gathered during a multi-day site visit at the lead agency’s location. These methods provide a full picture of compliance, context, and practices within each lead agency, and further explain how people benefit from these programs.

Description of activities

Kick-off telephone conference 

The kick-off teleconference takes place approximately 3 months prior to the site visit.  It is an introductory conversation between the lead agency and members of the Lead Agency Review (LAR) team that will be on site during the review.  The purpose of this call is to:

  • Give a general overview of the purpose of Lead Agency Review
  • Share what the lead agency can expect during a review
  • Gather general information on how the lead agency is structured
  • Address technical items, such as meetings rooms, case file structure and internet access
  • Confirm review dates and times

Supervisor interview

The supervisor interview will be conducted via telephone. The purpose of this interview is to gather some information to help us prepare for the site visit and to clarify information reported on the Lead Agency survey about your agency. We want to understand how the processes may be the same or different between waiver programs. Also, please indicate areas in which your agency’s practice may not be the formal policy. The interview results will be used alongside all of the other data collection tools to develop a full understanding of your agency’s practices, strengths, and challenges.

Case file review

A random sample of approximately 10% of case files for each HCBS program (AC, BI, CAC, CADI, DD, and EW) will be reviewed by our team on-site. Please reference “List of Items Reviewed” document for what specific documents are necessary during the review. A list of specific names will be sent approximately one month prior to the site visit. The purpose of the case file review is to:

  • Identify areas of non-compliance with technical requirements, including incidental items and patterns on non-compliance – all of which will require remediation.
  • Identify tools and practices used by your agency that contribute to both strong technical compliance and improved outcomes for individuals, including person centered practices. 

Entry meeting

The entry meeting will be conducted with directors, managers, and supervisors from the lead agency. This may include staff from Human Services and/or Public Health departments. Two members of the LAR team will also attend. The purpose of this meeting is to:

  • Gather information on major issues, strengths, and challenges the lead agency is currently experiencing in the management of HCBS programs.
  • Review changes that have occurred since the last site visit.
  • Share data about operational performance measures using a number of different measures and data comparisons.

Case manager and assessor focus group

The purpose of the case manager and assessor focus group is to gather staff feedback and insights into the operation of the lead agency’s HCBS programs. We will also review the results of the Lead Agency Review Survey that is administered prior to the site visit. The focus group(s) is typically conducted with staff who have direct involvement with individuals on HCBS waiver Programs.

Supervisor meeting

The supervisor meeting will be conducted on site with lead agency managers and/or supervisors to dig deeper into the agency’s practices and policies. This meeting will also include a review of the HCBS Lead Agency Review Survey. Some information will be gathered prior to the site visit via a supervisor phone interview.

Exit meeting

The exit meeting will be conducted with directors, managers, and supervisors at the completion of all site visit activities. The purpose of this meeting is to share preliminary themes and findings gathered from various sources throughout the site visit. During the meeting the remediation and reporting processes will also be outlined. 


All non-compliant items found during the review need to be remediated within 60 days of the site visit.  A member of the LAR team will assist the lead agency with this process and follow-up with any questions.  At the Exit Meeting the lead agency will receive a set of Compliance Worksheets; these worksheets will list all non-compliant item for each case.  Over the next 60 days, the lead agency will correct each non-compliant item then return the Compliance Worksheet to the LAR team, dating when each item was corrected. 

Corrective action

Corrective action(s) are issued when the case file review process determines a pattern of noncompliance exists in one or more HCBS program requirement.  Once the Lead Agency Review summative report of the review visit is finalized, the lead agency has 10 business days to develop and submit a corrective action plan to DHS.  The plan must outline how the lead agency will address each corrective action issued and bring all items into full compliance.

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