HCBS Waiver Provider Compliance Checklist
Use this form to document provider compliance status for HCBS waiver service requirements, review key operational areas, and record any issues or corrective actions.
Provider and Program Details
Provider organization name
*
Site/location name
*
Program/service setting
*
Please Select
Residential
Day program
Community-based
In-home
Other
Provider contact name
*
First Name
Middle Name
Last Name
Provider contact email
*
example@example.com
Provider contact phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Checklist date
*
 -
Month
 -
Day
Year
Date
Review period
*
Service Delivery and Staffing Compliance
Staff training completed
*
Yes
No
In progress
Not applicable
Required supervision in place
*
Direct supervision
On-call supervision
Remote supervision
Shift lead coverage
Other
Staff-to-participant supports
*
Please Select
Meets requirements
Partially meets requirements
Does not meet requirements
Not applicable
Documentation available for review
*
Service plans
Staff schedules
Timesheets
Training records
Incident logs
Other
Participant-centered planning completed
*
Yes
No
In progress
Not applicable
Incident reporting readiness
*
Ready
Needs improvement
Not ready
Not applicable
Service notes completion status
*
All notes current
Most notes current
Some notes missing
Notes pending review
Other
Staffing compliance verification
Background checks verified
Training refreshers scheduled
Coverage plan documented
Substitute staff identified
Other
Participant Rights, Safety, and Accessibility
Participant rights reviewed and upheld
*
Yes
No
Safety practices reviewed and compliant
*
Yes
No
Accessibility accommodations provided as needed
Yes
No
Not applicable
Emergency procedures are posted and staff are familiar
*
Yes
No
Identified issues or observations
Corrective actions or remediation notes
Documentation Review and Attestation
Records Reviewed
*
Missing Documents
Participant service records
Staff training records
Incident reports
Progress notes
Billing or claim records
Policy and procedure manual
None missing
Other
Audit Findings
*
Corrective Action Due Date
*
 -
Month
 -
Day
Year
Date
Reviewer Name
*
First Name
Middle Name
Last Name
Reviewer Title
*
Final Submission Confirmation
*
Submit Checklist
Submit Checklist
Should be Empty: