Since April 2004, the Office of Quality Enhancement has undergone a process through which it developed and implemented revisions to its survey and certification process, its survey instrument, and the way it shares information with its various audiences. A fundamental change in the process is that the license granted to a provider is determined based on their performance in the safeguard (or flagged) areas of the survey tool. A new report format was also created to:
  • Improve the efficiency and decrease the overall duration of the survey process,
  • Improve the transparency of the evaluation process,
  • Decrease the amount of narrative material,
  • Present information in a more easily understood format.

The following material should serve to orient the reader to the format and aid in their ability to interpret and understand the survey findings.

Executive Summary

This section of the report provides a concise synthesis of the key findings of the evaluation process and the current status of the organization's overall service quality. This section identifies the level of licensure and certification awarded to the organization, the members of the survey team, and the number and type of reviews completed. The general format for this narrative includes the following sections:

  • A description of the organization, and any notable changes within the organization since its last review,
  • A service quality section describing the organization's strengths and areas on which the organization should focus. This section speaks to both licensing and certification parts if conducted, but in a synthesized report format, including information about:
  • Licensure : A description of the agency's performance in supporting positive outcomes in people's lives in the areas of Rights and Dignity and Personal Well-Being. It also includes the evaluation of the organizational strength in the areas of supporting effective systems to safeguard people and to recruit and maintain competent staff. Positive supports in these areas are the basic thresholds for an agency to provider supports.
  • Certification Review : A description of the agency's performance in supporting positive outcomes in the areas of Individual Control, Community and Social Connections and Personal Growth and Accomplishment. It also includes the evaluation of the organizational strength in the area of supporting growth and change to improve the quality of its supports. These outcomes, combined with the licensure outcomes, describe the full quality of an agency's supports.

Provider Scoring Summary

This chart is divided into two sections that represent the agency's average rating for each service type, and across all services in each of the Quality of Life Areas and the Outcomes for the Organization. It provides a snapshot of the organization's overall performance in the licensure component of the process and in the certification review component.

Quality of Life Scoring Summaries

Following the principles, charts are provided which identifies the organization's rating for each outcome and the overall number yes/no responses given. This data provides the reader with the actual performance of the organization relative to each of the service quality indicators reviewed and within each service type. It also displays the overall percentage that the indicators were determined to be present for the sample of individuals participating in the survey. In considering this information, it is important to note that findings from reviews of Respite Supports are not currently rated. Consequently, the yes/no responses are provided for informational purposes only and are not represented within the Percentage of Indicators Present totals.

Outcomes for the Organization

While this section is presented in the same format as that of the Quality of Life Areas, this information is more focused on the way the organization has structured itself and the systems it employs to support the quality of life of individuals across settings and service types. These outcomes are separated between the two sections of the report as they pertain to the safeguard or service quality review.

Posting of Follow-Up Reports

Provider Follow-Up: Providers meeting 90% or more of the applicable licensure indicators will conduct their own internal correction and follow up on the identified issues.  The provider will then submit information on the status of correction to the regional DDS Office of Quality Enhancement 60 days after the Service Enhancement meeting.  This takes the place of direct follow-up by the QE surveyors.

DDS Follow-Up: Providers that meet the standard for 89% or fewer of the applicable indicators will have follow-up activities conducted on site by the regional DDS Office of Quality Enhancement surveyors



This information is provided by the Department of Developmental Services.