PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
ARC of Cape Cod, Inc., The
POB 428 171 Main St
 Hyannis, MA 02601    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
April 24, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
ARC of Cape Cod, Inc., The	

	

	

	

	
Review Dates	

	
3/31/2017 - 4/4/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
4/13/2017	

	

	

	

	

	

	
Survey Team	

	
Michael Marchese (TL)	

	

	

	

	
Citizen Volunteers	

	

	

	

	

	

	

	

Survey scope and findings for Residential and Individual Home Supports	

Service Group Type	
Sample Size	
Licensure Scope	
Licensure Level	
Certification Scope	
Certification Level	

Residential and Individual Home Supports	
4 location(s) 4 audit (s) 	
Targeted Review	
DDS 10 / 12
Provider 38 / 38

48 / 50 2 Year License 04/13/2017-  04/13/2019	
	
DDS 20 / 20
Provider 9 / 9

29 / 29 Certified 04/13/2017 -  04/13/2019	

Individual Home Supports	
4 location(s) 4 audit (s) 	

DDS Targeted Review	
23 / 23	

Planning and Quality Management	

	
DDS Targeted Review	
6 / 6	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

The Arc of Cape Cod, Inc. is a not for profit agency established in 1954, that supports people with developmental disabilities and their families living on Cape Cod.  They are a local affiliate of The Arc, a national, multi-agency advocacy group, but operating as an autonomous confederate agency that works collaboratively with other Arc affiliate agencies.
    
The agency is currently providing less-than-24 hour, Individual Home Support services, through its Gateway program, to 55 people who receive funding from the Department of Developmental Services (DDS).  This program offers a variety of services to the people they support, including: case management, individual supports, representative payee services, personal care assistance, housing assistance and 24/7 emergency services.  The agency also operates the Sandpipers Club, a self-governing adult social club that offers its more than 250 members the opportunity to participate in a variety of social and recreational activities, such as, dances, whale watches, and summer concerts.  The agency's Individual Home Supports model was the focus of this licensing and certification review.  

The agency received a two year license for its Residential Services in 2015, and was therefore eligible to conduct its own self-assessment and receive a DDS targeted License and Certification review for its Individual Home Supports service grouping.  Their targeted review comprised an evaluation of the eight critical licensing indicators, all indicators determined to have been 'Not Met' in their previous survey, and all new and/or revised Licensure and Certification indicators promulgated by DDS in August of 2016.  The findings of the DDS evaluations were then combined with the agency self-assessment findings and used to determine the agency's new Licensure and Certification levels.   

The DDS targeted review affirmed systems were in place that support essential safeguards in several domains including personal and environmental safety, as well as medication and health care review.  People's homes were safe and well maintained, accommodated their needs, afforded them privacy, and reflected their personal preferences and tastes.  In addition, all rated Licensure critical indicators were found to be met.  

In the Certification domain, survey outcomes reflected the agency's continued emphasis on providing people with individualized home supports tailored to their unique needs, interests and lifestyles.  For example, staffing supports are regularly modified and rescheduled to best meet the changes in people's needs.  There was also an observed emphasis by staff to fostering people's independence, and empower them to make informed choices related to activities, relationships, etc.  Individuals who participated in the review spoke positively of staff supporting them, and reported being treated respectfully, and having their opinions and choices honored.  Organizationally, the agency has developed an effective process for soliciting feedback regarding the performance of staff that support them, as well as their overall satisfaction with services.  Several unique features of this process honor the agency's emphasis on collecting meaningful feedback while honoring people's rights.  First, these annual surveys are conducted by office staff rather than the individual's case manager, so as to promote unbiased reporting.  The survey responses are then anonymously aggregated by case manager for review by senior management, and the input is utilized as part of their staff performance evaluation process, as well as incorporated into the agency's service improvement efforts.

One area identified as needing additional strengthening is with the timely submission of assessments and support strategies to DDS within the fifteen day time frame prior to people's Individualized Service Plan (ISP) meeting dates.

Based on the results of these combined reviews, the agency achieved a two-year license for its ndividual Home Supports with 96% of all licensing indicators receiving a rating of 'Met' and is certified with 100% of all certification indicators receiving a rating of 'Met'.  The agency will conduct its own follow-up of any licensing indicators rated 'Not Met'.

In preparation for this licensing review The Arc of Cape Cod has presented the following description of the organization's ongoing quality assurance program with special attention to the agency's current evaluation of compliance with DDS licensing standards:	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

The Arc of Cape Cod, Inc. has developed an active and continuous quality assurance system that helps to identify issues, patterns, trends and systemic issues with follow-up to correct issues, and ensure that individual and systemic corrections occur.  A re-assessment of reoccurring issues assures that there are no further problems.  Monthly meetings with DDS service coordinators and supervisor, risk assessments and action plans where appropriate, information from HCSIS reports, DDS quarterly contract reviews and the annual Member Satisfaction Survey insure the individualization of services.

Residential and individual support services utilize an ongoing monitoring system.  Case Managers perform standardized monthly tasks with program members  Monthly tasks include Food Stamp review, Fuel Assistance, Storm Preparation, etc.  Assessments of critical areas are performed annually by the Director of Direct Care Services (DDCS) to accurately determine the status of key skills and recommend changes in support services as indicated.  These Assessments include: Financial, Fire Safety (updated if the member moves), Medication Self-Administration & Assistive Technology. 

The DDCS meets monthly with the Office Manager to review paperwork turned in by Case Managers and follow-up where necessary.  Individual Support Staff have daily written assignments, the Case Managers monitor activity in their regular visits and the Program Coordinator does random check-ins.

Case Managers meet monthly with the Director of Direct Care Services and again with administrative staff to provide a detailed overview of each program members' status and discuss service options.  Administrative staff meet monthly with DDS to share information and develop/coordinate appropriate action plans.  

 This year's self-assessment team was split into two areas of concentration Financial and Programmatic   The Financial team consisted of the CFO/Assistant Executive Director, Executive Assistant and Office Manager who were responsible for reviewing all representative payee policies, procedures and practices for privacy, security and compliance with accounting and audit principles.  This team also reviewed all personnel records for compliance with training and agency policies.  
  
The Programmatic team consisted of the Executive Director, Director of Direct Care Services, Office Manager, Registered Nurse and a Case Manager.  This team reviewed confidential records, policies, procedures, practices and personal interactions with and between program members, staff and community.   

One recommendation was that the agency set aside a specific time annually to perform an all-encompassing review of practices.   This annual review will take place in August as part of our monthly tasks schedule.

The areas reviewed and the manner of their review are the following:

Physical Environment:

With the exception of The Arc's office location, all program members live in their own homes/apartments and receive services in their community.  The Arc works closely with all local housing authorities, their agents and property owners to address tenant concerns.  Safety Plans are prepared once every two years for individuals receiving 15 hours or more of services (more frequently when required), approved by the Executive Director and the DDS Area Director and then forwarded to the DDS Program Monitor for review.  Fire extinguishers are serviced annually to insure proper working order.  
   
During the Annual Safety Assessments, any changes in the ability of the individual, in comparison to the previous year, is reviewed for impact on the individuals' safety.  Where appropriate, action is taken to assure individual safety is maintained.  The DDCS checks water temperatures annually during the fire safety inspection and notifies the appropriate housing agencies if discrepancies from the safe range are found.  Each program member has an individualized emergency plan that includes the location of the nearest shelter.  Back packs with emergency supplies are distributed to program members at risk prior to severe storms.   

Health Care:
  
The Arc employs a part time R.N. who reviews medications, monitors all medical appointments and follow-ups are met via individual health summaries, checklists, a calendar and notifications to Case Managers of up-coming appointments.  The R.N. also acts as a medical liaison with physicians and case managers and program members.  The R.N. also provides program members with training relative to their medical conditions and nutrition (we recently hired a part time nutritionist to work with program members.)  The Self-Medication Assessment is done with each program member annually, updated if changes in their medical condition or cognitive ability occur.  Most program members have chosen to receive their medications pre-packaged in morning/afternoon/evening blister packs.  All of our program members are independent in self-administration of their medications.  

Program Supports and Implementation:

Timely submission of materials for each ISP (including the submitting of an annual assessment and the completion of Provider Support Strategies fifteen days prior to the ISP) Meeting, all materials are reviewed prior to submission to insure the quality of reports.  ISP dates are set annually in December with DDS service coordinators and entered on a spreadsheet available to staff through Dropbox in accordance with our ISP Protocol.  

The DDS Risk Committee is updated on the status and action plans for at risk individuals per a schedule based on the severity of the risk presented.  Written updates are provided to the Risk Committee chair in advance of meetings.

Program member profiles are updated weekly to keep information as current as possible.   Updates of medications and diagnosis are noted by the Program RN and forwarded to the Office Manager for entry into the program members' profile.  Information on the potential side effects of medications are placed in the program member's confidential record book at the same time.   

Case Managers develop Individual ISP goals based on program members' interests and needs.  Program members are empowered to play the primary role in goal development and implementation.  Where specific needs exist, options are presented to the program member on an ongoing basis so they can make informed decisions on their personal goals.  Case Managers record semi-annual progress notes on goals.  Case Managers meet with the DDCS who submits semi-annual progress notes in HCSIS.

To review the efficacy of the quality management process in meeting the licensing standards set by the Department of Developmental Services, The Arc of Cape Cod has composed a survey team of two senior administrators and three supervisory staff each with expertise in specific aspects of the overall program. This team, using all the DDS Licensing Standards, evaluates 100% of the program members subject to licensing standards. 

The evaluation will be conducted prior to the DDS targeted licensing review, then annually to maintain the standard in non-review years.  The Arc of Cape Cod survey team will summarize results of the findings and aggregate ratings for each indicator are established using 80% as the criteria for assigning a rating of standard met.  If, in any area, the license indicator is Not Met (less than 80%) the agency will outline the specific issues identified and identify the steps to correct the issues(s).  Timeframes for these actions will be developed with deadlines established to insure that issues are consistently met in our corrective action plan.  The Summary and ratings will be presented to the Arc's President & Executive Director.  The ratings from the final set of evaluations are recorded on the Provider Self-Assessment Form for licensing.

Human Rights:

The Arc of Cape Cod's Human Rights Committee has a Human Rights Coordinator and is properly constituted and scheduled to meet quarterly.  Each program member is assigned a random number for Human Rights Committee documents to maintain confidentiality.  The committee annually reviews Agency Policy and Practices that have impact on Human Rights review.  Human Rights Training for staff and program members occurs annually ensuring awareness of DPPC reporting requirements.  

The Arc of Cape Cod distributes business cards with D.P.P.C. contact numbers and information to all program members in both a wallet card and a refrigerator magnet.  The committee reviews restrictive practices, significant incidents and all investigations.  The Arc of Cape Cod does not permit restraints of its program members by staff or have any behavior plans for existing program members.  Human Rights policies are reviewed annually with all program participants.  If a program participant has a legal guardian this information is forwarded to them for their acknowledgement.  

Staff Training and Development:

The Arc of Cape Cod ensures all direct care staff are up to date with required DDS trainings.  The Training Coordinator, via a spreadsheet, assures that all personnel are up-to-date on all trainings.  Staff receives training in First Aid, CPR, Fire Safety, Human Rights, DPPC, ISP, Signs of Illness and Blood Borne Pathogens.   The Arc also encourages the attendance of its staff at the trainings sponsored by the Area Training Council and at the Arcs in Massachusetts trainings.	

	

	

	

		
LICENSURE FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/8	
0/8	

Residential and Individual Home Supports	
40/42	
2/42	

    Individual Home Supports

	

Critical Indicators	
5/5	
0/5	

Total	
48/50	
2/50	
96%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
2	

	

	

		

	

	
Residential Areas Needing Improvement on Standards not met/Follow-up to occur:
From DDS review:	

Indicator #	
Indicator	
Area Needing Improvement	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Required assessments were not submitted within the required 15-day timeline for two individuals reviewed.  The agency needs to ensure that all required assessments are submitted no later than 15 days prior to the scheduled ISP meeting date. 	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
ISP support strategies were not submitted within the required 15-day timeline for two individuals reviewed.  The agency needs to ensure that all support strategies are submitted no later than 15 days prior to the scheduled ISP meeting date.	

	

								

	
CERTIFICATION FINDINGS	

	

	

	
Reviewed by	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 1/1
Provider 5/5	
6/6	
0/6	

Residential and Individual Home Supports	
DDS 19/19
Provider 4/4	
23/23	
0/23	

Individual Home Supports	
DDS 19/19
Provider 4/4	
23/23	
0/23	

Total	
	
29/29	
0/29	
100%	

Certified	

	

	

	

								
	MASTER SCORE SHEET LICENSURE	

								
	Organizational: ARC of Cape Cod, Inc., The	

								
	
Indicator #	
Indicator	
Reviewed by	
Met/Rated	
Rating(Met,Not Met,NotRated)	

O	
 L2	
Abuse/neglect reporting	
DDS	
1/1	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
Provider	
-	
Met	

 L74	
Screen employees	
Provider	
-	
Met	

 L75	
Qualified staff	
Provider	
-	
Met	

 L76	
Track trainings	
Provider	
-	
Met	

 L83	
HR training	
Provider	
-	
Met	

								

Residential and Individual Home Supports:	

								
	
Ind. #	
Ind.	
Loc. or Indiv.	
Reviewed by	
Res. Sup.	
Ind. Home Sup.	
Place.	
Resp.	
ABI-MFP Res. Sup.	
ABI-MFP Place.	
Total Met/Rated	
Rating	

 L1	
Abuse/neglect training	
I	
Provider	
	
-	

-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
	
-	

-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
	
-	

-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
	
4/4	

	
	
4/4	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
	
-	

-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
	
-	

-	
-	
-	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
	
4/4	

	
	
4/4	
Met	

 L30	
Protective railings	
L 	
Provider	
	
-	

-	
-	
-	
Met	

 L31	
Communication method	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L33	
Physical exam	
I	
Provider	
	
-	

-	
-	
-	
Met	

 L34	
Dental exam	
I	
Provider	
	
-	

-	
-	
-	
Met	

 L35	
Preventive screenings	
I	
Provider	
	
-	

-	
-	
-	
Met	

 L36	
Recommended tests	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
	
-	

-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
	
1/1	

	
	
1/1	
Met	

 L39	
Dietary requirements	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L41	
Healthy diet	
L 	
Provider	
	
-	

-	
-	
-	
Met	

 L42	
Physical activity	
L 	
Provider	
	
-	

-	
-	
-	
Met	

 L43	
Health Care Record	
I 	
Provider	
	
-	

-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
	
2/2	

	
	
2/2	
Met	

 L47	
Self medication	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
	
4/4	

	
	
4/4	
Met	

 L50	
Respectful Comm.	
L	
DDS	
	
4/4	

	
	
4/4	
Met	

 L51	
Possessions	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
	
4/4	

	
	
4/4	
Met	

 L53	
Visitation	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
	
4/4	

	
	
4/4	
Met	

 L55	
Informed consent	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
	
-	

-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
	
-	

-	
-	
-	
Met	

 L84	
Health protect. Training	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L85	
Supervision 	
L	
Provider	
	
-	

-	
-	
-	
Met	

 L86	
Required assessments	
I	
DDS	
	
0/2	

	
	
0/2	
Not Met
(0 %)	

 L87	
Support strategies	
I	
DDS	
	
1/3	

	
	
1/3	
Not Met
(33.33 %)	

 L88	
Strategies implemented	
I 	
Provider	
	
-	

-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
	
4/4	

	
	
4/4	
Met	

#Std. Met/# 42 Indicator	

	

	

	
40/42	

	
Total Score	

	

	

	
48/50	

	

	

	

	
	
96.00%	

			
								
	MASTER SCORE SHEET CERTIFICATION	

								
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C1	
Provider data collection	
Provider	
-	
Met	

 C2	
Data analysis	
Provider	
-	
Met	

 C3	
Service satisfaction	
Provider	
-	
Met	

 C4	
Utilizes input from stakeholders	
DDS	
1/1	
Met	

 C5	
Measure progress	
Provider	
-	
Met	

 C6	
Future directions planning	
Provider	
-	
Met	

	

	

	
								
Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
4/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
3/4	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
4/4	
Met	

 C12	
Intimacy	
DDS	
3/4	
Met	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C14	
Choices in routines & schedules	
DDS	
4/4	
Met	

 C15	
Personalize living space	
DDS	
4/4	
Met	

 C16	
Explore interests	
DDS	
4/4	
Met	

 C17	
Community activities	
DDS	
3/4	
Met	

 C18	
Purchase personal belongings	
DDS	
4/4	
Met	

 C19	
Knowledgeable decisions	
DDS	
4/4	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C21	
Coordinate outreach	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
4/4	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

 C48	
Neighborhood connections	
DDS	
4/4	
Met	

 C49	
Physical setting is consistent 	
DDS	
4/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
4/4	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
4/4	
Met	

 C53	
Food/ dining choices	
DDS	
4/4	
Met	

 C54	
Assistive technology	
DDS	
4/4	
Met