PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
ARC OF GREATER PLYMOUTH (THE)
52 Armstrong Drive
 Plymouth, MA 02360    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	
Provider Web Report
November 3, 2016

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
ARC OF GREATER PLYMOUTH (THE)	

	

	

	

	
Review Dates	

	
10/4/2016 - 10/11/2016	

	

	

	

	
Service Enhancement 
Meeting Date	

	
10/25/2016	

	

	

	

	

	

	
Survey Team	

	
Sally Hajjar	

Tina Napolitan (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	
6 location(s) 6 audit (s) 	
Full Review	
64 / 74 2 Year License 10/25/2016 -  10/25/2018	
	
48 / 51 Certified 10/25/2016 -  10/25/2018	

Placement Services	
2 location(s) 2 audit (s) 	

Full Review	
21 / 22	

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

Full Review	
22 / 23	

Planning and Quality Management (For all service groupings)	

	
Full Review	
5 / 6	

Survey scope and findings for Employment and Day Supports	

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

Employment and Day Supports	
3 location(s) 7 audit (s) 	
Full Review	
47 / 51 2 Year License 10/25/2016 -  10/25/2018	
	
37 / 42 Certified 10/25/2016 -  10/25/2018	

Community Based Day Services	
1 location(s) 3 audit (s) 	

Full Review	
13 / 14	

Employment Support Services	
2 location(s) 4 audit (s) 	

Full Review	
19 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
5 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
The Arc of Greater Plymouth, Inc. is a non-profit human service organization serving neighboring towns of Carver, Duxbury, Hanson, Halifax, Hanover, Kingston, Marshfield, Plymouth, Plympton, and Pembroke and has expanded services to Cape Cod.   The agency was established in 1966 and is a member of the local chapter of The Arc, a national advocacy organization and The Arc of Massachusetts.  The agency's mission is centered on the following: 'Empowerment of children and adults with cognitive and developmental disabilities; provide individualized and innovative services through creative partnerships; strengthen families; promote independence, integration and commitment to community.'  

The Arc of Greater Plymouth provides support to individuals and their families and guardians through an array of services.  These include Supported Employment and Community Based Day Services, Family Support, Adult Family Care (AFC), Shared Living Program, Individual Home Supports (IHS), Agency With Choice (AWC) and Social Recreational Opportunities.   The agency continues to give back to the community by partnering with other area businesses and continuing to operate a food pantry in the Plymouth area.    The Arc of Greater Plymouth top funding sources include DDS, Mass Health, Fundraising and Grant income and United Way.  For the service models within the purview of the Department of Developmental Services the agency currently supports thirty eight people in the Employment Services, fifty-seven people in Community Based Day Supports, seven people with Individualized Home supports receiving  greater than 15 hours per week,  and five people  receiving Shared Living services model.  

This licensure and certification process included the new and revised indicators developed in response to requirements set forth by the Centers for Medicare and Medicaid (CMS).   All licensing and certification outcomes were reviewed for the DDS funded services.  Additionally, organization certification indicators related to data analysis and strategic planning.   

Since 2010, the agency has experienced significant growth and has realized the need to change the agencies infrastructure to continue to provide quality supports.  In 2016, the agency strengthened the managerial structure by adding positions such as a Human Resource Director, a Director of Health Care, a Director of Quality and Service Integrity and a Director of Clinical Support and Training.  The agency has also hired a consultant to assist with the development of a strategic plan.  

The survey team affirmed the continued presence of systems throughout the agency to support essentials safeguards in such areas as healthcare, healthy eating and activity, community inclusion and the maintenance of a competent workforce. People received routine and preventative healthcare with recommendations from professionals followed through on promptly.  People were supported to live a healthy and active lifestyle through memberships at gyms, increased activity and education regarding nutrition.  One person changed her nutritional habits so significantly the physician was able to remove the diagnosis of pre-diabetic.    

The agency has significantly enhanced the Human Rights Committee (HRC) to include membership from all specialty areas (legal, clinical, medical and individual) and addressing all issues that potentially impact the rights of individuals receiving services.  The HRC compiles more comprehensive meeting minutes that document the review of policies and incidents and documents service location visits.  

The agency has continued its commitment to assist people to exclusively obtain jobs within community settings earning at least minimum wage.  All individuals were paid either on an hourly basis, or as part of a paid internship through grant money the agency was awarded specifically for that purpose.  Within employment services, individual job preferences were assessed and ongoing efforts were made to support individual's unique choices and skills.   In the area of employment and Community Based Day Supports, additional emphasis needs to focus on the following indicators within the certification domains: assisting individuals/families to understand the positive aspects of integrated employment, complete an analysis of how income impacts entitlements per employed individual, providing individuals consistent opportunities to provide feedback of staff and assist individuals in understanding their earned benefits such as sick/vacation time.  

The agency has demonstrated a commitment to supporting people to have choice and control in their lives.  For instance, one person was supported to relocate into an apartment with a provider of her choosing. For another person, a consultant was hired to assist him with the development of clinical supports to foster/promote his success at home and in the community.  Additionally, the agency strives to enhance an individual's community experiences by providing individualized services tailored to honor their unique preferences and choices regarding community inclusive activities.  

The review identified both licensing and certification areas that need additional strengthening in the Placement and Individual Home Supports services including: supporting individuals to become self-medicating, providing assistance to explore and express needs for intimacy, the use of restrictive practices and interventions and the development and implementation of behavioral support plans.  The agency needs to continue to focus on ensuring all behavior support plans include the least restrictive intervention(s).  Additionally, the agency needs to oversee charges for care for all individuals, ensuring that all individuals paying charges for care are charged appropriately and are aware of their right to appeal.  

Based upon the findings of this survey, the agency is congratulated for receiving a Two Year License for its Employment/Day and Residential supports.  For residential and individual home supports, the agency achieved a standard Met in 64 of 74 licensure indicators (86%) and 48 of 51 certification indicators (94%).  DDS will follow up in 60 days for all not met licensure ratings within residential and individual home support models.  Within Employment and Community Based Day supports, the agency also achieved a standard Met in 47 of 51 licensure indicators (92%) and 37 of 42 certification indicators (88%).	

	

	

LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Residential and Individual Home Supports	
54/64	
10/64	

    Placement Services
    Individual Home Supports

	

Critical Indicators	
7/7	
0/7	

Total	
64/74	
10/74	
86%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
10	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Employment and Day Supports	
37/41	
4/41	

    Employment Support Services
    Community Based Day Services

	

Critical Indicators	
6/6	
0/6	

Total	
47/51	
4/51	
92%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
4	

	

	

			

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L47	
Individuals are supported to become self medicating when appropriate. 	
For one of the three individuals surveyed, the self-medication assessment included an attached statement from her MD indicating the individual would benefit from a teaching plan; however, the agency staff did not develop such a plan.   The agency needs to ensure individuals are supported to become self-medicating when appropriate. 	

 L56	
Restrictive practices intended for one individual that affect all individuals served at a location need to have a written rationale that is reviewed as required and have provisions so as not to unduly restrict the rights of others.	
At two homes, the agency has installed alarms on doors.   The rationale for the restrictive practices was not identified and lacked a plan to fade and/or eliminate the procedure.  The agency needs to ensure that all restrictive practices have a written rationale and have provisions so as not to unduly restrict the rights of others.  	

 L58	
All behavior plans contain the required components.	
In one of the two behavior plans reviewed, the criteria for eliminating or revising the restrictions were not included.  The agency needs to ensure that behavior plans contain all required components.	

 L60	
Data are consistently maintained and used to determine the efficacy of behavioral interventions.	
In one of two behavior plans reviewed, data indicated a lack of behavioral symptoms.  Based upon this data, the agency needs to ensure that the efficacy of behavior plans are reviewed and modified accordingly.  	

 L63	
Medication treatment plans are in written format with required components.	
One or both medication treatment plans reviewed did not include all the required components e.g.,  observable signs and symptoms, full information about side effects, procedures to minimize risks or descriptions of  clinical indications for terminating the drugs or  baseline data.   The agency needs to ensure that the person's medication treatment plan contains all the required components.    	

 L64	
Medication treatment plans are reviewed by the required groups.	
Two medication treatment plan were surveyed, neither of which had been reviewed by the ISP team.  The agency needs to ensure that all plans are reviewed by the required groups.  	

 L70	
Charges for care are calculated appropriately.	
The agency did not notify the rep-payee and/or the person of the charges for care.   The agency needs to oversee the charges for care process, e.g. to ensure that amounts are calculated appropriately, adequate notification is given to the person prior to implementing the charge. 	

 L71	
Individuals are notified of their appeal rights for their charges for care.	
There was no charges for care letter for one person, thus this person was not notified of his right to appeal his charges for care.  Agency needs to ensure all individuals are notified of their right to appeal their charges for care.  	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments for two out of five individuals were not submitted within required time frames. The agency needs to ensure that assessments are submitted to the respective DDS area office at least 15 days prior to the ISP.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Support strategies for three out of six individuals were not submitted within required time frames. The agency need to ensure that strategies are submitted to the respective DDS area office at least 15 days prior to the ISP.	

	

	

	
Employment/Day Areas Needing Improvement on Standards not met/Follow-up to occur:	

Indicator #	
Indicator	
Area Needing Improvement	

 L55	
Informed consent is obtained from individuals or their guardians when required; Individuals or their guardians know that they have the right to withdraw consent.	
The agency's process for obtaining photo consent needs to be strengthened.  For example, the agency published a photo without attaching the photo to the consent or providing evidence that the person was shown the picture.  As well, a standardized form was used where people were asked to check off multiple categories of photograph usage.   	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments for two out of six individuals were not submitted within required time frames. The agency needs to ensure that assessments are submitted to the respective DDS area office at least 15 days prior to the ISP.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Support strategies for five out of six individuals were not submitted within required time frames. The agency need to ensure that strategies are submitted to the respective DDS area office at least 15 days prior to the ISP.	

 L88	
Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	
Services and support strategies for three of seven individuals  in the survey had either not been developed or lacked documentation of progress.  For example, one individual in CBDS did not have a CBDS goal.  The agency needs to ensure that there are measurable support strategies designated for each DDS service per individual.	

		

		

	

	

CERTIFICATION FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
5/6	
1/6	

Residential and Individual Home Supports	
43/45	
2/45	

Individual Home Supports	
22/23	
1/23	

Placement Services	
21/22	
1/22	

TOTAL	
48/51	
3/51	
94%	

Certified	

	

	
	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
5/6	
1/6	

Employment and Day Supports	
32/36	
4/36	

Community Based Day Services	
13/14	
1/14	

Employment Support Services	
19/22	
3/22	

TOTAL	
37/42	
5/42	
88%	

Certified	

	

	

	

	

	
Planning and Quality Management Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C6	
The provider has mechanisms to plan for future directions in service delivery and implements strategies to actualize these plans.	
While the agency has hired a consultant to assist with the development of a strategic plan, this process has not been completed.  The agency needs to complete the process of developing a strategic plan.  	

	

	

	

	
Individual Home Supports- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For two out of four individuals who participated in the survey, staff had not assessed their interest and needs related to the area of sexuality and intimate relationships. The agency needs to ensure that staff has an understanding of individuals' interest in the area of intimacy and sexuality, and support them to explore and express those interests and needs.	

	

	
Placement Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For one of two individuals, who participated in the survey, staff had not assessed their interest and needs related to the area of sexuality and intimate relationships. The agency needs to ensure that staff has an understanding of individuals' interest in the area of intimacy and sexuality, and support them to explore and express those interests and needs.	

	

	
Community Based Day Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
Structured mechanisms were not in place to provide individuals the opportunity to express  input about the hiring and performance of their staff.  The agency needs to ensure that all individuals are offered opportunities to provide feedback on new hires and  on an ongoing basis.	

	

	
Employment Support Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C26	
Career planning includes an analysis of how an individual's entitlements can be managed in a way that allows them to work successfully in the community.	
The agency has not completed benefits analysis nor presented information to individuals and guardians about how future earnings could affect individuals' entitlements.  The agency needs to ensure that this analysis becomes a part of the employment program.  	

 C27	
Individuals and families are encouraged and supported to understand the benefits of integrated employment.	
There was no evidence that the agency has presented information to individuals and/or family members about the benefits of community employment.  The agency needs to ensure that individuals and families are supported to understand the benefits of integrated employment.  	

 C33	
Employee benefits and rights are clearly explained to the individual.	
Three of four people could not express a clear understanding of the benefits they were earning e.g. earned or unearned time off.  The agency needs to ensure that employee benefits and rights have been presented to the person in a way to enhance understanding.	

	

	

		

					
	MASTER SCORE SHEET LICENSURE	

					
	Organizational: ARC OF GREATER PLYMOUTH (THE)	

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

O	
 L2	
Abuse/neglect reporting	
10/10	
Met	

 L3	
Immediate Action	
4/4	
Met	

 L4	
Action taken	
4/4	
Met	

 L48	
HRC	
1/1	
Met	

 L65	
Restraint report submit	
2/2	
Met	

 L66	
HRC restraint review	
1/1	
Met	

 L74	
Screen employees	
2/2	
Met	

 L75	
Qualified staff	
1/1	
Met	

 L76	
Track trainings	
5/5	
Met	

 L83	
HR training	
5/5	
Met	

							
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
	
4/4	
2/2	

	
6/6	
Met	

 L5	
Safety Plan	
L	
	
3/3	
2/2	

	
5/5	
Met	

O	
 L6	
Evacuation	
L	
	
3/3	
2/2	

	
5/5	
Met	

 L8	
Emergency Fact Sheets	
I	
	
3/3	
2/2	

	
5/5	
Met	

 L9	
Safe use of equipment	
L	
	
3/3	
2/2	

	
5/5	
Met	

O	
 L11	
Required inspections	
L	

2/2	

	
2/2	
Met	

O	
 L12	
Smoke detectors	
L	

1/1	

	
1/1	
Met	

O	
 L13	
Clean location	
L	

1/1	

	
1/1	
Met	

 L14	
Site in good repair	
L	

1/1	

	
1/1	
Met	

 L15	
Hot water	
L	

1/1	

	
1/1	
Met	

 L16	
Accessibility	
L	
	
1/1	
1/1	

	
2/2	
Met	

 L17	
Egress at grade 	
L	
	
1/1	
1/1	

	
2/2	
Met	

 L21	
Safe electrical equipment	
L	

1/1	

	
1/1	
Met	

 L22	
Clean appliances	
L	

1/1	

	
1/1	
Met	

 L25	
Dangerous substances	
L	

1/1	

	
1/1	
Met	

 L26	
Walkway safety	
L	

1/1	

	
1/1	
Met	

 L27	
Pools, hot tubs, etc.	
L	

1/1	

	
1/1	
Met	

 L28	
Flammables	
L	

1/1	

	
1/1	
Met	

 L29	
Rubbish/combustibles	
L	

2/2	

	
2/2	
Met	

 L30	
Protective railings	
L	

1/1	

	
1/1	
Met	

 L31	
Communication method	
I	
	
4/4	
2/2	

	
6/6	
Met	

 L32	
Verbal & written	
I	
	
4/4	
2/2	

	
6/6	
Met	

 L33	
Physical exam	
I	

2/2	

	
2/2	
Met	

 L34	
Dental exam	
I	

2/2	

	
2/2	
Met	

 L35	
Preventive screenings	
I	

2/2	

	
2/2	
Met	

 L36	
Recommended tests	
I	

2/2	

	
2/2	
Met	

 L37	
Prompt treatment	
I	

2/2	

	
2/2	
Met	

O	
 L38	
Physician's orders	
I	
	
1/1	
1/1	

	
2/2	
Met	

 L39	
Dietary requirements	
I	
	
1/1	

	
	
1/1	
Met	

 L40	
Nutritional food	
L	

2/2	

	
2/2	
Met	

 L41	
Healthy diet	
L	
	
1/1	
2/2	

	
3/3	
Met	

 L42	
Physical activity	
L	
	
3/3	
2/2	

	
5/5	
Met	

 L43	
Health Care Record	
I	

2/2	

	
2/2	
Met	

O	
 L46	
Med. Administration	
I	
	
1/1	
2/2	

	
3/3	
Met	

 L47	
Self medication	
I	
	
1/1	
1/2	

	
2/3	
Not Met
(66.67 %)	

 L49	
Informed of human rights	
I	
	
4/4	
2/2	

	
6/6	
Met	

 L50	
Respectful Comm.	
L	
	
4/4	
2/2	

	
6/6	
Met	

 L51	
Possessions	
I	
	
4/4	
2/2	

	
6/6	
Met	

 L52	
Phone calls	
I	
	
4/4	
2/2	

	
6/6	
Met	

 L53	
Visitation	
I	
	
3/3	
2/2	

	
5/5	
Met	

 L54	
Privacy	
L	
	
3/3	
2/2	

	
5/5	
Met	

 L55	
Informed consent	
I	

1/1	

	
1/1	
Met	

 L56	
Restrictive practices	
I	

0/2	

	
0/2	
Not Met
(0 %)	

 L57	
Written behavior plans	
I	

2/2	

	
2/2	
Met	

 L58	
Behavior plan component	
I	

1/2	

	
1/2	
Not Met
(50.0 %)	

 L59	
Behavior plan review	
I	

2/2	

	
2/2	
Met	

 L60	
Data maintenance	
I	

1/2	

	
1/2	
Not Met
(50.0 %)	

 L63	
Med. treatment plan form	
I	

0/2	

	
0/2	
Not Met
(0 %)	

 L64	
Med. treatment plan rev.	
I	

0/2	

	
0/2	
Not Met
(0 %)	

 L67	
Money mgmt. plan	
I	

1/1	

	
1/1	
Met	

 L68	
Funds expenditure	
I	

1/1	

	
1/1	
Met	

 L69	
Expenditure tracking	
I	

1/1	

	
1/1	
Met	

 L70	
Charges for care calc.	
I	

1/2	

	
1/2	
Not Met
(50.0 %)	

 L71	
Charges for care appeal	
I	

1/2	

	
1/2	
Not Met
(50.0 %)	

 L77	
Unique needs training	
I	
	
3/3	
1/1	

	
4/4	
Met	

 L78	
Restrictive Int. Training	
L	

1/1	

	
1/1	
Met	

 L79	
Restraint training	
L	

1/1	

	
1/1	
Met	

 L80	
Symptoms of illness	
L	
	
4/4	
2/2	

	
6/6	
Met	

 L81	
Medical emergency	
L	
	
4/4	
2/2	

	
6/6	
Met	

 L85	
Supervision 	
L	
	
4/4	
2/2	

	
6/6	
Met	

 L86	
Required assessments	
I	
	
2/3	
1/2	

	
3/5	
Not Met
(60.0 %)	

 L87	
Support strategies	
I	
	
3/4	
0/2	

	
3/6	
Not Met
(50.0 %)	

 L88	
Strategies implemented	
I	
	
4/4	
1/2	

	
5/6	
Met
(83.33 %)	

 L90	
Personal space/ bedroom privacy	
I	
	
3/3	
2/2	

	
5/5	
Met	

#Std. Met/# 64 Indicator	

	

	

54/64	

	
Total Score	

	

	

64/74	

	

	

	

	
86.49%	

		
							
Employment and Day Supports:	

							
	
Ind. #	
Ind.	
Loc. or Indiv.	
Emp. Sup.	
Cent. Based Work	
Com. Based Day	
Total Met / Rated	
Rating	

 L1	
Abuse/neglect training	
I	
4/4	
	
3/3	
7/7	
Met	

 L5	
Safety Plan	
L	

1/1	
1/1	
Met	

O	
 L6	
Evacuation	
L	

1/1	
1/1	
Met	

 L7	
Fire Drills	
L	

1/1	
1/1	
Met	

 L8	
Emergency Fact Sheets	
I	
4/4	
	
3/3	
7/7	
Met	

 L9	
Safe use of equipment	
L	
2/2	
	
1/1	
3/3	
Met	

O	
 L11	
Required inspections	
L	

1/1	
1/1	
Met	

O	
 L12	
Smoke detectors	
L	

1/1	
1/1	
Met	

O	
 L13	
Clean location	
L	

1/1	
1/1	
Met	

 L15	
Hot water	
L	

1/1	
1/1	
Met	

 L16	
Accessibility	
L	

1/1	
1/1	
Met	

 L17	
Egress at grade 	
L	

1/1	
1/1	
Met	

 L20	
Exit doors	
L	

1/1	
1/1	
Met	

 L21	
Safe electrical equipment	
L	

1/1	
1/1	
Met	

 L22	
Clean appliances	
L	

1/1	
1/1	
Met	

 L25	
Dangerous substances	
L	

1/1	
1/1	
Met	

 L26	
Walkway safety	
L	

1/1	
1/1	
Met	

 L29	
Rubbish/combustibles	
L	

1/1	
1/1	
Met	

 L31	
Communication method	
I	
4/4	
	
3/3	
7/7	
Met	

 L32	
Verbal & written	
I	
4/4	
	
3/3	
7/7	
Met	

 L37	
Prompt treatment	
I	
2/2	
	
2/2	
4/4	
Met	

O	
 L38	
Physician's orders	
I	

2/2	
2/2	
Met	

 L39	
Dietary requirements	
I	

2/2	
2/2	
Met	

 L49	
Informed of human rights	
I	
4/4	
	
3/3	
7/7	
Met	

 L50	
Respectful Comm.	
L	
2/2	
	
1/1	
3/3	
Met	

 L51	
Possessions	
I	
4/4	
	
3/3	
7/7	
Met	

 L52	
Phone calls	
I	
4/4	
	
3/3	
7/7	
Met	

 L54	
Privacy	
L	
2/2	
	
1/1	
3/3	
Met	

 L55	
Informed consent	
I	
0/2	

0/2	
Not Met
(0 %)	

 L57	
Written behavior plans	
I	

1/1	
1/1	
Met	

 L58	
Behavior plan component	
I	

1/1	
1/1	
Met	

 L59	
Behavior plan review	
I	

1/1	
1/1	
Met	

 L60	
Data maintenance	
I	

1/1	
1/1	
Met	

 L77	
Unique needs training	
I	
2/2	
	
3/3	
5/5	
Met	

 L79	
Restraint training	
L	

1/1	
1/1	
Met	

 L80	
Symptoms of illness	
L	
2/2	
	
1/1	
3/3	
Met	

 L81	
Medical emergency	
L	
2/2	
	
1/1	
3/3	
Met	

 L85	
Supervision 	
L	
2/2	
	
1/1	
3/3	
Met	

 L86	
Required assessments	
I	
2/4	
	
2/2	
4/6	
Not Met
(66.67 %)	

 L87	
Support strategies	
I	
0/4	
	
1/2	
1/6	
Not Met
(16.67 %)	

 L88	
Strategies implemented	
I	
2/4	
	
2/3	
4/7	
Not Met
(57.14 %)	

#Std. Met/# 41 Indicator	

	

37/41	

	
Total Score	

	

47/51	

	

	

	
92.16%	

		
							
	MASTER SCORE SHEET CERTIFICATION	

							
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
4/4	
Met	

 C2	
Data analysis	
1/1	
Met	

 C3	
Service satisfaction	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
1/1	
Met	

 C5	
Measure progress	
1/1	
Met	

 C6	
Future directions planning	
0/1	
Not Met (0 %)	

	

	

							
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
1/3	
Not Met (33.33 %)	

 C8	
Family/guardian communication	
3/3	
Met	

 C13	
Skills to maximize independence 	
3/3	
Met	

 C37	
Interpersonal skills for work	
3/3	
Met	

 C40	
Community involvement interest	
3/3	
Met	

 C41	
Activities participation	
3/3	
Met	

 C42	
Connection to others	
3/3	
Met	

 C43	
Maintain & enhance relationship	
3/3	
Met	

 C44	
Job exploration	
3/3	
Met	

 C45	
Revisit decisions	
3/3	
Met	

 C46	
Use of generic resources	
3/3	
Met	

 C47	
Transportation to/ from community	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

 C54	
Assistive technology	
3/3	
Met	

Employment Support Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
3/4	
Met	

 C8	
Family/guardian communication	
4/4	
Met	

 C22	
Explore job interests	
4/4	
Met	

 C23	
Assess skills & training needs	
4/4	
Met	

 C24	
Job goals & support needs plan	
3/4	
Met	

 C25	
Skill development	
4/4	
Met	

 C26	
Benefits analysis	
0/4	
Not Met (0 %)	

 C27	
Job benefit education	
0/4	
Not Met (0 %)	

 C28	
Relationships w/businesses	
2/2	
Met	

 C29	
Support to obtain employment	
4/4	
Met	

 C30	
Work in integrated settings	
4/4	
Met	

 C31	
Job accommodations	
4/4	
Met	

 C32	
At least minimum wages earned	
4/4	
Met	

 C33	
Employee benefits explained	
1/4	
Not Met (25.00 %)	

 C34	
Support to promote success	
4/4	
Met	

 C35	
Feedback on job performance	
3/4	
Met	

 C36	
Supports to enhance retention	
4/4	
Met	

 C37	
Interpersonal skills for work	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C50	
Involvement/ part of the Workplace culture	
4/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/4	
Met	

 C54	
Assistive technology	
4/4	
Met	

Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
4/4	
Met	

 C8	
Family/guardian communication	
4/4	
Met	

 C9	
Personal relationships	
4/4	
Met	

 C10	
Social skill development	
4/4	
Met	

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

 C12	
Intimacy	
2/4	
Not Met (50.0 %)	

 C13	
Skills to maximize independence 	
4/4	
Met	

 C14	
Choices in routines & schedules	
1/1	
Met	

 C15	
Personalize living space	
1/1	
Met	

 C16	
Explore interests	
4/4	
Met	

 C17	
Community activities	
4/4	
Met	

 C18	
Purchase personal belongings	
2/2	
Met	

 C19	
Knowledgeable decisions	
4/4	
Met	

 C20	
Emergency back-up plans	
4/4	
Met	

 C21	
Coordinate outreach	
3/3	
Met	

 C46	
Use of generic resources	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C48	
Neighborhood connections	
2/2	
Met	

 C49	
Physical setting is consistent 	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/4	
Met	

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

 C53	
Food/ dining choices	
4/4	
Met	

 C54	
Assistive technology	
4/4	
Met	

Placement Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
2/2	
Met	

 C8	
Family/guardian communication	
2/2	
Met	

 C9	
Personal relationships	
2/2	
Met	

 C10	
Social skill development	
2/2	
Met	

 C11	
Get together w/family & friends	
2/2	
Met	

 C12	
Intimacy	
1/2	
Not Met (50.0 %)	

 C13	
Skills to maximize independence 	
2/2	
Met	

 C14	
Choices in routines & schedules	
2/2	
Met	

 C15	
Personalize living space	
2/2	
Met	

 C16	
Explore interests	
2/2	
Met	

 C17	
Community activities	
2/2	
Met	

 C18	
Purchase personal belongings	
2/2	
Met	

 C19	
Knowledgeable decisions	
2/2	
Met	

 C20	
Emergency back-up plans	
2/2	
Met	

 C46	
Use of generic resources	
2/2	
Met	

 C47	
Transportation to/ from community	
2/2	
Met	

 C48	
Neighborhood connections	
2/2	
Met	

 C49	
Physical setting is consistent 	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

 C52	
Leisure activities and free-time choices /control	
2/2	
Met	

 C53	
Food/ dining choices	
2/2	
Met	

 C54	
Assistive technology	
2/2	
Met