PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

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

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
October 29, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
ARC OF GREATER PLYMOUTH (THE)	

	

	

	

	
Review Dates	

	
10/9/2018 - 10/15/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
10/29/2018	

	

	

	

	

	

	
Survey Team	

	
Barbara Mazzella	

Katherine Gregory (TL)	

Scott Nolan	

Laura O'Connor	

	

	

	

	

	

	
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	
7 location(s) 7 audit (s) 	
Full Review	
69 / 77 2 Year License 10/29/2018 -  10/29/2020	
	
46 / 51 Certified 10/29/2018 -  10/29/2020	

Placement Services	
4 location(s) 4 audit (s) 	

Full Review	
19 / 22	

Individual Home Supports	
3 location(s) 3 audit (s) 	

Full Review	
21 / 23	

Planning and Quality Management (For all service groupings)	

	
Full Review	
6 / 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	
2 location(s) 7 audit (s) 	
Full Review	
63 / 64 2 Year License 10/29/2018 -  10/29/2020	
	
41 / 42 Certified 10/29/2018 -  10/29/2020	

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

Full Review	
14 / 14	

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

Full Review	
21 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
6 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
The ARC of Greater Plymouth, established in 1966, is a non-profit local chapter of the ARC of Massachusetts, serving individuals with disabilities and their families in Carver, Duxbury, Hanson, Halifax, Hanover, Kingston, Marshfield, Plymouth, Plympton, Pembroke and Cape Cod. The agency's mission is to empower and support people with disabilities and their families to belong, contribute, and thrive.

The agency provides a wide array of services for children and adults including; Adult Family Care, Shared Living, Individual Home Supports, Family Support Services, Agency with Choice, Social Recreation, Supported Employment, Community Based Day Supports (CBDS), Massachusetts Rehabilitation Commission (MRC) Discreet Services, and Pathways, a new program for those on the Autism Spectrum. 

This full licensing and certification conducted by the Department of Developmental Services (DDS) included a review of Placement Services, In Home Supports, Community Based Day Supports and Employment Support Services and included a review of organizational indicators relative to strategic planning, data collection and analysis. 

An array of practices, demonstrated the agency's commitment to soliciting ongoing input from individuals and families and fostering individual's ability to exert choice and control over their lives.

In the area of planning and quality improvement, a strength of the agency was seen in its efforts to solicit input from individuals and their families. Focus groups of various stakeholders including individuals served and family members met to discuss strategic planning topics including program services and satisfaction among other topics, and themes were developed. Input from families, guardians, and individuals resulted in the agency's strategic planning to include a goal for all programs to update families and guardians on program activities in the form of a monthly newsletter, and the development of a Family Advisory Committee. In another effort to solicit feedback, the agency utilizes a satisfaction survey that is available in three different formats, utilizing pictorial representations, which allow for varying types of comprehension to promote inclusion of all respondents. 

In addition, the agency implemented a strategic goal to assure competency throughout a growing workforce and has developed a 3 day orientation for all staff, which includes a variety of topics such as supporting choice and control, sexuality training as well as health and safety. The agency also utilizes Open Future Learning, an online interactive curriculum program featuring competency-based training. 

In an effort to increase meaningful community involvement and support individual-driven options within CBDS, mechanisms were in place that assured individual input and choice. Staff were respectful and interactions were consistently supportive and empowering. Individuals were encouraged to express their ideas, and to steer the direction of their supports through formal and informal processes. The results of individual interest inventories were consistently reflected in the activities offered at the CBDS location and within the community. A variety of community opportunities were offered that enriched individuals' lives and connected them to the community. A sample of community volunteer activities include a gardening program initiated by the individuals; the Talking in Communication program in which newspapers and books are read and recorded for the visually-impaired, and a local TV program produced by individuals served. When at the CBDS location, individuals were engaged in knowledge based and experiential activities including topics related to health, presentation skills, and work-related interpersonal skills among others. A menu of daily and weekly choices with corresponding icons was presented on a large screen and reviewed daily, with individuals taking an active role in presenting the day's choices, allowing all to select their activities for the day. For instance, one individual was supported to assist in preparing the morning meeting agenda maximizing her skills with technology, and others contributed by giving updated weather and sports reports and reviewing the day's options for activities.  Additionally, monthly and weekly calendars of events and activities was also posted and reviewed daily for updates and suggestions with dialogue encouraged. 

Within residential services noteworthy practices were seen within the domain of community access and integration.  Individuals were supported by staff dedicated solely to enhancing their involvement in community activities. Individuals enjoyed a wide variety of experiences in their communities including attending their church of choice, dances, library sponsored trips, harbor cruises, and parties with friends. 

An emphasis was also placed on ensuring that ongoing support of individuals' relationships with their families and friends was maintained. Staff assured contact was maintained over time and distance, and individuals were supported to connect with and visit relatives and friends frequently.

Organizationally, the agency had systems in place to effectively safeguard individuals in the area of human rights. Individuals and their guardians were routinely provided information regarding human rights and how to file a grievance or to report to the Disabled Person Protection Commission (DPPC). The agency has increased its focus on human rights and DPPC training for staff and is tracking both incidents and reports of abuse to determine trends and patterns and to implement preventative measures when called for. 

While the agency has demonstrated many positive practices and outcomes, the survey team identified areas where additional attention is recommended. In the area of managing individual's funds, the agency needs to ensure that in all instances where it has shared or delegated money management responsibility, that a funds management support plan is developed based on the results of an assessment of their skills.  Once developed, a mechanism to track expenditures needs to be developed based to the level of support provided and receipts maintained accordingly.  Medication treatment plans need to be developed, for each person that is supported with behavior modifying medications, to include the diagnosis and observable definitions of symptoms for each medication.   A review of medication treatment plans by the individuals' ISP team needs to occur.

Within the Employment Program, individuals actively employed would experience increased opportunities to improve their job skills through consistent evaluation of their work performance from employers. For those currently seeking employment, the agency needs to determine individuals' job interests and work-based skills to support the best match, offer training to strengthen skills, and assist individuals in job exploration, to provide broadened job options.

The agency had assessed all individuals for their need for assistive technology (AT), and a fair number of them were benefitting from the use of some form of AT. The agency should continue the trend of developing strategies to implement the use of assistive technology to maximize independence for all.

Based on the findings of this report, The ARC of Greater Plymouth has earned a two year license for Day Supports with 98% of all licensing indicators receiving a rating of met, and is Certified, achieving 98% of the certification indicators. They have earned a two year license for Residential Services with 88% of all licensing indicators receiving a rating of met, and is Certified, achi	

	

	

LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Residential and Individual Home Supports	
59/67	
8/67	

    Placement Services
    Individual Home Supports

	

Critical Indicators	
7/7	
0/7	

Total	
69/77	
8/77	
90%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
8	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Employment and Day Supports	
53/54	
1/54	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
8/8	
0/8	

Total	
63/64	
1/64	
98%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
1	

	

	

			

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L14	
Handrails, balusters, stairs, and stairways are in good repair. 	
2 out of 3 homes visited lack interior and / or exterior railings for stairs used by the individuals. At the third location, the railing was not properly secured.   The agency needs to assure that, where needed, all handrails, balusters, stairs, and stairways are in good repair.	

 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.	
One of two homes had an activated alarm on a basement door, and there was no rationale for this restrictive practice. The agency needs to ensure that a written rationale is in place when supporting individuals with restrictive practices or eliminate the use if not needed	

 L63	
Medication treatment plans are in written format with required components.	
Out of 5 medication treatment plans reviewed, three did not specify the diagnosis or symptoms for each medication prescribed, nor were symptoms defined, such as what does anxiety look like for an individual. One individual prescribed behavioral medication lacked a medication treatment plan. The agency needs to ensure that medication treatment plans are developed for each person that is supported with the use of behavior modifying medication.  These plans need to contain all the required components including the diagnoses and observable definitions of symptoms for each medication. 	

 L64	
Medication treatment plans are reviewed by the required groups.	
Three out of 5 medication treatment plans had not been included within the individual's ISP. The agency needs to ensure that all medication treatment plans are reviewed.	

 L67	
There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	
The funds management for four individuals, for whom the agency has shared or delegated money management responsibility, were reviewed. For all four reviews there was either missing or inconsistent money management assessments, a lack of money management support plan, or a lack of a training plan when indicated. The agency needs to assess all individuals' money management skills, develop thorough funds management support plans for individuals for whom the agency has shared management of funds, and assure a training plan is in place for those who are able to benefit from strategies to assist them to become more independent with their finances.	

 L68	
Expenditures of individual's funds are made only for purposes that directly benefit the individual.	
For three of four individuals funds reviewed, it could not be determined if all expenditures made directly benefitted the individuals due to lack of or inaccurate documentation. For individuals for whom the agency has shared or delegated money management responsibilities the agency needs to establish a system to ensure that all funds spent directly benefit the individuals.	

 L69	
Individual expenditures are documented and tracked.	
In 3 out of 4 reviews of individuals funds, tracking of expenditures was either lacking receipts and / or transaction records. The agency needs to ensure there is a consistent system for documenting all expenditures of individuals' funds accurately.	

 L91	
Incidents are reported and reviewed as mandated by regulation.	
For the two locations visited at which reportable incidents had occurred, there were instances in which incident reports had not been submitted and/or finalized within required timelines.  The agency needs to ensure that incident reports are submitted and/or finalized as mandated by regulation.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L91	
Incidents are reported and reviewed as mandated by regulation.	
Reportable incidents had occurred within both employment and CBDS services. There were instances in which incident reports had not been submitted and/or finalized within required timelines.  The agency needs to ensure that incident reports are submitted and/or finalized as mandated by regulation.	

		

						
	CERTIFICATION FINDINGS	

						
		
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
6/6	
0/6	

Residential and Individual Home Supports	
40/45	
5/45	

Individual Home Supports	
21/23	
2/23	

Placement Services	
19/22	
3/22	

TOTAL	
46/51	
5/51	
90%	

Certified	

	

Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
6/6	
0/6	

Employment and Day Supports	
35/36	
1/36	

Community Based Day Services	
14/14	
0/14	

Employment Support Services	
21/22	
1/22	

TOTAL	
41/42	
1/42	
98%	

Certified	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For three individuals there was no mechanism in place to solicit feedback at the time of hire or for the ongoing performance of their staff. The agency needs to ensure individuals have opportunities to provide feedback on staff that support them.	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
There was a lack of evidence that one individual was assessed to determine their interest and need for intimacy and companionship. The agency needs to ensure that staff have an understanding of  individuals' interest in the area of intimacy and companionship, and how to support them in this area. 	

	

	
Placement 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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For two out of four individuals there was no mechanism in place to solicit feedback at the time of match or for the ongoing  performance of their care providers'.  The agency needs to ensure individuals have opportunities to provide feedback on staff that support them.	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
Two out of four individuals expressed an interest in dating, however there was a lack of evidence that education and support had been provided. The agency needs to ensure that staff have an understanding of  individuals' interest in the area of intimacy and companionship, and provide education to them for intimacy and companionship. 	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Although assessments for assistive technology were conducted, for two individuals strategies were not developed to address how the use of assistive technology could be used to maximize their independence in identified areas of need. The agency needs to develop strategies to implement the use of assistive technology for those identified as having a need for increased independence. 	

	

	
Community Based Day Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

 C40	
Individuals are supported to explore, discover and connect with their personal interest and options for community involvement, personal interest and hobbies.	
Individuals were supported to explore and connect with their personal interests for community involvement. For example, one individual was supported to read books on tape for the elderly and broadcast for the public access channel while another individual volunteered at a pet store to distribute pet food to families who may struggle to afford to care for their pets. Staff took an active role in supporting individuals to explore new interests. The agency is commended for supporting individuals to become involved in their community based on personal interest and hobbies.	

 C45	
Individual's decisions of what to do during the day are revisited on a regular basis.	
The agency supports individuals to choose from a variety of options based on their personal interests in work and non-work activities.  An interest inventory is completed with each individual to identify personal favorites such as taking day trips to museums or seasonal events.  Individuals are also supported to pursue new interests such as cooking, Zumba Dancing or learning social skills (e.g., discussing relationships).   Staff developed weekly classroom session which utilized pictorial presentations and computer technology (SMART Board) to engage individuals in activities they chose and planning monthly calendars for community activities. The agency is commended for regularly providing meaningful choices for individuals to pursue their interests and goals.	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 C35	
Individuals are given feedback on job performance by their employer.	
One of three individuals reviewed did not receive feedback on their job performance on an annual employee evaluation. The agency needs to strengthen their system for evaluation of workers to ensure that all actively employed individuals receive an annual appraisal of their job performance.	

	

		

					
	MASTER SCORE SHEET LICENSURE	

					
	Organizational: ARC OF GREATER PLYMOUTH (THE)	

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

O	
 L2	
Abuse/neglect reporting	
9/9	
Met	

 L3	
Immediate Action	
9/9	
Met	

 L4	
Action taken	
6/6	
Met	

 L48	
HRC	
1/1	
Met	

 L65	
Restraint report submit	
1/1	
Met	

 L66	
HRC restraint review	
1/1	
Met	

 L74	
Screen employees	
4/4	
Met	

 L75	
Qualified staff	
1/1	
Met	

 L76	
Track trainings	
17/17	
Met	

 L83	
HR training	
17/17	
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	
	
3/3	
4/4	

	
7/7	
Met	

 L5	
Safety Plan	
L	
	
2/2	
4/4	

	
6/6	
Met	

O	
 L6	
Evacuation	
L	
	
2/2	
4/4	

	
6/6	
Met	

 L8	
Emergency Fact Sheets	
I	
	
2/3	
4/4	

	
6/7	
Met
(85.71 %)	

 L9	
Safe use of equipment	
L	
	
2/2	

	
	
2/2	
Met	

 L10	
Reduce risk interventions	
I	

1/1	

	
1/1	
Met	

O	
 L11	
Required inspections	
L	

4/4	

	
4/4	
Met	

O	
 L12	
Smoke detectors	
L	
	
2/2	
4/4	

	
6/6	
Met	

O	
 L13	
Clean location	
L	

4/4	

	
4/4	
Met	

 L14	
Site in good repair	
L	

0/3	

	
0/3	
Not Met
(0 %)	

 L15	
Hot water	
L	

4/4	

	
4/4	
Met	

 L16	
Accessibility	
L	
	
2/2	
4/4	

	
6/6	
Met	

 L17	
Egress at grade 	
L	
	
2/2	
3/3	

	
5/5	
Met	

 L18	
Above grade egress	
L	
	
1/1	
1/1	

	
2/2	
Met	

 L20	
Exit doors	
L	
	
2/2	

	
	
2/2	
Met	

 L21	
Safe electrical equipment	
L	

4/4	

	
4/4	
Met	

 L22	
Well-maintained appliances	
L	

4/4	

	
4/4	
Met	

 L26	
Walkway safety	
L	

4/4	

	
4/4	
Met	

 L27	
Pools, hot tubs, etc.	
L	
	
1/1	

	
	
1/1	
Met	

 L29	
Rubbish/combustibles	
L	

4/4	

	
4/4	
Met	

 L30	
Protective railings	
L	
	
1/1	
4/4	

	
5/5	
Met	

 L31	
Communication method	
I	
	
3/3	
4/4	

	
7/7	
Met	

 L32	
Verbal & written	
I	
	
3/3	
4/4	

	
7/7	
Met	

 L33	
Physical exam	
I	
	
2/2	
3/4	

	
5/6	
Met
(83.33 %)	

 L34	
Dental exam	
I	
	
2/2	
4/4	

	
6/6	
Met	

 L35	
Preventive screenings	
I	
	
2/2	
4/4	

	
6/6	
Met	

 L36	
Recommended tests	
I	
	
2/2	
4/4	

	
6/6	
Met	

 L37	
Prompt treatment	
I	
	
2/2	
4/4	

	
6/6	
Met	

O	
 L38	
Physician's orders	
I	
	
1/1	
2/2	

	
3/3	
Met	

 L39	
Dietary requirements	
I	
	
2/2	
1/2	

	
3/4	
Met	

 L40	
Nutritional food	
L	
	
2/2	

	
	
2/2	
Met	

 L41	
Healthy diet	
L	
	
3/3	
4/4	

	
7/7	
Met	

 L42	
Physical activity	
L	
	
3/3	
4/4	

	
7/7	
Met	

 L43	
Health Care Record	
I	
	
2/2	
3/4	

	
5/6	
Met
(83.33 %)	

O	
 L46	
Med. Administration	
I	

4/4	

	
4/4	
Met	

 L47	
Self medication	
I	
	
2/2	
3/4	

	
5/6	
Met
(83.33 %)	

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

	
7/7	
Met	

 L50	
Respectful Comm.	
L	
	
3/3	
3/4	

	
6/7	
Met
(85.71 %)	

 L51	
Possessions	
I	
	
3/3	
4/4	

	
7/7	
Met	

 L52	
Phone calls	
I	
	
3/3	
4/4	

	
7/7	
Met	

 L53	
Visitation	
I	
	
3/3	
4/4	

	
7/7	
Met	

 L54	
Privacy	
L	
	
2/2	
4/4	

	
6/6	
Met	

 L55	
Informed consent	
I	
	
1/1	
1/1	

	
2/2	
Met	

 L56	
Restrictive practices	
I	

1/2	

	
1/2	
Not Met
(50.0 %)	

 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	

 L63	
Med. treatment plan form	
I	
	
0/1	
1/4	

	
1/5	
Not Met
(20.0 %)	

 L64	
Med. treatment plan rev.	
I	
	
1/1	
2/4	

	
3/5	
Not Met
(60.0 %)	

 L67	
Money mgmt. plan	
I	
	
0/1	
0/3	

	
0/4	
Not Met
(0 %)	

 L68	
Funds expenditure	
I	
	
0/1	
1/3	

	
1/4	
Not Met
(25.00 %)	

 L69	
Expenditure tracking	
I	
	
0/1	
1/3	

	
1/4	
Not Met
(25.00 %)	

 L70	
Charges for care calc.	
I	

3/4	

	
3/4	
Met	

 L71	
Charges for care appeal	
I	

4/4	

	
4/4	
Met	

 L77	
Unique needs training	
I	
	
2/3	
4/4	

	
6/7	
Met
(85.71 %)	

 L78	
Restrictive Int. Training	
L	

1/1	

	
1/1	
Met	

 L79	
Restraint training	
L	

1/1	

	
1/1	
Met	

 L80	
Symptoms of illness	
L	
	
3/3	
4/4	

	
7/7	
Met	

 L81	
Medical emergency	
L	
	
3/3	
4/4	

	
7/7	
Met	

 L84	
Health protect. Training	
I	

1/1	

	
1/1	
Met	

 L85	
Supervision 	
L	
	
3/3	
4/4	

	
7/7	
Met	

 L86	
Required assessments	
I	
	
1/1	
3/3	

	
4/4	
Met	

 L87	
Support strategies	
I	
	
1/2	
4/4	

	
5/6	
Met
(83.33 %)	

 L88	
Strategies implemented	
I	
	
2/3	
4/4	

	
6/7	
Met
(85.71 %)	

 L90	
Personal space/ bedroom privacy	
I	
	
2/2	
4/4	

	
6/6	
Met	

 L91	
Incident management	
L	
	
1/1	
0/1	

	
1/2	
Not Met
(50.0 %)	

#Std. Met/# 67 Indicator	

	

	

59/67	

	
Total Score	

	

	

69/77	

	

	

	

	
89.61%	

		
							
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	
1/1	
	
1/1	
2/2	
Met	

 L10	
Reduce risk interventions	
I	

1/1	
1/1	
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	

 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	
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	
Well-maintained 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	

 L28	
Flammables	
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	
4/4	
	
2/2	
6/6	
Met	

O	
 L38	
Physician's orders	
I	
1/1	
	
3/3	
4/4	
Met	

 L39	
Dietary requirements	
I	

3/3	
3/3	
Met	

 L44	
MAP registration	
L	

1/1	
1/1	
Met	

 L45	
Medication storage	
L	

1/1	
1/1	
Met	

O	
 L46	
Med. Administration	
I	

2/2	
2/2	
Met	

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

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

 L55	
Informed consent	
I	
1/1	
	
3/3	
4/4	
Met	

 L56	
Restrictive practices	
I	
1/1	
	
1/1	
2/2	
Met	

 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	

 L61	
Health protection in ISP	
I	

1/1	
1/1	
Met	

 L62	
Health protection review	
I	

1/1	
1/1	
Met	

 L63	
Med. treatment plan form	
I	

2/2	
2/2	
Met	

 L64	
Med. treatment plan rev.	
I	

2/2	
2/2	
Met	

 L77	
Unique needs training	
I	
3/4	
	
3/3	
6/7	
Met
(85.71 %)	

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

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

O	
 L82	
Medication admin.	
L	

1/1	
1/1	
Met	

 L84	
Health protect. Training	
I	

1/1	
1/1	
Met	

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

 L86	
Required assessments	
I	
3/3	
	
3/3	
6/6	
Met	

 L87	
Support strategies	
I	
3/3	
	
3/3	
6/6	
Met	

 L88	
Strategies implemented	
I	
3/4	
	
3/3	
6/7	
Met
(85.71 %)	

 L91	
Incident management	
L	
0/1	
	
0/1	
0/2	
Not Met
(0 %)	

#Std. Met/# 54 Indicator	

	

53/54	

	
Total Score	

	

63/64	

	

	

	
98.44%	

		
							
	MASTER SCORE SHEET CERTIFICATION	

							
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
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	
1/1	
Met	

	

	

							
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
3/3	
Met	

 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 / care provider performance	
4/4	
Met	

 C8	
Family/guardian communication	
4/4	
Met	

 C22	
Explore job interests	
3/4	
Met	

 C23	
Assess skills & training needs	
4/4	
Met	

 C24	
Job goals & support needs plan	
4/4	
Met	

 C25	
Skill development	
4/4	
Met	

 C26	
Benefits analysis	
4/4	
Met	

 C27	
Job benefit education	
4/4	
Met	

 C28	
Relationships w/businesses	
1/1	
Met	

 C29	
Support to obtain employment	
3/4	
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	
2/2	
Met	

 C34	
Support to promote success	
4/4	
Met	

 C35	
Feedback on job performance	
2/3	
Not Met (66.67 %)	

 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 / care provider performance	
0/3	
Not Met (0 %)	

 C8	
Family/guardian communication	
3/3	
Met	

 C9	
Personal relationships	
3/3	
Met	

 C10	
Social skill development	
3/3	
Met	

 C11	
Get together w/family & friends	
3/3	
Met	

 C12	
Intimacy	
2/3	
Not Met (66.67 %)	

 C13	
Skills to maximize independence 	
3/3	
Met	

 C14	
Choices in routines & schedules	
2/2	
Met	

 C15	
Personalize living space	
2/2	
Met	

 C16	
Explore interests	
3/3	
Met	

 C17	
Community activities	
3/3	
Met	

 C18	
Purchase personal belongings	
3/3	
Met	

 C19	
Knowledgeable decisions	
3/3	
Met	

 C20	
Emergency back-up plans	
2/2	
Met	

 C21	
Coordinate outreach	
3/3	
Met	

 C46	
Use of generic resources	
3/3	
Met	

 C47	
Transportation to/ from community	
3/3	
Met	

 C48	
Neighborhood connections	
2/2	
Met	

 C49	
Physical setting is consistent 	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

 C52	
Leisure activities and free-time choices /control	
3/3	
Met	

 C53	
Food/ dining choices	
3/3	
Met	

 C54	
Assistive technology	
3/3	
Met	

Placement Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
2/4	
Not Met (50.0 %)	

 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	
4/4	
Met	

 C15	
Personalize living space	
4/4	
Met	

 C16	
Explore interests	
4/4	
Met	

 C17	
Community activities	
4/4	
Met	

 C18	
Purchase personal belongings	
4/4	
Met	

 C19	
Knowledgeable decisions	
4/4	
Met	

 C20	
Emergency back-up plans	
4/4	
Met	

 C46	
Use of generic resources	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C48	
Neighborhood connections	
3/4	
Met	

 C49	
Physical setting is consistent 	
4/4	
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	
2/4	
Not Met (50.0 %)