PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
ARC OF BRISTOL COUNTY
141 Park St.
 Attleboro, MA 02703    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
April 6, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
ARC OF BRISTOL COUNTY	

	

	

	

	
Review Dates	

	
2/21/2018 - 2/27/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
3/12/2018	

	

	

	

	

	

	
Survey Team	

	
Scott Nolan	

Ed Sutka (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) 	
Targeted Review	
DDS 13 / 14
Provider 66 / 66

79 / 80 Defer Licensure   	
	
DDS 30 / 35
Provider 12 / 12

42 / 47 Certified    	

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

DDS Targeted Review	
17 / 20	

Individual Home Supports	
2 location(s) 2 audit (s) 	

DDS Targeted Review	
19 / 21	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted 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	
1 location(s) 2 audit (s) 	
Targeted Review	
DDS 7 / 9
Provider 39 / 39

46 / 48 2 Year License 03/12/2018-  03/12/2020	
	
DDS 12 / 12
Provider 6 / 6

18 / 18 Certified 03/12/2018 -  03/12/2020	

Community Based Day Services	
1 location(s) 2 audit (s) 	

DDS Targeted Review	
12 / 12	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

	

	

	

EXECUTIVE SUMMARY :	

	

	

The Arc of Bristol County (the Arc) is a human service agency founded in 1959 whose services are mainly focused in Rhode Island and southeastern Massachusetts.  The agency has grown in size over the years  and currently includes autism services, children's services, day habilitation, adult day health, community based day supports (CBDS), adult foster care, guardianship, shared living, Trust management, family support, recreation, residential services, and extended day services.  The current review by the Department of Developmental Services (DDS) survey team encompassed the following service models: less than 24-hour residential support, shared living, and Community Based Day Supports.  As the agency had elected to complete a self-assessment for all supports under evaluation, the portion of this review completed by the DDS survey team was targeted to a limited number of indicators.  The scores for the complete licensure and certification review of the agency's day and residential services reflected a combination of the DDS targeted review and ratings from the agency's self-assessment.

The review by the DDS survey team highlighted a number of strengths.  Licensing requirements under review, such as having working smoke and carbon monoxide detectors, were found to be in place.    Shared living providers were observed to include the people they supported in decisions about important matters, such as finding a new home when moving had become a necessity.  Family connections were supported in a variety of ways, including arranging for transportation when family members lived at a distance.  Staff and shared living providers were observed to be respectful in their interactions with those whom they were supporting.  People were supported to engage in a variety of community activities, some of which were sponsored by the Arc.  In some instances, people's community involvement and possibilities to develop new friendships had the potential to be enriched by further exploring people's interests or by offering additional activities that were integrated.  For instance, people who had participated in the Arc's bowling league might enjoy opportunities to join local bowling leagues within their communities. 

The agency's community based day Supports component, which is known as Community Directions, involved providing people services where they lived as well as assistance with accessing community activities.  Community Directions staff were observed to respect the choices of those whom they supported, to offer individualized options to people in an on-going manner, and to take the time to understand people's concerns and respond to them.  A positive outcome of these efforts was seen in individualized community activities based on people's personal interests and preferences.  

Although the Arc staff had a number of safeguard systems in place, some of these systems were in need of strengthening.  For instance, oversight to ensure safe and accurate medication administration needed to be improved, and the monthly visits to shared living homes conducted by case managers could be used to more comprehensively review information and practices relating to the accuracy of medication administration.  

In some areas, the agency had begun promising initiatives that had not yet been fully actualized.  For instance, although the agency had received a grant to promote assistive technology, further assessment is recommended to assess each person's needs in this area and to design strategies for using assistive tech in a way that will enhance people's independence.  

Based on the findings of this report, the agency has received a Two Year License for its Employment and Day Supports group and a deferred license for its Residential and Individual Home Supports group.  Both of these service groupings have received a Two-Year Certification.  The residential license is deferred due to a rating of Not Met in a critical indicator relating to medication administration.  The DDS survey team will return in approximately 60 days to review this indicator for resolution, and a final level of licensure will be determined at that time.  The agency will conduct its own follow-up for its day supports for any licensing indicators rated Not Met and submit the results to the DDS Office of Quality Enhancement within 60 days.  A description of the provider's self-assessment process follows.	

	

	

	

	

Description of Self Assessment Process:	

	

The Arc of Bristol County received a two year license during its last DDS Licensing Survey and was therefore afforded the option to conduct a Self-Assessment. The Arc of Bristol County's programs have been deemed to be in significant compliance with DDS licensing indicators through the implementation and review of ongoing monitoring systems that are described in this document and through a self-assessment survey.

The Arc of Bristol County ensures that qualitative supports are being provided through a variety of on going Quality Management Systems.   The self-monitoring and self-assessment processes are comprised of ongoing audit reviews, quarterly environmental inspections, peer reviews,  satisfaction surveys, management reporting tools and internal and external monitoring systems. The Arc of Bristol County has several agency-wide committees to ensure regulation compliance and quality standards are met. All committees have staff members from various departments and board members to afford diversity, collaboration and share expertise.  Several committees are open to participation from individuals supported and families.  Key committees that assist in our Quality Management Process:  Incident Management (analysis of all incidents for policy recommendations and/or trends analysis); Safety Committee (on-going review of all safety plans, issues, policies, drill compliance, and Safety Officers at each location); Quality of Services (COOP oversight, quarterly disaster drills, and peer review); Human Rights Committee (review of incidents, human rights trainings and Human Rights Advocates at each location); Healthcare Committee (reviews Healthcare policies and procedures, staff training/resources and critical incidences)  PBS Leadership Team (ensures PBS Framework is being implemented agency wide) and Workforce Development and Diversity Committee (review proactive strategies for staff recruitment and retention). 

Each program is reviewed throughout each year by staff participating in our various agency committees and overseen by the Quality Management Coordinator. A variety of tools is used by each committee and includes provider specific monitoring tools and inspections in addition to DDS's licensing and certification tools. The reviews are highly comprehensive and are focused on all aspects of the DDS licensing indicators, CARF requirements, and The Arc of Bristol County's internal policies and procedures compliance. Any areas found deficient or partially met are reviewed again within 60 days by the Quality Management Coordinator or designees.

All Quality Management results are reviewed by each particular committee and submitted to The Arc of Bristol County's Senior Leadership Team and Board of Directors who further review results for trends, patterns and outstanding issues. Additionally, off-cycle reviews are conducted if there is a prolonged vacancy in management staff or if the program is newly opened. On an annual basis a summary of all quality and risk management activities including satisfaction survey results, internal audit results, and licensing outcomes to the Senior Leadership Team and the Board of Directors for their input and feedback.

Environmentally each of the program sites are tracked through The Arc of Bristol County's Safety Committee. This committee meets quarterly. When any of the individuals within the site locations have been in need of any type of accommodation, a Work Order has been submitted to make sure that The Arc of Bristol County has met the need of the individual. There is also a subcommittee of The Safety Committee entitled The Accessibility Committee.  This committee has been able to work within our agency in making sure that each program site has addressed the needs that range from: physical accessibility (ramps and accessible doors for of our buildings), more signage in our sites, language needs (our agency brochures in languages other than English), and computer/technological adaptations. 

Environmental Conditions are assessed on a quarterly basis utilizing our Facility Safety Inspection Checklist. The Operations Manager has been able to help with tracking the repairs to each site. The tracking system has a date of entry and anticipated date of repair and date of closure of the needed repair or maintenance. This system is online so the Team Supervisor and other Arc Administrators can track the progress of the repair(s).  This has helped to keep the sites maintained. Each site has regular and annual maintenance performed. 

Each location maintains annual inspections. Information gleaned from this inspection helps to ensure that The Arc of Bristol County is properly maintaining our sites. Any issues that the Operations Manager comes across while conducing this inspection is immediately addressed with the appropriate Arc administrative members. The Arc of Bristol County does not want any information taken from the inspections to disrupt the delivery of services to our individuals. We in fact try to improve upon our services if possible. 

Similar to environmental conditions, the quality of the supports being provided are also reviewed continuously. On a biannual basis, the DDS OQE tool is utilized to determine if any support adjustments need to be made, if individual capabilities have been maintained and if modifications need to be made to their care plans.  If recommendations are identified through this assessment process, Supervisors and Director are immediately notified which then in turn is shared with an individual's interdisciplinary team.  If additional support hours are needed to be procured, individual teams will review the request and discuss this need with their respective DDS Area Office.

The Arc of Bristol County has an internal reporting system for the incident reports of the agency. These reports are numbered from the beginning of the year. They are also categorized by program and incident type. The incidents are all logged into a database so they can be tracked from month to month or year to year. Findings and Trends are summarized on our Risk Management Report which assists in analyzing trends and patterns within certain sites or across the agency as a whole. Reports are generated quarterly, bi annually and annually for the President/CEO, Board of Directors, and The Human Rights Committee. The Incident Review Committee and Human Rights Committee both meet monthly to review the incidents. The Arc of Bristol County also makes full use of the HCSIS system's reports section. This has helped with our incidents and the follow up on incidents and action plans. After entering an incident report with an action plan, our Team Supervisors and staff work very diligently to rectify the concern act on the steps outlined in each particular incident. 

All of the individuals supported are asked to complete an Annual Satisfaction Survey. This survey was designed in a way (colors, pictures etc.) to make sure all of our individuals are comfortable in answering it. We take our results very seriously and use them towards improving any needed areas. We value our individual's opinions and respect their choices and beliefs. 

Our Quality of Services Committee reviews data from all areas including:  Peer Review Committee, Healthcare Committee, Corporate Compliance, PBS Leadership Team, Incident Review, Safety, and Human Rights Committee.  This internal review affords us the data necessary to assess areas for improvement to improve quality management systems throughout the organization.  Through these Quality Management Systems, The Arc of Bristol County has been able to consistently meet licensing and certification requirements for In Home Supports and takes pride in our holistic and person centered approach in providing services which empowers individuals to live fully in their communities.
 The self-assessment review was conducted by The Arc of Bristol County's management, Agency Committees and Quality Management Coordinator. A full review of all program services that fall under DDS Licensing and Certification standards was conducted December 7, 2017-January 26, 2018 as well as conducting additional visits to interview individuals served and staff at a sample of programs to rate a number of the certification indicators not addressed on the quality review tool. The review team utilized an 80% compliance factor to determine that an indicator was met and indicators receiving less than 80% were deemed unmet. In total, residential/in home supports was in 98.7% compliance with all licensing standards.  Community Based Day Support services achieved 95.9% of all licensing indicators rated and 100% of the certification indicators. Due to type of CBDS services The Arc of Bristol County provides in addition to the environments in which they are offered not all Licensing and Certification areas were able to be rated.  Please refer to Rating Section for specific Licensing and Certification indicators.

There were three unmet licensing indicators: L60 (Data Maintenance), L86 (Required Assessments), and L87 (Support Strategies). Although data collection tools were present at all locations, data was inconsistently completed and therefore rated unmet. All required assessments and provider support strategies were present however the required submission timeline was not consistently adhered to. Please refer to Unmet Areas in rating section for actions planned to address issues.	

	

	

	

LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/8	
0/8	

Residential and Individual Home Supports	
71/72	
1/72	

    Placement Services
    Individual Home Supports

	

Critical Indicators	
6/7	
1/7	

Total	
79/80	
1/80	
99%	

Defer Licensure	

	

# indicators for 60 Day Follow-up	
	
1	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/8	
0/8	

Employment and Day Supports	
38/40	
2/40	

    Community Based Day Services

	

Critical Indicators	
2/2	
0/2	

Total	
46/48	
2/48	
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	

O	
 L46	
 All prescription medications are administered according to the written order of a practitioner and are properly documented on a Medication Treatment Chart. 	
Two out of three individuals participating in the survey were administered medications according to the written order of practitioner. In one instance, an individual was given two medications without a written Dr's order. The agency needs to ensure all medications are administered according to the Dr's order, properly documented, reviewed for accuracy on a regular basis and that effective monitoring mechanisms are in place.	

	

	
Employment/Day 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.	
ISP Assessments were not submitted on time for 1 out of 2 people.  The agency needs to ensure that all ISP Assessments are submitted at least 15 days in advance of the ISP meeting.	

 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 were not submitted on time for 1 out of 2 people.  The agency needs to ensure that all ISP Support Strategies are submitted at least 15 days in advance of the ISP meeting.	

	

	
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 29/34
Provider 7/7	
36/41	
5/41	

Individual Home Supports	
DDS 15/17
Provider 4/4	
19/21	
2/21	

Placement Services	
DDS 14/17
Provider 3/3	
17/20	
3/20	

Total	
	
42/47	
5/47	
89%	

Certified	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

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

Employment and Day Supports	
DDS 11/11
Provider 1/1	
12/12	
0/12	

Community Based Day Services	
DDS 11/11
Provider 1/1	
12/12	
0/12	

Total	
	
18/18	
0/18	
100%	

Certified	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
Although staff were familiar with people's histories in this area, additional assessment of needs should be made to help people's to develop approaches that would resolve their questions and concerns.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Although the agency had promoted assistive technology, additional efforts should be made to assess people's needs in this area and to develop strategies that will help people use assistive technology in ways that would enhance their independence.	

	

	

	

Placement Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
A process was not in place to explore peoples' needs for intimacy and companionship.  The agency should assess, educate, and support individuals in the area of human sexuality.  The agency also needs to provide training opportunities to support home providers in this area.	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Two out of four individuals needed additional support regarding their access to community activities based on their individual preferences and interests.  One individual expressed an interest in art as she enjoys painting, while another enjoyed music trivia.  The agency needs to assist individuals to explore their interests and ensure individuals are offered consistent opportunities to participate in community activities based on these interests.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Three out of four individuals participating in the review had not been assessed to identify any assistive technology that may be of benefit and/or assistive technology and modifications to maximize independence in their homes. The agency needs to assess each individual's needs and determine how assistive technology or modifications can maximize each individual's independence.	

	

	

	

	MASTER SCORE SHEET LICENSURE	

								
	Organizational: ARC OF BRISTOL COUNTY	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
7/7	
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	

O	
 L2	
Abuse/neglect reporting	
L	
DDS	

2/2	

	
2/2	
Met	

 L4	
Action taken	
L	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
	
1/2	
4/4	

	
5/6	
Met
(83.33 %)	

 L8	
Emergency Fact Sheets	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

O	
 L11	
Required inspections	
L	
DDS	
	
1/1	
4/4	

	
5/5	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
	
1/1	
4/4	

	
5/5	
Met	

O	
 L13	
Clean location	
L	
DDS	
	
1/1	
4/4	

	
5/5	
Met	

 L14	
Site in good repair	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L15	
Hot water	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L16	
Accessibility	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L19	
Bedroom location	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L22	
Well-maintained appliances	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L27	
Pools, hot tubs, etc.	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L28	
Flammables	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L29	
Rubbish/combustibles	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
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	

 L40	
Nutritional food	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L41	
Healthy diet	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L42	
Physical activity	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L43	
Health Care Record	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	

2/3	

	
2/3	
Not Met
(66.67 %)	

 L47	
Self medication	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
	
1/2	
4/4	

	
5/6	
Met
(83.33 %)	

 L50	
Respectful Comm.	
L	
DDS	
	
2/2	
4/4	

	
6/6	
Met	

 L51	
Possessions	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
	
2/2	
4/4	

	
6/6	
Met	

 L53	
Visitation	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
	
2/2	
4/4	

	
6/6	
Met	

 L55	
Informed consent	
I	
DDS	
	
2/2	
1/1	

	
3/3	
Met	

 L56	
Restrictive practices	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L57	
Written behavior plans	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L63	
Med. treatment plan form	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L64	
Med. treatment plan rev.	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L70	
Charges for care calc.	
I	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L71	
Charges for care appeal	
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	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L87	
Support strategies	
I	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

 L88	
Strategies implemented	
I 	
Provider	
	
-	
-	
	
-	
-	
-	
Met	

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

	
6/6	
Met	

#Std. Met/# 72 Indicator	

	

	

	
71/72	

	
Total Score	

	

	

	
79/80	

	

	

	

	
	
98.75%	

			
								
Employment and Day Supports:	

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

 L1	
Abuse/neglect training	
I 	
Provider	

-	
-	
Met	

O	
 L2	
Abuse/neglect reporting	
L	
Provider	

-	
-	
Met	

 L4	
Action taken	
L	
Provider	

-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	

-	
-	
Met	

O	
 L6	
Evacuation	
L 	
Provider	

-	
-	
Met	

 L7	
Fire Drills	
L 	
Provider	

-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	

-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	

-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	

-	
-	
Met	

O	
 L13	
Clean location	
L 	
Provider	

-	
-	
Met	

 L14	
Site in good repair	
L 	
Provider	

-	
-	
Met	

 L15	
Hot water	
L 	
Provider	

-	
-	
Met	

 L16	
Accessibility	
L 	
Provider	

-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	

-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	

-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	

-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	

-	
-	
Met	

 L22	
Well-maintained appliances	
L 	
Provider	

-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	

-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	

-	
-	
Met	

 L31	
Communication method	
I 	
Provider	

-	
-	
Met	

 L32	
Verbal & written	
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	

 L49	
Informed of human rights	
I	
DDS	

2/2	
2/2	
Met	

 L50	
Respectful Comm.	
L	
DDS	

1/1	
1/1	
Met	

 L51	
Possessions	
I 	
Provider	

-	
-	
Met	

 L52	
Phone calls	
I	
DDS	

2/2	
2/2	
Met	

 L54	
Privacy	
L	
DDS	

1/1	
1/1	
Met	

 L55	
Informed consent	
I	
DDS	

1/1	
1/1	
Met	

 L61	
Health protection in ISP	
I 	
Provider	

-	
-	
Met	

 L62	
Health protection review	
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	

1/2	
1/2	
Not Met
(50.0 %)	

 L87	
Support strategies	
I	
DDS	

1/2	
1/2	
Not Met
(50.0 %)	

 L88	
Strategies implemented	
I 	
Provider	

-	
-	
Met	

#Std. Met/# 40 Indicator	

	

	
38/40	

	
Total Score	

	

	
46/48	

	

	

	
	
95.83%	

			
								
	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	

	

	

	
								
Community Based Day Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
2/2	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C13	
Skills to maximize independence 	
DDS	
2/2	
Met	

 C40	
Community involvement interest	
DDS	
2/2	
Met	

 C41	
Activities participation	
DDS	
2/2	
Met	

 C42	
Connection to others	
DDS	
2/2	
Met	

 C43	
Maintain & enhance relationship	
DDS	
2/2	
Met	

 C45	
Revisit decisions	
DDS	
2/2	
Met	

 C46	
Use of generic resources	
DDS	
2/2	
Met	

 C47	
Transportation to/ from community	
DDS	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
2/2	
Met	

 C54	
Assistive technology	
DDS	
2/2	
Met	

Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
2/2	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
2/2	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
1/2	
Not Met (50.0 %)	

 C13	
Skills to maximize independence 	
DDS	
2/2	
Met	

 C14	
Choices in routines & schedules	
DDS	
2/2	
Met	

 C15	
Personalize living space	
Provider	
-	
Met	

 C16	
Explore interests	
DDS	
2/2	
Met	

 C17	
Community activities	
DDS	
2/2	
Met	

 C18	
Purchase personal belongings	
DDS	
2/2	
Met	

 C19	
Knowledgeable decisions	
DDS	
2/2	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C21	
Coordinate outreach	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
2/2	
Met	

 C47	
Transportation to/ from community	
DDS	
2/2	
Met	

 C48	
Neighborhood connections	
DDS	
2/2	
Met	

 C49	
Physical setting is consistent 	
Provider	
-	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
2/2	
Met	

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

 C53	
Food/ dining choices	
DDS	
2/2	
Met	

 C54	
Assistive technology	
DDS	
1/2	
Not Met (50.0 %)	

Placement Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
4/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
4/4	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
0/4	
Not Met (0 %)	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C14	
Choices in routines & schedules	
DDS	
4/4	
Met	

 C15	
Personalize living space	
Provider	
-	
Met	

 C16	
Explore interests	
DDS	
4/4	
Met	

 C17	
Community activities	
DDS	
2/4	
Not Met (50.0 %)	

 C18	
Purchase personal belongings	
DDS	
4/4	
Met	

 C19	
Knowledgeable decisions	
DDS	
4/4	
Met	

 C20	
Emergency back-up plans	
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 	
Provider	
-	
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	
1/4	
Not Met (25.00 %)