PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
BEHAVIORAL ASSOCIATES OF MASS
20 Townsend Road, Unit 6
 Attleboro, MA 02703    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
August 31, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
BEHAVIORAL ASSOCIATES OF MASS	

	

	

	

	
Review Dates	

	
8/14/2018 - 8/20/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
8/31/2018	

	

	

	

	

	

	
Survey Team	

	
Ed Sutka (TL)	

Barbara Mazzella	

	

	

	

	

	

	
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	
2 location(s) 6 audit (s) 	
Full Review	
72 / 83 2 Year License 08/31/2018 -  08/31/2020	
	
20 / 28 Certified with Progress Report 08/31/2018 -  08/31/2020	

Residential Services	
2 location(s) 6 audit (s) 	

Full Review	
16 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
4 / 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) 4 audit (s) 	
Full Review	
57 / 62 2 Year License 08/31/2018 -  08/31/2020	
	
25 / 42 Certified with Progress Report 08/31/2018 -  08/31/2020	

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

Full Review	
9 / 14	

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

Full Review	
12 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
4 / 6	

	

	

EXECUTIVE SUMMARY :	

			
Behavioral Associates of Massachusetts, also known as the Halcyon Center, is a non-profit human service agency that has provided supports since 1986 and is part of The Groden Network, which is is based in Rhode Island.  A hallmark of the agency is to offer services to individuals with behavioral challenges. The administrative center for Behavioral Associates is located in Attleboro, Massachusetts. 

The scope of this survey consisted of a full Licensure and Certification review completed by the Department of Developmental Services (DDS).  The survey sample consisted of reviewing supports for nine individuals residing in two of the agency's six twenty-four hour group homes; four individuals receiving Community-Based Day supports (CBDS) and two individuals who receive Employment supports. In addition to the services that comprised this review, the agency also offers day habilitation services to adults with developmental disabilities.   

Within the agency's residential supports, a number of strengths relating to licensing areas were identified.  Health care was provided in a way that ensured that routine and specialized appointments were conducted as needed. Systems to administer medications worked effectively, and staff encouraged healthy lifestyles. It was particularly noteworthy that staff successfully supported one individual to achieve smoking cessation.  Several individuals had lost weight and commented on the opportunity to exercise on a regular basis.  A number of other strengths were also evident.  Homes were clean, and individuals could demonstrate emergency evacuation in a timely manner. A marked reduction was noted in the use of physical restraint to respond to challenging behaviors. Behavior plans for several individuals included positive behavioral support techniques which had made possible the fading of aversive interventions. 

The review also identified a number of strengths which were evident in the CBDS and Employment Services.  Staff were observed to be respectful of individuals and served as facilitators so that individuals could better understand communications from others. The physical setting for the agency's day supports was well maintained and offered outside space for individuals to exercise or have lunch.  For instance, staff were seen to provide a lunchtime barbecue, which many individuals enjoyed.  Staff were also seen to implement several positive behavioral support strategies during the day, as several individuals were supported to identify and use interventions that alleviated stress.

Individuals receiving residential supports were provided opportunities to exercise choice and control over day-to-day decisions.  For instance, individuals were included in menu planning and had options to make selections that deviated from the planned menu. As an alternative to the planned dinner selection, one individual was excited to make his own salad with ingredients from the garden that staff had helped him to maintain.  Staff were also knowledgeable about people's unique preferences and abilities and accommodated accordingly.  For instance, staff worked with an individual and his family to arrange for a vacation that accommodated his need for a smaller venue with more individualized supports.  

Within employment supports, people in the survey sample earned minimum wage, although most opportunities for interactions at their work sties were with others who received services.  Some jobs, such as delivering mail or supplies within the Groden Network, allowed people to spend time away from their day site.  Although people expressed satisfaction with their jobs, it is recommended that additional career planning and exploration should be prioritized to enhance people's opportunities.  Within CBDS, several individuals were supported to participate in volunteer jobs that connected them to community partners. For example, several individuals volunteered at the Meals on Wheels program.  

While the agency has demonstrated positive outcomes in a number of service delivery areas, this review also identified areas where additional attention is recommended, a number of which centered on community and social connectedness.  Within residential supports, a number of individuals would benefit from a further exploration of community activities that reflected their identified interests or that would help them develop new interests and social contacts.  As well, the agency was still in the early stages of efforts to help individuals understand the full range of relationship possibilities, including helping people define and express their need for intimacy and companionship.  

Within the agency's day supports, it is recommended that that staff develop further strategies to build upon existing efforts to help individuals to identify their interests for both employment as well as for enrichment activities and to develop further options for people that would match their interests.  For instance, while some agency ties to community businesses and organizations already exist, such as with a local college, it is suggested that efforts of this kind be expanded.   

Some of the findings of this review pertained to organizational indicators and/or cut across both day and residential settings.  For instance, an area where the agency's efforts were still at an early stage was seen in the development of assessments and support plans to help people enhance their independence through the use of assistive technology.   While many positive practices relating to human rights were in place, a number of areas were in need of further attention.  Examples included ensuring greater effectiveness for the agency's Human Rights Committee, more fully adhering to requirements relating to the use of restrictive interventions, such as door alarms, and developing practices that guarantee individuals are free from arbitrary eviction.

Based on the findings of this report, Behavioral Associates has earned a two-year license for both the Residential Supports group and the Employment and Day Supports group and is also Certified with a Progress Review for these services.  Within residential services, the agency met 87% of licensing indicators and 71% of certification indicators.  For Day and Employment Supports, the agency met 92% of licensing indicators and 60% of certification indicators.  The Department of Developmental Services will conduct follow-up within 60 days for licensing indicators rated Not Met within Residential Supports. Behavioral Associates will conduct the follow up for Employment and Day supports on licensing indicators rated Not Met and will submit its findings to the Office of Quality Enhancement within 60 days.  In 12 months, the agency will submit a Progress Report to the Office of Quality Enhancement pertaining to the certification indicators rated Not Met within both groups.	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/10	
2/10	

Residential and Individual Home Supports	
64/73	
9/73	

    Residential Services

	

Critical Indicators	
8/8	
0/8	

Total	
72/83	
11/83	
87%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
11	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/10	
2/10	

Employment and Day Supports	
49/52	
3/52	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
8/8	
0/8	

Total	
57/62	
5/62	
92%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
5	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
The Human Rights Committee needs to ensure that attendance and membership issues for members with professional expertise have been addressed, that HRC members are not precluded from discussion of Investigations until Action Plans are issued, and that the HRC reviews policies and fully discusses issues.	

 L65	
Restraint reports are submitted within required timelines.	
 Five out of six restraint reports were not submitted on time. Restraint Reports need to be submitted for review within required timelines. 	

		

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L15	
Hot water temperature tests between 110 and 120 degrees (as of 1/2014).	
The hot water temperature was tested at two locations. In one home, the hot water temperature was not within allowable limits. The agency needs to ensure that hot water temperatures are within allowable limits. 	

 L24	
Locks on doors not providing egress can be opened by the individuals from the inside and staff carry a key to open in an emergency.	
In one out of two locations, staff was not able to identify the appropriate keys needed to unlock bedroom doors in the event of an emergency. The agency needs to ensure that staff are able to access individuals' bedrooms in the event of an emergency.	

 L43	
The health care record is maintained and updated as required.  	
Six individuals' health care records were reviewed. In three instances, information included in the health care record was not accurate or up to date.  (medical examination dates were not most recent, guardian information was inaccurate, and inaccurate medications were included).  The agency needs to ensure that the health care record is updated as required. 	

 L45	
Medications are stored in a locked container or area in which nothing except such medications are stored. 	
In one location, knives were locked in the same area as medications. The agency needs to ensure that the area in which medications are stored and locked contains only medications. 	

 L49	
Individuals and guardians have been informed of their human rights and know how to file a grievance or to whom they should talk if they have a concern.	
The agency has not  informed individuals and guardians of their right to be free from arbitrary evictions. The agency needs to ensure that this protection is put into effect.  	

 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.	
Informed consent was reviewed for three individuals. In one instance, the signed consent to utilize a photo on the agency's website did not indicate whether consent was approved or denied. The agency needs to ensure that clarification is sought regarding consent prior to the use of an individual's photo. 	

 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.	
Restrictive practices were reviewed for six individuals. Restrictive practices included the locking of knives as well as the use of door chimes. These restrictions impacted all individuals residing in the homes; however, provisions to fade or reduce limitations were lacking. The agency needs to ensure that all restrictive practices include all required components. 	

 L64	
Medication treatment plans are reviewed by the required groups.	
Medication treatment plans were reviewed for five individuals. All of the plans were not reviewed by the ISP team as required. 	

 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 one out of three individuals was not submitted within required time frames. The agency needs to ensure that strategies are submitted to the DDS  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	

 L39	
Special dietary requirements are followed. 	
Special dietary requirements were reviewed for three individuals. In one instance,  all staff were not trained or implementing special dietary requirements as designed. The agency needs to ensure that staff are trained, knowledgeable and implement dietary requirements.  	

 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.	
Informed consent was reviewed for two individuals. In one instance, the signed consent to utilize a photo did not indicate whether consent was approved or denied. The agency needs to ensure that clarification is sought regarding consent prior to the use of an individual's photo. 	

 L67	
There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	
Money management plans were reviewed for three individuals. In one instance, the plan did not include a description of how funds would be used during the day and agreement to such use had not been obtained. The agency needs to ensure that money management plans include all required components. 	

			

	CERTIFICATION FINDINGS	

						
		
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
4/6	
2/6	

Residential and Individual Home Supports	
16/22	
6/22	

Residential Services	
16/22	
6/22	

TOTAL	
20/28	
8/28	
71%	

Certified with Progress Report	

	

Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
4/6	
2/6	

Employment and Day Supports	
21/36	
15/36	

Community Based Day Services	
9/14	
5/14	

Employment Support Services	
12/22	
10/22	

TOTAL	
25/42	
17/42	
60%	

Certified with Progress Report	

	

						

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

Indicator #	
Indicator	
Area Needing Improvement	

 C5	
The provider has a process to measure progress towards achieving service improvement goals.	
As identified in the agency's 2017 self-evaluation, challenges were present which prevented the agency from making mid course service improvements.  The agency needs to ensure that effective strategies are present when adjustments need to be made to enhance service improvement goals.  	

 C6	
The provider has mechanisms to plan for future directions in service delivery and implements strategies to actualize these plans.	
The Strategic Plan for the Groden Network needs to include additional strategies and objectives focusing on service improvement goals for Behavioral Associates of Massachusetts.	

	

		

Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C9	
Staff (Home Providers) act as bridge builders and provide opportunities to develop, and/or increase personal relationships and social contacts.	
Additional strategies to help people develop increased social contacts, including new relationships, need to be developed.	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
The agency needs to develop a process to assess each person's needs in this area and develop support plans, as appropriate.	

 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Although some information about people's preferences for community activities were known, a greater emphasis needs to be placed on helping people explore identified interests or develop new interests relating to activities within the community.	

 C17	
Community activities are based on the individual's preferences and interests.	
Although some community activities matched people's interests, additional strategies needs to be developed to ensure that this happens on a more consistent basis.	

 C48	
Individuals are a part of the neighborhood.	
 Staff were providing limited opportunities to connect with neighbors.  Additional strategies need to be developed to strengthen these relationships and help people to have experiences which could enhance their ties to the neighborhood. 	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Assessments had not been completed for individuals regarding their need for assistive technology. Assessments and Plans need to be developed that could help people to use assistive technology in ways that could enhance their independence. 	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 C40	
Individuals are supported to explore, discover and connect with their personal interest and options for community involvement, personal interest and hobbies.	
There was minimal information regarding people's personal interests and preferences for participating in community activities. The agency needs to assess individual's personal interests and provide a variety of means for individuals to explore those areas of interest. 	

 C41	
Individuals participate in activities, including those in the community, that reflect their interests and preferences.	
Although a menu of options are provided to individuals on a daily basis, there were no mechanisms utilized to incorporate individual's unique interests and preferences into activities. The agency needs to ensure that activities reflect individual's interests. 	

 C44	
Staff have effective methods to assist individuals to explore their job interests if appropriate.	
The agency needs to develop and implement ways to assess each individual's interests and incorporate these into the job development process. 	

 C45	
Individual's decisions of what to do during the day are revisited on a regular basis.	
Limited options were provided from which individuals could exercise choice. Staff need to expose individuals to different options for consideration on a regular basis in accordance with their unique learning style. 	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Assessments had not been completed for individuals regarding their need for assistive technology. Assessments and Plans need to be developed that could help people to use assistive technology in ways that could enhance their independence. 	

	

	
Employment Support 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.	
Opportunities to provide feedback on the performance of staff at the time of hire was not provided to one individual. 
The agency needs to ensure that individuals are provided opportunities to provide feedback on the performance of staff at the time of hire. 	

 C22	
Staff have effective methods to assist individuals to explore their job interests.	
The agency needs to develop mechanisms to explore job interests with people. These strategies need to include ways for people to learn about and experience what is involved in different types of employment to better identify what they may be interested in pursuing. 	

 C23	
Staff utilize a variety of methods to assess an individual's skills, interests, career goals and training and support needs in employment.	
The agency needs to further assess people's employment related skills and potential career paths. These should include a means to assess skills needed for a variety of professions. 	

 C24	
There is a plan developed to identify job goals and support needs.	
The agency needs to develop employment plans based on assessments of job/employment interests and of skills and training needs. The plan should identify job goals and support needs and should also be identified within the individual's ISP. 	

 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 needs to ensure that staff are knowledgeable about the relationship between employment and benefits and provide information to families about the effect future earnings may have on entitlements. 	

 C28	
Staff maintain and develop relationships with local businesses in order to facilitate job development opportunities.	
The agency had only limited connections with local businesses and needs to enhance its strategies to enrich these connections to promote job development. 	

 C30	
Individuals are supported to work in integrated job settings.	
The agency needs to ensure that individuals are provided opportunities to work in integrated job settings on an ongoing basis. The agency needs to develop plans that support efforts to work in integrated jobs.  	

 C33	
Employee benefits and rights are clearly explained to the individual.	
The agency needs to ensure that employee benefits and rights are explained to individuals in a format that is consistent with their learning style and that individuals are receiving the benefits to which they are entitled. 	

 C35	
Individuals are given feedback on job performance by their employer.	
The agency needs to ensure that individuals are provided feedback in an ongoing and timely manner and offer guidance regarding future skill development to ensure successful job performance.  	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Assessments had not been completed for individuals regarding their need for assistive technology. Assessments and Plans need to be developed that could help people to use assistive technology in ways that could enhance their independence at work. 	

	

		

	MASTER SCORE SHEET LICENSURE	

					
	Organizational: BEHAVIORAL ASSOCIATES OF MASS	

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

O	
 L2	
Abuse/neglect reporting	
4/4	
Met	

 L3	
Immediate Action	
15/15	
Met	

 L4	
Action taken	
13/13	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
1/6	
Not Met(16.67 % )	

 L66	
HRC restraint review	
5/5	
Met	

 L74	
Screen employees	
3/3	
Met	

 L75	
Qualified staff	
3/3	
Met	

 L76	
Track trainings	
5/6	
Met(83.33 % )	

 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	
6/6	

	

6/6	
Met	

 L5	
Safety Plan	
L	
2/2	

	

2/2	
Met	

O	
 L6	
Evacuation	
L	
2/2	

	

2/2	
Met	

 L7	
Fire Drills	
L	
2/2	

	

2/2	
Met	

 L8	
Emergency Fact Sheets	
I	
6/6	

	

6/6	
Met	

 L9	
Safe use of equipment	
L	
2/2	

	

2/2	
Met	

 L10	
Reduce risk interventions	
I	
4/5	

	

4/5	
Met
(80.0 %)	

O	
 L11	
Required inspections	
L	
2/2	

	

2/2	
Met	

O	
 L12	
Smoke detectors	
L	
2/2	

	

2/2	
Met	

O	
 L13	
Clean location	
L	
2/2	

	

2/2	
Met	

 L14	
Site in good repair	
L	
2/2	

	

2/2	
Met	

 L15	
Hot water	
L	
1/2	

	

1/2	
Not Met
(50.0 %)	

 L16	
Accessibility	
L	
2/2	

	

2/2	
Met	

 L17	
Egress at grade 	
L	
2/2	

	

2/2	
Met	

 L18	
Above grade egress	
L	
2/2	

	

2/2	
Met	

 L19	
Bedroom location	
L	
1/1	

	

1/1	
Met	

 L20	
Exit doors	
L	
2/2	

	

2/2	
Met	

 L21	
Safe electrical equipment	
L	
2/2	

	

2/2	
Met	

 L22	
Well-maintained appliances	
L	
2/2	

	

2/2	
Met	

 L23	
Egress door locks	
L	
1/1	

	

1/1	
Met	

 L24	
Locked door access	
L	
1/2	

	

1/2	
Not Met
(50.0 %)	

 L25	
Dangerous substances	
L	
2/2	

	

2/2	
Met	

 L26	
Walkway safety	
L	
2/2	

	

2/2	
Met	

 L28	
Flammables	
L	
2/2	

	

2/2	
Met	

 L29	
Rubbish/combustibles	
L	
2/2	

	

2/2	
Met	

 L30	
Protective railings	
L	
2/2	

	

2/2	
Met	

 L31	
Communication method	
I	
6/6	

	

6/6	
Met	

 L32	
Verbal & written	
I	
6/6	

	

6/6	
Met	

 L33	
Physical exam	
I	
6/6	

	

6/6	
Met	

 L34	
Dental exam	
I	
6/6	

	

6/6	
Met	

 L35	
Preventive screenings	
I	
6/6	

	

6/6	
Met	

 L36	
Recommended tests	
I	
6/6	

	

6/6	
Met	

 L37	
Prompt treatment	
I	
6/6	

	

6/6	
Met	

O	
 L38	
Physician's orders	
I	
3/4	

	

3/4	
Met	

 L39	
Dietary requirements	
I	
5/5	

	

5/5	
Met	

 L40	
Nutritional food	
L	
2/2	

	

2/2	
Met	

 L41	
Healthy diet	
L	
2/2	

	

2/2	
Met	

 L42	
Physical activity	
L	
2/2	

	

2/2	
Met	

 L43	
Health Care Record	
I	
3/6	

	

3/6	
Not Met
(50.0 %)	

 L44	
MAP registration	
L	
2/2	

	

2/2	
Met	

 L45	
Medication storage	
L	
1/2	

	

1/2	
Not Met
(50.0 %)	

O	
 L46	
Med. Administration	
I	
6/6	

	

6/6	
Met	

 L47	
Self medication	
I	
3/4	

	

3/4	
Met	

 L49	
Informed of human rights	
I	
0/6	

	

0/6	
Not Met
(0 %)	

 L50	
Respectful Comm.	
L	
2/2	

	

2/2	
Met	

 L51	
Possessions	
I	
6/6	

	

6/6	
Met	

 L52	
Phone calls	
I	
6/6	

	

6/6	
Met	

 L53	
Visitation	
I	
6/6	

	

6/6	
Met	

 L54	
Privacy	
L	
2/2	

	

2/2	
Met	

 L55	
Informed consent	
I	
2/3	

	

2/3	
Not Met
(66.67 %)	

 L56	
Restrictive practices	
I	
0/6	

	

0/6	
Not Met
(0 %)	

 L57	
Written behavior plans	
I	
6/6	

	

6/6	
Met	

 L58	
Behavior plan component	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L59	
Behavior plan review	
I	
6/6	

	

6/6	
Met	

 L60	
Data maintenance	
I	
6/6	

	

6/6	
Met	

 L63	
Med. treatment plan form	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L64	
Med. treatment plan rev.	
I	
0/5	

	

0/5	
Not Met
(0 %)	

 L67	
Money mgmt. plan	
I	
6/6	

	

6/6	
Met	

 L68	
Funds expenditure	
I	
6/6	

	

6/6	
Met	

 L69	
Expenditure tracking	
I	
6/6	

	

6/6	
Met	

 L70	
Charges for care calc.	
I	
6/6	

	

6/6	
Met	

 L71	
Charges for care appeal	
I	
6/6	

	

6/6	
Met	

 L77	
Unique needs training	
I	
6/6	

	

6/6	
Met	

 L78	
Restrictive Int. Training	
L	
2/2	

	

2/2	
Met	

 L79	
Restraint training	
L	
2/2	

	

2/2	
Met	

 L80	
Symptoms of illness	
L	
2/2	

	

2/2	
Met	

 L81	
Medical emergency	
L	
2/2	

	

2/2	
Met	

O	
 L82	
Medication admin.	
L	
2/2	

	

2/2	
Met	

 L85	
Supervision 	
L	
2/2	

	

2/2	
Met	

 L86	
Required assessments	
I	
3/3	

	

3/3	
Met	

 L87	
Support strategies	
I	
2/3	

	

2/3	
Not Met
(66.67 %)	

 L88	
Strategies implemented	
I	
6/6	

	

6/6	
Met	

 L90	
Personal space/ bedroom privacy	
I	
6/6	

	

6/6	
Met	

#Std. Met/# 73 Indicator	

	

	

64/73	

	
Total Score	

	

	

72/83	

	

	

	

	
86.75%	

		
							
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	
2/2	
	
2/2	
4/4	
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	
2/2	
	
2/2	
4/4	
Met	

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

 L10	
Reduce risk interventions	
I	
2/2	
	
2/2	
4/4	
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	
2/2	
	
2/2	
4/4	
Met	

 L32	
Verbal & written	
I	
2/2	
	
2/2	
4/4	
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	
1/1	
	
1/2	
2/3	
Not Met
(66.67 %)	

 L44	
MAP registration	
L	

1/1	
1/1	
Met	

 L45	
Medication storage	
L	

1/1	
1/1	
Met	

O	
 L46	
Med. Administration	
I	
1/1	
	
2/2	
3/3	
Met	

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

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

 L51	
Possessions	
I	
2/2	
	
2/2	
4/4	
Met	

 L52	
Phone calls	
I	
2/2	
	
2/2	
4/4	
Met	

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

 L55	
Informed consent	
I	
1/1	
	
0/1	
1/2	
Not Met
(50.0 %)	

 L57	
Written behavior plans	
I	
2/2	
	
2/2	
4/4	
Met	

 L58	
Behavior plan component	
I	
2/2	
	
2/2	
4/4	
Met	

 L59	
Behavior plan review	
I	
2/2	
	
2/2	
4/4	
Met	

 L60	
Data maintenance	
I	
2/2	
	
2/2	
4/4	
Met	

 L67	
Money mgmt. plan	
I	
1/1	
	
1/2	
2/3	
Not Met
(66.67 %)	

 L68	
Funds expenditure	
I	
1/1	
	
2/2	
3/3	
Met	

 L69	
Expenditure tracking	
I	
1/1	
	
2/2	
3/3	
Met	

 L77	
Unique needs training	
I	
2/2	
	
2/2	
4/4	
Met	

 L78	
Restrictive Int. Training	
L	
1/1	
	
1/1	
2/2	
Met	

 L79	
Restraint training	
L	
1/1	
	
1/1	
2/2	
Met	

 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	

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

 L86	
Required assessments	
I	
1/1	
	
2/2	
3/3	
Met	

 L87	
Support strategies	
I	
1/1	
	
2/2	
3/3	
Met	

 L88	
Strategies implemented	
I	
2/2	
	
2/2	
4/4	
Met	

#Std. Met/# 52 Indicator	

	

49/52	

	
Total Score	

	

57/62	

	

	

	
91.94%	

		
							
	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	
0/1	
Not Met (0 %)	

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

	

	

							
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

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

 C8	
Family/guardian communication	
2/2	
Met	

 C13	
Skills to maximize independence 	
2/2	
Met	

 C37	
Interpersonal skills for work	
2/2	
Met	

 C40	
Community involvement interest	
1/2	
Not Met (50.0 %)	

 C41	
Activities participation	
1/2	
Not Met (50.0 %)	

 C42	
Connection to others	
2/2	
Met	

 C43	
Maintain & enhance relationship	
2/2	
Met	

 C44	
Job exploration	
0/2	
Not Met (0 %)	

 C45	
Revisit decisions	
0/2	
Not Met (0 %)	

 C46	
Use of generic resources	
2/2	
Met	

 C47	
Transportation to/ from community	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

 C54	
Assistive technology	
0/2	
Not Met (0 %)	

Employment Support Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
1/2	
Not Met (50.0 %)	

 C8	
Family/guardian communication	
2/2	
Met	

 C22	
Explore job interests	
1/2	
Not Met (50.0 %)	

 C23	
Assess skills & training needs	
1/2	
Not Met (50.0 %)	

 C24	
Job goals & support needs plan	
1/2	
Not Met (50.0 %)	

 C25	
Skill development	
2/2	
Met	

 C26	
Benefits analysis	
0/2	
Not Met (0 %)	

 C27	
Job benefit education	
2/2	
Met	

 C28	
Relationships w/businesses	
0/1	
Not Met (0 %)	

 C29	
Support to obtain employment	
2/2	
Met	

 C30	
Work in integrated settings	
0/2	
Not Met (0 %)	

 C31	
Job accommodations	
2/2	
Met	

 C32	
At least minimum wages earned	
2/2	
Met	

 C33	
Employee benefits explained	
1/2	
Not Met (50.0 %)	

 C34	
Support to promote success	
2/2	
Met	

 C35	
Feedback on job performance	
0/2	
Not Met (0 %)	

 C36	
Supports to enhance retention	
2/2	
Met	

 C37	
Interpersonal skills for work	
2/2	
Met	

 C47	
Transportation to/ from community	
2/2	
Met	

 C50	
Involvement/ part of the Workplace culture	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

 C54	
Assistive technology	
0/2	
Not Met (0 %)	

Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
5/6	
Met (83.33 %)	

 C8	
Family/guardian communication	
6/6	
Met	

 C9	
Personal relationships	
3/6	
Not Met (50.0 %)	

 C10	
Social skill development	
6/6	
Met	

 C11	
Get together w/family & friends	
6/6	
Met	

 C12	
Intimacy	
0/6	
Not Met (0 %)	

 C13	
Skills to maximize independence 	
6/6	
Met	

 C14	
Choices in routines & schedules	
6/6	
Met	

 C15	
Personalize living space	
2/2	
Met	

 C16	
Explore interests	
4/6	
Not Met (66.67 %)	

 C17	
Community activities	
4/6	
Not Met (66.67 %)	

 C18	
Purchase personal belongings	
6/6	
Met	

 C19	
Knowledgeable decisions	
6/6	
Met	

 C20	
Emergency back-up plans	
2/2	
Met	

 C46	
Use of generic resources	
6/6	
Met	

 C47	
Transportation to/ from community	
6/6	
Met	

 C48	
Neighborhood connections	
3/6	
Not Met (50.0 %)	

 C49	
Physical setting is consistent 	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
6/6	
Met	

 C52	
Leisure activities and free-time choices /control	
6/6	
Met	

 C53	
Food/ dining choices	
6/6	
Met	

 C54	
Assistive technology	
0/6	
Not Met (0 %)