Provider	
BEHAVIORAL ASSOCIATES OF MASS	
	
Provider Address	
20 Townsend Road, Unit 6 , Attleboro	

Survey Team	
Mazzella, Barbara	
	
Date(s) of Review	
12-DEC-18 to 13-DEC-18	

	

Follow-up Scope and results :	

Service Grouping	
Licensure level and duration	
# Critical Indicators std. met/ std. rated at follow-up 	
  # Indicators std. met/ std. rated at follow-up	
Sanction status prior to Follow-up	
Combined Results post- Follow-up; for Deferred, License level	
Sanction status post Follow-up	

Residential and Individual Home Supports	
2 Year License	
	
7/10	
x	
Eligible for new business
(Two Year License)	
2 Year License	
x	
Eligible for New Business
(80% or more std. met; no critical std. not met)	

1 Locations 
4 Audits 	

	
o	
Ineligible for new business. (Deferred Status: Two year mid-cycle review License)	
	
o	
Ineligible for New Business
(<=80% std met and/or more critical std. not met)	

	

		
Summary of Ratings	

		
Residential and Individual Home Supports Areas Needing Improvement on Standard not met - Identified by DDS	

Indicator #	
L15	

Indicator	
Hot water	

Area Need Improvement	
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. 	

Status at follow-up	
The hot water was tested at one site. The hot water registered 109.9 at the bathroom sink and 112 in the shower. The agency will continue to test the hot water on a regular basis to ensure that temperatures remain within allowable limits. 	

#met /# rated at followup	
1/1	

Rating	
Met	

Indicator #	
L24	

Indicator	
Locked door access	

Area Need Improvement	
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.	

Status at follow-up	
One home was visited.  All locks were in working condition and staff carried keys that were accurately labeled and worked properly to unlock all bedroom doors. 	

#met /# rated at followup	
1/1	

Rating	
Met	

Indicator #	
L43	

Indicator	
Health Care Record	

Area Need Improvement	
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. 	

Status at follow-up	
Health Care Records were reviewed for three individuals. All HCR contained all required components. 	

#met /# rated at followup	
3/3	

Rating	
Met	

Indicator #	
L45	

Indicator	
Medication storage	

Area Need Improvement	
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. 	

Status at follow-up	
Medication storage was examined at home.  The medication closet contained only medications or appropriate materials in accordance with medication administration policies. 	

#met /# rated at followup	
1/1	

Rating	
Met	

Indicator #	
L49	

Indicator	
Informed of human rights	

Area Need Improvement	
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.  	

Status at follow-up	
The agency developed and distributed a letter to individuals and guardians regarding their right not to be arbitrarily evicted. The agency also developed a new grievance policy. Although the policy was submitted to guardians, training was not provided to all individuals.   	

#met /# rated at followup	
0/3	

Rating	
Not Met	

Indicator #	
L55	

Indicator	
Informed consent	

Area Need Improvement	
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. 	

Status at follow-up	
The agency has developed a new form to seek informed consent regarding the release of images and media.  Informed consent to utilize an individual's photo on an agency banner and on the Halcyon website was obtained. The purpose and picture was provided to the guardian. 	

#met /# rated at followup	
1/1	

Rating	
Met	

Indicator #	
L56	

Indicator	
Restrictive practices	

Area Need Improvement	
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. 	

Status at follow-up	
Restrictive practices were reviewed for two individuals. Written rationales were provided which included all required components as well as required reviews. The agency also discontinued a restrictive practice for another individual as they developed and implemented a less restrictive option.   	

#met /# rated at followup	
2/2	

Rating	
Met	

Indicator #	
L64	

Indicator	
Med. treatment plan rev.	

Area Need Improvement	
Medication treatment plans were reviewed for five individuals. All of the plans were not reviewed by the ISP team as required. 	

Status at follow-up	
Medication Treatment Plans were reviewed for two individuals. The MTP's were reviewed at the ISP as required. 	

#met /# rated at followup	
2/2	

Rating	
Met	

Indicator #	
L87	

Indicator	
Support strategies	

Area Need Improvement	
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. 	

Status at follow-up	
Support strategies were reviewed for two individuals. In both instances DDS did not provide a 30 day notice in order for the agency to submit support strategies per required timeframes. 	

#met /# rated at followup	

Rating	
Not Rated	

Administrative Areas Needing Improvement on Standard not met - Identified by DDS	

Indicator #	
L48	

Indicator	
HRC	

Area Need Improvement	
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.	

Status at follow-up	
The agency's Human Rights Committee met once during the follow up period. Although the minutes reflect discussion of investigations, restraints and incidents, the composition of the committee does not meet requirements. The HRC does not have legal representation or an individual that receives services from the agency. The agency needs to continue to explore strategies to ensure that the HRC composition meets DDS requirements. 	

#met /# rated at followup	
0/1	

Rating	
Not Met	

Indicator #	
L65	

Indicator	
Restraint report submit	

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

Status at follow-up	
Two restraint reports were filed between August 31, 2018 and December 12, 2018. In both instances the agency did not meet required timeframes for creation of the report and finalization by the agency manager. The agency is exploring strategies to increase the number of staff who are able to utilize HCSIS to enter restraint information. 	

#met /# rated at followup	
0/1	

Rating	
Not Met