ࡱ > k m j bjbj -n @ ( ( ( 8 ` $ 4 ( ( $ " \ [ [ [ [ [ [ [ p:c4f [ { 0 [ # { # [ # [ [ [ # : Provider: BERKSHIRE COUNTY ARC INC Provider Address: 395 South St. POB 2 , Pittsfield Name of PersonCompleting Form: Christopher M. Andrews Date(s) of Review: 01-AUG-18 to 26-SEP-18 Follow-up Scope and results : Service Grouping Licensure level and duration # Indicators std. met/ std. rated Residential and Individual Home Supports 2 Year License 1/2 Employment and Day Supports 2 Year License 1/3 Summary of Ratings Administrative Areas Needing Improvement on Standard not met - Identified by DDS Indicator # L65 Indicator Restraint report submit Area Need Improvement The agency needs to ensure restraint reports are submitted in HCSIS within three days of the occurrence and the restraint manager reviews the report within five days. Process Utilized to correct and review indicator Reinforced our existing systems of email notification to restraint managers notifying them that a restraint has been filed for prompt review. Restraint managers check HCSIS twice per week on alternating days to ensure prompt review of restraints. Status at follow-up To date there have been four residential restraints; all four have met both required timelines 100%. Rating Met Employment and Day Supports Areas Needing Improvement on Standard not met - Identified by Provider Indicator # L86 Indicator Required assessments Issue Identified Of the fifty assessments requested by DDS, twenty-five met the criteria for submission of fifteen days prior to the ISP meeting date. Actions Planned/Occurred To ensure required assessments are submitted on time, the agency plans to increase management monitoring of HCSIS. In addition, the agency plans to reestablish a tracking system for all ISP documents that will be monitored by the Coordinator/Director and reviewed during supervisory meetings. Process Utilized to correct and review indicator Supervisory meetings held with employment staff to review process and timeframes needed to complete assessments. Supervisory staff increased monitoring of HCSIS ISP alerts/due dates. Internal ISP tracking system reestablished to monitor timeliness of submissions. Status at follow-up Submitting assessments on time improved by 15%. However, more improvements needed to reach and maintain a minimum of 80%NOT MET (65%) Rating Not Met Indicator # L87 Indicator Support strategies Issue Identified Thirty-four support strategies were submitted for thirty individuals in the sample. Sixteen of the support strategies were submitted on time. Actions Planned/Occurred To ensure support strategies are submitted on time, the agency plans to increase management monitoring of HCSIS. In addition, the agency plans to reestablish a tracking system for all ISP documents that will be monitored by the Coordinator/Director and reviewed during supervisory meetings. Process Utilized to correct and review indicator Supervisory meetings held with employment staff to review process and timeframes needed to complete support strategies. Supervisory staff increased monitoring of HCSIS ISP alerts/due dates. Internal ISP tracking system reestablished to monitor timeliness of submissions. Status at follow-up While process and tracking systems have been reestablished, submission rate stayed the same (50%) over the past month. This is being addressed with the staff.NOT MET (50%) Rating Not Met Residential and Individual Home Supports Areas Needing Improvement on Standard not met - Identified by DDS Indicator # L63 Indicator Med. treatment plan form Area Need Improvement A review of thirteen medication treatments found that twelve of the plans did not include all the required components. The plans must include a description of the behavior to be modified, data, procedures to minimize risk and clinical indicators for terminating the medication. Process Utilized to correct and review indicator Quality Facilitator met with Clinical department last month to go over all requirements for the plan; our existing plan will be modified to ensure compliance with all requirements. Status at follow-up Plan format and content is being finalized; plan to be submitted to OQE for final review. Once approved, plan will be utilized first with medication plans identified as not met t in survey and then on all future plans going forward starting this month. Rating Not Met DEPARTMENT OF DEVELOPMENTAL SERVICES LICENSURE AND CERTIFICATION PROVIDER FOLLOW-UP REPORT PAGE 1 of NUMPAGES 4 * . ? 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