PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
BETA COMMUNITY PARTNERSHIPS
146 Bank St  POB 695
 Attleboro, MA 02703    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report

February 6, 2018

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
BETA COMMUNITY PARTNERSHIPS	

	

	

	

	
Review Dates	

	
1/3/2018 - 1/9/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
1/24/2018	

	

	

	

	

	

	
Survey Team	

	
Michael Marchese	

Barbara Mazzella (TL)	

Tina Napolitan	

	

	

	

	

	

	
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) 11 audit (s) 	
Full Review	
57 / 77 2 Year License with Mid-Cycle Review 01/24/2018 -  01/24/2020	
	
34 / 51 Certified with Progress Report 01/24/2018 -  01/24/2020	

Residential Services	
3 location(s) 7 audit (s) 	

Full Review	
13 / 22	

Individual Home Supports	
4 location(s) 4 audit (s) 	

Full Review	
19 / 23	

Planning and Quality Management	

	
Full Review	
2 / 6	

	

	

EXECUTIVE SUMMARY :	

			
Beta Community Partnerships, Inc. is a non-profit human service organization that has been providing services since 1973.   The agency provides community based residential and individual home support options to adults with developmental disabilities residing in the greater Attleboro, Taunton and Brockton communities.  The agency currently serves 28 individuals who receive 24-hour residential supports and 25 individuals who receive varying hours of in-home supports based on an individual's level of independence. Beta Community Partnerships, Inc. also provides representative payee services to approximately 225 people.  

The scope of this survey conducted by the Office of Quality Enhancement (OQE) was a full review of all licensing and certification indicators within the agency's Residential and Individual Home Supports services for those receiving at least 15 hours of supports per week.  

Since their last survey, the agency has strengthened its focus on ensuring that individuals maintain good health.  Practices such as compiling a summary log of all historical medical appointments provided a quick reference guide to monitor that individuals have received routine and preventative care as well as recommended follow up appointments.  Staff also ensured that physician recommendations and follow-up, if needed, occurred in a timely manner resulting in individual's receiving continuous health care coordination.  Findings also revealed that prescription medications were administered according to the written order of a practitioner and are properly documented on a Medication Treatment Chart.   Several individuals who participated in the survey commented positively regarding the support they received from staff to lose and maintain a healthier weight. 

The agency recognized the need to improve the safety and accessibility of individuals' homes and conducted an inventory of needed maintenance projects to prioritize those capital improvement needs that were deemed most pressing.  One completed project was seen in one of the homes reviewed during the survey where an individual was supported with a newly renovated, accessible bathroom.  All other residential and individualized home support locations visited met licensing indicators regarding environmental safety. Staff supported individuals to evacuate within required timeframes and conducted fire drills in accordance with safety plans. 

Within Individual Home Supports positive outcomes were seen in the area of assisting to develop social connections and access their communities.  Two individuals who receive individual home supports commented on the support they receive to know their neighbors and participate in community activities on a frequent basis.  One surveyor met with an individual at an establishment in his community and it was evident that all the patrons knew him well and that he had longstanding social connections. The agency is also recognized for supporting individuals to maintain long term relationships as several people who were part of the review continue to maintain close relationships with individuals they met through the Community of Friends program. 

In an effort to capture individuals' personal preferences regarding interests, activities and interaction styles, staff supported individuals to develop personal narratives titled 'Uniquely Me.'  These narratives provided individually tailored information to help all supporters understand a person's unique background, such as where the person grew up, what services and supports should be promoted based on individuals interests and preferences, and how to best interact with them given that many individuals are aging and need additional time to process information. It was identified that information within these documents was not fully utilized to assist people with developing social connections or participating in activities based on their personal interests.   The agency is encouraged to continue with its efforts to strengthen the focus on supporting individuals to explore and expand activities that match individual's interests for cultural, social and recreational opportunities in the community.  Increased attention should also be directed to educating staff to support individuals to explore, define and express their need for intimacy and companionship that are in concert with individual's unique learning styles. 

There were several areas identified in this review that would benefit from further attention that involve the protection of individuals' rights, the provision of training for individuals' regarding potential abuse and neglect and the implementation of strategies to minimize risk. The agency needs to improve its focus on those areas that impact human rights including strengthening its Human Rights Committee to ensure that all investigations are reviewed and agency policies that potentially impact rights are evaluated on an annual basis. Individuals' receiving supports should receive training on DPPC and the agency grievance procedures on an annual basis. Additionally, monitoring and guidance is needed to ensure that staff are knowledgeable and implement strategies in a timely fashion for those individuals who present with risk.  Staff should be supported to review these plans on an ongoing basis as many individual's medical needs are reflective of an aging population.  Another area of focus should also be directed to ensuring that staff are aware of all required components when supporting individuals who have supportive and protective devices such as including provisions for safety checks and receiving required reviews.  

The agency also needs to strengthen its practices in assisting individuals with their finances.  The agency's financial tracking systems need to include documentation regarding the amount of monies taken to use for making purchases. Practices need to be revised to ensure that money management plans include a component regarding the amount of monies that can be independently managed by individuals.  The agency needs to revise its notification regarding charges for services to include a provision regarding the right to appeal these charges as well as ensure that all charges for services are included in its calculations.   

Organizationally, the agency needs to strengthen its system to address timely implementation of action plans when an individual is subject to abuse or neglect and for monitoring these actions to ensure that safeguards are in place to prevent recurrent incidents. 

Across the agency, a focus should be directed towards supporting individuals' to have greater control and independence.  The agency should develop a formal process for all individuals to provide feedback on staff performance on a regular basis and to share this information with staff for training purposes.  Individuals should continue to receive support to assess, identify and utilize assistive technology or modifications to maximize their independence at home. 
 
Organizationally, the agency needs to enhance its system for utilizing information and data to identify any patterns and trends in order to identify and address issues that impact quality of services across the agency. The agency is also encouraged to continue to work with key stakeholders, including individuals supported to solicit input and incorporate findings into strategies to improve services. 

Based on the findings of this report, the agency has earned a Two Year License with a Mid Cycle review for Residential and Individual Home support Services. Licensing scores were 74% of indicators met. The DDS will conduct follow up within 60 days for any licensing indicators rated Not Met. Certification scores were 67% for Residential and Individual Home Support services.  In one year, the agency will submit a Progress Report to the DDS office of Quality Enhancement relative to any certification indicators rated Not Met.	

	

LICENSURE FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
5/8	
3/8	

Residential and Individual Home Supports	
52/69	
17/69	

    Residential Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
57/77	
20/77	
74%	

2 Year License with Mid-Cycle Review	

	

# indicators for 60 Day Follow-up	
	
20	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L4	
Action is taken when an individual is subject to abuse or neglect.	
Eight action plans were reviewed, six of which were not fully implemented within specific time frames or in content. The agency needs to have a system for ensuring that all specific actions are taken, and for monitoring these actions to ensure that strategies are implemented as identified.	

 L48	
The agency has an effective Human Rights Committee.	
Although the agency has a Human Rights Committee, there are a number of areas that the agency needs to strengthen in order to improve its effectiveness. The agency needs to ensure that its Human Rights Committee serves as an effective safeguard for all individuals.	

 L74	
The agency screens prospective employees per requirements.	
The job descriptions for two staff were reviewed. In both instances, hiring requirements were not included to determine if potential job applicants met applicable provider requirements. The agency needs to ensure that job descriptions include qualifications to determine whether potential candidates meet job specifications.	

		

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L1	
Individuals and guardians are trained in how to report alleged abuse/ neglect.	
Eleven individuals were interviewed and documentation reviewed regarding how to report alleged abuse and neglect. Of these, four individuals were not aware of how to report potential abuse and neglect nor was there evidence that training was provided regarding how to report potential abuse and neglect. The agency needs to ensure that all individuals are trained in how to report potential abuse and neglect.	

 L8	
Emergency fact sheets are current and accurate and available on site.	
Four out of the eleven Emergency Fact Sheets did not contain all of the required components. The agency needs to ensure that all Emergency Fact Sheets contain all required components, such as diagnosis, emergency contacts, and how the individual may react to an emergency.	

 L10	
The provider implements interventions to reduce risk for individuals whose behaviors may pose a risk to themselves or others.  	
Five individuals' supports were reviewed regarding the implementation of strategies to reduce risk. In two instances, staff had not been trained regarding the implementation of these types of interventions, and in another instance the development of an intervention to reduce the potential risk had not been actualized. The agency needs to ensure that staff are knowledgeable about strategies to reduce risk and implement interventions as needed. 	

 L39	
Special dietary requirements are followed. 	
The special dietary requirements in place for nine individuals were reviewed. In two instances strategies had not been implemented to assist individuals to follow special dietary requirements. The agency needs to ensure that staff support individuals to follow specialized dietary requirements.	

 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.	
Five out of eleven individuals were not informed of their human rights and how to file a grievance. The agency needs to ensure that individuals are informed and trained regarding human rights, how to file a grievance, or to whom they should talk to if they have a concern.	

 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 six individuals. In five of these instances the agency obtained consent without identifying the purpose or to whom the information would be released. The agency needs to ensure that when informed consent is obtained from individuals or their guardians, information is included which specifies the purpose and to whom the information is to be released.	

 L61	
Supports and health related protections are included in ISP assessments and the continued need is outlined.	
Supportive and health related protections were reviewed for seven individuals. For three of these reviews all required components including frequency and duration of use and procedures for safety checks were not present. Agency needs to ensure that all required information is in place to ensure proper utilization of such supports.	

 L62	
Supports and health related protections are reviewed by the required groups.	
The supportive and health related protections for five of eight individuals were not reviewed by the required groups. The agency needs to ensure that such protections are reviewed by all required groups.	

 L63	
Medication treatment plans are in written format with required components.	
The use of behavior modifying medication was reviewed for seven individuals. In one instance, a plan had not been developed for the administration of an anti-psychotic medication. For two people, the medication treatment plans did not contain all required components including data regarding the observation of target behaviors, so the effectiveness of the treatment plan could be evaluated, as well as a listing of all prescribed medications that modify behavior. The agency needs to ensure that medication treatment plans are developed when necessary and include all required components.	

 L64	
Medication treatment plans are reviewed by the required groups.	
Six medication treatment plans did not receive reviews by the required groups. The agency needs to ensure that medication treatment plans are reviewed by the required groups.	

 L69	
Individual expenditures are documented and tracked.	
There were nine instances where proper tracking and accounting of individuals' funds did not occur. The agency needs to ensure timely completion of all required documentation regarding expenditures and tracking of funds.  Additionally, the agency needs to assist individuals with expending funds in a timely manner to prevent an accumulation of resources.	

 L70	
Charges for care are calculated appropriately.	
The agency does not collect charges for care, rather individuals remunerate charges for care by paying occupancy related expenses directly to vendors and landlords.  To ensure that occupancy related expenses a person has incurred each month does not exceed 75% of the person's reoccurring income per DDS regulation, the agency calculates monthly and provides reimbursement on a quarterly basis if necessary.  The occupancy related expenses encompassed in these calculations, however do not include expenses incurred by the person that are typically considered the responsibility of an agency when 24 hour services are provided, such as furnishings for common areas, kitchen equipment and televisions.  
Additionally, the notification Financial Consent Authorization Form regarding how individuals will be assisted to pay for occupancy related expenses such as rent, electricity, food, and heat does not identify that individuals will be purchasing furnishings and equipment that will be used by the group living in that location.  In some instances, consent was sought for a large purchase but this was not consistently in place.  The agency needs to include all occupancy related expenses in its monthly calculations to ensure that expenses paid do not exceed 75% of the person s reoccurring income.  As a proactive measure, if the agency continues using this process for individual s to contribute toward occupancy related expenses it should develop a budget that includes projected expenses and available funds to adequately plan for upcoming needs and ensure individuals are not exceeding the 75% limit.  

	
 L71	
Individuals are notified of their appeal rights for their charges for care.	
A review of the agency's practices regarding monthly charges for rent, food, electricity, heat, and basic telephone revealed the individuals were not provided with information regarding their right to appeal. The agency needs to ensure that individuals are notified of their appeal right for charges for these services.

	
 L84	
Staff are trained in the correct utilization of health related protections per regulation.	
Eight individuals required the use of supportive and health related protections. Training of staff regarding the proper use of this equipment was not present for two individuals.  The agency needs to ensure that all staff are trained in correct utilization of all supportive and health related protections.	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Although the agency received the required 30-day notice from the DDS Area Office regarding the ISP, the agency did not submit the required assessments within the 15 day time frame for three individuals. The agency needs to ensure that assessments are submitted to the DDS Area Office at least 15 days prior to the scheduled 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.	
Although the agency received the required 30-day notice from the DDS Area Office regarding the ISP, the agency did not submit the required Support Strategies within the 15 day time frame for 4 individuals. The agency needs to ensure that Support Strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting.	

 L88	
Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	
In three out of eleven reviews documentation did not demonstrate agreed upon ISP goals were being implemented as designed. The agency needs to ensure that service and supports are provided as agreed upon in the ISP.	

	

	

CERTIFICATION FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

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

Residential and Individual Home Supports	
32/45	
13/45	

Individual Home Supports	
19/23	
4/23	

Residential Services	
13/22	
9/22	

TOTAL	
34/51	
17/51	
67%	

Certified with Progress Report	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 C2	
The provider analyzes information gathered from all sources and identifies patterns and trends.	
The agency quality management system does not identify patterns and trends that would be beneficial in developing appropriate actions and ongoing strategies to enhance service delivery across all service settings. The agency needs to utilize data/information gathered to systemically evaluate the quality of services and identify trends and patterns which could assist in identifying areas in need of additional oversight and monitoring.	

 C3	
The provider actively solicits and utilizes input from the individuals and families regarding satisfaction with services.	
Although the agency recently conducted a satisfaction survey which solicited input from guardians and staff, input was not solicited from individuals being supported by the agency in order to improve service delivery. The agency needs to ensure feedback is solicited from all stakeholders to address areas of concern and enhance service delivery systems.	

 C4	
The provider receives and utilizes input received from DDS and other stakeholders to inform service improvement efforts.	
Although the agency has established mechanisms to receive input from DDS to inform service improvement efforts, additional efforts to strengthen systems to ensure that feedback is incorporated in service improvement efforts in a timely manner is needed. The agency needs to ensure that its system to monitor program quality is adjusted in response to feedback.	

 C5	
The provider has a process to measure progress towards achieving service improvement goals.	
The agency has recently developed a three year work plan with accompanying goals, an analysis of its progress towards achieving those goals has not been completed as of yet. Additionally, information regarding progress made on previous improvement goals was not available for review.  The agency needs to ensure that it measures progress on an ongoing basis and makes mid-course corrections to continually enhance services.	

	

	

	
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 and on an ongoing basis on the performance of staff that support them.	
Opportunities for individuals to provide feedback at the time of hire and on an ongoing basis on the performance of staff were not provided to three individuals. The agency needs to ensure that a process is developed to solicit feedback at the time of hire and on an ongoing basis .	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For two out of four individuals there was no evidence to document that the agency has a curriculum or that education has been provided to staff supporting individuals in the area of sexuality and intimacy. In addition, there were no formal or informal assessments made of each individuals' needs for intimacy and companionship in concert with the individuals' unique learning styles. The agency needs to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship.	

 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Exploration of individuals' interests regarding cultural, social, recreational and spiritual activities was not identified for two individuals on a consistent and ongoing basis. The agency needs to support individuals to explore, discover and encourage participation of integrated cultural, social, recreational and spiritual activities on a regular basis.

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for four individuals were reviewed, and in two instances assessments of assistive technology needs had not yet gone beyond the initial stages. The agency needs to assess each individuals' needs and determine how assistive technology modifications could help people to maximize their independence.	

	

	
Residential 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 and on an ongoing basis on the performance of staff that support them.	
Opportunities for individuals to provide feedback at the time of hire and on an ongoing basis on the performance of staff were not provided to six individuals. The agency needs to ensure that a process is developed to solicit feedback at the time of hire and on an ongoing basis .	

 C9	
Staff (Home Providers) act as bridge builders and provide opportunities to develop, and/or increase personal relationships and social contacts.	
Opportunities to develop and/or increase personal relationships were reviewed for seven individuals. Of these, two individuals could benefit from additional opportunities to develop or increase social contacts and personal relationships. The agency needs to develop and implement strategies to increase opportunities for individuals to develop personal relationships.  	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For seven individuals there was no evidence to document that the agency has a curriculum or that education has been provided to staff supporting individuals in the area of sexuality and intimacy. In addition, there were no formal or informal assessments made of the individuals' need for intimacy and companionship in concert with individuals' unique learning styles. The agency needs to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship.	

 C13	
Staff (Home Providers) provide support for individuals to develop skills to enable them to maximize independence and participation in typical activities and routines. 	
Three individuals were not provided opportunities to develop skills which could enable them to maximize their independence and participation in typical activities and routines. The agency needs to ensure that staff support individuals to develop skills that could maximize their independence which afford the individuals greater opportunities to participate in activities and routines.	

 C15	
Staff (Home Providers) support individuals to personalize and decorate their rooms/homes and personalize common areas according to their tastes and preferences.	
The common area of one location did not include decorations that reflected the interests or hobbies of the individuals residing in the home. The agency needs to ensure that common living areas include decorations that reflect individuals' tastes and preferences. 	

 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Exploration of individuals' interests regarding cultural, social, recreational and spiritual activities was not identified for four individuals on a consistent and ongoing basis. The agency needs to support individuals to explore, discover and encourage participation of integrated cultural, social, recreational and spiritual activities on a regular basis.	

 C17	
Community activities are based on the individual's preferences and interests.	
Seven individuals were reviewed regarding their access to community activities that were based on their individual preferences and interests. Two of the seven individuals were not provided with frequent opportunities to participate in community activities that aligned with their preferences. Additionally, there was limited evidence of staff knowledge regarding local events and activities. The agency needs to ensure that staff are knowledgeable about local events and activities that reflect individuals' interests and afford opportunities for individuals to participate in these events.	

 C48	
Individuals are a part of the neighborhood.	
Seven individuals were reviewed regarding their connections with neighbors. In all instances there was limited evidence of staff support to provide opportunities which encourage interactions with neighbors and participation in neighborhood activities. The agency needs to ensure that opportunities are provided which encourage and support neighborhood connections.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for seven individuals were reviewed, and in all instances assessments of assistive technology needs had not yet gone beyond the initial stages. The agency needs to assess each individuals' needs and determine how assistive technology modifications could help people to maximize their independence.	

	

	

		

					
	MASTER SCORE SHEET LICENSURE	

					
	Organizational: BETA COMMUNITY PARTNERSHIPS	

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

O	
 L2	
Abuse/neglect reporting	
6/7	
Met(85.71 % )	

 L3	
Immediate Action	
10/10	
Met	

 L4	
Action taken	
2/8	
Not Met(25.00 % )	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L74	
Screen employees	
0/2	
Not Met(0 % )	

 L75	
Qualified staff	
1/1	
Met	

 L76	
Track trainings	
17/20	
Met(85.00 % )	

 L83	
HR training	
19/20	
Met(95.00 % )	

						
	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	
4/7	
3/4	

	
	
7/11	
Not Met
(63.64 %)	

 L5	
Safety Plan	
L	
3/3	
3/4	

	
	
6/7	
Met
(85.71 %)	

O	
 L6	
Evacuation	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L7	
Fire Drills	
L	
3/3	

	

3/3	
Met	

 L8	
Emergency Fact Sheets	
I	
4/7	
3/4	

	
	
7/11	
Not Met
(63.64 %)	

 L9	
Safe use of equipment	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L10	
Reduce risk interventions	
I	
1/3	
1/2	

	
	
2/5	
Not Met
(40.0 %)	

O	
 L11	
Required inspections	
L	
3/3	
2/2	

	
	
5/5	
Met	

O	
 L12	
Smoke detectors	
L	
3/3	
3/3	

	
	
6/6	
Met	

O	
 L13	
Clean location	
L	
3/3	
1/1	

	
	
4/4	
Met	

 L14	
Site in good repair	
L	
3/3	
1/1	

	
	
4/4	
Met	

 L15	
Hot water	
L	
2/3	
1/1	

	
	
3/4	
Met	

 L16	
Accessibility	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L17	
Egress at grade 	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L18	
Above grade egress	
L	
1/1	
1/1	

	
	
2/2	
Met	

 L19	
Bedroom location	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L20	
Exit doors	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L21	
Safe electrical equipment	
L	
3/3	
1/1	

	
	
4/4	
Met	

 L22	
Clean appliances	
L	
3/3	
1/1	

	
	
4/4	
Met	

 L23	
Egress door locks	
L	
2/2	

	

2/2	
Met	

 L24	
Locked door access	
L	
3/3	

	

3/3	
Met	

 L25	
Dangerous substances	
L	
3/3	
1/1	

	
	
4/4	
Met	

 L26	
Walkway safety	
L	
2/3	
1/1	

	
	
3/4	
Met	

 L28	
Flammables	
L	
2/2	
1/1	

	
	
3/3	
Met	

 L29	
Rubbish/combustibles	
L	
3/3	
1/1	

	
	
4/4	
Met	

 L30	
Protective railings	
L	
2/2	
2/2	

	
	
4/4	
Met	

 L31	
Communication method	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L32	
Verbal & written	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L33	
Physical exam	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L34	
Dental exam	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L35	
Preventive screenings	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L36	
Recommended tests	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L37	
Prompt treatment	
I	
7/7	
4/4	

	
	
11/11	
Met	

O	
 L38	
Physician's orders	
I	
7/7	
1/2	

	
	
8/9	
Met
(88.89 %)	

 L39	
Dietary requirements	
I	
4/6	
3/3	

	
	
7/9	
Not Met
(77.78 %)	

 L40	
Nutritional food	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L41	
Healthy diet	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L42	
Physical activity	
L	
2/3	
4/4	

	
	
6/7	
Met
(85.71 %)	

 L43	
Health Care Record	
I	
6/7	
3/4	

	
	
9/11	
Met
(81.82 %)	

 L44	
MAP registration	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L45	
Medication storage	
L	
3/3	
2/2	

	
	
5/5	
Met	

O	
 L46	
Med. Administration	
I	
7/7	
2/2	

	
	
9/9	
Met	

 L47	
Self medication	
I	
7/7	
2/4	

	
	
9/11	
Met
(81.82 %)	

 L49	
Informed of human rights	
I	
4/7	
2/4	

	
	
6/11	
Not Met
(54.55 %)	

 L50	
Respectful Comm.	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L51	
Possessions	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L52	
Phone calls	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L53	
Visitation	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L54	
Privacy	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L55	
Informed consent	
I	
0/3	
1/3	

	
	
1/6	
Not Met
(16.67 %)	

 L61	
Health protection in ISP	
I	
4/6	
0/1	

	
	
4/7	
Not Met
(57.14 %)	

 L62	
Health protection review	
I	
2/6	
1/2	

	
	
3/8	
Not Met
(37.50 %)	

 L63	
Med. treatment plan form	
I	
4/6	
0/1	

	
	
4/7	
Not Met
(57.14 %)	

 L64	
Med. treatment plan rev.	
I	
0/5	
0/1	

	
	
0/6	
Not Met
(0 %)	

 L67	
Money mgmt. plan	
I	
6/7	
3/4	

	
	
9/11	
Met
(81.82 %)	

 L68	
Funds expenditure	
I	
6/7	
4/4	

	
	
10/11	
Met
(90.91 %)	

 L69	
Expenditure tracking	
I	
0/7	
2/4	

	
	
2/11	
Not Met
(18.18 %)	

 L70	
Charges for care calc.	
I	
4/7	
1/1	

	
	
5/8	
Not Met
(62.50 %)	

 L71	
Charges for care appeal	
I	
0/7	

	

0/7	
Not Met
(0 %)	

 L77	
Unique needs training	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L80	
Symptoms of illness	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L81	
Medical emergency	
L	
3/3	
4/4	

	
	
7/7	
Met	

O	
 L82	
Medication admin.	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L84	
Health protect. Training	
I	
6/6	
0/2	

	
	
6/8	
Not Met
(75.00 %)	

 L85	
Supervision 	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L86	
Required assessments	
I	
5/7	
1/2	

	
	
6/9	
Not Met
(66.67 %)	

 L87	
Support strategies	
I	
4/7	
2/3	

	
	
6/10	
Not Met
(60.0 %)	

 L88	
Strategies implemented	
I	
4/7	
4/4	

	
	
8/11	
Not Met
(72.73 %)	

 L90	
Personal space/ bedroom privacy	
I	
7/7	
3/4	

	
	
10/11	
Met
(90.91 %)	

#Std. Met/# 69 Indicator	

	

	

52/69	

	
Total Score	

	

	

57/77	

	

	

	

	
74.03%	

		
						
	MASTER SCORE SHEET CERTIFICATION	

						
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
Met	

 C2	
Data analysis	
0/1	
Not Met (0 %)	

 C3	
Service satisfaction	
0/1	
Not Met (0 %)	

 C4	
Utilizes input from stakeholders	
0/1	
Not Met (0 %)	

 C5	
Measure progress	
0/1	
Not Met (0 %)	

 C6	
Future directions planning	
1/1	
Met	

	

	

						
Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
1/4	
Not Met (25.00 %)	

 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	
3/3	
Met	

 C16	
Explore interests	
2/4	
Not Met (50.0 %)	

 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	

 C21	
Coordinate outreach	
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 %)	

Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
1/7	
Not Met (14.29 %)	

 C8	
Family/guardian communication	
7/7	
Met	

 C9	
Personal relationships	
5/7	
Not Met (71.43 %)	

 C10	
Social skill development	
7/7	
Met	

 C11	
Get together w/family & friends	
7/7	
Met	

 C12	
Intimacy	
0/7	
Not Met (0 %)	

 C13	
Skills to maximize independence 	
4/7	
Not Met (57.14 %)	

 C14	
Choices in routines & schedules	
7/7	
Met	

 C15	
Personalize living space	
2/3	
Not Met (66.67 %)	

 C16	
Explore interests	
3/7	
Not Met (42.86 %)	

 C17	
Community activities	
5/7	
Not Met (71.43 %)	

 C18	
Purchase personal belongings	
7/7	
Met	

 C19	
Knowledgeable decisions	
7/7	
Met	

 C20	
Emergency back-up plans	
3/3	
Met	

 C46	
Use of generic resources	
7/7	
Met	

 C47	
Transportation to/ from community	
7/7	
Met	

 C48	
Neighborhood connections	
1/7	
Not Met (14.29 %)	

 C49	
Physical setting is consistent 	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
7/7	
Met	

 C52	
Leisure activities and free-time choices /control	
7/7	
Met	

 C53	
Food/ dining choices	
7/7	
Met	

 C54	
Assistive technology	
0/7	
Not Met (0 %)