Provider:  Better Community Living, Inc.							Provider Address:  5 Ventura Drive, Dartmouth, MA

Survey Team:  Edward Sutka (TL), Barbara Mazzella, and Jennifer Petersen		Dates of Review:  April 4 – 9, 2013

Mid-Cycle Scope and Results: 	

Service Grouping	
Licensure Level and Duration	# Indicators Std. Met/Std. Rated at Mid-Cycle	
Sanction Status Prior to Mid-Cycle	Combined Results Post- Mid-Cycle	
Sanction Status Post Mid-Cycle	
Residential and Individual Home Supports	Deferred Licensure	12/13	x	Eligible for New Business	Two-Year License with Mid-Cycle Review
80/81  (98.77%)	x	Eligible for New Business
(80% or more std. met; no critical std. not met.)
	
  9 Locations 
11 Audits 	 

 

 
 
 	o	Ineligible for New Business 	 

 
 	o	Ineligible for New Business
(<=80% std met and/or more critical std. not met.)

 

Summary of Ratings
 
Organizational Area Needing Improvement on Standard Not Met:	
Indicator #	
L48	

Indicator	
HRC	

Area Need Improvement	
To further strengthen the effectiveness of the HRC, the agency needs to ensure that: 
-  Complaints of mistreatment and the results of investigations are provided to and reviewed by the HRC on a more regular basis to promote proactive feedback.  (The HRC was not notified or provided with DPPC investigations for one year.);
-  Significant incident reports must be provided and reviewed by the HRC in a timely manner;
-  Meeting minutes are expanded to more consistently identify the roles of voting members who are present and absent, and to capture key discussion points and any recommendations made by the HRC;
-  Site visits should occur as described in the HRC bylaws;
-  Policies and procedures that could potentially impact individuals' rights should be reviewed by the HRC on an annual or as needed basis.	

Status at Mid-Cycle	
The agency was successful in bringing its HRC into compliance with the regulations.  Meeting minutes showed that HRC members were actively discussing and questioning a wide range of issues that fell within its purview (100%).	

# Met /# Rated at Mid-Cycle	
1/1	

Rating	
MET	

 	

Residential and Individual Home Supports Areas Needing Improvement on Standards Not Met:	
Indicator #	
L8	

Indicator	
Emergency Fact Sheets	

Area Need Improvement	
The Emergency Fact Sheets need to accurately include all of the required information (e.g., medications prescribed but not dosages, medical diagnoses). 8 out of 12 audits met the indicator (67%).	

Status at Mid-Cycle	
A new computer generated form had been developed to ensure the consistency of this information.  In all instances except one this information was found to be accurate and complete (90.91%).  	

# Met /# Rated at Mid-Cycle	
10/11	

Rating	
MET	

 	

Residential and Individual Home Supports Areas Needing Improvement on Standards Not Met, cont.	
Indicator #	
L38	

Indicator	
Physicians’ orders.	

Area Need Improvement	
When individuals receiving supports have unique medical needs that require that written protocols be in place (e.g., diabetes), the agency needs to ensure these are developed.  In addition, the agency needs to ensure that staff are trained in following treatment protocols and knowledgeable of individuals’ needs so that these protocols are consistently implemented (e.g., monitoring sugar levels, notifying doctor when level are outside of specified parameters.  3 out of 7 audits met the standard (43%).	

Status at Mid-cycle	
Detailed protocols had been developed where these were needed.  Some of the training materials for staff, such as photographs of various food textures, were particularly helpful (100%).	

# Met /# Rated at Mid-Cycle	
8/8	

Rating	
MET	

	

	
Indicator #	
L46	

Indicator	
Medication administration.	

Area Need Improvement	
The agency needs to ensure all prescription medications are properly administered, recorded, and tracked (Medication Administration Record) to document medications are administered as prescribed. In addition, Medication Administration Procedures (MAP) need to be followed where applicable (e.g., Leave of Absence Procedure, licensing home with DPH if individuals cannot self-medicate under HIS). 5 out of 9 audits met the standard (55%).	

Status at Mid-Cycle	
The items cited in the original survey had been successfully addressed through a number of means, including the use of a new pharmacy, a new computer generated system, and additional monitoring for accuracy (100%).	

# Met /# Rated at Mid-Cycle	
9/9	

Rating	
MET	

 	

Residential and Individual Home Supports Areas Needing Improvement on Standards Not Met, cont.	
Indicator #	
L47	

Indicator	
Self-medication.	

Area Need Improvement	
When individuals are supported to become self-medicating, the agency needs to have a clear assess-ment documenting their skills in this area and a training plan needs to be in place to address those skill areas in which the individual does not meet the criteria to be independent in self-medication.  5 out of 7 audits met the standard (71%).	

Status at Mid-Cycle	
For four people, a self-medication assessment tool was used in a way that was appropriate to determine if people could already self-medicate, but was not appropriate to determine if they would have the potential to learn these skills.  For other people, greater success had been achieved in this area through the provision of additional details on the self-medication assessment form or through additional means to assess people's skills in this area (63.64%).	

# Met /# Rated at Mid-Cycle	
7/11	

Rating	
NOT MET	

	

	
 Indicator #	
L55	

Indicator	
Informed consent.	

Area Need Improvement	
The agency needs to ensure that when seeking photo consent from individuals; the consent is specific to the event or information for which the consent is being sought which includes the right to withdraw consent at any time.  2 out of 5 audits met the standard (40%).	

Status at Mid-Cycle	
No instances were identified where informed consent had been used inappropriately (100%).	

# Met /# Rated at Mid-Cycle	
11/11	

Rating	
MET	

 	

Residential and Individual Home Supports Areas Needing Improvement on Standards Not Met, cont.	
Indicator #	
L60	

Indicator	
Data maintenance	

Area Need Improvement	
The agency needs to ensure that data is consistently maintained and accurate to determine the plan’s efficacy (e.g., collecting data on target behaviors).  1 out of 5 audits met the standard (20%).	

Status at Mid-Cycle	
Appropriate data was found to be consistently in place where this was required (100%).	

# Met /# Rated at Mid-Cycle	
8/8	

Rating	
MET	

 	

 Indicator #	
L61	

Indicator	
Health protection in ISP.	

Area Need Improvement	
Two individuals in the sample required support and health-related protections.  In one instance, the use of a shower chair in which a lap belt was needed was not included on the form; while required health-related documentation was not in place for another individual.  The agency needs to ensure that the need for supports and health related protections are clearly outlined.  2 out of 3 audits met the standard (67%).	

Status at Mid-Cycle	
Documentation in regard to the use of these supports was consistently detailed and complete (100%).	

# Met /# Rated at Mid-Cycle	
5/5	

Rating	
MET	

 	

Indicator #	
L62	

Indicator	
Health protection review.	

Area Need Improvement	
Support and health-related protections need to have the required reviews (e.g., guardian signature, HRC review, supervising clinician.  2 out of 3 audits met the standard (67%).	

Status at Mid-Cycle	
Required reviews were in place, and ISP modifications had been done to include these supports where this was needed (100%).	

# Met /# Rated at Mid-Cycle	
5/5	

Rating	
MET	

 	

 

Residential and Individual Home Supports Areas Needing Improvement on Standards Not Met, cont.	
Indicator #	
L67	

Indicator	
Money Management Plan	

Area Need Improvement	
When the agency had shared and delegated money management responsibility, agreement for the written plan need to be obtained from the guardian or representative payee.  6 out of 8 audits met the standard (75%).	

Status at Mid-Cycle	
Money Management Plans generally met requirements, such as securing agreement from guardians, although some aspects of these plans could be further refined.  For instance, more detail could be provided in regard to how much money people can independently manage, and teaching plans for some people could benefit from additional detail.  As well, staff could be more knowledgeable in regard to appropriate safeguards when people's money is restricted for behavioral reasons rather than due to lack of skills (100%).	

# Met /# Rated at Mid-Cycle	
9/9	

Rating	
MET	

	

	
Indicator #	
L69	

Indicator	
Expenditure tracking.	

Area Need Improvement	
The agency’s system for monitoring that expenditures are properly tracked and documented needs to be consistently implemented.  The agency generated computer tracking sheet needs to accurately reflect cash carried to the next month, consistently identify the correct amount of cash on hand, and be regularly reviewed for accuracy.  5 out of 8 audits met the standard (62%).	

Status at Mid-Cycle	
Systems to document and track individuals' expenditures were generally working well, and expendi-tures were consistently audited for accuracy (100%).	

# Met /# Rated at Mid-Cycle	
9/9	

Rating	
MET	

 	

 

Residential and Individual Home Supports Areas Needing Improvement on Standards Not Met, cont.	
Indicator #	
L84	

Indicator	
Health protection training.	

Area Need Improvement	
Staff need to be trained to safely and effectively implement health-related protections per regulation.  Documentation of such training should be maintained.  1 out of 3 audits met the standard (33%).	

Status at Mid-Cycle	
Staff training in relation to the use of these supports was found to be consistently in place (100%).	

# Met /# Rated at Mid-Cycle	
5/5	

Rating	
MET	

	

	
Indicator #	
L85	

Indicator	
Supervision 	

Area Need Improvement	
Although there were mechanisms to provide supervision, effective supervision was not provided on a consistent basis.  For example, minimal supervision was provided for an extended period of time (e.g., approximately nine months) in one home.  Evidence was lacking of identification, analysis or remediation of issues present in supports provided to individuals (e.g., training for new managers, nursing oversight, implementing financial safeguards by training staff).  5 out of 8 audits met the standard (62%).	

Status at Mid-Cycle	
The agency had made a number of key changes in its management structure, including the addition of a Chief Operating Officer, and supervision and staff training were found to be significantly improved since the original survey (100%).	

# Met /# Rated at Mid-Cycle	
9/9	

Rating	
MET