PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
Bridgewell Inc.
10 Dearborn Rd
 Peabody, MA 01960    	

	

	

	

	

	

	

	

December 12, 2016	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
Bridgewell Inc.	

	

	

	

	
Review Dates	

	
10/13/2016 - 10/19/2016	

	

	

	

	
Service Enhancement 
Meeting Date	

	
11/3/2016	

	

	

	

	

	

	
Survey Team	

	
Anne Carey	

Jennifer Conley-Sevier	

John Downing	

Sarah Flibotte	

Patty McCarthy	

Mark Boghoian	

Raymond Edi-Osagie	

Steve Goldberg	

John Hazelton (TL)	

	

	

	

	

	

	
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	
23 location(s) 23 audit (s) 	
Targeted Review	
DDS 18 / 21
Provider 68 / 68

86 / 89 2 Year License 11/03/2016-  11/03/2018	
	
DDS 39 / 39
Provider 12 / 12

51 / 51 Certified 11/03/2016 -  11/03/2018	

Residential Services	
18 location(s) 18 audit (s) 	

DDS Targeted Review	
22 / 22	

Respite Services	
1 location(s) 1 audit (s) 	

No Review	
No Review	

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

DDS Targeted Review	
23 / 23	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 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	
3 location(s) 7 audit (s) 	
Targeted Review	
DDS 15 / 17
Provider 50 / 50

65 / 67 2 Year License 11/03/2016-  11/03/2018	
	
DDS 19 / 21
Provider 21 / 21

40 / 42 Certified 11/03/2016 -  11/03/2018	

Community Based Day Services	
1 location(s) 3 audit (s) 	

DDS Targeted Review	
12 / 14	

Employment Support Services	
2 location(s) 4 audit (s) 	

DDS Targeted Review	
22 / 22	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

Bridgewell, Inc. is a large non-profit human service organization providing a wide range of services for people with developmental disabilities. The agency serves individuals throughout the Northeast, Merrimack Valley and Greater Lowell areas of the Massachusetts Department of Developmental Services (DDS).  Supports include, but are not limited to, 24-hour residential supports, Individual Home Supports (IHS), facility based respite, as well as Employment, and Community Based Day Supports (CBDS). 

During the 2014 survey, Bridgewell met over 90% of licensing indicators within their Residential/Individual Home Supports and Employment/Day Services programs, and thus were eligible to complete a self-assessment during this licensing review.  The agency is also accredited by CARF, and chose a 'deemed' status for some certification indicators.  As a result, the scope of the DDS licensing and certification review was limited to critical indicators, indicators receiving a rating of 'not met' during the 2014 survey, and any new or strengthened licensing and certification indicators that came into effect in August of 2016.  The ratings from this survey process are a combination of DDS and Bridgewell application of licensing and certification standards; any instances where different rating decisions were reached resulted in the use of the DDS rating.  The scope of the DDS targeted survey included review of 18 residential homes, four Individual Home Supports individuals, one respite home, three audits within the CBDS program, and four audits within the Employment program.

Throughout the course of the survey, it was noted that the agency has incorporated many of the new or strengthened standards recently implemented by DDS in response to the CMS requirements of the Community Rule.  For each location surveyed, bedroom doors had been fitted with locks, affording individual's choice regarding the use of locks to ensure privacy.  The agency has also taken steps to protect individuals served in 24 hour settings from arbitrary eviction or relocation, and involves individuals in both the hiring and evaluating of supporters.  Within the agency's residential homes, sites were found to be clean and well maintained; heating and sprinkler systems had received the required inspections, and individuals were found to be successfully participating in routine evacuation drills.  Individuals were administered medications as prescribed, and necessary medical treatment protocols were in place.  The agency employs several practices to support human rights, including the dissemination of human rights materials to guardians, and ensuring any discovered instances of abuse or neglect are reported to the DPPC.  Staff were observed to be respectful of individuals in their direct communication with and about individuals, and by employing such practices as knocking on doors before entering bedrooms.  Individuals were found to be supported to make choices in such areas as decorating their personal living spaces, how to spend their leisure time, and where and with whom they would like to eat meals.  The agency recently increased its efforts in supporting individuals to increase their exposure to various social and recreational activities through the use of an interest inventory, and were generally found to be assisting individuals to participate in both familiar and new activities.

Some areas requiring further attention were identified during the survey.  Organizationally, the agency needs to ensure that each of their three human rights committees has the required membership composition, and that restraint reporting occurs within the required timelines.  Within the residential system, focus needs to be placed on ensuring that medication treatment plans are present, and contain the required components when individuals are prescribed behavior modifying medications. 

Many positive practices and outcomes were observed within the employment and CBDS programs.  Individuals were found to have privacy when needed, both when making phone calls and caring for personal needs.  Individuals were involved in the hiring and evaluating of supporters, and guardians received human rights educational materials.  Both programs met ISP submission timeline requirements, and individuals were found to be receiving support to accomplish their identified ISP goals.  

Within the employment program, individuals were generally found to be working in integrated settings, and were involved in the culture of the workplace.  Individuals stated they were happy with the types of  group employment jobs they were offered, and the majority of individuals surveyed were receiving the needed supports to be successful in their work.  Staff were knowledgeable regarding plans to fade supports in efforts to obtain individualized competitive employment when desired; job developers demonstrated strong community connections and a commitment to working with local businesses to cultivate individualized employment opportunities.

Specifically within the CBDS program, individuals were observed to be active in their communities, visiting local establishments throughout the day; support staff provided transportation, and assisted individuals to develop relationships with community members.  Individuals were provided support to increase independence, and the frequent opportunity to make decisions regarding what types of activities they want be involved with.  The program site was found to be clean, and individuals' safety was ensured through the use of routine evacuation drills and annual inspection of the heating and sprinkler systems.

Within the CBDS program, many individuals were supported to explore and discover activities and hobbies of interest, as well as provided the opportunity to engage in those activities; however the agency needs to provide further emphasis on ensuring that all individuals are afforded this opportunity.

Within the Residential Services/Individual Home Supports programs Bridgewell received a rating of met in 97% of licensing indicators; all critical indicators were met.  The agency also received a rating of met in 100% of certification indicators reviewed.  As a result, the agency will receive a Two Year License for Residential Services/Individual Home Supports; follow-up on all not met licensing indicators will be conducted by Bridgewell within 60 days.  Within the Employment and Day Supports program, the agency met 97% of all licensing indicators, including all critical indicators.  The agency also met 90% of the certification indicators reviewed.  As a result, the agency will receive a Two Year License for its Employment and Day Supports program; follow-up on all not met licensing indicators will be conducted by the agency and submitted to the DDS OQE within 60 days.

Below is a description of the self-assessment process completed by the provider.	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

Bridgewell has many ongoing assessment systems to continuously monitor the quality of services and ensure health and safety among other priorities in providing services. Our systems work to ensure ongoing compliance with DDS, CARF and Bridgewell standards. We have successfully developed a culture of heightened awareness where every employee is empowered to identify and take action to improve health, safety or any aspect of the services provided. Throughout Bridgewell we emphasize that quality assurance and improvement is an every day awareness, expectation and responsibility.  

Safety Program
 
     Bridgewell has solid, pragmatic systems and procedures to ensure the personal safety and health of each person served and employed. Our safety program monitors safety activities and provides preventative measures.

     An annual Safety Calendar is used to assure the completion and submission of all required safety and emergency drill trainings. This calendar is also used to assure other trainings occur regularly such as seasonal preparedness and safe lifting.

     A Preventative Maintenance Schedule is coordinated by the Facilities Dept. to assure all required inspections are completed, reviewed and that identified issues are addressed. Inspections are scheduled centrally for all programs within the same time frame annually. This allows for consistent scheduling and assures annual completion.

     Bridgewell has an active Safety Committee with cross representation of staff. Committee Members conduct semi-annual Safety Audits at each program. Results are shared with program managers and reviewed by the Safety Committee. Program managers work with support departments to resolve identified issues.

     Each program has an identified Safety Coordinator. Among their responsibilities are to assure the Bio-Hazard Response and First Aid Kits are in place and fully supplied.

     The Facility Department in conjunction with the Safety Committee continuously assesses accessibility and adaptations needed. Bridgewell maintains and regularly updates its accessibility plan to remove items that have been addressed and to add newly identified items.

     A comprehensive work order system is in place to provide programs easy communication and quick resolution of facility and safety maintenance needs.

     All program Safety Plans are reviewed, revised and tracked centrally.

Abuse and Neglect  

     An educational packet is sent annually to individuals and guardians explaining rights and how to file a complaint and the DPPC and Elder Affairs reporting procedures.

     Staff receives Abuse and Neglect training during orientation and annually thereafter.

     Bridgewell has an immediate response system to all reports of potential abuse or neglect. Program managers take immediate action to assure the health and safety of all individuals is protected. 

     All allegations are reported up to the Director of QA, DPPC or Office of Elder Affairs, and the Director of Human Resources.

     The Assistant Director of QA along with the appropriate Senior Program Manager and the Employee Relations Manager, conduct an internal review and take any necessary personnel action.

     The finalized internal review includes action steps when necessary which are carried out/monitored by senior managers.  

Human Rights

     An educational packet is sent out annually to individuals and guardians explaining rights and identifies the Human Rights Officer and Committee responsibilities. 

     This information is reviewed with individuals during individual and group meetings and throughout their typical daily routines.  

     Annual satisfaction surveys are conducted and assess how individuals feel their rights are respected, they are treated with dignity and respect, and they are supported to understand communications. Identified issues/trends are addressed with the guidance of the Director of QA.  

     Three Human Rights Committees are in place to meet the needs of Bridgewell's programs.

     Upon hire and annually thereafter, staff are trained in Human Rights which includes the understanding of restrictive practices, the use of behavior modifying medication and supportive and health related protections. All restrictive practices, consents for use of behavior modifying medications and supportive and health related protections are on standard forms to assure the proper information is provided on the rationale, criteria for reduction of need and staff training and are presented to the Human Rights Committee for  review.

     All restraint reports are submitted to the Assistant Director of QA who enters them in HCSIS and provides them to the appropriate Human Rights Coordinator for review prior to committee meetings.

Behavior Support Management

     Trained behavioral specialists are on staff and involved in the assessment and development of support plans for those individuals with challenging behaviors.

     The behavioral specialists meet with individuals and staff on a regular basis for training and continual monitoring of the success of the support plans. 

     All support plans follow a consistent format, describe how the efficacy of the intervention is determined, include criteria for reduction of need, and are reviewed by all required parties.

Health

     Bridgewell provides services to individuals with varying healthcare issues. Attention to the physical well-being and health status of each person is the constant responsibility of each employee.

     Each program has a nurse assigned who regularly reviews and monitors the health status and treatment protocols of the individuals. Additionally nurses provide training to staff and individuals; provide expertise in discussions with healthcare providers and recommend when further medical attention is needed; conduct periodic audits of medications; maintain the Health Care Record in HCSIS; monitor records to assure all needed exams are up to date and medical follow ups have occurred.
 
QA Audits

     Periodic audits are completed to assure individual record, HCSIS, medication and fund management, staff training and supervision, human rights, safety and emergency systems, physical facility safety, cleanliness and maintenance needs are being met. Audits occur by program managers, nurses, Safety Committee members, Facility Dept. staff, and QA Dept. staff.

     Supervisors work with Program Directors and support departments to ensure identified issues are addressed in a timely manner.

     Bridgewell has a comprehensive electronic health record (TIER) for all individuals served.  This allows for a variety of reporting capabilities, as well as, random audits and spot checks through automated reporting at multiple supervisory levels.

Workforce

     Staff is recruited to meet the specific individualized needs of each person.

     An extensive screening and interview process is followed along with on-site meetings to assure the candidate has the skills and abilities to meet the unique needs of and to work well with the individuals. 

     A 6 month probationary period is in place to allow for further assurance that they are a good match to work effectively with each person.

Staff Training

     A mandatory comprehensive Employee Orientation assures employees receive training and orientation to both DDS's and Bridgewell's philosophy of providing services.

     An On-Site Orientation is utilized by programs and is tracked to assure staff is properly oriented to support the unique needs of individuals.

     Extensive training materials are available on Bridgewell's intranet for easy access; comprehensive, consistent curriculums are used.

     "Essential Learning" is an easily accessible online course library of over 400 classes used by staff.  Among the advantages is that it provides and tracks required and elective trainings. 

     The Training Dept. distributes a training calendar offering required topics, specific medical and safety topics and professional development classes.

     The Training Dept. tracks and reports to all managers monthly on the status of employee trainings listing trainings that will be expiring 3 months in advance.  This enables managers to schedule staff for trainings in advance so as not to disrupt the program.	

	

	

	

	
LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/10	
2/10	

Residential and Individual Home Supports	
78/79	
1/79	

    Residential Services
    Respite Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
86/89	
3/89	
97%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/10	
2/10	

Employment and Day Supports	
57/57	
0/57	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
8/8	
0/8	

Total	
65/67	
2/67	
97%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
2	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
There are three human rights committees utilized by the agency.  All committees were found to be meeting at the required intervals, however two committees did not have the required representation from a member with medical expertise.  The agency needs to ensure that all human rights committees have the required composition, including members with medical expertise.

	
 L65	
Restraint reports are submitted within required timelines.	
Of the 199 restraint reports created over the previous 12 months, 51 (26%) were not reported within three days of the restraint and/or were not reviewed and finalized by the agency restraint manager within the required five days of the restraint event. The agency needs to ensure restraint reports are created within three days of the restraint and reviewed by the restraint manager within five days in accordance with DDS regulatory requirements.

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L63	
Medication treatment plans are in written format with required components.	
For seven of the nineteen individuals surveyed, medication treatment plans were missing at least one of three required components; a description of the behavior to be controlled, consistent data collection to inform prescriber's, and clinical indicators for the medication's reduction or discontinuance. For one individual, medication treatment plans had not been developed for the pair of sleep medications prescribed. The agency needs to ensure that medication treatment plans include all required components, and ensure that plans are developed for all medications prescribed to change behavior (including sleep).

	

	

	

	
CERTIFICATION FINDINGS	

	

	

	

	

Reviewed by	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 1/1
Provider 5/5	
6/6	
0/6	

Residential and Individual Home Supports	
DDS 38/38
Provider 7/7	
45/45	
0/45	

Individual Home Supports	
DDS 19/19
Provider 4/4	
23/23	
0/23	

Residential Services	
DDS 19/19
Provider 3/3	
22/22	
0/22	

Respite Services	
	
0/0	
0/0	

Total	
	
51/51	
0/51	
100%	

Certified	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 1/1
Provider 5/5	
6/6	
0/6	

Employment and Day Supports	
DDS 18/20
Provider 16/16	
34/36	
2/36	

Community Based Day Services	
DDS 9/11
Provider 3/3	
12/14	
2/14	

Employment Support Services	
DDS 9/9
Provider 13/13	
22/22	
0/22	

Total	
	
40/42	
2/42	
95%	

Certified	

	

	

	

	

	

	
Community Based Day Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C42	
Individuals are involved in activities that connect them to other people in the community.	
The agency supports individuals within its CBDS program to develop and maintain relationships with business owners, employees, and patrons in the immediate vicinity; this is especially beneficial because the CBDS program is located in the business district of Lynn, surrounded by various types of businesses. Some of the men and women Bridgewell supports regularly perform service at places such as the Eastern bank where they sort coins and paper for recycling purposes; Phillip's Manor Nursing home where they entertain residents; and the Pine Grove Cemetery.  In addition to involvement with these companies, the agency recently received a donation from a neighborhood shelter that hosted a concert of songs by some of the CBDS individuals.  While in the community, individuals are supported to not only engage in activities, but to initiate social contact with community members, and attempt to develop relationships based on common interests and activities.	

	

	

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

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.	
For one individual surveyed, the agency had completed an interest inventory, however the agency had not utilized a variety of assessment methods to determine the individual¿s interests in community activities. The agency needs to ensure that individuals are supported to determine what is of interest to them as they explore, discover, and participate in activities related to community involvement, personal interests and hobbies. 

	
 C41	
Individuals participate in activities, including those in the community, that reflect their interests and preferences.	
For one individual surveyed, it was unclear what types of personal interests and community activities the individual preferred to participate in, therefore it could not be determined if the individual was participating in activities of interest to him.  The agency needs to ensure that once interests are identified, individuals are supported to frequently participate in activities consistent with their preferences and interests.  

	

	

	

	

								
	MASTER SCORE SHEET LICENSURE	

								
	Organizational: Bridgewell Inc.	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
25/25	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
DDS	
1/3	
Not Met(33.33 % )	

 L65	
Restraint report submit	
DDS	
148/199	
Not Met(74.37 % )	

 L66	
HRC restraint review	
Provider	
-	
Met	

 L74	
Screen employees	
Provider	
-	
Met	

 L75	
Qualified staff	
Provider	
-	
Met	

 L76	
Track trainings	
Provider	
-	
Met	

 L83	
HR training	
Provider	
-	
Met	

								
	Residential and Individual Home Supports:	

								
	
Ind. #	
Ind.	
Loc. or Indiv.	
Reviewed by	
Res. Sup.	
Ind. Home Sup.	
Place.	
Resp.	
ABI-MFP Res. Sup.	
ABI-MFP Place.	
Total Met/Rated	
Rating	

 L1	
Abuse/neglect training	
I	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L3	
Immediate Action	
L	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
18/18	
4/4	
	
1/1	

23/23	
Met	

 L7	
Fire Drills	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

O	
 L11	
Required inspections	
L	
DDS	
18/18	
1/1	
	
1/1	

20/20	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
18/18	
4/4	
	
1/1	

23/23	
Met	

O	
 L13	
Clean location	
L	
DDS	
18/18	
1/1	
	
1/1	

20/20	
Met	

 L14	
Site in good repair	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L15	
Hot water	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L16	
Accessibility	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L19	
Bedroom location	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L22	
Clean appliances	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L23	
Egress door locks	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L24	
Locked door access	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L28	
Flammables	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L29	
Rubbish/combustibles	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L30	
Protective railings	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L31	
Communication method	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L33	
Physical exam	
I	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L34	
Dental exam	
I	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L35	
Preventive screenings	
I	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L36	
Recommended tests	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
12/12	

	

12/12	
Met	

 L39	
Dietary requirements	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L40	
Nutritional food	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L41	
Healthy diet	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L42	
Physical activity	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L43	
Health Care Record	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
18/18	

1/1	

19/19	
Met	

 L47	
Self medication	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
18/18	
4/4	
	
1/1	

23/23	
Met	

 L50	
Respectful Comm.	
L	
DDS	
18/18	
4/4	
	
1/1	

23/23	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
18/18	
4/4	
	
1/1	

23/23	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
18/18	
4/4	
	
1/1	

23/23	
Met	

 L55	
Informed consent	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L56	
Restrictive practices	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L57	
Written behavior plans	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L60	
Data maintenance	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L63	
Med. treatment plan form	
I	
DDS	
9/16	
3/3	

	
	
12/19	
Not Met
(63.16 %)	

 L64	
Med. treatment plan rev.	
I	
DDS	
13/16	
3/3	

	
	
16/19	
Met
(84.21 %)	

 L65	
Restraint report submit	
L	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I	
DDS	
15/18	
1/1	

	
	
16/19	
Met
(84.21 %)	

 L68	
Funds expenditure	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L69	
Expenditure tracking	
I	
DDS	
15/18	
1/1	
	
1/1	

17/20	
Met
(85.00 %)	

 L70	
Charges for care calc.	
I	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L71	
Charges for care appeal	
I	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

O	
 L82	
Medication admin.	
L	
DDS	
18/18	

1/1	

19/19	
Met	

 L84	
Health protect. Training	
I 	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L85	
Supervision 	
L	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
-	
-	
	
-	
-	
-	
-	
Met	

 L87	
Support strategies	
I	
DDS	
17/18	
4/4	

	
	
21/22	
Met
(95.45 %)	

 L88	
Strategies implemented	
I	
DDS	
17/18	
4/4	

	
	
21/22	
Met
(95.45 %)	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
18/18	
4/4	

	
	
22/22	
Met	

#Std. Met/# 79 Indicator	

	

	

	
78/79	

	
Total Score	

	

	

	
86/89	

	

	

	

	
	
96.63%	

			
								
Employment and Day Supports:	

								
	
Ind. #	
Ind.	
Loc. or Indiv.	
Reviewed by	
Emp. Sup.	
Cent. Based Work	
Com. Based Day	
Total Met / Rated	
Rating	

 L1	
Abuse/neglect training	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L2	
Abuse/neglect reporting	
L	
Provider	
	
-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
	
-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	

1/1	
1/1	
Met	

 L7	
Fire Drills	
L 	
Provider	
	
-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
	
-	
-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
	
-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L11	
Required inspections	
L	
DDS	

1/1	
1/1	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	

1/1	
1/1	
Met	

O	
 L13	
Clean location	
L	
DDS	

1/1	
1/1	
Met	

 L14	
Site in good repair	
L 	
Provider	
	
-	
-	
-	
Met	

 L15	
Hot water	
L 	
Provider	
	
-	
-	
-	
Met	

 L16	
Accessibility	
L 	
Provider	
	
-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
	
-	
-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	
	
-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
	
-	
-	
-	
Met	

 L22	
Clean appliances	
L 	
Provider	
	
-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
	
-	
-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	
	
-	
-	
-	
Met	

 L27	
Pools, hot tubs, etc.	
L 	
Provider	
	
-	
-	
-	
Met	

 L28	
Flammables	
L 	
Provider	
	
-	
-	
-	
Met	

 L29	
Rubbish/combustibles	
L 	
Provider	
	
-	
-	
-	
Met	

 L30	
Protective railings	
L 	
Provider	
	
-	
-	
-	
Met	

 L31	
Communication method	
I 	
Provider	
	
-	
-	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
	
-	
-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
1/1	

1/1	
Met	

 L39	
Dietary requirements	
I 	
Provider	
	
-	
-	
-	
Met	

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

 L49	
Informed of human rights	
I	
DDS	
4/4	
	
3/3	
7/7	
Met	

 L50	
Respectful Comm.	
L	
DDS	

1/1	
1/1	
Met	

 L51	
Possessions	
I 	
Provider	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
4/4	
	
3/3	
7/7	
Met	

 L54	
Privacy	
L	
DDS	

1/1	
1/1	
Met	

 L55	
Informed consent	
I 	
Provider	
	
-	
-	
-	
Met	

 L57	
Written behavior plans	
I 	
Provider	
	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
	
-	
-	
-	
Met	

 L60	
Data maintenance	
I 	
Provider	
	
-	
-	
-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
	
-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
	
-	
-	
-	
Met	

 L65	
Restraint report submit	
L 	
Provider	
	
-	
-	
-	
Met	

 L72	
DOL requirements	
I 	
Provider	
	
-	
-	
-	
Met	

 L73	
DOL certificate	
L 	
Provider	
	
-	
-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	
	
-	
-	
-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	
	
-	
-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	
	
-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
	
-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L82	
Medication admin.	
L	
DDS	

1/1	
1/1	
Met	

 L84	
Health protect. Training	
I 	
Provider	
	
-	
-	
-	
Met	

 L85	
Supervision 	
L 	
Provider	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
DDS	
4/4	
	
3/3	
7/7	
Met	

 L87	
Support strategies	
I	
DDS	
4/4	
	
3/3	
7/7	
Met	

 L88	
Strategies implemented	
I	
DDS	
4/4	
	
3/3	
7/7	
Met	

#Std. Met/# 57 Indicator	

	

	
57/57	

	
Total Score	

	

	
65/67	

	

	

	
	
97.01%	

			
								
	MASTER SCORE SHEET CERTIFICATION	

								
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C1	
Provider data collection	
Provider	
-	
Met	

 C2	
Data analysis	
Provider	
-	
Met	

 C3	
Service satisfaction	
Provider	
-	
Met	

 C4	
Utilizes input from stakeholders	
DDS	
1/1	
Met	

 C5	
Measure progress	
Provider	
-	
Met	

 C6	
Future directions planning	
Provider	
-	
Met	

	

	

	
								
Community Based Day Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
3/3	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C13	
Skills to maximize independence 	
DDS	
3/3	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C40	
Community involvement interest	
DDS	
2/3	
Not Met (66.67 %)	

 C41	
Activities participation	
DDS	
2/3	
Not Met (66.67 %)	

 C42	
Connection to others	
DDS	
3/3	
Met	

 C43	
Maintain & enhance relationship	
DDS	
3/3	
Met	

 C44	
Job exploration	
Provider	
-	
Met	

 C45	
Revisit decisions	
DDS	
3/3	
Met	

 C46	
Use of generic resources	
DDS	
3/3	
Met	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

 C54	
Assistive technology	
DDS	
2/2	
Met	

Employment Support Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
3/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C22	
Explore job interests	
Provider	
-	
Met	

 C23	
Assess skills & training needs	
Provider	
-	
Met	

 C24	
Job goals & support needs plan	
Provider	
-	
Met	

 C25	
Skill development	
Provider	
-	
Met	

 C26	
Benefits analysis	
Provider	
-	
Met	

 C27	
Job benefit education	
DDS	
4/4	
Met	

 C28	
Relationships w/businesses	
DDS	
1/1	
Met	

 C29	
Support to obtain employment	
Provider	
-	
Met	

 C30	
Work in integrated settings	
DDS	
3/4	
Met	

 C31	
Job accommodations	
Provider	
-	
Met	

 C32	
At least minimum wages earned	
Provider	
-	
Met	

 C33	
Employee benefits explained	
Provider	
-	
Met	

 C34	
Support to promote success	
DDS	
3/4	
Met	

 C35	
Feedback on job performance	
Provider	
-	
Met	

 C36	
Supports to enhance retention	
Provider	
-	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

 C50	
Involvement/ part of the Workplace culture	
DDS	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
4/4	
Met	

 C54	
Assistive technology	
DDS	
4/4	
Met	

Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
4/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
4/4	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
4/4	
Met	

 C12	
Intimacy	
DDS	
4/4	
Met	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C14	
Choices in routines & schedules	
DDS	
4/4	
Met	

 C15	
Personalize living space	
DDS	
3/3	
Met	

 C16	
Explore interests	
DDS	
4/4	
Met	

 C17	
Community activities	
DDS	
4/4	
Met	

 C18	
Purchase personal belongings	
DDS	
4/4	
Met	

 C19	
Knowledgeable decisions	
DDS	
4/4	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C21	
Coordinate outreach	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
4/4	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

 C48	
Neighborhood connections	
DDS	
4/4	
Met	

 C49	
Physical setting is consistent 	
DDS	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
4/4	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
4/4	
Met	

 C53	
Food/ dining choices	
DDS	
4/4	
Met	

 C54	
Assistive technology	
DDS	
4/4	
Met	

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
18/18	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
18/18	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
18/18	
Met	

 C12	
Intimacy	
DDS	
15/18	
Met (83.33 %)	

 C13	
Skills to maximize independence 	
DDS	
18/18	
Met	

 C14	
Choices in routines & schedules	
DDS	
18/18	
Met	

 C15	
Personalize living space	
DDS	
18/18	
Met	

 C16	
Explore interests	
DDS	
18/18	
Met	

 C17	
Community activities	
DDS	
17/18	
Met (94.44 %)	

 C18	
Purchase personal belongings	
DDS	
18/18	
Met	

 C19	
Knowledgeable decisions	
DDS	
18/18	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
18/18	
Met	

 C47	
Transportation to/ from community	
DDS	
18/18	
Met	

 C48	
Neighborhood connections	
DDS	
17/18	
Met (94.44 %)	

 C49	
Physical setting is consistent 	
DDS	
18/18	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
18/18	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
18/18	
Met	

 C53	
Food/ dining choices	
DDS	
17/17	
Met	

 C54	
Assistive technology	
DDS	
18/18	
Met