Provider:  	  Brockton Area Arc, Inc.						Provider Address:  	1250 West Chestnut Street, Brockton, MA	

Name of Person Completing Form:  	Robert Biela				Dates of Review:  		September 7, 2012			

Follow-up Scope and Results:	

Service Grouping
	Licensure Level and Duration	# Indicators Std. Met/Std. Rated	
Employment and Day Supports	Two-Year License
(7/6/2012 - 07/6/2014)	    2     of 2	

Summary of Ratings

Administrative Areas Needing Improvement on Standards Not Met:

Indicator #	L48	
Indicator	Human Rights Committee	
Area Need Improvement	The agency needs to fill its clinical vacancy on the Human Rights Committee to ensure that such expertise is accessed when reviewing information.  It is recommended that the agency collaborate with the Office of Human Rights to develop ways to meet the requirements while actively recruiting a member with such expertise.

	

Administrative Areas Needing Improvement on Standards Not Met, cont.

Indicator #	L48, cont.	
Process utilized to correct and review indicator.	Previous to the 2012 Survey and Certification process the BAArc HR Committee has been diligently searching for a Clinician.  The process included the HR Coordinator contacting the DDS regional office and speaking with Maureen Pereira for advice; HR Committee member’s personally networking, reaching out to the area High Schools, Colleges and Universities and calling other area providers for any leads they could provide.  During this process we had one possible candidate from the Brockton High School who originally seemed interested but due to personal conflicts was not able to follow through.

After the Survey and Certification process and at the exit interview Jennifer Peterson and Rick Cavicchi suggested that BAArc contact Maureen Pereira again to discuss the DDS Waiver Process as a possible alternative to satisfying our Clinician requirement.  Rob Biela, HR Coordinator discussed with Maureen on 8/14/12 the Waiver Process and along with the above listed recruiting methods the BAArc HR Committee have been using will add the DDS Waiver Process to our recruiting methods.  Just recently at a Lions Club meeting, that a BAArc staff member attended, she discussed with a Clinician her interest in participating in the BAArc Human Rights Committee.  I called and spoke to Laura O’Neal LMHC regarding the possibility of her joining BAArc’s HR Committee.  Laura requested information about BAArc and the HR Committee.
	
Status at follow-up.	Laura O’Neal, LMHC, attended the Brockton Area Arc September 5, 2012 Human Rights Committee Meeting.  Laura introduced herself and her experience working as a counselor with people having a variety of cognitive disabilities. After the conclusion of the Human Rights meeting Rob Biela, BAArc Human Rights Coordinator met with Laura to discuss her interest in joining the BAArc Human Rights Committee as a voting member full time.  Laura graciously accepted the invitation to become a voting member and filling our vacant opening as the BAArc Human Rights Committee Member Clinician.
	
Rating	MET	

Administrative Areas Needing Improvement on Standards Not Met, cont.

Indicator #	L65	
Indicator	Restraint Report submitting.	
Area Need Improvement	The agency needs to ensure that the managerial review of restraint reports is completed within five days of the incident.
	
Process utilized to correct 
and review indicator.	The initial information for the restraint report and the consumer interview was completed and submitted via HCSIS within 24 hours of the incident. The error was not completing the Provider Restraint Manager Review within 5 days and submitting to the DDS Area Office for them to perform the Area Management Review.  The BAArc Human Rights Committee reviewed the restraint incident within the required 120 days from the incident event but the Human Rights Committee Review and Comment section in HCSIS was not completed.	
Status at follow-up.	During the 2012 Survey and Certification process the DDS surveyor brought the error to the BAArc HR Coordinator, Rob Biela.  Rob informed the surveyor, Jennifer Peterson, that neither he nor the Executive Director was aware of the requirement of completing the Provider Restraint Manager Review and the Human Rights Committee Review and Comment section in HCSIS.  I informed the surveyor that the DDS area office had not notified BAArc that they could not complete the Area Management Report until the Provider Restraint Manager Review was complete.  Once the surveyor informed me of the error I completed the Provider Restraint Manager Review on 6/20/12, informed the DDS area office of the error on 6/20/12 and they finalized the Area Management Report on 6/22/12 where I then finalized the Human Rights Committee Review and Comment section in HCSIS on 6/22/12.  As of 8/15/12 the event ID #168771 in HCSIS is listed as Open.  It is my understanding that once the Commissioner’s review is completed or within 120 days after the Human Rights Committee Review and Comment section in HCSIS was completed, the incident will be listed as Closed.  There have been no further restraints performed at BAArc since the one restraint on 6/6/11.  Rob Biela, Employment Program Director, has met with all of BAArc managers and Jay Lynch, BAArc Executive Director, explaining the four step protocol required through the HCSIS process whenever a restraint is necessary.  The Employment Program Director is the staff who is responsible that the correct HCSIS protocol is followed whenever a restraint is performed.	
Rating	MET