PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
BROCKTON AREA MULTI-SERVS INC
10 Christy Drive
 Brockton, MA 02301    	

	

	

	

	

	

	

	

September 29, 2017	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
BROCKTON AREA MULTI-SERVS INC	

	

	

	

	
Review Dates	

	
8/29/2017 - 9/5/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
9/18/2017	

	

	

	

	

	

	
Survey Team	

	
Sally Hajjar	

Margareth Larrieux	

Michael Marchese	

Barbara Mazzella	

Tina Napolitan	

Scott Nolan (TL)	

Laura O'Connor	

Ed Sutka	

	

	

	

	

	

	
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	
24 location(s) 26 audit (s) 	
Targeted Review	
DDS 16 / 19
Provider 71 / 71

87 / 90 2 Year License 09/18/2017-  09/18/2019	
	
DDS 50 / 58
Provider 15 / 15

65 / 73 Certified 09/18/2017 -  09/18/2019	

Residential Services	
16 location(s) 16 audit (s) 	

DDS Targeted Review	
17 / 22	

ABI-MFP Residential Services	
4 location(s) 6 audit (s) 	

DDS Targeted Review	
19 / 22	

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	
1 location(s) 4 audit (s) 	
Targeted Review	
DDS 6 / 8
Provider 20 / 21

26 / 29 2 Year License 09/18/2017-  09/18/2019	
	
DDS 10 / 10
Provider 18 / 18

28 / 28 Certified 09/18/2017 -  09/18/2019	

Employment Support Services	
1 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 :	

	

	

BAMSI (Brockton Area Multi-Services, Inc.) is a private, non-profit human services organization providing an array of services to adults and children with developmental disabilities, Acquired Brain Injury (ABI), mental illness, behavioral health, and public health needs, which was founded in 1975 to serve individuals in Southeastern Massachusetts.  The agency's roots are centered in the greater Brockton area and it continues to maintain a strong presence there.  Over the years, the agency has expanded its services to individuals residing in other areas within eastern, central, and northern Massachusetts.  BAMSI provides 24 hour services to individuals living in approximately 80 residential homes; 11 of which are new since the last review and specifically developed to meet the needs of the ABI/MFP population.  In addition, the agency provides supports to 35 people receiving Individualized Home Supports and 45 people in employment services.   . 

The current review is a DDS Targeted Licensure and Certification Review, which included all new and revised indicators. In 2015, the agency received a two year license for its Residential and Employment services and was therefore eligible to conduct a self-assessment and receive a DDS Targeted Licensure and Certification Review of both Residential and Day Service groupings. The scope of the current review focused on residential and employment supports, consisting of competitive employment, 24 hour residential services, Individual Home Supports, and ABI/MFP services. The findings of the DDS evaluations were then combined with the agency's findings from its self-assessment and used to determine the agency's new Licensure and Certification levels. 
 
The DDS targeted review confirmed that across all residential settings surveyed, there were effective systems in place to promote the presence of key safeguards.  All critical licensing indicators, which relate to areas such as the implementation of health care protocols, medication administration, and maintenance of people's homes, were identified as met.  These positive outcomes were noted as a result of the agency's  focus on providing training and oversight in critical areas such as, ensuring staff were knowledgeable of individuals' unique health related support needs such as aspiration, choking or fall prevention strategies.  Additionally, staff were observed to interact with individuals in a respectful manner, and affirmed individual's privacy.

Through the agency's employment services, three out of four individuals have successfully experienced long term employment in competitive jobs that paid minimum wage.  For each individual, a tailored support plan was in place that emphasized unique skills and abilities that promoted independence in the workplace. A fourth individual was recently laid off and was being assisted with exploring other career options.  The agency offered training in human rights, job skills, opportunities for individuals to meet with their employment coordinator to discuss employment related issues. Individuals expressed satisfaction in working in positions that reflected their interests.

The agency is recognized for providing individuals an avenue to voice their concerns, impact staff practices, and influence strategic planning. The agency supported a Person Served Advisory Board which was made up of individuals served by the agency.  This group provided feedback on individuals' satisfaction with services and met with the agency's leadership team to promote their recommendations or concerns such as the development or use of a Welcoming Packet for individuals new to the agency. This advisory board also met and presented their concerns to the Board of Directors. Information gathered from this stakeholder group has been incorporated into the agency's strategic plan to "encourage and inspire persons served to have more self-direction and ownership of their services and life path." The agency is encouraged to explore a means for individuals who are unable to communicate their ideas or wishes to be represented on the committee.  

Although the agency was noted to have many positive findings, the agency is encouraged to strengthen its efforts to meet the composition requirement for its two Human Rights Committees and its oversight of meeting DDS timelines for submission of ISP assessments and strategies.  These findings were also identified by the agency and a corrective action plan developed as part of the agency's self-assessment.

Within the residential certification domain of supporting and enhancing relationships, further efforts were needed to support individuals to develop and/or increase personal relationships.  To address this, the agency has undertaken an initiative to enhance supports in this area.  A plan was introduced to assist individuals to develop healthy relationships and companionship with others.  The agency had a Certified Socialization & Sexuality Educator who provided training to individuals, staff, guardians and community members to further individuals' personal growth in this area and is available for individual assistance when referred by agency personnel. While these efforts have assisted some individuals to understand and develop different types of relationships, further staff training to support individuals on an individual basis to explore and express their needs for intimacy and companionship is needed for people who may not be able to verbally express this desire.  

Another area of focus for the agency is to enhance supports for individuals to develop social contacts with others in their community. The agency's recognition and a recent initiative in this area were seen through its efforts to conducted interest inventories.  These assessments were geared towards gathering information to support individuals to explore and participate in cultural, social, recreational and spiritual activities. A review of interest inventories however, revealed the inventories had not been fully completed, or that individualized strategies to assist people with accessing community activities based on their interests have yet to be implemented. The agency needs to strengthen its plans to have staff implement individual goals for individuals to participate in activities of interest.  

The findings of this review also concurred with the agency's self-assessment that individuals needed more support to develop connections and be part of their neighborhoods.

Based on the results of these evaluations, the agency achieved a Two-Year license for its Residential Supports with 97% of all licensing indicators receiving a rating of Met" and is Certified with 89% of certification indicators receiving a rating of "Met". The agency will conduct its own follow-up for the licensing indicators rated Not Met within 60 days.  The agency also achieved a Two-Year license for its Employment Supports with 90%of all indicators receiving a rating of "Met" and is Certified with 100% of all certification indicators receiving a rating of "Met".  

Brockton Area Multi-Services, Inc. has presented the following self-assessment inclusive of a description of the organizations ongoing quality assurance systems.	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

BAMSI utilizes an ongoing quality management process that ensures the highest quality services are delivered. The self-monitoring and self-assessment processes are comprised of ongoing audit reviews, satisfaction surveys, management reporting tools and internal and external inspections or visits. Each program is reviewed twice a year by staff in the Quality and Improvement Department, which is comprised of Program Monitors, the Director of Quality Assurance, and the Director of Healthcare Monitoring. The reviews are highly comprehensive and are focused on all aspects of the DDS licensing indicators, CARF requirements, and BAMSI internal policies and procedures compliance. Any areas found deficient or partially met are reviewed again within 60 days by a member of the Quality and Improvement Department.

These reviews are submitted to the Quality and Improvement Department and to the assigned Director of Operations and are reviewed for trends, patterns and outstanding issues. Additionally, off-cycle reviews are conducted if there is a prolonged vacancy in management staff or if the program is newly opened. On an annual basis the VP of Quality and Improvement presents a summary of all quality management activities including satisfaction survey results, internal audit results, and licensing outcomes to the Executive Management Team and the Board of Directors for their input and feedback.

A number of management reporting tools are utilized including Monthly Management reports completed by the Program Manager, Nurse Manager, and Assistant Director, as well as various financial reports related to household and persons served funds. Each program has a Financial Officer who, in conjunction with the Program Manager, reviews all petty cash, grocery, gas and person served expenditures to ensure that accounts balance and that all expenditures are legitimate. These monthly reports are submitted to the next level supervisor and the Director of Operations and are reviewed during monthly supervision meetings to ensure all levels of management are informed of program operations, successes, and challenges.

BAMSI received a two year license during its last DDS Licensing Survey and was therefore afforded the option to conduct a Self-Assessment. BAMSI programs have been deemed to be in significant compliance with DDS licensing indicators through the implementation and review of ongoing monitoring systems that are described in this document and through a self-assessment survey.

The self-assessment review was conducted by senior management and quality and improvement staff comprised of eight team members. The review consisted of randomly selecting a sample of program reviews that were conducted Feb 15, 2017-August 15, 2017 as well as conducting additional visits to interview individuals served and staff at a sample of programs to rate a number of the certification indicators not addressed on the quality review tool.  In total, 40 residential homes were sampled for the licensing indicators and 36 individuals were reviewed for certification indicators. In-Home Supports had six people reviewed for both licensing and certification indicators. A total of 4 people receiving Employments Services were reviewed for both the licensing and certification indicators. 

In total, 88 licensing indicators were reviewed for residential/in home supports, 32 for employment services, and 28 certification indicators were reviewed for all service types.  The results of the self-assessment determined that 84/88 licensing indicators were met for residential/in home supports and 29/32 indicators were achieved in employment services. For the certification indicators, 27/28 residential/ in home support indicators were met and 28/28 indicators were achieved in employment services. The review team utilized an 80% compliance factor to determine that an indicator was met and indicators receiving less than 80% were deemed unmet. In total, residential/in home supports was in 95.5% compliance with all licensing standards and in 96.4% compliance with all certification standards. Employment services achieved 90.6% of all licensing indicators rated and 100% of the certification indicators.

There were four unmet licensing indicators: L60 (Data Maintenance), L86 (Required Assessments), L87 (Support Strategies), and L48 (Human Rights Committee). Data collection tools were present at all locations however data was collected inconsistently and therefore rated unmet. All required assessments and provider support strategies were present however the required submission timeline was not consistently adhered to. Although the agency's Human Rights Committees have maintained high quality standards and are well versed in their responsibilities, they continue to struggle with maintaining the required composition of committee members and having the appropriate representation at all meetings. 

There was one unmet certification indicator: C48 (neighborhood connections). Overall people are supported to connect to the community and build relationships. Developing connections with neighbors continues to be an area needing enhancement by providing more guidance to staff and person served.

Listed below are other specialized areas in which quality assurance is supported.

Human Rights Committee and Persons Served Advisory Board: BAMSI has two fully operational Human Rights Committees that meet a minimum of quarterly and typically six times per year. The committees review restrictive practices, behavior plans, investigations, human rights complaints, supportive and protective devices, restraints, and significant incidents. The committees also ensure that the person served and their guardian/family are informed of their human rights and the reporting mechanisms for suspected abuse. The educational process includes discussing topics at house meetings, mailing information out to family members and guardians on an annual basis, and visits to a sample of programs.

BAMSI's Persons Served Advisory Board is another method of assuring high quality of services. The Advisory Board is comprised of people served in the agency's developmental disability programs as well as those served by MRC, DMH and family supports. The Board meets monthly and reviews and edits pertinent agency policies, reviews the annual satisfaction surveys, attends program quality management reviews, and designs staff training modules. The Advisory Board shares their unique and valuable perspective through formal reporting to the Executive Management Team and the Board of Directors.

Positive Behavior Supports: Since the last licensing review BAMSI has fully implemented PBS in all of its DDS funded programs. All of the required elements of PBS such as staff training, staff reward system, targeted team, intensive team and universal teams are fully operational. The Leadership Team reviews restraint data, staff training curriculum, universal outcomes and QUIC's (staff observation) data to determine the effectiveness of environmental and behavioral interventions.

Healthcare: BAMSI supports a highly medically complex population of individuals throughout a significant portion of its residential network. As a result, the agency has many comprehensive healthcare systems in place to minimize risk and to assure that each individual can maintain their optimal health. BAMSI's Medical Risk Committee provides oversight of the medical policies and procedures utilized. The committee is comprised of senior managers, senior nurses, the medical director and a medical attorney. The committee reviews risk data related to hospitalizations, falls, frequent illnesses, medication errors and deaths. BAMSI currently uses more than 100 medical protocols that have been reviewed and approved by the committee. All specialized protocols and Medication Treatment Plans are developed by a nurse.

Nurses conduct a full medical and clinical chart review at each residential location on a quarterly basis; nurses and program managers follow up on any outstanding areas. Nurses are available to all BAMSI programming including Brockton Employment Services and Individual Supports. A Medication Documentation and Chart Review form is completed by the Program Manager and Nurse Manager, as applicable each week. The form asks people to report on medication administration and documentation, medical appointments, hospitalizations, and review of data collection related to medical issues. These forms are submitted with the Monthly Management Report. 

Staff Development and Training: It is imperative that all staff receive supervision, support and training. BAMSI requires all supervisory staff to conduct supervision on a regularly scheduled and structured basis. Supervision occurs in many ways, including one-to-one individual meetings, staff meetings, and case review meetings. Performance evaluations are completed for all employees annually with input from person served.

The Professional Development and Training Department maintains an extensive database to monitor employee training requirements, design programs to assure ongoing skill enhancement, and to assure renewal of required certifications. This database was used during the Self-Assessment Review to assure compliance with all training requirements. The Training Department issues 30, 60 and 90 day reminder notices to alert supervisors about trainings that are up for renewal. BAMSI has an extensive orientation process that includes training in person-specific needs, agency policies, DDS required training, OSHA mandates, van safety, ISP development, and an introduction to developmental disabilities. Additional trainings include MAP, NVMAB, social networking, and community membership. BAMSI maintains a catalog of over 200 topic-specific training modules that are offered on an as-needed basis.

Physical Environment: BAMSI ensures the maintenance and safety of its physical environments through the use of monitoring tools, facilities staff inspections and by outsourcing of ongoing maintenance. Each program completes Site Safety Reviews that includes the DDS licensing indicators, OSHA mandates, and the touches that make a house a home. These reports are submitted to the Facilities Department with corresponding work order requests. The Facilities Department conducts inspections of properties to determine capital projects and to project funding cost. Staff submit work orders for requests of maintenance and repairs. BAMSI outsources some of its maintenance needs such as landscaping, trash removal, plowing, generator inspections, vehicle maintenance, etc. Since the last licensing review BAMSI has implemented an electronic facilities management system called EnvVisual. The system tracks work orders, inspections, leases, maintenance performed and information about the property such as landlord contact, oil heat, floor plans, etc. Each program manager has access to the system and can track when maintenance is scheduled to be performed.	

	

	

	

	
LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
78/80	
2/80	

    Residential Services
    ABI-MFP Residential Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
87/90	
3/90	
97%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
17/19	
2/19	

    Employment Support Services

	

Critical Indicators	
1/1	
0/1	

Total	
26/29	
3/29	
90%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

	

	

	

	

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.	
The agency had two Human Rights Committee's (HRC) that supported four regions across the DDS service areas. The agency did not meet composition requirements for the Foxboro and Brockton committees. The agency needs to ensure the Human Right's Committees meet  composition requirements.	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Completion of the required assessments for six out of twenty individuals (70%) were not submitted within the established timelines. The agency needs to ensure that ISP assessment are submitted 15 days prior to the 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.	
Completion of the support strategies for six out of twenty-one individuals (71%) were not submitted within the established timelines.  The agency needs to ensure that support strategies are completed and submitted 15 days prior to the ISP meeting. 	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Completion of the support strategies for one out of three individuals (67%) were not submitted within the established timelines.  The agency needs to ensure that support strategies are completed and submitted 15 days prior to the ISP meeting. 	

	

	

	
Employment/Day Areas Needing Improvement on Standards not met/Follow-up to occur:
From Provider review:	

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments were not consistently submitted 15 days prior to the ISP.	
A quarterly report will be generated that will determine each program's adherence to required submission timelines that will be reviewed by upper level management to emphasize the importance of adhering to timelines. Additionally, the Program Manager, Assistant Director and Director will populate their calendars (jointly) with ISP related timelines. The Director will randomly review Monthly Management reports and cross reference adherence to ISP submission requirements	

	

	

	
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 49/57
Provider 10/10	
59/67	
8/67	

ABI-MFP Residential Services	
DDS 16/19
Provider 3/3	
19/22	
3/22	

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

Residential Services	
DDS 14/19
Provider 3/3	
17/22	
5/22	

Total	
	
65/73	
8/73	
89%	

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 9/9
Provider 13/13	
22/22	
0/22	

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

Total	
	
28/28	
0/28	
100%	

Certified	

	

	

	

	

	

	
ABI-MFP Residential Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C9	
Staff (Home Providers) provide opportunities to develop and/or increase personal relationships and social contacts.  	
Two out of six individuals were not provided consistent opportunities to develop and/or increase social contacts with members of their communities. Staff were aware of their interests in friendships, however there was insufficient evidence that opportunities were provided for them to reconnect with pre-existing relationships and/or develop new relationships.  The agency needs to provide individuals with opportunities to increase social contacts with others in the community.	

	
 C17	
Community activities are based on the individual's preferences and interests.	
For two of six individuals, interest inventories were completed.  However, they were not provided with opportunities to participate in communities activities in line with the interests and preferences identified in their inventories.  The agency needs to ensure staff are knowledgeable about individual's interests and preferences to promote exploration of community activities. 	

	
 C48	
Individuals are a part of the neighborhood.	
For three of six individuals, there was insufficient evidence that opportunities were provided to participate in routines and/or activities that would facilitate connections with their neighbors.  The agency needs to support individuals to be involved as members of the neighborhood.	

	

	

	
Residential Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C9	
Staff (Home Providers) provide opportunities to develop and/or increase personal relationships and social contacts.  	
Four out of sixteen individuals were not provided consistent opportunities to develop and/or increase social contacts with other members of their communities. The agency needs to provide individuals with opportunities to increase social contacts with others in the community.	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
Nine out of sixteen individuals, needed further support to explore and express their need for intimacy and companionship based on their unique preference and needs. The agency needs to ensure individuals are supported to explore 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.	
The agency recently conducted interest inventories to gather information to support individual's to explore participation in cultural, social, recreational and spiritual activities. Four out of sixteen individuals needed staff assistance to explore and connect with activities of interest on a regular basis. The agency needs to support staff to assist individuals to connect individuals with their interest for cultural, social, recreational and spiritual activities. 	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Four out of sixteen individuals were not supported by staff to engage in community activities based on their preferences and interests on an ongoing basis.  The agency needs to ensure staff are knowledgeable about individual's interests and preferences to promote exploration of community activities. 	

	
 C48	
Individuals are a part of the neighborhood.	
For nine of sixteen individuals, there was insufficient evidence that opportunities were provided to participate in routines and/or activities that would facilitate connections with their neighbors. The agency needs to support individuals to be involved as members of the neighborhood.	

	

	

	

	

								
	MASTER SCORE SHEET LICENSURE	

								
	Organizational: BROCKTON AREA MULTI-SERVS INC	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
24/25	
Met(96.00 % )	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
DDS	
0/2	
Not Met(0 % )	

 L65	
Restraint report submit	
DDS	
93/100	
Met(93.00 % )	

 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	

 L4	
Action taken	
L	
Provider	
-	
-	

-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
16/16	
4/4	

4/4	
	
24/24	
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	
16/16	
3/3	

4/4	
	
23/23	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
16/16	
4/4	

4/4	
	
24/24	
Met	

O	
 L13	
Clean location	
L	
DDS	
16/16	
3/3	

4/4	
	
23/23	
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	

 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	

 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	
16/16	

	
6/6	
	
22/22	
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	
16/16	

	
6/6	
	
22/22	
Met	

 L47	
Self medication	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
16/16	
4/4	

6/6	
	
26/26	
Met	

 L50	
Respectful Comm.	
L	
DDS	
16/16	
4/4	

4/4	
	
24/24	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
16/16	
4/4	

6/6	
	
26/26	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
16/16	
4/4	

4/4	
	
24/24	
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	
DDS	
9/11	
1/1	

1/1	
	
11/13	
Met
(84.62 %)	

 L61	
Health protection in ISP	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L63	
Med. treatment plan form	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L64	
Med. treatment plan rev.	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L65	
Restraint report submit	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L69	
Expenditure tracking	
I	
DDS	
15/16	

	
5/5	
	
20/21	
Met
(95.24 %)	

 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	
16/16	

	
4/4	
	
20/20	
Met	

 L84	
Health protect. Training	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L85	
Supervision 	
L	
Provider	
-	
-	

-	
-	
-	
Met	

 L86	
Required assessments	
I	
DDS	
10/15	
1/1	

3/4	
	
14/20	
Not Met
(70.0 %)	

 L87	
Support strategies	
I	
DDS	
10/15	
2/2	

3/4	
	
15/21	
Not Met
(71.43 %)	

 L88	
Strategies implemented	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L89	
Complaint and resolution process	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
16/16	
4/4	

5/6	
	
25/26	
Met
(96.15 %)	

#Std. Met/# 80 Indicator	

	

	

	
78/80	

	
Total Score	

	

	

	
87/90	

	

	

	

	
	
96.67%	

			
								
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	

 L8	
Emergency Fact Sheets	
I 	
Provider	
	
-	
	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
	
-	
	
-	
Met	

 L31	
Communication method	
I 	
Provider	
	
-	
	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
	
-	
	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
	
-	
	
-	
Met	

 L39	
Dietary requirements	
I 	
Provider	
	
-	
	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
4/4	

4/4	
Met	

 L50	
Respectful Comm.	
L	
DDS	
1/1	

1/1	
Met	

 L51	
Possessions	
I 	
Provider	
	
-	
	
-	
Met	

 L52	
Phone calls	
I	
DDS	
4/4	

4/4	
Met	

 L54	
Privacy	
L	
DDS	
1/1	

1/1	
Met	

 L77	
Unique needs training	
I 	
Provider	
	
-	
	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
	
-	
	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
	
-	
	
-	
Met	

 L85	
Supervision 	
L 	
Provider	
	
-	
	
-	
Met	

 L86	
Required assessments	
I 	
Provider	
	
-	
	
-	
Not Met

	
 L87	
Support strategies	
I	
DDS	
2/3	

2/3	
Not Met
(66.67 %)	

 L88	
Strategies implemented	
I 	
Provider	
	
-	
	
-	
Met	

#Std. Met/# 18 Indicator	

	

	
17/19	

	
Total Score	

	

	
26/29	

	

	

	
	
89.66%	

			
								
	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	

	

	

	
								
ABI-MFP Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
6/6	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
4/6	
Not Met (66.67 %)	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
6/6	
Met	

 C12	
Intimacy	
DDS	
6/6	
Met	

 C13	
Skills to maximize independence 	
DDS	
6/6	
Met	

 C14	
Choices in routines & schedules	
DDS	
6/6	
Met	

 C15	
Personalize living space	
DDS	
4/4	
Met	

 C16	
Explore interests	
DDS	
6/6	
Met	

 C17	
Community activities	
DDS	
4/6	
Not Met (66.67 %)	

 C18	
Purchase personal belongings	
DDS	
5/6	
Met (83.33 %)	

 C19	
Knowledgeable decisions	
DDS	
6/6	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
5/6	
Met (83.33 %)	

 C47	
Transportation to/ from community	
DDS	
6/6	
Met	

 C48	
Neighborhood connections	
DDS	
3/6	
Not Met (50.0 %)	

 C49	
Physical setting is consistent 	
DDS	
3/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
6/6	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
6/6	
Met	

 C53	
Food/ dining choices	
DDS	
6/6	
Met	

 C54	
Assistive technology	
DDS	
5/6	
Met (83.33 %)	

Employment Support Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
4/4	
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	
4/4	
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	
4/4	
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	
4/4	
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	
4/4	
Met	

 C16	
Explore interests	
DDS	
3/4	
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	
4/4	
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	
16/16	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
12/16	
Not Met (75.00 %)	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
16/16	
Met	

 C12	
Intimacy	
DDS	
7/16	
Not Met (43.75 %)	

 C13	
Skills to maximize independence 	
DDS	
16/16	
Met	

 C14	
Choices in routines & schedules	
DDS	
16/16	
Met	

 C15	
Personalize living space	
DDS	
16/16	
Met	

 C16	
Explore interests	
DDS	
12/16	
Not Met (75.00 %)	

 C17	
Community activities	
DDS	
12/16	
Not Met (75.00 %)	

 C18	
Purchase personal belongings	
DDS	
15/16	
Met (93.75 %)	

 C19	
Knowledgeable decisions	
DDS	
16/16	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
15/16	
Met (93.75 %)	

 C47	
Transportation to/ from community	
DDS	
16/16	
Met	

 C48	
Neighborhood connections	
DDS	
7/16	
Not Met (43.75 %)	

 C49	
Physical setting is consistent 	
DDS	
16/16	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
15/15	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
15/16	
Met (93.75 %)	

 C53	
Food/ dining choices	
DDS	
14/15	
Met (93.33 %)	

 C54	
Assistive technology	
DDS	
14/16	
Met (87.50 %)