PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
CAPE ABILITIES
895 Mary Dunn Road
 Hyannis, MA 02601    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report

February 22, 2018

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
CAPE ABILITIES	

	

	

	

	
Review Dates	

	
1/25/2018 - 1/31/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
2/14/2018	

	

	

	

	

	

	
Survey Team	

	
Laura O'Connor	

Michael Marchese	

Tina Napolitan	

Scott Nolan (TL)	

Barbara Mazzella	

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	
12 location(s) 18 audit (s) 	
Full Review	
74 / 86 Defer Licensure    	
	
102 / 117 Certified    	

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

Full Review	
18 / 22	

ABI-MFP Residential Services	
1 location(s) 3 audit (s) 	

Full Review	
18 / 22	

Placement Services	
3 location(s) 3 audit (s) 	

Full Review	
18 / 22	

ABI-MFP Placement Services	
1 location(s) 1 audit (s) 	

Full Review	
21 / 22	

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

Full Review	
21 / 23	

Planning and Quality Management (For all service groupings)	

	
Full 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	
4 location(s) 9 audit (s) 	
Full Review	
47 / 49 2 Year License 02/14/2018 -  02/14/2020	
	
40 / 42 Certified 02/14/2018 -  02/14/2020	

Community Based Day Services	
1 location(s) 4 audit (s) 	

Full Review	
13 / 14	

Employment Support Services	
3 location(s) 5 audit (s) 	

Full Review	
21 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
6 / 6	

	

	

EXECUTIVE SUMMARY :	

			
Cape Abilities, Inc. is a multi-dimensional human service agency serving Cape Cod for over 49 years which was founded in 1968 by a concerned group of parents and families. It serves over 420 individuals with a broad range of disabilities, service provided by the agency include but are not limited to individuals with autism, Intellectual and Developmental Disabilities (I/DD), Acquired Brain Injury (ABI), and mental health needs. Cape Abilities provides a range of residential and day/employment services to individuals served by the Department of Developmental Services (DDS).  

The DDS services were the subject of this current full licensing and certification review, and included the following service types:  24 hour residential, 24 hour residential to individuals with ABI, placement, ABI/MFP placement, individual home supports, and employment and community based day supports.  As the agency used a deemed process (CARF) to evaluate and report on the quality outcomes covered under the certification indicators for its residential supports, Community Based Day and Employment services and the organizational indicators, the review of residential and day services was inclusive of certification indicators which were new or revised in August 2016.

The licensing review of residential services identified positive outcomes for individuals across all the service types. A positive outcome was noted in the agency's provision of health care supports.  Survey findings revealed that individuals received routine and preventative health screenings in a timely manner as well as receiving services from specialists when needed. Findings also revealed that individuals were supported to have healthy meals and were encouraged to regularly exercise such as walking in their neighborhoods and local parks.  It was also noted that staff were respectful when interacting with individuals who could freely communicate their opinions and concerns as well as individuals who used alternate forms of communication such as gestures. For example, staff recognized and understood one gentleman's use of gestures to have his providers sit next to him where they showcased his talents in photography.    

The licensing review of the employment/ day service grouping also evidenced positive findings.  The newly opened community based day site in Falmouth was well maintained and provided sufficient space for individuals to participate in activities of interest. It was also noted that written and verbal communications were respectful and staff encouraged individuals to freely express any concerns.

In the certification areas for residential services, the agency continued its commitment to assisting individuals to maintain connections with family and friends. Individuals visited with their families on weekends or called them when they chose to. In placement and Individual Home Supports (IHS), individuals were recognized as valued family members and were actively involved in family and social activities on a frequent basis. Individuals residing in 24 hour homes were also supported to connect with neighbors.  For example, individuals residing in one home baked organic dog cookies for a neighbor who has two dogs which resulted in an ongoing friendship with this neighbor. 

The agency is also recognized for its long standing efforts to solicit feedback from individuals regarding the performance of staff and is encouraged to implement this practice for individuals in placement services. In addition, staff supported individuals to make choices in their daily routines such as relaxing in their room, doing laundry or participating in preparing meals. One individual was excited to select a recipe of his choice from healthy menus and work with staff to prepare a meal for his housemates.  Another individual freely accessed the community store to purchase items of his choice on a daily basis.  

Positive practices were also seen within the certification areas in the agency's community based day and employment services. Individuals commented about the varied options offered to participate in job exploration, volunteer events or community activities.  Staff supported individuals to spend the majority of their time actively involved in local community based choices such as the town recreation facility, senior center or library and spent minimal time at the agency's Falmouth day support site. 
   
The agency had initiated a change of direction in its employment supports, which was evidenced by an increased emphasis on employment at community businesses with less emphasis on agency operated enterprises.  Individuals expressed satisfaction with jobs and were paid minimum wage or above.  Staff were aware of individuals' unique needs and were flexible in their provision of supports.  Supports had been faded to help individuals to maximize their independence at their jobs. Individuals were encouraged to use social media sites such as "Pinterest" to learn about areas that may potentially help them to explore and discover new areas of interest and growth.  Additional use of this and other assistive technologies is recommended to further assist individuals to maximize their independence.

Along with strengths identified in the report, findings identified several licensing areas which could benefit from further attention. These included: increased focus on individualized treatment protocols and adherence to requirements under the medication administration program (MAP) to ensure staff are knowledgeable and implement practices as required. The agency also needs to strengthen its practices in assisting individuals with managing their finances. The agency's financial tracking systems need to include documentation regarding the amount of monies withdrawn for assisting individuals' to make purchases and  ensure that money management plans include a component regarding the amount of monies that can be independently managed by individuals.. In addition, staff should be supported to implement support strategies as agreed upon in the ISP.

Organizationally, the agency needs to ensure that the human rights committee is comprised of the requisite expertise among its membership and that members with required expertise (i.e. legal, nursing) are present at meetings.  The HRC needs to ensure that members' feedback on issues that potentially impact the rights of individuals served is given to the agency. Additionally, the agency needs to strengthen its mechanisms to provide ongoing supervision, oversight and monitoring in areas such as medication administration, funds management, and maintenance of homes. 

The agency is encouraged to support staff to assess, educate and assist individuals in human sexuality and intimacy. Individuals also need to be effectively supported to explore and pursue community interests and activities that involve individuals without disabilities. Additionally, staff need to support individuals receiving residential services to discover activities that may expand their interests.  Cape Abilities should also identify where assistive technology might be used to maximize individuals' independence. 

As a result of the current review, the agency's Residential Services license will be deferred based upon receiving a 'Not Met' rating in two of the critical indicators relating to medical treatment protocols and medication administration. That review will evaluate the status of correction for these indicators, as well as the other licensing indicators that were rated "Not Met." The License level will be determined pending the results of a follow-up review which will occur within 60 days. The agency is Certified for Residential supports.  The organization will receive a Two-Year License and is Certified for its Employment and Day Supports group. For the Employment and Day Supports group, follow-up on all licensing indicators that received a rating of Not Met will be completed by the agency within sixty days.	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
65/76	
11/76	

    ABI-MFP Residential Services
    Placement Services
    ABI-MFP Placement Services
    Individual Home Supports
    Residential Services

	

Critical Indicators	
6/8	
2/8	

Total	
74/86	
12/86	
86%	

Defer Licensure	

	

# indicators for 60 Day Follow-up	
	
12	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
38/39	
1/39	

    Employment Support Services
    Community Based Day Services

	

Critical Indicators	
6/6	
0/6	

Total	
47/49	
2/49	
96%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
2	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
The agency needs to ensure that the human rights committee is comprised of the requisite expertise among its membership and that members with required expertise( i.e. legal, nursing) are present at meetings.  The HRC needs to ensure that feedback on issues that potentially impact the rights of individuals served is given to the agency.	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L8	
Emergency fact sheets are current and accurate and available on site.	
Four out of eighteen Emergency Fact Sheets did not contain all of the required components. The agency needs to ensure that all Emergency Fact Sheets contain all required components, such as diagnosis, photographs, and how current medications.	

 L15	
Hot water temperature tests between 110 and 130 degrees.	
The hot water temperature was tested at nine locations. The hot water temperature at three of these locations exceeded the allowable limits.  The agency needs to ensure that hot water temperatures are within allowable limits of 110-120 degrees.

O	
 L38	
Physicians' orders and treatment protocols are followed (when agreement for treatment has been reached by the individual/guardian/team). 	
While individualized treatment protocols were in place and implemented by staff for six individuals, there were two instances where individual protocols needed to be written and staff trained in their implementation.  The agency needs to ensure staff follow treatment protocols as ordered by the physician.	

O	
 L46	
 All prescription medications are administered according to the written order of a practitioner and are properly documented on a Medication Treatment Chart. 	
A review of medication administration procedures for three individuals out of the twelve reviewed; revealed medications were not being administered as prescribed or properly documented. All prescription medications need to be administered according to the written order of the practitioner, properly documented on a Medication Treatment Chart, and medication procedures are done in accordance with the Medication Administration Program (MAP).	

 L56	
Restrictive practices intended for one individual that affect all individuals served at a location need to have a written rationale that is reviewed as required and have provisions so as not to unduly restrict the rights of others.	
Restrictive practices were in place at eight locations.  In two instances, the necessary safeguards for the use of such practices were not in place.  These included a lack of strategies to mitigate the effect of the restriction on the other individuals residing in the home, and no evidence that the restriction utilized was the least restrictive. The agency needs to ensure that restrictive practices have the necessary reviews and include provisions so as to not unduly restrict the rights of others.

	
 L58	
All behavior plans contain the required components.	
The agency needs to ensure that behavior plans have all required components, including an accurate description of the current supports that are being provided. One behavior plan reviewed included interventions that are no longer being utilized.	

 L69	
Individual expenditures are documented and tracked.	
The Financial Tracking records (FTR's) needs to accurately reflect an accounting for cash being removed for purchases, proper recording of expenditures and balances with receipts according to agency policy). The agency needs to ensure staff follow agency procedures; individual expenditures are properly documented, and tracked on financial transaction records.	

 L85	
The agency provides ongoing supervision and staff development	
Although there were mechanisms to provide supervision, oversight and monitoring was not provided on a consistent basis.  For example, evidence was lacking in the identification or remediation of significant issues present in three of the nine homes reviewed (e.g. nursing and financial oversight, staff knowledge of individuals' medical protocols, maintenance of homes).	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments for eight out of eighteen individuals were not submitted within required time frames. The agency needs to ensure that assessments are submitted to the DDS Area Office at least 15 days prior to scheduled ISP meeting.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Support strategies for twelve out of eighteen individuals were not submitted within required timeframes. The agency needs to ensure that support strategies are submitted to the DDS Area Office at least 15 days prior to scheduled ISP meeting. 	

 L88	
Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	
The implementation of support strategies was reviewed for eighteen individuals. In seven instances, strategies agreed upon in the ISP were not being implemented by staff. The agency needs to ensure that support strategies agreed upon in the ISP are being implemented.  	

	

	

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

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.	
Support strategies for four out of eight individuals were not submitted within required timeframes. The agency needs to ensure that support strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meetings. 	

			

	

	

CERTIFICATION FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
6/6	
0/6	

Residential and Individual Home Supports	
96/111	
15/111	

ABI-MFP Residential Services	
18/22	
4/22	

ABI-MFP Placement Services	
21/22	
1/22	

Individual Home Supports	
21/23	
2/23	

Residential Services	
18/22	
4/22	

Placement Services	
18/22	
4/22	

TOTAL	
102/117	
15/117	
87%	

Certified	

	

	
	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
6/6	
0/6	

Employment and Day Supports	
34/36	
2/36	

Community Based Day Services	
13/14	
1/14	

Employment Support Services	
21/22	
1/22	

TOTAL	
40/42	
2/42	
95%	

Certified	

	

	

	

	

	

	
ABI-MFP Placement Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
While the individual was involved in the process of finding a successful placement match, opportunities to provide feedback at the time of hire of potential hires and on an ongoing basis on the performance of the provider have not been provided.  The agency needs to fully implement a process for incorporating feedback from the individual on an ongoing basis on the performance of staff and his shared living provider.  	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

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

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
The agency has not developed a plan for exploring individual's needs' regarding intimacy and companionship. The agency needs to assess, educate, and support individuals in the areas of human sexuality. The agency also needs to provide training opportunities to support staff in this area.	

 C17	
Community activities are based on the individual's preferences and interests.	
Three individuals were reviewed regarding their access to community activities based on their individual preferences and interests. One of the three individuals had not provided with regular opportunities to participate in community activities that aligned with his preferences. The agency needs to ensure that staff afford the individual frequent and consistent opportunities to participate in community based activities of his interest.	

 C48	
Individuals are a part of the neighborhood.	
Three individuals were reviewed regarding their connections with their neighbors. For all three, there was no evidence of staff provided opportunities which encouraged interactions with neighbors and participation in neighborhood activities. The agency needs to ensure that opportunities are provided which encourage and support neighborhood connections.	

	

	
Individual Home Supports- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
The agency indicated a process for exploring individuals needs' regarding intimacy and companionship but a plan to implement this was not in place at the time of the review. The agency needs to continue its efforts to assess, educate, and support individuals in the areas of human sexuality, intimacy, and companionship. The agency also needs to continue to provide training opportunities to support staff in this area as well.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
In three of four instances, assessments of assistive technology needs had not started been started by the agency.  The agency needs to assess each individual's needs and determine how assistive technology or modifications could maximize individual's independence.	

	

	
Placement Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
Opportunities for two of the individuals to provide feedback at the time of hire and on an ongoing basis on the performance of staff were not provided to three individuals. The agency needs to ensure that a process is developed to solicit feedback at the time of hire and on an ongoing basis.	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
The agency has not developed a plan for exploring individual's needs' regarding intimacy and companionship. The agency needs to assess, educate, and support individuals in the areas of human sexuality. The agency also needs to provide training opportunities to support staff in this area.	

 C15	
Staff (Home Providers) support individuals to personalize and decorate their rooms/homes and personalize common areas according to their tastes and preferences.	
In one location, bedrooms did not reflect individual's personal tastes or preferences. The agency needs to ensure that individual bedrooms include decorations that reflect personalized preferences.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for three individuals were reviewed. In one instances an assessment of assistive technology needs had not gone beyond the initial stages.  The agency needs to assess each individual's needs and determine how assistive technology or modifications could maximize individual's independence.	

	

	
Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
The agency has not developed a plan for exploring individual's needs' regarding intimacy and companionship. The agency needs to assess, educate, and support individuals in the areas of human sexuality. The agency also needs to provide training opportunities to support staff in this area.	

 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Survey findings revealed that three out of seven individuals had not been supported to develop, explore, and pursue activities and interests in community-based activities that were consistent with their cultural, recreational, social, and spiritual interests. The agency needs to develop methods to evaluate and assist individuals to explore and pursue interests that include these areas.	

 C17	
Community activities are based on the individual's preferences and interests.	
Survey findings revealed that four out of seven individuals were not provided with frequent and ongoing opportunities to participate in community activities that reflected the person's interests and preferences. The agency needs to ensure that opportunities for community involvement reflect individual preferences.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for seven individuals were reviewed. In all instances assessments of assistive technology needs had been started at the time of the review.  The agency needs to assess each individual's needs and determine how assistive technology or modifications that could maximize individual's independence.	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for seven individuals were reviewed. In all instances assessments of assistive technology needs had not gone beyond the initial stages.  The agency needs to assess each individual's needs and determine how assistive technology or modifications that could maximize individual's independence.	

	

	

Employment Support Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for seven individuals were reviewed. In all instances assessments of assistive technology needs had been started at the time of the review. The agency needs to assess each individual's needs and determine how assistive technology or modifications that could maximize individual's independence.	

	

	

		

	MASTER SCORE SHEET LICENSURE	

					
	Organizational: CAPE ABILITIES	

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

O	
 L2	
Abuse/neglect reporting	
13/13	
Met	

 L3	
Immediate Action	
14/14	
Met	

 L4	
Action taken	
14/14	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
6/6	
Met	

 L66	
HRC restraint review	
6/6	
Met	

 L74	
Screen employees	
4/4	
Met	

 L75	
Qualified staff	
2/2	
Met	

 L76	
Track trainings	
19/20	
Met(95.00 % )	

 L83	
HR training	
19/20	
Met(95.00 % )	

							
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
7/7	
3/4	
2/3	
	
3/3	
1/1	
16/18	
Met
(88.89 %)	

 L5	
Safety Plan	
L	
2/3	
1/1	
3/3	
	
1/1	
1/1	
8/9	
Met
(88.89 %)	

O	
 L6	
Evacuation	
L	
3/3	
1/1	
3/3	
	
1/1	
1/1	
9/9	
Met	

 L7	
Fire Drills	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L8	
Emergency Fact Sheets	
I	
4/7	
3/4	
3/3	
	
3/3	
1/1	
14/18	
Not Met
(77.78 %)	

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

1/1	
	
7/7	
Met	

 L10	
Reduce risk interventions	
I	
2/2	

	
1/1	
	
3/3	
Met	

O	
 L11	
Required inspections	
L	
3/3	
1/1	
3/3	
	
1/1	
1/1	
9/9	
Met	

O	
 L12	
Smoke detectors	
L	
3/3	
1/1	
3/3	
	
1/1	
1/1	
9/9	
Met	

O	
 L13	
Clean location	
L	
3/3	
1/1	
3/3	
	
1/1	
1/1	
9/9	
Met	

 L14	
Site in good repair	
L	
3/3	
1/1	
2/2	
	
1/1	
1/1	
8/8	
Met	

 L15	
Hot water	
L	
2/3	
1/1	
3/3	
	
1/1	
0/1	
7/9	
Not Met
(77.78 %)	

 L16	
Accessibility	
L	
3/3	
1/1	
3/3	
	
0/1	
1/1	
8/9	
Met
(88.89 %)	

 L17	
Egress at grade 	
L	
3/3	
	
3/3	
	
1/1	
	
7/7	
Met	

 L18	
Above grade egress	
L	
2/3	
1/1	

	
	
3/4	
Met	

 L19	
Bedroom location	
L	
2/2	

	
1/1	
	
3/3	
Met	

 L20	
Exit doors	
L	
3/3	
1/1	

1/1	
	
5/5	
Met	

 L21	
Safe electrical equipment	
L	
2/3	
1/1	
3/3	
	
1/1	
1/1	
8/9	
Met
(88.89 %)	

 L22	
Clean appliances	
L	
2/3	
1/1	
3/3	
	
1/1	
1/1	
8/9	
Met
(88.89 %)	

 L23	
Egress door locks	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L24	
Locked door access	
L	
2/3	

	
1/1	
	
3/4	
Met	

 L25	
Dangerous substances	
L	
3/3	
1/1	

1/1	
	
5/5	
Met	

 L26	
Walkway safety	
L	
2/3	
1/1	
3/3	
	
1/1	
1/1	
8/9	
Met
(88.89 %)	

 L28	
Flammables	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L29	
Rubbish/combustibles	
L	
3/3	
1/1	
3/3	
	
1/1	
	
8/8	
Met	

 L30	
Protective railings	
L	
3/3	
1/1	
2/2	
	
1/1	
1/1	
8/8	
Met	

 L31	
Communication method	
I	
7/7	
3/4	
3/3	
	
3/3	
1/1	
17/18	
Met
(94.44 %)	

 L32	
Verbal & written	
I	
7/7	
4/4	
3/3	
	
3/3	
1/1	
18/18	
Met	

 L33	
Physical exam	
I	
7/7	
1/1	
3/3	
	
3/3	
1/1	
15/15	
Met	

 L34	
Dental exam	
I	
7/7	
1/1	
3/3	
	
3/3	
1/1	
15/15	
Met	

 L35	
Preventive screenings	
I	
6/7	
1/1	
3/3	
	
3/3	
1/1	
14/15	
Met
(93.33 %)	

 L36	
Recommended tests	
I	
7/7	
1/1	
3/3	
	
3/3	
1/1	
15/15	
Met	

 L37	
Prompt treatment	
I	
7/7	
2/2	
3/3	
	
3/3	
1/1	
16/16	
Met	

O	
 L38	
Physician's orders	
I	
1/1	
0/2	
2/2	
	
3/3	
	
6/8	
Not Met
(75.00 %)	

 L39	
Dietary requirements	
I	
2/3	
2/2	
3/3	
	
3/3	
	
10/11	
Met
(90.91 %)	

 L40	
Nutritional food	
L	
3/3	
1/1	

1/1	
	
5/5	
Met	

 L41	
Healthy diet	
L	
3/3	
2/2	
2/2	
	
1/1	
1/1	
9/9	
Met	

 L42	
Physical activity	
L	
3/3	
2/2	
3/3	
	
1/1	
1/1	
10/10	
Met	

 L43	
Health Care Record	
I	
7/7	
2/3	
3/3	
	
3/3	
1/1	
16/17	
Met
(94.12 %)	

 L44	
MAP registration	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L45	
Medication storage	
L	
3/3	

	
1/1	
	
4/4	
Met	

O	
 L46	
Med. Administration	
I	
5/7	
	
2/2	
	
2/3	
	
9/12	
Not Met
(75.00 %)	

 L47	
Self medication	
I	
7/7	
1/1	
1/2	
	
3/3	
1/1	
13/14	
Met
(92.86 %)	

 L49	
Informed of human rights	
I	
7/7	
4/4	
3/3	
	
3/3	
1/1	
18/18	
Met	

 L50	
Respectful Comm.	
L	
3/3	
4/4	
3/3	
	
1/1	
1/1	
12/12	
Met	

 L51	
Possessions	
I	
7/7	
4/4	
3/3	
	
3/3	
1/1	
18/18	
Met	

 L52	
Phone calls	
I	
7/7	
4/4	
3/3	
	
3/3	
1/1	
18/18	
Met	

 L53	
Visitation	
I	
7/7	
4/4	
3/3	
	
3/3	
1/1	
18/18	
Met	

 L54	
Privacy	
L	
2/3	
3/3	
3/3	
	
1/1	
1/1	
10/11	
Met
(90.91 %)	

 L55	
Informed consent	
I	

1/1	

	
1/1	
Met	

 L56	
Restrictive practices	
I	
4/5	
1/1	
1/2	

	
6/8	
Not Met
(75.00 %)	

 L57	
Written behavior plans	
I	
1/1	

	

1/1	
Met	

 L58	
Behavior plan component	
I	
0/1	

	

0/1	
Not Met
(0 %)	

 L59	
Behavior plan review	
I	
1/1	

	

1/1	
Met	

 L60	
Data maintenance	
I	
1/1	

	

1/1	
Met	

 L61	
Health protection in ISP	
I	
0/1	
2/2	

3/3	
	
5/6	
Met
(83.33 %)	

 L62	
Health protection review	
I	
1/1	
2/2	

3/3	
	
6/6	
Met	

 L63	
Med. treatment plan form	
I	
3/4	
1/1	
1/2	
	
3/3	
	
8/10	
Met
(80.0 %)	

 L64	
Med. treatment plan rev.	
I	
4/4	
1/1	
2/2	
	
3/3	
	
10/10	
Met	

 L67	
Money mgmt. plan	
I	
5/6	
1/2	
2/2	
	
3/3	
	
11/13	
Met
(84.62 %)	

 L68	
Funds expenditure	
I	
6/6	
2/2	
1/2	
	
3/3	
	
12/13	
Met
(92.31 %)	

 L69	
Expenditure tracking	
I	
1/6	
1/2	
1/2	
	
0/2	
	
3/12	
Not Met
(25.00 %)	

 L70	
Charges for care calc.	
I	
7/7	
1/1	
3/3	
	
3/3	
1/1	
15/15	
Met	

 L71	
Charges for care appeal	
I	
7/7	
1/1	
3/3	
	
3/3	
1/1	
15/15	
Met	

 L77	
Unique needs training	
I	
7/7	
3/4	
3/3	
	
3/3	
1/1	
17/18	
Met
(94.44 %)	

 L78	
Restrictive Int. Training	
L	
1/1	
1/1	
1/1	

	
3/3	
Met	

 L80	
Symptoms of illness	
L	
3/3	
4/4	
3/3	
	
1/1	
1/1	
12/12	
Met	

 L81	
Medical emergency	
L	
3/3	
4/4	
3/3	
	
1/1	
1/1	
12/12	
Met	

O	
 L82	
Medication admin.	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L84	
Health protect. Training	
I	
1/1	
2/2	

3/3	
	
6/6	
Met	

 L85	
Supervision 	
L	
1/3	
4/4	
3/3	
	
0/1	
1/1	
9/12	
Not Met
(75.00 %)	

 L86	
Required assessments	
I	
7/7	
1/4	
2/3	
	
0/3	
0/1	
10/18	
Not Met
(55.56 %)	

 L87	
Support strategies	
I	
2/7	
1/4	
2/3	
	
0/3	
1/1	
6/18	
Not Met
(33.33 %)	

 L88	
Strategies implemented	
I	
3/7	
3/4	
1/3	
	
3/3	
1/1	
11/18	
Not Met
(61.11 %)	

 L89	
Complaint and resolution process	
L	

	
	
1/1	
1/1	
2/2	
Met	

 L90	
Personal space/ bedroom privacy	
I	
7/7	
2/2	
3/3	
	
3/3	
1/1	
16/16	
Met	

#Std. Met/# 76 Indicator	

	

	

65/76	

	
Total Score	

	

	

74/86	

	

	

	

	
86.05%	

		
							
Employment and Day Supports:	

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

 L1	
Abuse/neglect training	
I	
5/5	
	
4/4	
9/9	
Met	

 L5	
Safety Plan	
L	

1/1	
1/1	
Met	

O	
 L6	
Evacuation	
L	

1/1	
1/1	
Met	

 L7	
Fire Drills	
L	

1/1	
1/1	
Met	

 L8	
Emergency Fact Sheets	
I	
5/5	
	
3/3	
8/8	
Met	

 L9	
Safe use of equipment	
L	
2/2	
	
1/1	
3/3	
Met	

 L10	
Reduce risk interventions	
I	
1/1	
	
1/1	
2/2	
Met	

O	
 L11	
Required inspections	
L	

1/1	
1/1	
Met	

O	
 L12	
Smoke detectors	
L	

1/1	
1/1	
Met	

O	
 L13	
Clean location	
L	

1/1	
1/1	
Met	

 L14	
Site in good repair	
L	

1/1	
1/1	
Met	

 L15	
Hot water	
L	

1/1	
1/1	
Met	

 L16	
Accessibility	
L	

1/1	
1/1	
Met	

 L17	
Egress at grade 	
L	

1/1	
1/1	
Met	

 L20	
Exit doors	
L	

1/1	
1/1	
Met	

 L21	
Safe electrical equipment	
L	

1/1	
1/1	
Met	

 L22	
Clean appliances	
L	

1/1	
1/1	
Met	

 L25	
Dangerous substances	
L	

1/1	
1/1	
Met	

 L26	
Walkway safety	
L	

1/1	
1/1	
Met	

 L28	
Flammables	
L	

1/1	
1/1	
Met	

 L29	
Rubbish/combustibles	
L	

1/1	
1/1	
Met	

 L31	
Communication method	
I	
5/5	
	
4/4	
9/9	
Met	

 L32	
Verbal & written	
I	
5/5	
	
4/4	
9/9	
Met	

 L37	
Prompt treatment	
I	
4/4	
	
4/4	
8/8	
Met	

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

 L39	
Dietary requirements	
I	

1/1	
1/1	
Met	

 L49	
Informed of human rights	
I	
5/5	
	
4/4	
9/9	
Met	

 L50	
Respectful Comm.	
L	
3/3	
	
1/1	
4/4	
Met	

 L51	
Possessions	
I	
5/5	
	
4/4	
9/9	
Met	

 L52	
Phone calls	
I	
5/5	
	
4/4	
9/9	
Met	

 L54	
Privacy	
L	
2/2	
	
1/1	
3/3	
Met	

 L55	
Informed consent	
I	
1/1	
	
2/2	
3/3	
Met	

 L77	
Unique needs training	
I	
5/5	
	
4/4	
9/9	
Met	

 L80	
Symptoms of illness	
L	
3/3	
	
1/1	
4/4	
Met	

 L81	
Medical emergency	
L	
3/3	
	
1/1	
4/4	
Met	

 L85	
Supervision 	
L	
3/3	
	
1/1	
4/4	
Met	

 L86	
Required assessments	
I	
5/5	
	
2/3	
7/8	
Met
(87.50 %)	

 L87	
Support strategies	
I	
5/5	
	
1/3	
6/8	
Not Met
(75.00 %)	

 L88	
Strategies implemented	
I	
5/5	
	
4/4	
9/9	
Met	

#Std. Met/# 39 Indicator	

	

38/39	

	
Total Score	

	

47/49	

	

	

	
95.92%	

		
							
	MASTER SCORE SHEET CERTIFICATION	

							
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
Met	

 C2	
Data analysis	
1/1	
Met	

 C3	
Service satisfaction	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
1/1	
Met	

 C5	
Measure progress	
1/1	
Met	

 C6	
Future directions planning	
1/1	
Met	

	

	

							

ABI-MFP Placement Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
0/1	
Not Met (0 %)	

 C8	
Family/guardian communication	
1/1	
Met	

 C9	
Personal relationships	
1/1	
Met	

 C10	
Social skill development	
1/1	
Met	

 C11	
Get together w/family & friends	
1/1	
Met	

 C12	
Intimacy	
1/1	
Met	

 C13	
Skills to maximize independence 	
1/1	
Met	

 C14	
Choices in routines & schedules	
1/1	
Met	

 C15	
Personalize living space	
1/1	
Met	

 C16	
Explore interests	
1/1	
Met	

 C17	
Community activities	
1/1	
Met	

 C18	
Purchase personal belongings	
1/1	
Met	

 C19	
Knowledgeable decisions	
1/1	
Met	

 C20	
Emergency back-up plans	
1/1	
Met	

 C46	
Use of generic resources	
1/1	
Met	

 C47	
Transportation to/ from community	
1/1	
Met	

 C48	
Neighborhood connections	
1/1	
Met	

 C49	
Physical setting is consistent 	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
1/1	
Met	

 C52	
Leisure activities and free-time choices /control	
1/1	
Met	

 C53	
Food/ dining choices	
1/1	
Met	

 C54	
Assistive technology	
1/1	
Met	

ABI-MFP Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
3/3	
Met	

 C8	
Family/guardian communication	
3/3	
Met	

 C9	
Personal relationships	
2/3	
Not Met (66.67 %)	

 C10	
Social skill development	
3/3	
Met	

 C11	
Get together w/family & friends	
3/3	
Met	

 C12	
Intimacy	
0/3	
Not Met (0 %)	

 C13	
Skills to maximize independence 	
3/3	
Met	

 C14	
Choices in routines & schedules	
3/3	
Met	

 C15	
Personalize living space	
1/1	
Met	

 C16	
Explore interests	
3/3	
Met	

 C17	
Community activities	
2/3	
Not Met (66.67 %)	

 C18	
Purchase personal belongings	
3/3	
Met	

 C19	
Knowledgeable decisions	
3/3	
Met	

 C20	
Emergency back-up plans	
1/1	
Met	

 C46	
Use of generic resources	
3/3	
Met	

 C47	
Transportation to/ from community	
3/3	
Met	

 C48	
Neighborhood connections	
0/3	
Not Met (0 %)	

 C49	
Physical setting is consistent 	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

 C52	
Leisure activities and free-time choices /control	
3/3	
Met	

 C53	
Food/ dining choices	
3/3	
Met	

 C54	
Assistive technology	
3/3	
Met	

Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
4/4	
Met	

 C8	
Family/guardian communication	
4/4	
Met	

 C13	
Skills to maximize independence 	
4/4	
Met	

 C37	
Interpersonal skills for work	
4/4	
Met	

 C40	
Community involvement interest	
4/4	
Met	

 C41	
Activities participation	
4/4	
Met	

 C42	
Connection to others	
4/4	
Met	

 C43	
Maintain & enhance relationship	
3/4	
Met	

 C44	
Job exploration	
4/4	
Met	

 C45	
Revisit decisions	
4/4	
Met	

 C46	
Use of generic resources	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/4	
Met	

 C54	
Assistive technology	
2/4	
Not Met (50.0 %)	

Employment Support Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
5/5	
Met	

 C8	
Family/guardian communication	
5/5	
Met	

 C22	
Explore job interests	
5/5	
Met	

 C23	
Assess skills & training needs	
5/5	
Met	

 C24	
Job goals & support needs plan	
5/5	
Met	

 C25	
Skill development	
5/5	
Met	

 C26	
Benefits analysis	
5/5	
Met	

 C27	
Job benefit education	
5/5	
Met	

 C28	
Relationships w/businesses	
3/3	
Met	

 C29	
Support to obtain employment	
5/5	
Met	

 C30	
Work in integrated settings	
5/5	
Met	

 C31	
Job accommodations	
5/5	
Met	

 C32	
At least minimum wages earned	
5/5	
Met	

 C33	
Employee benefits explained	
5/5	
Met	

 C34	
Support to promote success	
5/5	
Met	

 C35	
Feedback on job performance	
5/5	
Met	

 C36	
Supports to enhance retention	
5/5	
Met	

 C37	
Interpersonal skills for work	
5/5	
Met	

 C47	
Transportation to/ from community	
5/5	
Met	

 C50	
Involvement/ part of the Workplace culture	
5/5	
Met	

 C51	
Ongoing satisfaction with services/ supports	
5/5	
Met	

 C54	
Assistive technology	
0/5	
Not Met (0 %)	

Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
4/4	
Met	

 C8	
Family/guardian communication	
2/2	
Met	

 C9	
Personal relationships	
4/4	
Met	

 C10	
Social skill development	
4/4	
Met	

 C11	
Get together w/family & friends	
3/3	
Met	

 C12	
Intimacy	
2/3	
Not Met (66.67 %)	

 C13	
Skills to maximize independence 	
4/4	
Met	

 C14	
Choices in routines & schedules	
2/2	
Met	

 C15	
Personalize living space	
2/2	
Met	

 C16	
Explore interests	
3/3	
Met	

 C17	
Community activities	
4/4	
Met	

 C18	
Purchase personal belongings	
3/3	
Met	

 C19	
Knowledgeable decisions	
4/4	
Met	

 C20	
Emergency back-up plans	
4/4	
Met	

 C21	
Coordinate outreach	
3/4	
Met	

 C46	
Use of generic resources	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C48	
Neighborhood connections	
3/3	
Met	

 C49	
Physical setting is consistent 	
4/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

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

 C53	
Food/ dining choices	
3/3	
Met	

 C54	
Assistive technology	
1/3	
Not Met (33.33 %)	

Placement Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
2/3	
Not Met (66.67 %)	

 C8	
Family/guardian communication	
3/3	
Met	

 C9	
Personal relationships	
3/3	
Met	

 C10	
Social skill development	
3/3	
Met	

 C11	
Get together w/family & friends	
3/3	
Met	

 C12	
Intimacy	
1/3	
Not Met (33.33 %)	

 C13	
Skills to maximize independence 	
3/3	
Met	

 C14	
Choices in routines & schedules	
3/3	
Met	

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

 C16	
Explore interests	
3/3	
Met	

 C17	
Community activities	
3/3	
Met	

 C18	
Purchase personal belongings	
3/3	
Met	

 C19	
Knowledgeable decisions	
3/3	
Met	

 C20	
Emergency back-up plans	
3/3	
Met	

 C46	
Use of generic resources	
3/3	
Met	

 C47	
Transportation to/ from community	
3/3	
Met	

 C48	
Neighborhood connections	
3/3	
Met	

 C49	
Physical setting is consistent 	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

 C52	
Leisure activities and free-time choices /control	
3/3	
Met	

 C53	
Food/ dining choices	
3/3	
Met	

 C54	
Assistive technology	
1/3	
Not Met (33.33 %)	

Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
7/7	
Met	

 C8	
Family/guardian communication	
7/7	
Met	

 C9	
Personal relationships	
6/7	
Met (85.71 %)	

 C10	
Social skill development	
7/7	
Met	

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

 C12	
Intimacy	
2/7	
Not Met (28.57 %)	

 C13	
Skills to maximize independence 	
7/7	
Met	

 C14	
Choices in routines & schedules	
7/7	
Met	

 C15	
Personalize living space	
3/3	
Met	

 C16	
Explore interests	
4/7	
Not Met (57.14 %)	

 C17	
Community activities	
3/7	
Not Met (42.86 %)	

 C18	
Purchase personal belongings	
7/7	
Met	

 C19	
Knowledgeable decisions	
7/7	
Met	

 C20	
Emergency back-up plans	
3/3	
Met	

 C46	
Use of generic resources	
6/7	
Met (85.71 %)	

 C47	
Transportation to/ from community	
7/7	
Met	

 C48	
Neighborhood connections	
6/7	
Met (85.71 %)	

 C49	
Physical setting is consistent 	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
7/7	
Met	

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

 C53	
Food/ dining choices	
7/7	
Met	

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