Provider: ____	CHARLES RIVER ARC__________        Provider Address: __59 E. Militia Heights Rd. Needham, MA 02492_______
Name of Person Completing Form: ___Anne-Marie Bajwa_____              Date(s) of Review: _______12-JUL-13 to 16-JUL-13_____

Follow-up Scope and Results:	
Service Grouping

	Licensure level and duration	# Indicators std. met/std. rated

	
Employment and Day Supports

	2 Year License	3/4 Met	
Residential and Individual Home Supports

	2 Year License	3/3 Met	

Summary of Ratings

Administrative Areas Needing Improvement on Standard not met- Identified by DDS
Indicator #	L65	
Indicator	Restraint Report Submit	
Area Need Improvement	According to HCSIS information reviewed, restraint reports were submitted within required timelines 76% of the time. The agency needs to ensure that it submits all restraint reports within 3 days and that a management review is documented as having occurred within 5 days.	
Process Utilized to correct and review indicator	Appointed a HCSIS point person per department.  This person is responsible for ensuring timely submission and processing of restraint reports.	
Status at follow-up	Since 5/3/2013 the timeliness is 100% on initial reporting and 90% on restraint manager finalization.  	
Rating	Met	

Employment and Day Supports Areas Needing Improvement on Standard not met – Identified by DDS
Indicator #	L8	
Indicator	Emergency Fact Sheets	
Area Need Improvement	Emergency Fact Sheets were found to be lacking required information and/or not to contain updated information contained in such documents as the DDS Healthcare Record. The agency needs to ensure that the emergency fact sheets remain current and up-to-date.	
Process Utilized to correct and review indicator	Staff have been directed to verify the diagnosis on the EFS against information contained on Doctor Encounter forms when obtained	
Status at follow-up	July 2013 is the month in which CRC annually verifies the information contained on the EFS and has the guardians sign the document.  	
Rating	Not met	

Indicator #	L9	
Indicator	Safe use of equipment	
Area Need Improvement	The agency has not routinely completed evaluations for individuals relative to the same use of equipment and machinery. The agency needs to ensure that all individuals are assessed with regard to the safe use of equipment and machinery.	
Process Utilized to correct and review indicator	Assessment developed.  Will be added to the assessment package developed earlier this year.   	
Status at follow-up	Completed.  All individuals will be assesses using the safety tool by October 2013.	
Rating	Met	

Indicator #	L55	
Indicator	Informed Consent	
Area Need Improvement	The agency obtained informed consent for photographs of individuals to be taken/used. However, they were not situation specific. The agency needs to ensure that these requests are situation specific. 	
Process Utilized to correct and review indicator	The agency reviewed its policy on photo releases.  The policy states that a release must be signed for each instance and it is valid for one year.	
Status at follow-up	The release form has been changed to reflect that it is for one specific instance.  	
Rating	Met	

Indicator #	L88	
Indicator	Strategies Implemented	
Area Need Improvement	Progress notes were vague and lacked sufficient information to conclude that strategies were being followed as identified. The agency needs to ensure that it documents progress relative to staff’s implementation of services and support strategies for individuals served.	
Process Utilized to correct and review indicator	Both data collection and progress report formats have been revised to reflect the changes.  Staff will be trained in the use of them within the next three months.	
Status at follow-up	Forms have been revised to allow for documentation of staff’s implementation of the support strategies.  	
Rating	Met	

Residential and Individual Home Supports Areas Needing Improvement on Standard not met –Identified by DDS
Indicator #	L30	
Indicator	Protective railings	
Area Need Improvement	There were two locations where decks and railings were in disrepair. The agency needs to ensure that all decks and railings remain in good repair at all times. 	
Process Utilized to correct and review indicator	Both repairs are listed as a high priority on CRC’s capital planning budget.  Bids are currently being obtained by contractor who can do the repairs.	
Status at follow-up	Bids are being obtained. In the meantime, both locations have been repaired for safety.	
Rating	Met	

Indicator #	L55	
Indicator	Informed Consent	
Area Need Improvement	The agency obtained informed consent for photographs of individuals to be taken/used. However, they were not situation specific. The agency needs to ensure that these requests are situation specific.	
Process Utilized to correct and review indicator	Forms have been revised to allow for documentation of staff’s implementation of the support strategies.  	
Status at follow-up	Forms have been revised to allow for documentation of staff’s implementation of the support strategies.  	
Rating	Met	

Indicator #	L88	
Indicator	Strategies Implemented	
Area Need Improvement	Progress Notes were vague and lacked sufficient information to conclude that strategies were being followed as identified. The agency needs to ensure that it documents progress relative to staff’s implementation of services and support strategies for individuals served.	
Process Utilized to correct and review indicator	Both data collection and progress report formats have been revised to reflect the changes.  Staff will be trained in the use of them within the next three months.	
Status at follow-up	Forms have been revised to allow for documentation of staff’s implementation of the support strategies.  	
Rating	Met