PERSONAL SAFETY

L1

Individuals and guardians are trained in how to report alleged abuse/neglect.

	Regulations 9.04 (2): All providers shall provide to all individuals served an initial and subsequent, annual training on when and how to file a complaint or obtain assistance under 115 CMR 9.00.  Such training shall include use of alternative means of communication where the individual is hearing or speech impaired or unable to communicate without assistance or an interpreter. 

Guidelines:

Individuals must be informed of how to file a complaint, including DPPC Hotline information, what constitutes a reportable condition and their right to file a Complaint if they have reason to believe that there is mistreatment, abuse or neglect occurring.  Individuals should be trained in accordance with their communication and other needs.

Guardians of individuals need to be provided with information and training on how to file a complaint. This serves as an additional safeguard for individuals who, even with individualized training, may not comprehend how to file a complaint.  
	
Abuse and mistreatment training documentation 

Staff interview 

	
A sample of individuals’ training records is reviewed to determine whether there is documented abuse and mistreatment training to individuals that has occurred in the past year.  This is further validated by checking those with communication needs and any special accommodations needed against methods used to train.

A sample of guardian documentation is reviewed to determine whether guardians have been apprised of how to report alleged abuse/neglect.

Individuals have received training in the past year in accordance with their method of communication and guardians received information on the procedures for reporting alleged abuse/neglect.

Individuals have not received training at all or did not receive training in accordance with their method of communication and/or guardians did not receive information on the procedures for reporting alleged abuse/neglect.

L2

Allegations of abuse/neglect are reported as mandated by regulation

	
Regulations 9.06 (2):  A Department or provider employee is mandated to and shall immediately file a complaint under 115 CMR 9.00 with the senior investigator for the region when he or she has reason to believe that there is a non-frivolous allegation of mistreatment, an illegal, dangerous or inhumane condition or incident, or a medicolegal death of an individual. … 

Guidelines:
 (Note: since this regulation was promulgated, all complaints get filed with DPPC which decides on the appropriate disposition).

Policies and procedures need to outline staff’s role as mandated reporters, and specify those conditions and situations requiring the filing of a complaint.  All staff need to be knowledgeable concerning what constitutes a reportable condition, their role as mandated reporter, and practices for filing with the DPPC, and reporting to supervisory personnel.   
	
Policies and procedures for reporting abuse and mistreatment

DPPC Complaint Allegations 

Communication Log 

Individual Record 

Staff interview	
Review of Policy.

A review of complaints filed to identify those complaints that have been filed.

A review of a sample of documentation (individual and location) is conducted to assess whether reportable items noted within communication log or incident reports were also filed as complaints.

Staff interviewed to determine knowledge of what constitutes reportable allegations.	
Policy is in place, and does not require someone to ask permission of their supervisor prior to filing; review of complaints indicates that staff are filing, and information shared through either interview or documentation showed no evidence of unreported allegations.
	
Policy is either not in place or requires someone to ask permission of their supervisor prior to filing, and/or information shared either through interview or documentation shows that an allegation went unreported.
	
L3

Immediate action is taken to protect the health and safety of individuals when potential abuse/neglect is reported

	Regulations 9.06 (4)(a): the Regional Director or designee shall notify the provider, who shall be responsible for taking immediate action; (b):  The head of any provider notified of a complaint alleging any physical abuse including any sexual activity between an individual and an employee of the provider shall immediately remove such employee from all direct contact responsibilities pending resolution or investigation of the complaint.

Guidelines:
Immediate actions must be taken by the provider once the provider becomes aware of the allegation.  These activities, such as removing the employee from all contact with individuals, must remain in place pending the results of the investigation.  

The agency needs to have a system for ensuring that immediate actions are issued when necessary, and for monitoring these actions to ensure that they remain in place pending resolution.
	DPPC Complaint allegations 

Staff Interviews 

Agency policy

	A sample of complaint allegations is reviewed to determine if immediate action occurred as required. 

In discussion with agency determine whether action has occurred to protect individuals.

	Immediate actions were determined to have occurred.	Immediate actions referenced did not occur.	
L4

Action is taken when an individual is subject to abuse or neglect 	Regulations 9.10 (5): Any individual or provider required to implement corrective action or protective services set forth in the Action Plan shall provide documentation to the designated staff person that the corrective action or protective services have been implemented in accordance with the time-lines set forth in the Action Plan.  The designated staff person is responsible for enforcing this provision.

Guidelines:
There are a variety of specific actions that are typically set forth in the Action Plan including but not limited to (re)training, suspension, increased supervision and monitoring and disciplinary actions. 

The agency needs to have a system for ensuring that all specific actions are taken, and for monitoring these actions to ensure that they remain in place as indicated.

	HCSIS Action Plans- off site

Interview with “designated staff person responsible for enforcing this provision” –corporate office

Provider documentation relative to action plan – corporate office.
	A sample of action plans is reviewed to determine whether actions outlined within the reports have occurred

When the action plan resolution page does not indicate that action was completed, follow-up with staff to determine whether actions were completed as required.

	Actions outlined in the plan occurred within specified time frame.	Actions outlined in the plan were not fully implemented within specified time frame.

L5

There is an approved safety plan in home and work locations	
Regulations 7.08 (3):  All providers, except those providing family respite and home-based respite, shall prepare and file with the area office a written safety plan assuring the safety of individuals in the event of a disaster, such as fire, explosion, loss of heat or electricity, interior flooding, or any other circumstances requiring the evacuation and temporary or indefinite resettlement of individuals. (See regulations for details.)
 
Guidelines:

The safety plan must be approved every two years.  It cannot require staff to return to the building to evacuate others.

Existing practices must be consistent with the safety plan.  (e.g. individuals names; staffing patterns; protocol as written is what is being performed)

All required components need to be contained in the safety plan.

Plans must include any environmental / other exceptions noted to be present. (e.g. large porch in lieu of second means of egress in house; nighttime fire drills simulated)
	Safety Plan on site
Provider Assurance form

Site review
Staff interviews	A sample of Safety Plans is reviewed to determine whether plans are updated as required, contain all the required components and reflect actual conditions in the home or workplace.  	Safety Plan must be approved by AD or designee, be less than two years old, include all elements, and reflect current practices.	Safety plan is  outdated, and/or reflects staffing pattern not in place and/or does not include all individuals and/or needs to be revised.	
L6

All individuals are able to evacuate homes in 2.5 minutes with or without assistance and workplaces within a reasonable amount of time

	
Regulations 7.08 (3) (b) 6:  Procedures for safe evacuation of individuals and staff from the location where services are provided.  For homes, safe evacuation is defined as assuring that all individuals can get out of the home or any other location in which services are provided in 2 ½ minutes with or without assistance without the necessity of staff who have evacuated returning, in accordance with professionally accepted fire safety evacuation procedures.  For work/day supports, safe evacuation is defined as assuring that individuals can evacuate in a safe, orderly and timely manner, with staff assigned to individuals needing assistance.

Guidelines:
This regulation applies to all homes, not just 24 hour locations as well as all site based day services.

Where an individual who has consistently evacuated historically, but experiences current difficulties and has not evacuated in 2.5 minutes, there is a (training) plan to resolve this situation.

When simulation is part of the plan, the rationale for this due to the fragility of the individual(s) is clearly outlined, and nighttime fire safety is adequately assured (e.g. staff training; at least one nighttime drill per year)  

When living in a high rise apartment, ambulatory individuals must evacuate promptly via the stairs.  If the building has a plan for rescue of disabled individuals from the upper floors, staff may remain with individuals in wheelchairs pending fire department rescue.

In site based respite, staff need to be familiar with evacuate strategies, and fire drills must occur to ensure that staff can implement evacuation procedures consistent with safety plan.
	Fire drill logs for 24 hour homes and site based day supports 

Staff interview
Less than 24 hour residential supports – individual interview	A review of the fire drill records for a sample of locations for the past year to determine whether individuals were able to evacuate in 2.5 minutes from residences and in a reasonable amount of time from day services.  

Where the location has a current approved FSES waiver in place, fire drills are assessed to determine whether the evacuation time is consistent with the approved FSES waiver time limit.  

Determine if individuals have been trained and know how to evacuate safely.

In homes where regulation does not specify a minimum requirement for drills, the provider has a means for initial and periodic assessment of the individual’s ability to evacuate. 

	Individuals in homes are able to evacuate in 2.5 minutes or less or in site based day services in a reasonable time.

The provider is implementing strategies, which are supported by documentation, to resolve a temporary new situation relative to one individual.	Individuals are not able to evacuate homes in 2.5 minutes or less or in site based day services in a reasonable time.

Fire drill logs for the location indicate that some shifts/ staff have delayed evacuation times, and /or there is no evidence that the provider is  implementing any strategy to resolve a temporary situation. 	
L7

Fire drills are conducted as required.	
Regulations 7.08 (3) (b) 7
a. Residential supports providing 24 hour staffing shall conduct quarterly fire drills with records of evacuation times and types of assistance, if needed, and assessments of individual and staff performance.  At least two drills per year shall be conducted in the nighttime when individuals are in bed and asleep.  
b. Providers of work/day supports shall conduct two fire drills annually, with records of evacuation times and types of assistance needed, if any, and assessments of individual and staff performance.  

Guidelines:
The purpose of the fire drills is to ensure that both staff and individuals are trained and familiar with strategies for evacuation, and can demonstrate evacuation within 2.5 minutes (unless an approved FSES waiver is in place for extended time).  

Fire drills need to be conducted with the minimum number of staff noted in the safety plan, and the Provider needs to demonstrate success in meeting evacuation time with the requisite number of staff.

Fire drills must be documented correctly (e.g. type of assistance needed; time to exit, etc.)

Blocked egress fire drills so that both staff and individuals become knowledgeable and trained in the utilization of both ways out, is strongly recommended.  

Where the location has a fire drill strategy that differs from regulation, fire drills must meet that particular standard. (e.g. more frequent drills).

If approved through the safety plan, simulated fire drills can be conducted (e.g. when there are medical contraindications to night-time fire drills due to the fragility of the individuals(s)). The need for the provider to forgo the individual’s actual participation must be documented in the safety plan along with the basis for this determination.  Where simulated drills are in place, staff need to  serve in place of the individuals in the drill and to replicate, to the fullest extent possible, the conditions the fire drill is intending to demonstrate.  (e.g. Ensure that staff are knowledgeable and practiced in evacuating all individuals should there be a night time fire when individuals are in bed).
	Fire drill logs 
	Fire drill records for a sample of locations for the past year are reviewed to determine whether fire drills were conducted as indicated in regulation and documented appropriately.  

	Fire drill logs for the location indicate that fire drills were conducted at the frequency and with the minimum ratio of staff outlined in the safety plan (but not less than 4 per year with 2 at night in 24 hour homes and 2 per year in site based day services ); documentation of fire drills is complete.

	Fire drill logs for the location indicate that fire drills were not conducted as frequently as required and/or are not conducted with the minimum ratio of staff; or there are 
several documentation omissions/ errors. 
	
L8

Emergency fact sheets are current and 
accurate and available on site
	Regulations 4.03 (4):  Emergency Information.  Each individual’s area office and provider record shall contain, in readily accessible and duplicate form, descriptive and other information of use in finding an individual if missing, or otherwise in an emergency, as more fully set forth in 4.03 (4) (a) through (n).

Guidelines:
The Emergency Fact Sheet must be accurate and current.  It needs to include identifying information such as age, general physical characteristics, emergency contacts, guardian information, general nature of abilities and physical handicaps, special medical needs and current medications.

However, confidential information (e.g. HIV status) must be maintained separately.  
	
Emergency Fact Sheets -  on site

Other individual documentation 	
A sample of Emergency Fact Sheets at the provider location are reviewed and compared with other individual information to determine whether information is complete and current.	
The Emergency Fact Sheet is current and complete.	
The Emergency Fact Sheet is not current and/or is incomplete.	
L9

Individuals are able to utilize equipment and machinery safely.	Regulations 7.08 (2)(a) and  (c):
a. All providers shall assure that individual safety assessments are conducted and that strategies are developed for meeting the specific and unique safety needs of each individual.  Individual’s safety needs shall be conducted as part of the individual’s ISP.

c.  Safety strategies may include modification to the location where services are provided, other environmental modifications and use of adaptive technology, staff supports, staff training focused on the individual’s needs, and education of the individual to assure optimal understanding and independence regarding safety precautions and procedures.

Guidelines:
Training and education are essential pre-requisites to using equipment and machinery as independently as possible.  Guidance, supervision, review of safety precautions, and generalized training must be provided for any equipment, such as a microwave or a lawn mower or a piece of machinery before individuals begin to use them independently.  

Evaluation of the individual’s skills and his/her  independence in operating devices needs to occur as the first step in the formulation of individualized training that matches an individual’s learning style.  
Formalized documented training to individuals to use appliances or daily equipment at home such as the stove, microwave, or blender is not necessary; however, it is important that individuals receive some basic instruction and information prior to use.  This will assist individuals to become more independent as well as informed and knowledgeable concerning basic safety precautions of appliances and equipment such as caution around stove tops and avoiding the use metal objects in microwaves.  
	Staff interview
Individual Record
Staff Log	A sample of individual information is reviewed to determine whether individuals received the necessary training to utilize equipment and machinery safely.	Training has occurred so that individuals are using equipment and machinery safely.  	Training has not occurred and/or is inadequate in teaching an individual to utilize equipment and machinery safely.	
L10

The provider implements interventions to reduce risk for individuals whose behavior may pose a risk to themselves or others. 
	Regulations 5.03(2)(e) Services and supports are to be provided in such a manner that promotes;  ….The opportunity to undergo typical developmental experiences, even though such experiences may entail an element of risk; provided, however, that the individual’s safety and well-being shall not be unreasonably jeopardized;

Guidelines:
Some individuals may exhibit behaviors, actions, or have conditions that may pose a risk to themselves or others.  Staff must be familiar with those behaviors, “triggers”, and situations that, when they occur, are identified.  For example, risks may include the presence of certain health care conditions, exercising poor choices, engaging in activities that place the person or others at risk as well as exhibiting certain risky behaviors.

Once identified, an assessment of the degree of risk, as well as strategies must be outlined to address this risk.  Strategies may include, but are not necessarily limited to risk plans.  Staff must be knowledgeable about the particular behaviors and conditions as well as strategies in place to address them.  Training in how to implement strategies as designed must occur.

Reviews of the risks and effectiveness of the strategies to manage the risk must also occur.  
	Staff Interview 

Staff Log/Individual Record 

Risk Plans/ ISP/ Meditech information	Review staff’s knowledge of potential individual risky behavior and their plans and activities to mitigate that risk.

Review individual record and staff log to identify needs in this area, which should then be reviewed with staff during staff interview.  Review whether staff aware of the individual risks and whether they are being addressed.	Clear strategies are in place as needed outlining interventions to reduce risk for individuals and are implemented. 	Clear strategies are not in place when needed and/or do not outline needed interventions to reduce risk and/or plans are not fully implemented.	
ENVIRONMENTAL SAFETY

L11

All required annual inspections have been conducted
Revised 3/1/19

	Regulations 7.07 (1): All homes and work/day supports must meet all applicable building, sanitary, health, safety, and zoning requirements.

7.07 (5) (f) Heating and plumbing systems shall be installed and maintained for safe, healthy, and comfortable use by the individuals supported by the provider.

Guidelines:
Required inspections  include the following:
•	Section 8 Housing Inspection
•	Certificate of Occupancy (CO) for day/work program
•	Signed building permits for any renovations; CO if needed for major renovations performed prior to occupancy
•	Certificate of inspection from Board of Health for any work/day service location that prepares food for retail sale
•	If sprinklers are present, annual inspection for sprinklers are needed
•	Elevator inspection
•	Annual*** maintenance inspections and service (for oil/gas furnaces)*
•	Annual maintenance inspections and cleaning for fireplaces, wood-burning and pellet stoves*
•	Annual inspection by Placement Service Provider for each home provider location

Where Section 8 Inspections are in place, only a partial site review would be conducted for several of the following indicators.   (** this item is reviewed as part of Section 8)  Although several indicators are not designated for review, if a deficiency is noted while completing other sections of licensure, the deficiency must be noted and the indicator rated.  

Each furnace varies, and each manufacturer may assign different level(s) and type(s) of ongoing routine service requirements and maintenance schedules for safe operation.  In order to ensure that heating systems are well-maintained and safe, at least annually the furnace needs to be inspected by a qualified service technician to confirm that it is functioning effectively and determine whether any service or maintenance is needed.  Demonstration through a tag, invoice, receipt or notation from a qualified person that the unit has been inspected and either requires “no service” or “needs (something) in some (time parameter)” is sufficient to meet this requirement.  

(*furnaces must be serviced in accordance with Manufacturer’s specifications)

(***As of 9/1/17, Providers have up to 15 months between heating inspections to be considered acceptable as annual inspections)
	Inspection and service documentation

Current Section 8 inspection letter

	A sample of home and work locations is visited and inspections are viewed. 	Presence of all inspections including annual service inspections from qualified technicians. 

Or Section 8 letter	One or more inspections (including annual service inspections from qualified technicians) is missing.	
L12

Smoke detectors and carbon monoxide detectors, and other elements of the fire alarm system required for evacuation are located where required and are operational.  

	Regulations 7.07 (7)(c):
All homes shall have approved smoke detectors in accordance with current Massachusetts State Building Code requirements.  If more than one detector is required per home, each detector shall be interconnected so as to activate all other detectors.

Guidelines:
Carbon Monoxide detectors are now required by the Massachusetts State Building Code and must be within 10 feet of bedrooms.

In homes, there must be  at least one approved smoke detector on each level of the home, including basements.  On any floor, level or story exceeding 1200 square feet or part thereof, smoke detectors are located outside sleeping areas on every floor of the home (or inside bedrooms if the fire system has been installed or upgraded after 8/27/97).  

In residential homes not owned or leased by the individual(s), if more than one smoke detector is required in the home, each detector must be interconnected so that when one activates, all will sound.

Where present, such as in sites supporting individuals who are deaf or blind, additional adaptations should be in place and operational including bed shakers, audible horns and strobe lights.	Site review 

Current Section 8 inspection letter	A sample of locations is reviewed to determine whether smoke and CO detectors are located as required and are tested to determine if they are operational. If sounding the alarm would disrupt others in the building, documentation indicating that alarms are operational will suffice. 

Not reviewed if reviewed by Section 8
	Smoke detectors and Carbon Monoxide detectors are present in the proper locations and are operational.  If home is owned or leased by the provider, if one smoke detector sounds, all detectors sound.  When needed for evacuation additional adaptations are operational.

Or Section 8 letter	Smoke detectors and/or Carbon Monoxide detectors are not present in the correct locations and /or are not fully operational and/or other needed adaptations are not operational.	
L13

Location is clean and free of rodent and/or insect infestation 

	Regulations 7.07 (3):  
All providers must assure that the location in which supports are provided is clean, environmentally safe, free of vermin 

Guidelines:
The site must be free of infestation and in clean, sanitary condition.  Cleanliness and sanitation of all areas of the location is critical to prevent the likelihood of infestation.

If the agency has experienced difficulty with rodent or insect infestation in the past, there must be an initial, and possibly a routine pest/insect control service consultation(s)/ schedule established.

Interior:  Home must be clean and free of unnecessary garbage and rubbish that would invite pests.

Exterior:  Garbage and rubbish are stored in rodent-proof, water tight receptacles with tight fitting covers.  There is no rubbish accumulating against or near the home.  
	Site review

Documentation of consultation with Pest control services, if pests are present

Section 8 inspection
	A sample of locations is reviewed, and the location is inspected for evidence of rodents and/or insects and for clean sanitary conditions.  

Not reviewed if reviewed by Section 8

	Location is observed to be free of evidence of rodents or insect infestation and the site is clean and sanitary.

Or Section 8 letter
	Location is not free from rodent/ insect infestation, and/or the location is not engaged in actions moving toward resolution and/or site is not in clean, sanitary condition.	
L14

Handrails, balusters, stairs and stairways are in good repair.	Regulation 7.07 (1):  All homes and work/day supports must meet all applicable building, sanitary, health, safety, and zoning requirements.

Guidelines:
Handrails both inside and outside need to be present when required. (shall be provided on at least one side of each continuous run of treads or flight with three or more risers).  The handrails need to be between 34-38 inches in height.  They need to be sturdy and able to support use of stairs for all individuals.
	Site review
current Section 8 inspection letter	A sample of sites is reviewed to determine if handrails and balusters are located as required and in good repair.

Not reviewed if reviewed by Section 8
	All handrails and balusters are located as required and in good repair.

Or Section 8 letter	Handrails and balusters are not located as required and/or are not in good repair.	
L15

Hot water temperature tests between 110 and 130 degrees. (Effective January2014: Hot water temperature tests between 110 and 120 degrees.)
	Regulations 7.07 (1):
All homes and work/day supports must meet all applicable building, sanitary, health, safety, and zoning requirements.
7.07(5)(f) Heating and plumbing systems shall be installed and maintained for safe, healthy and comfortable use by individuals.

Guidelines:

Sanitary codes indicate the need for water temperature in homes to be 110 to 130 degrees.  As of January 2014 the more stringent standard which is based on the plumbing code and the Consumer Product Safety Commission’s recommendations will be:  Deliverable water temperatures should be no more than 112 degrees for shower temperatures, and no more than 120 degrees for residential faucets and 110 degrees for faucets in public buildings (employment / day sites).  

While water heaters can be set slightly higher to ensure that bacteria is killed and dishwashers are accommodated, the delivered water temperature (temperature when it comes out of the faucet) should be at these lower levels.  This can be accomplished by equipping faucets and shower heads with thermostatic mixing valves and/ or anti-scald devices.  To ensure that the temperatures remain within acceptable limits, it is important that the providers develop a system to regularly check deliverable water temperatures, and take any necessary actions such as replacement of the mixing valves or adjustment of the thermostat, when the deliverable water temperature exceeds the standard. 

In work/day locations, standard for water temperature at sinks must be no higher than 110 degrees; plumbing fixtures requiring higher temperatures for their proper use e.g. if showering facilities present must be between 110 and 130 degrees.

In all locations, where individuals are utilizing water with staff assistance, all necessary precautions must be taken to regulate the water temperature, and to keep the temperatures at safe optimal levels.  For example, in locations where individuals are less mobile, water may pool/ collect on the individual and is more likely to scald at lower temperatures.  In these locations, use of scald protectors, adjustment of the water temperature to lower levels, and ongoing checks of the water temperature is advised.

Anti-scalding devices installed that shut water off when temperature exceeds 130 degrees are typically found in apartment dwellings where water temperature is not under the control of the provider.
	Site review
current Section 8 inspection letter	A sample of sites is reviewed, and water is tested with a thermometer to determine if it is within acceptable range.  

Not reviewed if reviewed by Section 8 and explicitly written in report (sometimes performed and referenced; sometimes not)
	Water temperature is within acceptable limits.

If reviewed by Section 8, the  inspection letter confirms the standard was met.	Water temperature is not within limits.	
L16

The location is adapted and accessible to the needs of the individuals.	Regulation 7.07 (4): All providers must assure that a barrier-free environment is provided in those locations used by persons with substantial mobility impairment, to the extent necessary to permit access to the supports, services, personal, and common areas.  A location shall be deemed to be barrier free, in whole or part, if it meets the applicable standards of the Architectural Access Board (521 CMR) as adopted in the Massachusetts State Building Code (780 CMR).

Guidelines:
A barrier free environment is essential for individuals with mobility impairments to fully access their home as independently as possible.  

Additionally, adaptations to meet individual needs, such as rails on walls for individuals with vision impairments, color coded charts for laundry and adapted cooking equipment provide opportunities for individuals to gain skills and to perform activities such as personal care and cooking with increasing independence, which enhances feeling of self worth.     	Site Review
Observation
Staff Interview
Individual record review	A sample of locations is reviewed to determine whether the location is adapted and accessible to meet the needs of the individuals supported at the site.  	The site has the necessary accessibility and adaptations to meet the needs of the individuals supported at the site.	The site does not have the necessary accessibility and/or adaptations to meet the needs of the individuals supported at the site.
	
L17

There are two means of egress from floors at grade level	Regulations 7.07(7) (a):
All homes shall have two means of egress from floors at grade level; all other floor above grade level shall have one means of egress and one escape route serving each floor and leading to grade.  Any proven usable path to the open air outside at grade shall be deemed acceptable as an escape route, including but not limited to connecting doors, porches, windows within six feet of grade, ramps, fire escapes, balcony evacuation systems, etc.  Double cylinder deadbolt locks that require key operation from within are prohibited on egress doors.

Guidelines:

Egresses must be proven and usable by all individuals;  e.g. if stairs are present for front and back egresses,  these egresses cannot be utilized for individuals in wheelchairs.  The location must have at least one usable egress for those in wheelchairs; .e.g. ramp without stairs. 

Egresses cannot be blocked.	Site review

Staff interview/ observation

current Section 8 inspection letter

	A sample of locations is reviewed to determine whether there are two means of egress from floors at grade level.  .  

Individual’s ability to utilize the egress is assessed.

Since the Section 8 review does not review whether egresses are usable, this aspect will always be reviewed.  

If there are non-ambulatory individuals, the location is reviewed to determine whether there is at least one ramp.	The location has two means of egress from floors at grade level that individuals are able to use  or at least one ramp and one other exit in sites supporting individuals in wheelchairs.  

	The location does not have two means of egress at grade level that individuals are able to use or at least one ramp and one other exit in sites supporting individuals in wheelchairs.	
L18

All other floors above grade have one means of egress and one escape route on each floor leading to grade	Regulations 7.07(7) (a):
…all other floor above grade level shall have one means of egress and one escape route serving each floor and leading to grade.  Any proven usable path to the open air outside at grade shall be deemed acceptable as an escape route, including but not limited to connecting doors, porches, windows within six feet of grade, ramps, fire escapes, balcony evacuation systems, etc.  …

Guidelines:
Escape routes/ egresses must be proven and usable by all individuals; e.g. If requiring an individual to leave from a window, the individual(s) must have the physical capacity to use this route and their ability to use this route has been tested successfully.

High rise apartments are subject to different building codes.  As such, apartments within the high rise must have one egress and one escape route, and an apartment plan that identifies units within the building that rely on fire department rescue.     

Residential elevators cannot be utilized in the event of a fire, and therefore do not “count” as an egress/ escape route for individuals in wheelchairs. 

Basement levels utilized  as sleeping space must also have one means of egress and one escape route from that floor.  

Exceptions to environmental requirements can be waived through inclusion in the safety plan and approval by the Area Director provided however that the safety needs of individuals are otherwise adequately addressed.(Regulations 7.07(8))	Site review

Staff interview/ observation

current Section 8 inspection letter

	A sample of locations is reviewed to determine the individual’s ability to utilize the egress is assessed.

Since the Section 8 review does not assess that the egresses are “proven usable” this aspect will always be reviewed.  

	The location has one means of egress and one proven escape route from floors above grade level that individuals are able to use or there is an exception approved through the Safety Plan.	The location does not have one means of egress and one proven  escape route from floors above grade level that individuals can use, and there is no exception to this requirement noted and approved through the Safety Plan.	
L19

Bedrooms for individuals requiring hands on physical assistance to evacuate or who have mobility impairments are on a floor at grade or with a horizontal exit.	Regulations 7.07 (g):
Bedrooms of individuals requiring hands on assistance to evacuate or who have a mobility impairment, including individuals who use a wheelchair, shall be on a floor at grade or on a floor with a horizontal exit: as set forth in current Massachusetts State Building Code requirements for horizontal exits.

Guidelines:
Individuals who need assistance to ambulate or move from one place to another using stairs cannot have bedrooms above grade.  This would include individuals in wheelchairs and most likely individuals that use a walker.  Individuals must be capable of walking down the stairs on their own, although they may need physical guidance from staff because they are confused or unsure of what to do in an emergency. 

High rise apartments are subject to different building codes.  As such, apartments within the high rise can serve individuals in wheelchairs on the upper floors provided that the apartment building has a plan that identifies units within the building that rely on fire department rescue, and the fire department is aware of their role in evacuation.

Residential elevators cannot be utilized in the event of a fire, and therefore placement of individuals in wheelchairs on upper floors in homes is not permitted. 	Site Review

Individual / staff interview/ observation

	A sample of locations is reviewed  to determine whether any individuals with mobility impairments are situated in bedrooms not located at grade or with a horizontal exit.	Bedrooms where individuals requiring hands on physical assistance to evacuate or who have mobility impairments are on a floor at grade or with a horizontal exit.	Bedrooms where individuals requiring hands on physical assistance to evacuate or who have mobility impairments are not on a floor at grade or with a horizontal exit.  	
L20

Exit doors are easily operable by hand from inside without the use of keys.	Regulations 7.07 (7) (a) 
…Double cylinder dead bolt locks that require key operation from within are prohibited on egress doors.

Guidelines:
If a connecting door between two apartments is utilized as each apartment’s second exit (e.g. through the other apartment to the outside), both sides of the door must be easily openable by residents from either apartment without use of keys.  

For physically involved individuals who cannot operate door knobs, door handles can be used in place of the door knobs. 	Site Review

current Section 8 inspection letter
	A sample of locations is reviewed, to determine whether there are any exit doors that require the use of keys.

Not reviewed if reviewed by Section 8
	Exit doors are free of inside locks that require keys, and are easily operable. 

Or Section 8 inspection letter 	Exit doors have inside locks that require keys, and/or are not easily operable.	
L21

Electrical equipment is safely maintained.	Regulations: All homes and work/day supports must meet all applicable building, sanitary, health, safety and zoning requirements.

Guidelines:
Locations must meet the following:
•	Wall receptacles and power strips are not overloaded; e.g. there must be no more than one appliance cord plugged into an outlet and no more than a few low current devices such as electronics plugged into power strips. .  
•	All visible cords are free from cracks or wear.  Multiple plug adapters are not used on any appliance.
•	There is no electrical wiring passing across frequently traveled floor areas, under floor coverings such as rugs, or extending through doorways or other openings.  
•	When necessary, only heavy-duty cords can be used on major appliances such as air conditioners.  
•	Fuses and circuit breakers are labeled.  A supply of fuses is kept next to the fuse box.
	Site Review

Section 8 letter	A sample of locations is reviewed to determine if electrical equipment is safely maintained.

Not reviewed if reviewed by Section 8
	Each of the five requirements as outlined in the guidelines has been met.
 
Or  Section 8 letter.	The presence of one or more issues as noted in the guidelines is observed.	
L22

All appliances and equipment are clean, operational and properly maintained.
(changes effective 5/1/16)	
Guidelines:
All major appliances and equipment, including seasonally and periodically used appliances need to be properly maintained and in good working order.  This includes items such as washers, dishwashers, stoves, toasters, toaster ovens, air conditioners, dehumidifiers, and other equipment that requires proper maintenance to assure its safe use.  

Appliances need to be free of visible leaks.  Dryer vents and filters need to be properly maintained, and lint free.  

Provider must assure that appliances and equipment are maintained in good working order by conducting and documenting on-going safety checks.  Provider must also obtain any necessary inspections for equipment as indicated. 

Portable free-standing heaters can only be utilized in limited circumstances.  Radiator-type heaters that are UL inspected, and electric or oil-filled with automatic shut-off switches are acceptable.  They must not be used as the primary source of heat, nor can they be used when people are asleep.  They can be used in cases of unusual or rare situations, and not routinely through the winter.  A written plan outlining the proposed use and addressing the implementation and monitoring is required.  

The outdoor grill is located away from the home, and is properly maintained according to local town ordinances.  Gas grills cannot be located on wooden porches or on balconies. They must be located at least 10 feet from the house. 	Site Review

current Section 8 inspection letter

	A sample of locations is reviewed to determine if appliances are clean and properly maintained as outlined in the guidelines.

Not reviewed if reviewed by Section 8
	Each appliance within the location is clean and properly maintained.

Or Section 8 inspection letter	The location has one or more appliance or equipment that are found to be not clean and/or properly maintained in good working order and/or provider does not have an adequate system to assure the ongoing maintenance and safety of equipment/ appliances.  

(“Point in time” -  new situations in which immediate actions have already been taken by the agency to resolve, do not require a rating of “not met”; e.g. dishwasher broke on date of visit; plumber was immediately called)

Lint in the dryer filter, without any other problem in this area is not sufficient to rate “standard not met.”  Lint build-up in the dryer hose, behind the drier or in the vent must be rated “standard not met.”
	
L23

There are no locks on bedroom doors that provide access to an egress.	Regulations 7.07 (7) (e):
Locks on bedroom doors which provide access to an egress are prohibited.

Guidelines:
Privacy may be impacted for any individual whose bedroom provides access to an egress.    Therefore the individual must understand that his/her bedroom will be used during fire drills and fire emergencies, and not to use a lock on his/her bedroom door. 
	Site Review	A sample of locations is reviewed to determine whether there are any locks on bedroom doors that provide access to an egress. 
	There are no locks on bedroom door(s) that provide access to an egress.	There is a lock on bedroom door(s) that provides access to an egress.	
L24

Locks on doors not providing egress can be opened by the individuals from the inside and staff carry a key to open in an emergency.	Regulations 7.07 (7) (f) : Locks on bedroom doors which do not provide access to an egress shall be permitted only in accordance with the following: 1. The head of the provider has documentation that the lock may be easily opened from the inside without a key and that the individual is able to unlock the door from the inside; and 2. At all times staff carry a key or have immediate access to a key to open the door in the event of an emergency.

Guidelines:
Doors not providing access to an egress (bedrooms, bathrooms, closets) can only have a lock if they can be opened by the individuals and staff are able to open in an emergency.    	Site Review

Documentation review	A sample of homes is reviewed to determine if locks on bedroom doors can be opened by the individual from the inside and staff carry a key to open in an emergency.	Locks on doors are either not present or individuals can open and staff have a key. 	Locks on doors are present and individuals can not open and/or staff do not have a key. 	
L25

Potentially dangerous substances are stored separately from food and are in containers that are accurately labeled.

	Regulations 7.07 (5) (h):
All substances that are potentially dangerous in nature shall be stored separately from food in containers which are accurately labeled.  

Guidelines:
Household cleaners and other non-edible, toxic items must be stored away from food items, and clearly labeled.

If anyone at the location exhibits pica, the provider must take necessary steps to eliminate access to these items for those who need that level of support / restriction; e.g. supplies are locked up.

This is also a requirement at placement service locations; however, the manner in which this is assessed may differ from other services.  For example, the home care provider should be encouraged to participate in a full environmental review of their home, including review of storage.  Information from the Placement Service Provider’s monthly visits to this location may also be reviewed.  
	Site Review	A sample of locations is reviewed to determine that potentially dangerous substances are stored separately from food and are in containers that are accurately labeled.	No dangerous substances present near food, and/or unlabeled.	Potentially dangerous items are present near food and /or unlabeled.	
L26

Walkways, driveways and ramps are in good repair and clear of ice and snow.	Regulation 7.07 (1):  All homes and work/day supports must meet all applicable building, sanitary, health, safety and zoning requirements.

Guidelines:
Ramps, driveways and handrails must be adequately maintained (accessible, useable, functional, safe, and with adequate lighting on pathways, exits and ramps.)  

Walkways need to be maintained in safe condition in all seasons (e.g. kept reasonably clear of ice, leaves, snow, and other elements of the weather).  This includes both the primary and secondary egress pathways.  Following a snow storm or other weather condition, actions need to be taken promptly.	Site Review	A sample of locations is reviewed to determine whether driveways and ramps are in good repair and clear of ice and snow.	Walkways, driveways and ramps are in good repair and clear of ice and snow.	One or more walkways, driveways and ramps are not in good repair and/or are not clear of ice and snow.	
L27

Swimming pools are safe and secure according to policy.	Regulation 7.07 (1):  All homes and work/day supports must meet all applicable building, sanitary, health, safety and zoning requirements.

Guidelines:
Having a pool in the home can be a positive addition to individuals’ quality of life.  If used safely, it can increase a person’s physical fitness and overall sense of well being.  There needs, however, to be procedures in place that support safety when there is a pool.  Safety requirements are covered in the DDS “Safeguards for Pools.”  The safety requirements for staffed residences  include when the pool is in use, there needs to be at least one staff present that has completed an American Red Cross course in Emergency Water Safety (or equivalent) and one that is certified in CPR.  For all service locations where a pool is present, there need to be policies and procedures that cover the assessment of individual water safety skills, staff training and supervision requirements and environmental safeguards that meet applicable local ordinances and for when the pool temporarily is not in use to ensure individuals are protected from accidently falling in or accessing the pool without supervision.   
	Site review 

Policies, procedures, and training around the use of the pool 

Staff interview	Homes with swimming pools are reviewed to determine whether the entrance to the pool is locked and the pool is maintained safely as per DMR policy.

Review of training information (water safety), policies and precautions regarding pool use.

Determine whether staff are knowledgeable about the agency pool policies and procedures.	Swimming pool is safe and secure according to DDS policy.	Compliance with one or more requirements from the DDS policy is not occurring.	
L28

Flammables are stored appropriately.	
Regulations 7.07 (5) (h):
No flammable liquids, such as gasoline, shall be stored in the home or in spaces attached to the home.

Guidelines:
Store oxygen per manufacturer’s direction, and away from heat sources.  Regarding other materials such as small amounts of lighter fluid for grills and the like, placement must be at least 10 feet away from the house and/or stored in a fireproof container away from heat sources.  	Site Review

	A sample of locations is reviewed to determine that flammables are stored appropriately.

	Flammables are stored appropriately in fire rated containers (UL listing).

	Flammables are not stored appropriately in fire rated containers (UL listing)	
L29

No rubbish or other combustibles are accumulated within the location including near heating equipment and exits.	Regulation 7.07 (1):  All homes and work/day supports must meet all applicable building, sanitary, health, safety and zoning requirements.

Guidelines:
This gets evaluated when the provider has either direct (e.g. provider as homeowner) or indirect responsibility (e.g. provider as renter).  For example, when the provider is leasing the home from a community landlord who has stored items inappropriately by the furnace, the provider needs to ensure that rubbish and/or combustibles are removed from the heating equipment and exits.
	Site visit 

current Section 8 inspection letter

	A sample of locations is reviewed to determine that no rubbish or other combustibles are accumulated near heating equipment and exits.

Not reviewed if reviewed by Section 8

	No excessive rubbish or other combustibles are accumulated within the location near heating equipment and exits.

Or Section 8 inspection letter	Excessive rubbish or other combustibles are present near heating equipment and /or exits.	
L30

The exterior of the home, including every porch, balcony, deck or roof used as a porch or deck has a wall or protective railing, is in good repair.	Regulation 7.07 (1):  All homes and work/day supports must meet all applicable building, sanitary, health, safety and zoning requirements.

Guidelines:
The exterior of the home / work location including porches roof, decks, and other elements are in good repair.   Structural safety concerns relative to porches and balconies need to be ensured.  Guardrails shall be no less than 36 inches in height.	Site visit

Current Section 8 inspection letter

	A sample of locations is reviewed to determine whether the exterior of the location is in good repair and porches, balconies, decks or roofs used as a porch or deck has a wall or protective railing in good repair.

Not reviewed if reviewed by Section 8

	At each location visited, the decks, porches, walls and exterior of the location are in good repair.

Or Section 8 inspection letter	At each location visited one or more item is in need of repair.	
COMMUNI-CATION

L31

Staff understand and can communicate with individuals in their primary language and method of communication.	Regulation 7.03 (1) (b) Individual Control: Opportunities for exercising control and choice in all aspects of an individual’s life, education necessary to assist the individual to make informed decisions, and assurance that the individual’s opinions are listened to and treated seriously.  (e) Personal Growth and Accomplishments: Training, education, supports and services necessary to meet the goals articulated in the individual’s ISP. Included are the requirements that the provider shall assure the assessment, training, and supports to assist the individual to acquire skills that increase self-reliance and that are necessary for desired and valued outcomes…

Guidelines:
The ability of staff to understand what an individual is communicating is essential in assisting an individual to meet his/her needs.

The primary language of the individual is often not the same as the primary language of staff that support them.  Staff need to have a familiarity and be well versed in the individual’s mode of communication, whether it is English, ASL, or other language or method of communication.

If the individual is difficult to understand, staff need to make on-going efforts to understand their form of communication; e.g. asking to repeat, get a communication assessment, learn non-verbal signs for communication.  

If augmentative devices and communication tools are recommended, these must be present, well-maintained, and used. 
	Staff Interview 

Individual Record 	Review if staff have an understanding of and competence in the individual’s communication style including the use of any augmentative devices, if needed, and can communicate and respond to the individual.  

Review documentation to determine if there are any additional communication needs and whether they are being addressed.	Staff have an understanding of the individual’s communication needs and can communicate or are making concerted efforts to communicate with the individual.	Staff either do not have an understanding of the individual’s communication needs and/or can not communicate or are not making concerted efforts to communicate with the individual.	
L32

Individuals receive support to understand verbal and written communication.	Regulations 5.04(1) (a), (b): The right to communicate, including (a) the right to have reasonable access to a telephone and opportunities to make and receive confidential calls, and to have assistance when desired and necessary to implement this right, and (b) the right to unrestricted mailing privileges, to have access to stationery and postage, and to assistance when desired and necessary to implement this right. 

Guidelines:
This includes support to use the telephone, write and receive letters and emails, as well as understand written reports sent to the individual.  Staff need to serve as a bridge so that communication from others to the individual is facilitated and understood.  For example, staff can assist the individual to understand a third party by facilitating the conversation.  Staff need to be attuned to the individual and the third party, assisting as needed to facilitate a positive exchange such as by using demonstration, going over the information carefully, etc.  

Staff also need to support individuals so that written communication from others to the individual can be understood.  For example, when the individual receives a letter from family, staff can support the individual by offering to read it to him/her.  This also includes supporting the individual to understand written information about him/her.  
	Staff Interview 

Individual interview 

Observation	Review and observe if staff support individuals to understand verbal and written communication involving them.  

Review if individuals feel they receive needed support.	Staff support individuals to understand verbal and written communication.	Staff do not support individuals to understand verbal and/or written communication.	
HEALTH

L33

Individuals receive an annual physical exam.	Regulation 6.22(3)(b): In the case of individuals residing in facilities or in homes operated, licensed or funded by the Department, the residential provider shall provide or arrange for annual health and dental assessments.  

Guidelines:
Agencies providing residential supports need to support individuals to receive annual physical exams.  To better assure that individuals receive consistent and appropriate standardized preventive and routine health care screenings, provider staff must complete the Preventive Health Screening Checklist (HC-1) prior to the annual physical.  The checklist serves as a guide for the individual and support providers regarding what to request or expect during the annual physical examination.  
	Health Care Record 

Physical exam documentation if needed	A sample of health care records is reviewed to check the date of the most current physical exam.  If the date of the last exam identified in the record exceeds 15 months,. determine if there is physical exam documentation on site within the last 15 months that has not yet been updated in the electronic health care record.	The physical exam has occurred within the past 15 months (to allow reasonable time for any potential scheduling difficulties/ reporting)	The physical exam did not occur within the past 15 months.	
L34

Individuals receive an annual dental exam.	Regulation 6.22(3)(b): In the case of individuals residing in facilities or in homes operated, licensed or funded by the Department, the residential provider shall provide or arrange for annual health and dental assessments.  

Guidelines
Individuals who are edentulous require an oral examination annually by a Health Care Practitioner or dentist to assess for oral disease or cancer.  This can be performed by the individual’s physician during the annual physical examination.

This indicator should not be rated for individuals who are edentulous.  Another individual who is not edentulous should be chosen for audit. 	Health Care Record 

Dental exam documentation in the individual’s record if exam is not in the Health Care Record.  	A sample of Health Care Records is reviewed to check the date of the most recent dental exam.  If the date of the last exam identified in the Health Care Record exceeds15 months, determine if there is  dental exam documentation present on site within the last 15 months that has not yet been updated in the Health Care Record.	Dental examination occurred within the past 15 months (to allow reasonable time for any potential scheduling difficulties/ reporting).  	Dental examination did not occur within the past 15 months or is not present.) 	
L35

Individuals receive routine preventive screenings.	Regulation 7.03 (f) 1:  … promote optimal health of the individual through arrangements for coordinated routine, preventive, specialty, and emergency health care, professional clinical services …

Guidelines:
Individuals need to be supported to receive routine screenings in accordance with the “Preventive Health Recommendations for Adults with Mental Retardation” developed by DDS as part of the Department’s Health Promotion and Coordination Initiative..  Several screenings are recommended to be performed annually.

Screenings are typical of those recommended for the  general population (e.g. mammography, pap smear, prostate cancer screen, Colonoscopy for individuals over 50, eye exam/hearing exam done by the primary care physician satisfactory without need for referral to specialist, gyn exam)

	Health Care Record 

Staff interview/ active health care information 

	A sample of Health Care Records is reviewed to check the routine screenings (dates and type) conducted in the past two years.  

When screenings are not present, discussion with staff and review of documentation of communication and coordination of routine screenings to Health Care Practitioners is completed to determine whether routine screenings have been discussed with the Health Care Practitioner. . 	Screenings have occurred for individuals in 24 hour residential supports or in less than 24 hour supports if it is part of the contract, or if screenings did not occur, staff can demonstrate that recommendations outlined in the DDS preventive Health Recommendations in the Health Promotion and Coordination Initiative were communicated to the physician. Staff can explain why the physician did not conduct (e.g. ability of the individual to cooperate).	Key screenings (e.g. colonoscopy, mammogram; PSA) were not conducted and staff cannot demonstrate that  recommendations outlined in the DDS Preventive Health Recommendations in the Health Promotion and Coordination Initiative were  brought to the attention of the Health Care Practitioner.	
L36

Recommended tests and appointments with specialists are made and kept.	Regulation 7.03 (f) 1:  … promote optimal health of the individual through arrangements for coordinated routine, preventive, specialty, and emergency health care, professional clinical services …

Guidelines:
Optimal health care includes assuring that recommended specialty referrals are made and appointments kept.  This includes both initial and ongoing follow-up with specialists including but not limited to neurology,  psychiatry, gastro-enter logy, nutritionist, and podiatry	Health care record and other medical information 	A sample of individuals’ medical records and medical appointment logs is reviewed to determine whether recommendations for tests and appointments are scheduled and kept.	Regular visits to specialists occur when recommended Additional tests and appointments recommended are made and kept within the time frames recommended by the Health Care Practitioner.	Regular visits to specialists are not occurring when recommended and/ or notation of appointments/ tests needed  have not been scheduled within the timeframes recommended by the HCP. 	
L37

Individuals receive prompt treatment for acute and  episodic health care conditions.	Regulation 7.03 (f) 1:  … promote optimal health of the individual through arrangements for coordinated routine, preventive, specialty, and emergency health care, professional clinical services …

Regulation 4.03 (10) (d):
Each individual’s area office and provider’s record shall contain the following information:..
d.  A list of any conditions requiring ongoing management by health care professionals including a summary of necessary treatment(s) for each condition; 

Guidelines:
The health status of individuals does not neatly lend itself to an annual review and physical exam.  Accurately recognizing signs and symptoms of illness will facilitate individuals receiving timely medical care.  It is critical that direct support professionals, as the first line of defense, be knowledgeable about what issues to report on and to whom they need to report them.  Fact sheets included in the “Health Promotion and Coordination Initiative” are useful tools as quick reference guides to better define a condition, identify observable symptoms, and recommend action for direct support professionals.   
	Policies and procedures for reporting and obtaining treatment for acute and episodic conditions.

Staff interview  

Current health care record and other medical information  

Communication logs  	Review existing policies in place to determine whether there is a clear protocol for staff to use to respond to illness.

A sample of staff are interviewed to determine their knowledge in identifying and responding to signs and symptoms of illness such as fever and acute pain.

A sample of individuals’ medical records, is reviewed and compared to other site information to determine whether acute or episodic health care conditions identified receive prompt treatment.	Staff are knowledgeable concerning signs and symptoms of illness and information indicates that individuals are receiving prompt treatment for episodic conditions.	Staff are not knowledgeable concerning signs and symptoms of illness and / or information indicates that individuals are not always receiving prompt treatment for episodic conditions.	
L38

Physicians’ orders and treatment protocols are followed (when agreement for treatment has been reached by the individual/ guardian/ team).

	
Regulation 4.03 (10) (c)and (d):
Each individual’s area office and provider’s record shall contain the following information…
c.  Upon recommendation of a physician, a record of frequency and type of all seizures, in order to assess the effects of anti-convulsant medications, other therapies, and environmental factors; 
d.  A list of any conditions requiring ongoing management by health care professionals including a summary of necessary treatment(s) for each condition; 

Guidelines:
Effective implementation of treatment protocols recommended by an individual’s health care practitioner is central to maintaining optimal health.  Examples of protocols can include but are not limited to seizure protocols, bowel regimens, and protocols to prevent aspiration.
	Current health care record and other medical information 

Staff interview  

Review of staff training

	A sample of individuals’ medical records and other treatment orders is reviewed to determine who is on a treatment protocol. A comparison is made with other site information (e.g. communication log; training information; staff interview) to determine whether treatment protocols are being followed.  If the protocol or treatment recommendation is not being followed determine whether a second opinion or guardian approval being sought.

A sample of staff is interviewed to evaluate their training, knowledge and implementation of treatment protocols..  Validate that staff have received training in necessary treatment protocols; e.g. seizure, use of O2, PAP, vital signs, etc.
	Staff are knowledgeable concerning physician’s orders and treatment protocols and information indicates that these are being consistently followed.  If not followed, this is due to seeking a second opinion or obtaining guardian approval.  	Staff are not knowledgeable concerning physician’s orders and treatment protocols and /or information indicates that these are not being consistently followed and/or a second opinion or guardian approval has not been pursued.	

L39

Special dietary requirements are followed.	Regulation 7.03 (f) 3:  … assure that … all individuals have nourishing and well-balanced meals, provided at typical times and frequencies, of typical variety, and chosen by the individual, unless there exist medical contraindications related to the health of an individual and these have been documented by a physician.

Regulations 4.03 (10)(b)
Each individual’s area office and provider record shall contain… (b) A record of special diets prescribed for the individual, if any, upon recommendation of a physician;

Guidelines:
This includes but is not limited to specialized diets such as diets to manage diabetes, weight loss diets, and diet textures for individuals with swallowing disorders.  Dietary guidelines and practices at the location should recognize and be responsive to all individuals’ particular food allergies and conditions.  This includes addressing such items as lactose intolerance, celiac’s disease, need for a glutton-free diet, or food allergies such as to peanut butter or shell-fish.
	Current health care record and medical information including diets, protocols, menus 

Staff interview 
	A sample of individuals’ medical records and other treatment orders is reviewed to determine who is on a specialized diet, and /or a dietary treatment protocol. A comparison is made with other site information to determine whether treatment protocols are being followed.

A sample of staff are interviewed to evaluate their training, knowledge and implementation of specialized diets, dining protocols, G tube, J tube, etc.

	Staff are knowledgeable concerning specialized diets and information indicates that specialized diets are being consistently followed.	Staff are not knowledgeable concerning specialized diets and / or information indicates that specialized diets are not being consistently followed.	
L40

There is an adequate supply of nutritional foods available at all times.	Regulation 5.04(4):  … Basic goods and services include at least the following:  (a) A nutritionally sound diet of wholesome and appetizing food served at appropriate times and in as normative a manner as possible;

Guidelines:
Providers must be aware of the array of foods that are nutritional and homes must have a sufficient supply available.   The provider can certainly acknowledge and take into full consideration an individual(s) tastes or preferences (e.g. does not like fresh fruit), while also making available an adequate supply of various fresh foods such as vegetables, fruits, and other perishables such as milk, juice and eggs.   

There needs to be at least a two days supply of nutritious food in the home, stocked with healthy items consistent with the tastes and preferences of the individuals (e.g. juice for the person who does not like fresh fruit).   This expectation to ensure an adequate supply of healthy foods does not limit providers from fully promoting individual’s choices in other ways.  For example, other favorite (e.g. non-nutritious) food items might be also made available consistent with individual’s tastes.  Care Providers must also ensure the adequate supply, variety and array of nutritional foods.
	Site visit

Staff/ home care provider –interview 

 	A sample of homes is reviewed and the kitchen and pantries checked to determine the adequacy of nutritional food available, including the presence of at least a 2 day supply of fresh or combination of fresh and frozen items such as fruits, vegetables, bread, as well as dairy items.

Staff / care providers are interviewed to determine grocery shopping routines, and the types and amounts of nutritional foods typically available on site for individuals at all times.

	The home has at least a two day supply of nutritional foods in the home.
 	The home does not have at least a two day supply of nutritional foods in the home.
	
L41

Individuals are supported to follow a healthy diet.	Regulation 7.03 (f) 3:  … assure that when the provider arranges or provides for meals, it shall store, prepare and serve food in a clean, safe, nutritious, typical, and appetizing manner.  Such providers must assure that all individuals have nourishing and well-balanced meals, provided at typical times and frequencies, of typical variety, and chosen by the individual, unless there exist medical contraindications related to the health of an individual and these have been documented by a physician.

Guidelines:
Staff can play an important role in supporting individuals to make healthy choices regarding diet and food intake.  While individuals may not always make healthy choices, staff must prepare nutritional meals and assist individuals to learn about healthy diets.  www.MyPyramid.gov is an excellent resource.  “MyPyramid”, released by the United States Department of Agriculture (USDA) on April 19, 2005, is an update on the American food guide pyramid.  As part of the MyPyramid food guidance system, people may visit the website for proper food groups that should be included within a healthy diet, sample menus, further dietary guidelines, and personalized nutrition information.
The 2005 Dietary Guidelines describe a healthy diet as one that 
•	Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products; 
•	Includes lean meats, poultry, fish, beans, eggs, and nuts; and 
•	Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars. 
Staff need to assist individuals to make smart choices from every food group, get the most nutrition out of calories, and find a balance in the quantity consumed.
This expectation to support individuals to follow a healthy diet does not restrict providers from fully promoting individual’s choices.  The provider must first promote a variety of healthy choices, encouraging the individuals to make personal choices from a variety of healthy alternatives.  Providers may also make non-nutritious preferred food items available for snacks and desserts consistent with individual’s tastes.  
	Review of menus and snack items – on site

Staff/care provider interview – on site 	Menus and snack items are reviewed to determine whether an adequate, nutritional diet is provided.

Staff are interviewed to assess their knowledge about what constitutes a nutritionally sound diet, including familiarity with the food pyramid and/or other nutritional models; e.g. American Heart Association.  Staff/care providers are interviewed to determine what the typical meals are offered/ provided within the home, and how individuals are being supported to make healthy choices.	Menus, meals and snack items indicate that over the course of one week, a balanced diet has been offered, and staff are knowledgeable about what constitutes a nutritionally sound diet.
 	Menus, meals and snack items indicate that over the course of one week, a balanced diet has not been consistently offered, and / or staff are unfamiliar with what constitutes a nutritionally sound diet.
	
L42

Individuals are supported to engage in physical activity. 	Regulations 5.04 (4) (b):
… Basic goods and services include at least the following…
(b) Opportunities for daily recreational activity and physical exercise, as appropriate to the age and interests of the individual...

Guidelines:
While there is no exact standard established, it is generally recommended that adults try to get at least some exercise daily.  According to www.MyPramid.gov, it is recommended that adults get at least 30 minutes of moderate level activity most days. 

While individuals may choose not to engage in some form of daily activity, there is an expectation that staff at the home will support and offer opportunities for regular physical activity. 
 
Unless contraindicated, (e.g. for medically involved individual where exercise is not advised within the ISP) the provider needs to encourage physical exercise and movement routinely.   Movement for any length of time is good.   

For individuals who have a specific weight loss/ exercise goal noted within their ISP, the provider needs to develop and implement specific support strategies to address these.  For example, implementation of more structured exercise plans such as supporting the individual to attend an aerobics class three times per week may be appropriate.  

	Site visit including review of schedules, routines and activities listed 

Staff interview 
 	A sample of homes is visited and the schedules, routines and activities of the individuals is checked to determine the frequency and duration of physical activity for each individual, and for the group of individuals on average.  

Staff are interviewed to assess their knowledge about the importance of physical activity in daily life, and on their provision of options and encouragement to individuals.	Individuals have engaged in (or have been offered) physical activity routinely. 	Individuals have not been offered or have had limited opportunities to engaged in physical activity routinely.	
L43

The health care record is maintained and updated as required.  	Regulations 4.03 (10)(a- e)
Medical information.  Each individual’s area office and provider record shall contain…see regulations for details

Guidelines:
The electronic Health Care Record is required to be updated annually (and submitted to the Area Office in preparation for the ISP).

The medical information in the individual record located within the residential home needs to be current and updated in an ongoing manner, so that it can serve to facilitate routine, specialty and emergency medical contacts and encounters. For example, doctor or hospital visits should be documented in the record. 
	Electronic Health Care Record 

Current health care and medical information

Staff interview

	A sample of Health Care Records  is reviewed to determine whether the electronic ISP has been updated annually.  

If needed, a sample of Health Care Records is reviewed on site to determine whether it has been completed as required.  Discussion occurs with staff and medical information in the individual record is reviewed to determine if information is current.	The electronic Health Care Record is updated annually, or is current at the site.  Medical information in the individual record is located at the home, is current.	The electronic or paper Health Care Record has not been updated within the past year and/or medical information in the individual record located at the home is not current.	
L44

The location where MAP certified staff is administering medication is registered by DPH.	Regulation 5.15 (6);  Certified program staff of community programs may administer prescription medications to non-self-medicating individuals, provided that the community program is registered with the Department of Public Health in accordance with 105 CMR 700.004 …

Guidelines:
Licensed, funded or operated community residential programs that are individuals’ primary residences and/or are locations where individuals are participating in day programs and short-term respite programs must apply for a Massachusetts Controlled Substance Registration (MCSR) from DPH for the purpose of authorizing non-licensed employees to administer or assist in the administration of medications and for storage of medications on site.  The MCSR is issued to the geographic site where the medication is stored.  

The original MCSR must be kept at the site with a copy of the MCSR kept at the service provider’s administrative office, or vice versa.    
	DPH Registration 	A sample of locations is reviewed to determine whether the site is registered with DPH when medications are administered by MAP certified staff.  	Site has a DPH MAP registration number where medications are administered by MAP certified staff.	Site has does not have a DPH MAP registration number where medications are administered by MAP certified staff.	
L45

Medications are stored in a locked container or area in which nothing except such medications are stored.	Regulation 5.15 (7) (a): prescription medications for all individuals who are non-self-medicating shall be labeled and stored in a locked container or area in which nothing except such medications are stored.

Guidelines:
Each program site must have a specific area dedicated to the storage of all Schedule II-VI prescription medications and OTC medications.  Procedures must limit access to this area to the individual authorized to administer medications during each shift and limit possession of the key to the medication area to the authorized staff on that shift.  The key must be stored in a locked area within the house accessible to designated staff only.  	Medication storage area 	A sample of locations is reviewed to determine whether medications are stored properly.	Medications are stored in a locked container or area in which nothing but medications is stored, and external medications and medications that require refrigeration are stored correctly.	Medications are not stored in a locked container or area in which nothing but medications is stored and /or external medications and /or medications that require refrigeration are not stored correctly.
	
L46

All prescription medications are administered according to the written order of a practitioner and are properly documented on a Medication Treatment Chart.

	Regulation 5.15 (9) (a):  All prescription medications shall be administered in accordance with the written prescription of a practitioner. 

Regulation 5.15 (10):  All prescriptions for, and administration of, medication shall be documented in accordance with 105 CMR 700.003(F)(6), 115 CMR 5.19(9) …

Guidelines:
Prescription medications must be administered exactly as ordered by the practitioner, which could include a physician, dentist, nurse practitioner or physician’s assistant).  

Medications and dosage information as listed on the doctor’s orders needs to match the container obtained from the pharmacy.  

Failure to accurately record and/or transcribe an order is the second leading contributing factor in medication occurrences in MAP.  An improperly transcribed order is at risk of remaining incorrect for some time and poses a significant risk for serious outcomes.

Review PRN guidelines for medications prescribed PRN as well as over-the-counter products.  Both require Doctor’s order including specific, observable criteria for determining when the medication is needed.  

All prescription medications are documented on the Medication Treatment Chart and specifies:
Name of medication and dosage;
When and how the medication is to be given; 
if the medication is ordered for a set number of days, the start and stop dates, and 
special instructions for administration.

Documentation on the Medication Treatment Chart is in ink with no white out, erasures.

While MAP does not apply to placement service locations, all prescriptions need to be administered in accordance with a written order, and there needs to be some system of documentation indicating that medications are being administered correctly.
	Individual Medication Administration information documentation 	A sample of locations is reviewed, medication documentation is reviewed for a sample of individuals and containers of prescription medications are compared against written orders and documentation on Medication Treatment Charts. Three months medication and treatment charts and medication information is reviewed.	There is no evidence of any unidentified medication errors.  Past MORs have been appropriately identified and addressed.  Any recent discrepancy is in the process of being resolved and the doctor has been contacted.  No significant errors that either have caused harm or have the potential to cause harm and/or frequent and recurring medication issues are revealed. There are no significant discrepancies in written documentation and information.
	There is evidence of previously unidentified or uncorrected MORs. 
Past MORs have not been appropriately identified and/or addressed.  Any recent discrepancy was not noted and /or is not in the process of being resolved.  Significant errors that either have caused harm or have the potential to cause harm and/or frequent and recurring medication issues are revealed. There are significant discrepancies in written documentation and information.

L47

Individuals are supported to become self medicating when appropriate.	Regulation 5.15 (11):  Programs shall permit and encourage self medication by individuals capable of self-medicating, provided that (a) the risks of misuse or abuse to the individual and other persons within the program are minimal, and (b) the program provides the individual with adequate training and assistance.

Guidelines:
Individuals must be supported to self medicate whenever possible.  In order to self medicate, an individual must be able to store his/her medication so that it is inaccessible to others, understand the type of medication, its purpose and for what symptoms or condition it is being prescribed, know the frequency of doses and have a familiarity with the most common side effects.

MAP policy manual requires that a periodic review of the individual is in place to ensure that individuals who are found to be self-medicating continue to take their medications independently.  If the individual requires assistance to administer medications, the agency must apply as a DPH MAP registered location.

MAP does not apply to Placement Services; nevertheless the home provider needs to have some system to ensure that individuals who are self-medicating understand the type of medication, its purpose and for what symptoms or condition it is being prescribed, know the frequency of doses and have a familiarity with the most common side effects.
	ISP including self-medication assessment 

Medication systems review 

Staff interview 	Review the self-medication assessments for individuals identified in the ISP as being independent in medications.

Medication documentation and storage is reviewed for a sample of individuals noted to be self-medicating to determine whether appropriate safeguards are in place. 

A comparison of the individual’s current status and capabilities with the self-medication assessment referenced within the ISP is conducted to determine whether there is a process of re-evaluating individuals who are found to be unable to continue to take their medications independently so that they can obtain additional support.  	Individuals that are self-medicating have a clear assessment documenting their skills in this area; medications are stored appropriately; and the location takes appropriate actions when individuals are found unable to remain independent.	Individuals that are self-medicating do not have a clear assessment documenting their skills in this area, and / or medications are not stored appropriately; and/or the location has not taken appropriate actions when the individual is found unable to remain independent.	
HUMAN RIGHTS 

L48

The agency has an effective Human Rights Committee.	Regulation 3.09 (1):  The head of every provider of residential, day, or site-based respite services … and every specialized home care placement agency subject to 115 CMR 5.00 shall establish and empower a human rights committee in accordance with the requirements of 115 CMR 3.09 …
3.09 (1) 
(a) location requirements
(b) responsibilities and duties
( c)  membership requirements
(d) meeting and minutes requirements

Guidelines:
An effective human rights committee provides an essential safeguard for individuals served by the provider.  As an independent, neutral voice, members of the human rights committee both assure that basic reviews and approvals have occurred for behavior plans as well as whether rights are affirmed on an on-going basis.  

The HRC must perform reviews of behavior plans, restraints, and other items within their purview.  

An approved waiver for HRC location (e.g. to serve locations in more than one region) or composition can be granted.

	Administrative review- HRC membership, HRC by-laws, HRC minutes 

HRC Coordinator interview 	Review of HRC membership, by-laws, and minutes for the past two years to determine whether the agency is in compliance with regulations.

Review of training to HRC members to determine whether they have been trained in their responsibilities and duties.  Review of mechanisms to familiarize the HRC members with the locations they serve.

Assess whether specific behavior plans have been reviewed by the HRC.  

Determine whether the expectation not being met is an anomaly.	The HRC meets the following:
 mandated composition, 
 quarterly meetings;
maintaining a quorum at meetings; requisite expertise present at the meetings during reviews; 
reviews and makes recommendations in mandated areas;
 trained and knowledgeable in their role; familiarity with the locations they serve.  	The HRC fails to fully meet any of the following:
 mandated composition, 
 quarterly meetings;
maintaining a quorum at meetings;  requisite expertise present at the meetings during reviews; reviews and makes recommendations in mandated areas;  trained and knowledgeable in their role;
familiar with the locations they serve.  

A pattern of no meetings, or not meeting mandated composition would result in a standard “not met” rating.

(“Point in time” - situations in which immediate actions have already been taken by the agency to resolve, do not require a “not met;” e.g. the committee didn’t have a quorum for one meeting during the year and got feedback by phone for this meeting would not in and of itself cause the standard to be “not met” )	
L49
ALL 

Individuals and guardians have been informed of their human rights and know how to file a grievance or to whom they should talk if they have a concern.

	Regulations 3.09 (3) (b) (1) through and (4) ….shall designate and empower a person employed or affiliated with the provider or agency…
3.  to provide individuals served with opportunities to exercise their rights to the fullest extent of their capabilities and interests, including informing them of the grievance procedures and the right to go to the human rights committee on any issue involving human rights;……

Guidelines:
Both individuals and guardians need to be apprised of their rights to file a grievance.  This is distinct from being trained in reporting an allegation of abuse or mistreatment, and is more focused on ensuring that individuals know that there is at least one person that they can turn to if questions or concerns arise.  Therefore, while individuals may not understand the exact process or be familiar with the human rights committee, individuals should be able to identify one person, be it the Human Rights Officer, or someone else referenced by name with whom they feel comfortable sharing concerns and raising issues.

In addition, guardians also need to be aware that there is someone that they can speak to in the event that they have a concern.  The Office of Human Rights suggests identifying for guardians and family members the Human Rights Officer for the program, the Human Rights Coordinator for the agency and the DDS Human Rights Specialist.   

Lastly, individuals residing in provider owned or operated homes are expected to have the same protections from arbitrary and capricious eviction that are afforded to others renting in the community.  	Individual training and guardian documentation 

Individual interview and observation

Guardian information

Guardian Interview	Review training to individuals and guardians and whether human rights training has occurred at least annually.

Determine whether individuals/ guardians have been informed of the right to be free from arbitrary eviction, through the presence of a residential agreement.

Assess whether individuals are aware of whom they can talk to in the event of a concern. Observe individual’s capabilities and how they share concerns within the setting.

Determine whether guardians have been informed of how to file a grievance and report concerns to human rights and/or can identify someone to whom they feel comfortable talking to if they have a concern. 

	Individuals and/or guardians have been trained in how to file a grievance and/or individuals and guardians can identify someone to whom they feel comfortable talking to if they have a concern.  Individuals and guardians have received annual training  in human rights and residential agreements are in place as appropriate.	Individuals and/or guardians have not been trained in how to file a grievance and/or
Individuals and /or guardians cannot identify someone to whom they feel comfortable talking to if they have a concern and/or individuals and guardians have not received annual training in human rights and/or residential agreement is not in place when appropriate.

	
L50

Written and oral communication with and about individuals is respectful.

	Regulations 7.03 (1) (a):
All providers shall assure that the supports and services they provide to individuals promote the following …
(a) Rights and dignity:  Protection and enhancement of the rights of individuals, including but not limited to a focus of respect of the individual… 

CMS § 441.530 Home and Community-Based Setting.(a) (1)  (iii) Ensures an individual’s rights of privacy,  dignity and respect, and freedom from coercion and restraint.

Guidelines:
Promoting people’s self-esteem is a fundamental ingredient in all services and supports.  It is demonstrated when interactions with and attitudes about individuals are respectful and acknowledge the inherent value of each person.  Service practices and supports, such as using a respectful tone of voice, and adult language when speaking with and assisting people, encourage people to see themselves and have others view them as unique, valuable individuals and adults.  Staff call people by their preferred names instead of overly familiar terms like “honey” or “sweetie”. Staff do not talk about people in the third person or use labels (“the runner”, “the autistic”). Staff need to listen to what individuals have to say and support individuals to have a voice.  Staff should always have conversations with individuals, rather than talking at or over individuals. If staff cannot immediately address a need, staff ensure that the individual understands that the need has been heard and will be addressed soon. 

In addition, it is essential that respectful communication when discussing or reporting information about individuals occurs.  

Staff are sensitive to the ways to approach and relate to an individual with a disability when interacting with individuals specific to their needs.  This includes  proper wheelchair use which recognizes that wheelchairs are an extension of personal space, speaking at the appropriate tone/level of voice for people who are hearing impaired (no shouting), and having a person who is blind hold the arm instead of leading or propelling the person, etc. Staff describe people in positive and affirming ways with a focus on their abilities, not their disabilities. This includes the use of people –first language. 	Individual Record

Staff Log

Staff Interview

Observation

Individual Interview	A sample of individual supports are reviewed to determine whether written and oral communication with and about individuals is respectful.	Oral and written communication with and about individuals is respectful and supports individuals as adults.	Oral and/or written communication with and about individuals is not always respectful and/or does not always support individuals as adults.	
L51

Individuals can access and keep their own possessions.	Regulations 5.10 (1); No provider subject to 115 CMR 5.00 shall interfere with the right of an individual to acquire, retain, and dispose of personal possessions unless authorized by a guardian, conservator, or representative payee, unless the interference or restriction is part of a duly developed and reviewed ISP or behavior modification plan; unless otherwise ordered by the court, or unless possession poses an immediate threat of serious physical harm to the individual or other persons.  In the event of restriction of possession by the provider on the grounds of imminent and serious physical harm, the provider shall be authorized to place the object in custodial safekeeping for the individual.  (a) Any restriction on personal possessions … shall be documented in the individual’s record, and a copy sent promptly to the provider’s human rights committee. (b) Such restriction shall be accompanied where appropriate by a training plan, documented in the individual’s record, to eliminate the need for the restriction.

Guidelines:
Any restrictions on possessions need to be included in the individual’s record, reviewed by the ISP team and the Human Rights Committee.

When a restriction is in place at a location shared by others that are impacted by this restriction, provision must be made for others to maintain access. e.g. locked household items for one person; reasonable access via key to others.

Restriction needs to be accompanied where appropriate by a training plan, documented in the individual’s record, to eliminate the need for this restriction. 

At an employment / work setting, storage of personal possessions and reasonable practices for the use of and access to possessions, may be established.  For example, all employees, including staff, may be required to store personal possessions within lockers prior to initiating work, and have access to these items only during lunch and free time. 
	Site Review 

ISP 
	Review a sample of sites to determine whether individuals can access and keep their own possessions. 

Compare site restrictions (e.g. locked possessions) with a corresponding plan.	There is free access to individuals to keep and own their personal possessions; or restrictions on possessions are in place with a plan that has been reviewed and approved per regulation.	There is a restriction(s) on possessions without evidence of a plan that has been reviewed and approved per regulation.	
L52

Individuals can make and receive phone calls and use other communication technology.

	Regulation 5.04 (1) (a): … the right to have reasonable access to a telephone and opportunities to make and receive confidential calls and to have assistance when desired and necessary to implement this right … 

CMS § 441.530 Home and Community-Based Setting.(a) (1)  (iii) Ensures an individual’s rights of privacy...

Guidelines:
Individuals must have the opportunity to privately use communication technology (telephone, mail, email, instant messaging, facebook, twitter, and other applications) in most circumstances.  However, opportunities to make and receive calls or use communication devices can be restricted for clinical / safety reasons provided however, it is part of an approved written plan, with approval from the necessary review groups including but not limited to the individual/guardian and the human rights committee. 

At an employment / work settings, reasonable practices concerning use and access to the telephone and other communication technologies  may be established.  For example, the service may establish guidelines in which all employees, including staff, have access to the telephone and other communication devices for personal calls only during lunch and free time.  Opportunities to make and receive calls in emergency situations should not be restricted.

Communication technology must be accessible to all individuals including individuals who are deaf or hard of hearing.

Staff need to provide assistance to those who need help utilizing communication devices and the telephone such as by facilitating dialing, adjusting the volume, holding the phone, assisting individuals to send/ receive emails etc. This assistance should still allow for privacy to the greatest extent possible.  Staff provide support in other ways as well including, but not limited to, training on computer use and internet safety.  Training may also be provided by an outside agency/source as necessary.
	Individual interview and observation 

Site review and staff interview 	Review a sample of individuals to determine whether individuals can access communication devices such as telephone, cell phone, computer, mail in private if wanted. 

Compare observations and staff reports of communication practices and restrictions if any with a corresponding written rationale, plan and approval to determine whether there is consistency between what is being reported and any written plan.	There is free access to individuals to use communication devices in private or restrictions to such use are in place with plan that has been reviewed and approved per regulation.	There is not free access to individuals to use communication devices in private or restrictions to such use are in place without a plan that has been reviewed and approved per regulation.	
L53

Individuals can visit with family and friends.	Regulation 5.04 (3) (a-c):  The right to be visited and to visit with others under circumstances that are conducive to friendships and relationships, in accordance with the following requirements:
(a)	An individual shall be permitted to receive visitors, unless ill or incapacitated to the degree that a visit would cause serious physical or emotional harm; provided that the individual’s attorney, guardian, legal or designated representative, personal physician, clergy, or family members shall be permitted to visit at all time, unless the individual objects, and shall be provided with a suitable place to confer on a confidential basis;
(b)	Reasonable restrictions may be placed on the time and place of the visit in order to protect the welfare of the individual or the privacy of other individuals and to avoid serious disruptions in the normal functioning of the provider.  Arrangements shall be made for private visitation to the maximum extent possible;
(c)	Denial of visitation or restrictions for any reason other than those stated in 115 CMR 5.04 (3) (b), shall be treated as a modification of the ISP, and requires compliance with the regulations governing ISP modifications.  The human rights committee shall be notified of the intention to deny or restrict visitation.

Guidelines:
Providers need to assist individuals to visit with family and friends in accordance with their clinical needs and to the extent of their interests and desires.  
	Site review and staff interview 

Individual interview  

Guardian/ family interview 
	A sample of sites is reviewed and staff is interviewed regarding visitation patterns and routines.

A sample of individuals is interviewed to determine whether individuals understand and are given opportunities to visit with family and friends unless otherwise indicated. 

A sample of guardians is interviewed to determine whether family and friends understand and are given opportunities visit with individuals unless otherwise indicated.	Individuals have free access to visit with family and friends or any restriction on visitation in place is in writing and has been reviewed and approved by the ISP team.	Individuals do not have free access to visit with family and friends and/or there is a restriction(s) on visitation in place without being documented and/or has not been reviewed and approved by the ISP team.	
L54

Individuals have privacy when taking care of personal needs and discussing personal matters.

	Regulation 5.03 (8): Privacy, including the opportunity wherever possible, to be provided clearly defined private living, sleeping and personal care spaces …

CMS § 441.530 Home and Community-Based Setting.(a) (1)  (iii) Ensures an individual’s rights of privacy...

Guidelines:
Individuals have the right to privacy.  Personal care, provided for or by the individual, must occur in a private space.  This means that  e.g., among other situations, the bathroom door is shut when in use and that staff assist individuals with dressing/undressing in the individuals’ bedroom/bathroom.   Opportunities are provided for individuals to have private conversations with family, friends, other housemates and staff.  
Personal information and personal conversations must be kept private and not be posted or discussed. 	 

Staff interview 

Staff log 

Individual interview/ observation 

	
A sample of staff is interviewed and individuals are interviewed/ observed to determine whether individuals understand that they must be afforded privacy when engaging in personal needs or discussing personal matters. 

A sample of sites is observed to determine whether privacy is supported in practice.	There is observational evidence that individuals have privacy when taking care of personal needs and discussing personal matters.  There is no publicly displayed information about individuals.	There is minimal observational evidence that individuals have privacy when taking care of personal needs and discussing personal matters and/or there is publicly displayed information about individuals.	
L55

Informed consent is obtained from individuals or their guardians when required; Individuals or their guardians know that they have the right to withdraw consent.
	Regulation 5.08 (1):  The informed and voluntary consent of the individual or of a guardian if the individual is incompetent or is not capable of providing informed consent, shall be required in the following circumstances (see regulations for details).

Regulation 5.08 (3) (a-f):  Whenever the informed consent of the individual or guardian is required, the following criteria shall apply (see regulations for details).

Regulation 5.08 (3) (e) 4:  The personal securing the consent shall explain that consent may be withheld or withdrawn at any time, with no punitive action taken against the individual;

Guidelines:
This indicator does not cover consents for behavior modifying medications or behavior plans, there are covered in other indicators.

Individuals or their guardians need to knowingly and voluntarily give consent and have the opportunity to refuse  approval in the following circumstances:
•	Release of personal information
•	Involvement in research activities

Items covered in this indicator include release of information, and specific photo/media and news release consents; these consents need to be issued for each situation in which the individuals’ picture/ information is being shared.

Individuals and guardians need to be informed of their right to withdraw their consent at any point in time.  Typically the consent form itself outlines the parameters for which consent is being requested.
	Any informed consent documentation – on site	Review of sample of required informed consent documents to determine whether consent was obtained and that provision to withdraw consent was outlined.

	Consents such as photo/media releases are present as required.	Consents such as photo/media releases are not present as required.	
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.	Regulation 7.03 (1) (a): 
All providers shall assure that the supports and services they provide to individuals promote the following ….
(a) Rights and dignity:  Protection and enhancement of the rights of individuals, including but not limited to…. Assuring an individual’s freedom of movement both at home and in the workplace…

Regulations 5.14 (4) (b) (2):
No interventions shall be approved in the absence of a determination, arrived at in accordance with all applicable requirements of 115 CMR 5.14, that the behaviors sought to be addressed may not be effectively treated by any less intrusive, less restrictive intervention and that the predictable risks, as weighed against the benefits of the procedure would not pose an unreasonable degree of intrusion, restriction of movement, physical harm or psychological harm.

Guidelines:
If there are any interventions in place for one person, provision needs to be made to ensure that others in the same location are not unnecessarily subject to restrictions.  Any house or site restriction to safeguard a specific individual(s) but not all individuals served at the site (such as a lock on a refrigerator) needs to have a written rationale for the restriction, review by the Human Rights Committee and have practices in place that ensure access for those not requiring the restriction.	Documentation of site restrictions 

Staff interview

Site review
	Sample of site are reviewed to determine whether required reviews have been conducted when restrictions are imposed.  

Compare observations and staff reports of restrictions with a corresponding written rationale, plan and approval by the HRC.

 Determine if there are any additional site restrictions without a plan	Required components are in place and practices are in place to mitigate the restriction for others.	One or more of the required components are missing when there are restrictions and/or practices are not in place to mitigate the impact of the restriction on others.	
L57

All behavior plans are in a written plan.	Regulation 5.14(4) (b) 6: No intervention may be administered to any client in the absence of a written behavior modification plan.

Guidelines
There needs to be a written behavior plan for all restrictive practices and/or negative components (level I or II).  Aversive consequences that are part of house rules, teaching programs, etc. need to be spelled out in writing.  This is the first step in ensuring that the proper reviews are conducted.

Behavior plans do not need to be revised if they are working, but do need to be reviewed at least annually by the ISP team, and the data for plans containing level 2 or 3 interventions need to be reviewed at least weekly by the treating clinician.	Behavior plan documentation 

Staff log 

Staff interview 	
Through staff logs and interviews, determine if any restrictive interventions are implemented without the presence of a written plan.  

Compare observations and staff reports of restrictions with a corresponding written rationale, and plan.

	All restrictive practices and/or negative components are part of a written plan.	There are any restrictive practices and/or negative components that are not part of a written plan.	
L58

All behavior plans contain the required components.	Regulations 5.14 (4)(b) 2:  … No interventions shall be approved in the absence of a determination, arrived at in accordance with all applicable requirements of 115 CMR 5.14  that the behaviors sought to be addressed may not be effectively treated by any less intrusive, less restrictive procedure, would not pose an unreasonable degree of intrusion, restriction of movement, physical harm, or psychological harm. 

Regulations 5.14 (4)(b) 6:  … No interventions may be administered to any client in the absence of a written Behavior Modification plan.

Regulation 5.14 (4) (c) 1-5:  Written Plan.  All proposed uses of Level II and Level III Interventions for treatment purposes shall be set forth in a written plan which shall contain at least the following:  (see guidelines for detail).

 Guidelines:
Plan needs to identify:
•	Target behavior(s to decrease
•	Desired positive replacement behavior(s)
•	Level(s) of intervention(s)
•	Rationale based on functional analysis of target behavior(s) & antecedents
•	Less restrictive alternatives/measures tried & that this is least intrusive intervention
•	Person providing clinical oversight
•	Procedures outlined for monitoring, documenting & clinical oversight
•	Criteria for eliminating or revising plan

Most of the above components also apply to Level I Plans which include interventions beyond positive reinforcement. 	Behavior plan documentation 	Sample of behavior plans are reviewed to determine whether they contain all required components.
	Plans contain all required components	Plans do not contain all required components	
L59

Behavior plans have received all the required reviews.	Regulation 5.14 (4) (d) 1-6: Review and Approval.  In addition to consent requirements stated in 115 CMR 5.14(4)(e) the following reviews and approvals are required prior to the implementation of any Behavior Modification plan involving the use of level II or Level III Interventions: (see guidelines for details).

Guidelines:
Behavior plans with restrictive interventions have been reviewed and approved by:
•	Individual and/or guardian
•	ISP team
•	Human Rights Committee
•	Peer Review Committee (level II and III)
•	Physician (level II and III)

This also includes ensuring that any additional required reviews are followed.  For example that court review substituted judgment has occurred for Level III plans.  	Behavior plan documentation 	Behavior plan documentation is reviewed for sample of individuals, including dates and times of required reviews to determine whether all required reviews have occurred.  	All required reviews have occurred.	One or more of the required reviews has not occurred.	
L60

Data are consistently maintained and used to determine the efficacy of behavioral interventions.	Regulation 5.14 (4) (c) 5:  … A procedure for monitoring, evaluating and documenting the use of each Intervention including a provision that the treating clinician(s) who will oversee implementation of the plan shall review a daily record of the frequency of target behaviors, frequency of interventions, safety checks, reinforcement data, and other such documentation as is required under the plan.  Such treating clinician(s) shall review the plan for effectiveness at least weekly and shall record his/her assessment of the plan’s effectiveness in achieving the stated goals.

Guidelines:
Data are kept consistently.  Data are kept on both the target behaviors and the interventions being utilized.  Data are cross walked with review of behavioral interventions and changes made to plan as needed.	Behavior plan data documentation 

Interview with clinician (if employed by the provider).

	Review record to determine if data on target behaviors and interventions are kept and utilized to make changes.

	Data are maintained regularly and reviewed as required to determine the plan’s efficacy.  Plans are revised when indicated by data.	Data are not maintained regularly and/or reviewed as required to determine the plan’s efficacy and/or plans are not revised when indicated by data.	
L61

Supports and health related protections are included in ISP assessments and the continued need is outlined 

	Regulations5.12 (2): Limitations on health related protections and supports…Supports needed to achieve proper body position, balance, or alignment shall be authorized only if determined in the individual’s ISP to be the least restrictive means of achieving a therapeutic objective.  Where such a determination is required, the ISP shall specify the device to be used, and the individual’s record shall contain the indications for use, discontinuance, the alternatives continued, the frequency and duration of use, procedures for safety checks, and the qualified professional supervising the use of the device.

Guidelines:
Any health related protection being utilized is clearly outlined in the ISP and articulated in a written plan for implementation.  The ISP also needs to identify the continued need for the support and/or health related protection.	Health related protection documentation  (individual record, ISP)
 
Staff communication log 
	Review information for sample of individuals that have a health related protection to determine if it is included in ISP and the continued need is outlined.

Review staff log to determine if any health related protection is utilized without required approval.
	Health related protections and supports are included in the ISP and the continued need is outlined.	Health related protections and/or supports are not included in the ISP and/or the continued need is not outlined.	
L62
Supports and health related protections receive the required reviews. 	Regulation 5.12 (2): … Health-related protections ordered by a physician or other authorized clinician for the individual’s protection during the time that a medical, dental, or other condition requiring treatment exists may be employed if authorized by the clinician.  

Regulations 5.12 (3)(a), (c)
Supports permitted under 5.12(2) shall be designed and applied:
(a)	With the authorization and supervision of a qualified practitioner;
(c) in accordance with safety checks and opportunities for exercise as specified by the qualified professional, and if applicable, set forth in the individual’s ISP, and….

Regulations 5.11 (1) define supports and health related protections as limitations on movement.  See also 2.01 Limitations on movement definition

Regulations 3.09 (1)(b) 2 Protection of Human Rights/Human Rights Committee
The committee shall have the following duties...
1.	 To monitor and review the authorization and use of all emergency restraints and other limitations on movement in accordance with 115 CMR 5.04 and 5.05…

Guidelines:
The support or health related protection as implemented needs to be authorized through the ISP (including individual or guardian agreement).  In addition, any limitation of movement needs to be reviewed by the Human Rights Committee.
	Health related protection documentation  (individual record, ISP)
 
Staff communication log 
	Review information for sample of individuals that have a health related protection or support to determine if required reviews have occurred.

Review staff log to determine if any health related protection is utilized without required approval.

	Approvals and authorizations are in place.	Approval and/or authorizations are not in place.	
L63

Medication treatment plans are in written format with required components.	Regulation 5.15 (4) (b): No medication shall be administered  by programs subject to 115 CMR 5.00 for the purpose of controlling or modifying behavior, except: … in accordance with the recommendations of an individual service plan or support service plan containing at least the following information (see regulations for details).

Regulation 5.11(5)e:  ….Sedatives or anti-anxiety medication prescribed by a qualified practitioner for the sole purpose of relaxing or calming an individual so that he or she may receive medical treatment is not a restraint.  Administration of such medication shall be deemed incidental to the treatment, and, except in an emergency situation requires the consent of the individual or guardian.  Providers should incorporate into an individual’s ISP objectives that assist the individual to learn how to cope with medical treatments and that lead to the decrease or elimination of medication for chemical relaxation incidental to treatment.

Guidelines:
If the individual is prescribed any medication to modify behavior the ISP contains:
•	Description of behavior to be controlled/modified
•	Data on behavior prior to medication forming basis from which clinical course is evaluated
•	Information about side effects, procedures to minimize risks and clinical indications for terminating the drug

If the individual is prescribed any medication to calm or relax him or her during medical treatment, the ISP contains:
•	Plan to reduce or eliminate the need for medication 
	Medication information 

ISP/Individual Record 	A sample of individual medication information is reviewed to determine if medication to control or modify behavior is utilized.  If medication is used to control or modify behavior confirm that there is a written plan in place with the required components through a review of the ISP and individual record.  	Written treatment plans with all required components are present.	One or more of the required components is missing.	
L64

Medication treatment plans are reviewed by the required groups.	Regulations5.15 (4)(a-b)
…No mediations shall be administered by programs subject to 115 CMR 5.00 for the purpose of controlling or modifying behaviors, except…:
b.	in accordance with the recommendations of an individual service plan or support service plan containing at least the following information…

Guidelines:
Both medication treatment plans and medication to calm or relax during medical procedures need review by the ISP team.   

Any medications used to control or modify behavior such as medications prescribed to decrease agitation, need to receive the required reviews.	Medication information 

Individual Record/ISP 
	Review a sample of individual medication information to determine if any medication is used to modify behavior or calm or relax during medical treatment.

If medication is used to modify behavior or calm or relax during medical treatment, confirm that the required reviews through the ISP process have been conducted.	Medications used to modify behavior or calm or relax during medical treatment have the required reviews.	Medications used to modify behavior or calm or relax during medical treatment do not have the required reviews.	
L65

Restraint reports are submitted within the required timelines.	Regulation 5.11 (8) (a), (c) (d) (e):  Documentation Requirements.  … Each provider shall ensure that a restraint form is completed on each occasion when an individual is placed in emergency restraint … and on each occasion when an order for such restraint is renewed.  (See regulations for details.)

Guidelines:
It is important that restraint information be reported in a timely and accurate way.  The initial information must be completed, including the consumer interview, within 24 hours from the restraint.  The completed incident report must be forwarded to the Service Coordinator within 5 days of the restraint.  	Restraint Forms 

Staff Log 	HCSIS report of restraint forms is reviewed to determine if timelines were met.

Review staff logs in sample to determine if any restraints were applied that were not reported.	Restraint forms conform with identified time lines and there were no identified restraints that were not documented.	Restraint forms did not conform with identified time lines and/or there were identified restraints that were not documented.	
L66

All restraints are reviewed by the Human Rights Committee.	Regulation 5.11 (8) (e) 1:  At the end of each month, the provider shall send to its human rights committee copies of all restraint forms and attachments, if any, sent to the Office of Human Rights and the area office pursuant to 115 CMR 5.11.  (See regulations for details.)

Guidelines:
Restraint forms need to be sent to the Human Rights Committee which will review all pertinent data concerning the behavior which necessitated restraint.  The Human Rights Committee must review the restraint at the next meeting following the restraint (up to 60-90 days).  This may be before the Area Office review has been completed.  

	Restraint forms 

Administrative Interview

Human Rights Committee minutes	A HCSIS report of restraints is reviewed to determine if the restraint forms are reviewed by the Human Rights Committee within the required timelines.

If the HCSIS report indicates that restraint reports were not reviewed by the human rights committee in a timely manner, this is further reviewed during the administrative interview and in a review of the committee minutes.	Restraints were reviewed by the human rights committee within the required timeframes.	One or more restraints were not forwarded to the human rights committee and/or restraints are not reviewed by the committee within the required timeframes..

L67

There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	Regulation 5.10 (3) (c) 4:  A plan for shared or delegated management responsibilities shall be accompanied by a training plan,… to eliminate the need for such assistance, unless it is established by clinical evaluation that the individual cannot learn how to manage or spend any portion of his or her funds, even with supports.

Guidelines:
When staff hold an individual’s money and provide support in the use of their funds, there needs to be a plan for the money management responsibilities which includes a training plan to eliminate or reduce the need for assistance unless there is a clinical evaluation that the individual cannot learn how to manage or spend his or her funds. There needs to be agreement to the plan by the individual, guardian or conservator. The plan needs to establish the personal spending money which can be managed by the individual and specify the agency’s responsibilities in its role.

It is important that the training plan contain the required components, and foster increased independence on the part of the individual in the management of his/her money.  Providers need to support individuals to actively participate and develop skills in the management of money on both a daily and long-term basis, such as in provision of assistance in long term planning, budgeting and bill-paying activities.  Training plans need to be utilized as effective tools to promote individuals to become more involved and independent.  

It is only in the event that a clinical evaluation determines that the individual cannot learn to manage or spend his/her money (any portion) and would not benefit from a training plan, that this will not be present.  The ISP team, in lieu of one specific clinician can review the individuals’ need for training in the area of financial management.  	Money management plan review –	A sample of individuals is reviewed for whom the provider has shared or delegated money management responsibilities.  To determine whether there is a training plan with the required components.	Training plan is present and there is a plan to reduce or eliminate assistance or clinical evaluation and agreement is present as required.	Training plan not present and/or no plan to reduce or eliminate without clinical confirmation and/or agreement has not been obtained.	
L68

Expenditures of individual’s funds are made only for purposes that directly benefit the individual. 	Regulation 5.10 (3) (c) 1-2:  Individuals’ funds shall not be applied to goods or services which the provider is obligated by law or funded by contract to provide;  The provider … may not expend or borrow the funds of any individual for the use of anyone other than the individual.

Guidelines:
When staff hold an individual’s money and provide support in the use of their funds, expenditures must be made only to directly benefit the individual.  Individuals’ money cannot be used for such things as paying for staff or buying items for the house that the agency should be providing.

The provider needs to have a system of financial protection, monitoring, and reimbursement in place in the event that funds are erroneously expended for something that does not directly benefit the individual.  	Review of money expenditure documentation 	Review identified sample of individuals’ Financial Transaction Record information and personal cash on hand to determine that individual money is used only to benefit the individual. (Three month audit)	Individuals’ funds are used only to directly benefit the individual.	Individuals’ funds are utilized to pay for items that do not directly benefit the individual.	
L69

Individual expenditures are documented and tracked.  	Regulation 5.10 (3) (c) 6:  A record shall be kept of every transaction, including (see regulations for details).

Guidelines:
When staff hold an individual’s money and provide support in the use of funds, they need to document and track all expenditures, maintaining receipts for purchases over $25.   Although receipts for purchases less than $25 are not required, staff need to be aware of spending habits that limit individuals’ exposure to financial exploitation.  An individual’s money might also include food stamps, pay checks and gift cards.
	Review of money expenditure documentation 

Documentation should include bank books and check books in addition to transaction logs.	Review identified sample of individuals’ money to determine whether receipts over $25 are kept and money is tracked accurately.   Documentation for the past year needs to be available from which the surveyor chooses 3 months to audit.	Money is tracked with receipts and cash in/ out is accurate and timely.	Money is not tracked accurately, and /or receipts are not available and /or tracking is not accurate and/or timely.	
L70

Charges for care are calculated appropriately.	Regulations 3.05 (5) (e)  Determination of Charges:  For an individual receiving recurrent payments other than earned income, the monthly fee-pay or charge shall be an amount equal to 75% of the individual’s recurrent payments received in the month for which the charge for residential services and supports accrued … 

Guidelines:
Charges for Care are calculated as required.  Notification of charges is conducted annually with adjustments as necessary.

At Placement Service homes, room and board may be charged rather than Charges for Care.	Charges for Care documentation 	Review a sample of Charges for Care to determine that they have been calculated appropriately.	Charges for care are calculated properly.	Charges for care are not calculated properly. 	
L71

Individuals are notified of their appeal rights for their charges for care. 	Regulation 5.10 (3) (c) 8: … These charges shall be treated as any other significant debt of the individual, to be collected only after an appropriate explanation and written billing, including notice of means available to contest the charges for care.

Guidelines:
Individuals and guardians are informed of their right to appeal their charges for care or room and board charges.	Charges for Care documentation 	Documentation is reviewed for a sample of individuals and guardians to determine if they have been informed of their right to appeal their charges for care.	Individuals and guardians have been informed of their appeal rights. 	Individuals and guardians have not been informed of their appeal rights.	
L72
 
Sub-minimum wages earned are paid in accordance with Department of Labor ( DOL) requirements for compensation.

	Regulations 7.03 (1) (e) 8: … comply with state and federal wage-hour requirements when individuals engage in any work which must be compensated;

Guidelines:
Wages are in accordance with DOL requirements.	Day service time studies and DOL documentation.
Payroll and time records.	A sample of DOL documentation is reviewed to determine if DOL rates are being computed and wages are earned in accordance with DOL standards.	DOL wage and hour requirements are being computed correctly and wages are earned in accordance with DOL standards.	DOL wage and hour requirements are not computed correctly and/or wages are not earned in accordance with DOL standards.	
L73

The provider has a current DOL certificate.

	Regulations 7.03 (1) (e) 8: … comply with state and federal wage-hour requirements when individuals engage in any work which must be compensated;

Guidelines:
Current federal and state DOL Certificates need to be in place.	DOL document	Review to determine if there is a current DOL certificate for the program.	A current DOL certificate is present	A current DOL certificate is not present	
COMPETENT  AND SKILLED WORKFORCE
L74

The agency screens prospective employees per requirements. 	Regulations 7.06 (1) (h):
h. All providers shall comply with applicable federal and state labor laws and ensure nondiscriminatory practices.

Regulation 7.06 (1) (a):  All providers shall assure that the … qualifications of staff meet the training, care, support, health, safety and evaluation needs of the individuals served by the provider … (b) All providers shall assure that staff receive supervision to assist them in providing supports which lead to outcomes identified in the individual’s ISP … (c) All providers shall have current staff job descriptions which are relevant to the education, skills and experience necessary to assist individuals to achieve the outcomes delineated at 115 CMR 7.03.

Guidelines:
The agency has a process for interviewing prospective employees, check references and qualifications for the particular job, as needed so as to hire qualified staff. 

Note: effective as of 7/1/14, DDS has begun to license ABI/ MFP residential and placement services.  MRC required, and DDS will continue to require staff serving individuals in ABI/ MFP residential habilitation or placement services, to abide by certain additional screenings.  The agency is required to screen ABI/ MFP employees against the List of Exclusionary Individuals and Entities (LEIE).  The agency is also required to ensure that all ABI/ MFP staff are TB tested upon hire and every two years thereafter.  Lastly, ABI/MFP staff whose job requires driving must be screened to ensure that he/she has a valid current driver’s license.  
 	Review of agency system 

Job descriptions

Resumes	Compare the hiring requirements against new hire information to determine whether employees met applicable provider and DDS requirements.

For ABI/MFP services, look for an annual attestation from the agency that LEIE reviews and TB testing was done for all ABI/MFP employees. 

For ABI/ MFP services, look for policy and procedure for screening staff to ensure that the agency screens everyone who drives as part of their job and that he/she has a valid current Driver’s license.  

	Staff were hired in accordance with requirements.

When ABI/ MFP services are in place, rating in this indicator is a combination of whether the attestations are in place and # employees successfully screened over the number of items reviewed.
	Staff did not meet requirements and/or screening did not occur.	
L75

The agency assures that staff have the required qualifications and certifications to do the job as applicable. 	Regulations 7.06 (1)(f):
f. All providers arranging or providing professional services or consultation shall assure that such professionals are licensed, certified, or registered if such is required by law for persons who provide such professional services to the general public.

Guidelines:
There must be systems in place to assure that all staff have the necessary qualifications and certifications specific to the job description to support the individuals for whom they are responsible.

There should be applicable state licensure and certification requirements for specific professional designations and agency policies relative to staff qualifications.  The agency needs to have a process to ensure that applicable licenses, certificates, and professional designations are renewed as necessary and remain current.
	Agency system 

Hiring, training, licensure  and certification information

	The agency personnel system is reviewed to determine how the agency ensures they have qualified staff to support individuals.  

Applicable licensures for employees such as Nursing and Psychologists are checked to assure that they are present.	Staff have the required qualifications	Staff do not have the required qualifications.	
L76

The agency has and utilizes a system to track required trainings. 	Regulations – 7.06 (1) (e) All providers shall meet the following training requirements in 115 CMR 7.06 (1) (e) 1, 2, and 3, including maintaining up to date certifications.  All providers except those specifically exempted in 115 CMR 7.06 (1) (E) 4 and 5 shall also comply with those additional requirements:  1. Training of staff … in safety awareness, environmental modifications to increase the safety of individuals based on their individual needs, and all aspects of the safety plan, including specific evacuation plans for individuals requiring assistance to evacuate. 2. Training … in fire safety, which shall include, but need not be limited to: fire safety techniques, evacuation of persons with disabilities, fire drills, and evacuation procedures. 3. Training … in first aid. 4. Training in fire safety of at least one staff person in each location from an approved fire safety training agency, local fire department or from the Department… At least one person who has received fire safety training must be present at the home and in the work/day service. 5. Training in cardiopulmonary resuscitation (CPR) such that at least one trained staff person shall be present in homes providing 24-hour supports; work/day supports; and in site based respite.  

Guidelines:
There is a set of required trainings that all staff need to have.  These baseline trainings are necessary regardless of the individuals a staff person supports.  Additionally, there are trainings when one person per location needs to be trained.  There needs to be a system that ensures staff have completed all trainings as required.  Mandated trainings include some trainings that one person per location is required to receive (e.g. formal fire safety; CPR) as well as those trainings that all staff are required to have (e.g. first aid, fire safety, abuse and mistreatment).  Finally training on specific topics is required depending on staff role (e.g. MAP; HRO) staff role.  
 	Agency system – administrative office

Review of required trainings – at agency offices or on-site 	Agency system for tracking required trainings and a sample of training records are reviewed to determine that the agency has an effective tracking system, and that mandated trainings are current.

	The agency has an effective tracking system and/or all required trainings being completed within identified timelines.	Required trainings have not been completed within identified timelines.

L77

The agency assures that staff are familiar with and trained to support the unique needs of individuals. 	Regulation 7.06 (1) (a) 1-5:  All providers shall assure that the number, organization and qualifications of staff meet the training, care, support, health, safety and evacuation needs of the individuals served by the provider … (b). All providers shall assure that staff receive supervision to assist them in providing supports which lead to outcomes identified in the individual’s ISP … 

Guidelines:
Beyond the trainings required for all staff regardless of the individuals they support, it is important that staff are knowledgeable concerning the specific and unique needs that individuals they are supporting have.  Staff have read the individuals’ ISPs and have had training on any of the unique needs of each individual they are supporting.  For example, training in such topics as seizures, Deaf culture, and cerebral palsy may be indicated.  
	Staff interview

Training documentation 	A sample of staff are interviewed to determine their knowledge of the individuals they supports and what their role is in supporting those individuals.  

Training documentation for a sample of staff is reviewed.

	Staff can describe each person they support and their specific needs, and have received the requisite information / training.	Staff do not have a clear understanding of each person they support and their specific needs and/or have not received the requisite information / training.	
L78

Staff are trained to safely and consistently implement restrictive interventions	Regulation 7.06 (1) (a):  All providers shall assure that the … qualifications of staff meet the training, care, support, health, safety and evaluation needs of the individuals served by the provider…

Guidelines:
Staff have been trained in any restrictive behavioral interventions.  Documentation confirms that plans have been implemented correctly, consistently and safely.	Staff training documentation 

Staff interview 

Behavior Plan Information

	Sample of staff training is reviewed to determine if staff have been trained.

Staff are interviewed to assess whether they understand how to implement any restrictive interventions.

Behavior plan information is reviewed to determine if plan is implemented as written.

	Staff have been trained to safely and consistently implement restrictive interventions.

	Staff have not been trained to safely and consistently implement restrictive interventions.	
L79

Staff are trained in safe and correct administration of restraint.	Regulation 5.11 (6) (a):  Providers utilizing mechanical or physical restraint shall train all direct contact staff in the safe and appropriate use of such restraint.  (See regulations for details.)

Guidelines:
It is critical that when the use of restraint is necessary, staff have the requisite training to assure its safe utilization.  A list of approved restraint training is available through the regional Human Rights Specialist.  Authorizer training is provided by the Human Rights Specialist or by agency staff certified by the Human Rights Specialist to provide this training.  	Staff training documentation 

HCSIS restraint forms 

HSCIC forms regarding associated injuries with restraints

Staff Log	Training documentation reviewed to determine if staff have been trained in administering restraints using an approved curriculum. 

Restraint forms in HCSIS are reviewed to determine whether all restraints were applied by trained staff as well as being authorized by a trained authorizer.

Staff log reviewed to determine whether there have been any instances of restraint not documented as required.  	All restraints were applied by trained staff.	Restraints are found that were not applied by trained staff.	
L80

Support staff are trained to recognize signs and symptoms of illness.	Regulation 7.03 (1) (f) 1:  … promote optimal health of the individual through arrangements for coordinated routine, preventive, specialty, and emergency health care, professional clinical services, and availability of first aid supplies.

Guidelines:
Staff are often the first line of defense for individuals, particularly for individuals who may not be able to describe their symptoms of illness.  It is critical, therefore, that staff are knowledgeable about general signs and symptoms of illness.  General signs and symptoms of illness are outlined in the Health Promotion and Coordination Initiative Training and Resource Manual under “signs and symptoms of illness”, which includes signs and symptoms of illness and health observation guidelines.	Staff Interview 

Staff Log 	A sample of staff is interviewed to determine if they have an understanding of the signs and symptoms of illness, such as fever, sudden acute pain, etc. as outlined in the Health Promotion & Coordination Initiative.  

Staff log is reviewed to determine the presence of any instances where staff did not respond as needed to signs and symptoms of illness.	Staff demonstrate knowledge and there are no identified instances of a lack of an appropriate response.	Staff do not demonstrate knowledge and/or there are identified instances of a lack of an appropriate response.	
L81

Support staff know what to do in a medical emergency.	Regulation 7.03 (1) (f) 1:  … promote optimal health of the individual through arrangements for coordinated routine, preventive, specialty, and emergency health care, professional clinical services, and availability of first aid supplies.

Guidelines:
Staff respond correctly to medical emergencies. Medical emergencies generally consist of acute episodic events that require intervention.  For example, high fevers, cuts, injuries, and choking are a few of the types of situations that might require staff to seek outside assistance.  

There is no specific definition of a medical emergency, however, as the same symptoms for one person may constitute a medical emergency for someone else.  For example, a fever of 100 degrees may be more significant and alarming for someone whose typical body temperature runs around 96 degrees.   
	Any policy, procedure, or protocols which outline what constitutes a medical emergency and what staff are instructed to do when these occur (e.g. call PCP; go to ER, etc.)

HCSIS reports

Staff Interview 

Staff Log 	A sample of staff is interviewed to determine their knowledge of what to do in an emergency.  

Staff log reviewed for any instances of inappropriate response to an emergency.

The presence and adequacy of first aid supplies are determined.  	Staff demonstrate knowledge and there are no identified instances of inappropriate response.  	Staff do not demonstrate knowledge and/or there are identified instances of inappropriate response.	
L82

Medications are administered by licensed professional staff, MAP certified staff (or authorized PCA staff) for individuals unable to administer their own medications.
	Regulation 5.15 (5):  … For non-self-medicating individuals, prescription medication shall be administered by licensed professional staff, provided, however, that for non-self-medicating individuals receiving services in the community, prescription medication may be administered by community program staff who have successfully completed the Department approved Medication Administration Training Program and have been certified by the Department for such activities.

Guidelines:
There is documentation that for non-self medicating individuals, prescription medication is administered by licensed professional staff, PCA staff or by MAP certified staff.

For PCAs, there is documentation of an assessment of need for assistance and authorization from MassHealth.
	License/MAP certification documentation 

Medication review 	Documentation of required training is reviewed to determine that certification is present as needed.

A sample of medication records is reviewed to determine if medication was administered by licensed, certified or PCA staff. There must be a separate storage and documentation when medication is administered by anyone other than licensed/MAP certified staff.	Staff administering medication have required license or MAP certification or are PCA staff. 	Staff administering medication do not have required license or MAP certification and are not PCA staff working for the person 	
L83

Support staff are trained in human rights.	Regulation 7.06 (1) (a) 1:  All providers shall assure that the number, organization and qualifications of staff meet the training, care, support, health, safety and evacuation needs of the individuals served by the provider (see regulations for details.)

Guidelines:
Staff are trained and knowledgeable of individual rights including basic rights and what constitutes mistreatment.  Staff need to be trained in reporting responsibilities to DPPC for abuse and mistreatment.  Often Human Rights training is provided in concert with Abuse and Mistreatment training.  
	Training documentation 

	A sample of training documentation is reviewed to determine whether required training has occurred.  Training includes individual rights and what constitutes mistreatment as well as DPPC reporting responsibilities.

	Documentation of training present 	Documentation of training not present 	
L84

Staff are trained in the correct utilization of health related protections per regulation.	Regulation 7.06 (1) (a) 1:  All providers shall assure that the number, organization and qualifications of staff meet the training, care, support, health, safety and evacuation needs of the individuals served by the provider (see regulations for details.)

Guidelines:
Staff are trained, knowledgeable and capable of safely implementing any health related protection authorized through the ISP.  	Staff Interview 

	A sample of staff is interviewed to assess their understanding of how to safely and effectively implement health related protections authorized in individual’s ISP.  

	Staff demonstrate understanding of safe implementation as authorized through ISP.  There is evidence that implementation
correctly occurred 	Staff lack knowledge of safe and effective implementation and/or there is information available that implementation was not correctly 
performed	
L85

The agency provides on-going supervision and staff development. 	Regulation 7.06 (b): All providers shall assure that staff receive supervision to assist them in providing supports which lead to outcomes identified in the individual’s ISP.  The adequacy of supervision provided to staff shall be determined by all of the following (see regulations for details.)

Guidelines:
Staff receive supervision in ways determined by the provider that ensure staff are competent to support individuals to achieve ISP goals and outcomes that support increased skills and ability to support individuals.

The agency has a process in place that supports the retention of qualified staff.  This may include supervision, training, opportunities for further education, staff evaluations etc. 

The agency has a process for annual, and as needed performance evaluations and follow-up on personnel issues. 

The agency needs to have an orientation for new employees as well as options for additional trainings.
	Administrative interview

Administrative documentation including performance evaluation forms and process

Staff Interview 

Staff Log 	Review of policies and procedures and administrative interview to determine the presence of a supervisory structure, frequency and expectations for supervision and expectations for staff development.

Compare the expectations (e.g. weekly supervision or monthly group staff meetings), to what is occurring.	The agency has a system of ongoing supervision that is being followed.	The agency does not have a system of ongoing supervision and/or it is not being consistently followed.	
GOAL DEVELOPMENT AND IMPLEMENTATION 

L86

Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	Regulation 6.21 (6) (a):  The responsibilities of the provider in the ISP process are to complete assessments or professional consultations of the individual that are within the legal or contractual responsibility of the provider … to work collaboratively with the individual and other team members to identify the individual’s goals, and to develop an ISP which is likely to be effective in assisting the individual to achieve those goals.

 Guidelines:
The completion of quality assessments are critical to the development of objectives and supports that address the needs of the individual.  Assessments must be submitted at least 15 days in advance of the ISP meeting.  Required assessments include an assessment of the general type of supports needed by the individual, of the individual’s ability to make informed decisions regarding financial & personal affairs & of financial status eligibility for services or benefits from other entities. DDS funded supports conduct safety assessment & other assessments required by their contract. Residential provider insures annual health & dental assessments occur.   	Individual Record

	Ssample of individual records reviewed for presence of ISP assessments and date of submission.	Required assessments present & submitted at least 15 days in advance of the ISP.	One or more required assessments not present &/or not submitted within required timelines	
L87

Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	Regulation 6.21 (6) (c): Within 15 days of the ISP meeting, to develop and forward to the service coordinator for incorporation into the ISP, strategies for the provision of the supports identified during the ISP meeting.

Guidelines:
The submission of support strategies by the provider designed to assist an individual to achieve agreed upon objectives is an important component of the ISP.  They must be submitted within 15 days of the ISP meeting.  	Individual Record

	A sample of individual records is reviewed for presence of support strategies and date of submission..	Support strategies are submitted within required timelines	Support strategies were not submitted within required timelines.	
L88

Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented. 	Regulation 6.21 (6) (e):  To implement the ISP by providing the agreed upon supports.

Guidelines:
Staff need to have a clear understanding of the needed services and supports identified in the ISP and their responsibility in delivery in order to support individuals in reaching their goals.  It is important that staff, even if they are not directly responsible for ISP support implementation, understand the goals an individual is working on in order to fully support goal implementation.  It is important that the Provider implement agreed upon strategies and actions to support the individual to accomplish his/her ISP objectives.	Individual record 

Progress notes 

Staff interview 	A sample of individual records is reviewed for documentation of service & support strategy implementation (progress notes.).  

A sample of staff is interviewed for knowledge about the needed supports and their role in delivery or can identify who is responsible.	Staff are knowledgeable of support strategies and they are being implemented as designed.	Staff are not knowledgeable of support strategies and /or they are not being implemented as designed.	
(HUMAN RIGHTS)
L-89

The provider has a complaint and resolution process that is effectively implemented at the local level.

	Note: effective as of 7/1/14, DDS has begun to license ABI/ MFP residential and placement services.  MRC required, and DDS will continue to require locations serving individuals in ABI/ MFP residential habilitation or placement services, to abide by certain additional requirements. DDS will continue to expect:  There should be a policy and procedure from the provider outlining their complaint resolution process.  Each location should follow the agency’s policy and procedures, and documentation that the staff, participants and guardians have been trained, should be available.  Each location should have a log, either on paper or electronic which records the complaint with date, short description, name of the complainant, date resolved and who and how this was resolved.	Individual record 

Progress notes 

Administrative documentation including policies and procedures

Staff Interview 

Staff Log
	Review of policies and procedures and administrative interview to determine the presence of a complaint resolution system and structure, frequency and expectations for reporting and responding and frequency of training to staff.

Compare the expectations to what is occurring.	The agency has a system of ongoing complaint resolution that is being followed.	The agency does not have a system of ongoing complaint resolution and/or it is not being consistently followed.	
(HUMAN RIGHTS)
L-90 

Individuals are able to have privacy in their own personal space.

	CMS § 441.530 Home and Community-Based Setting.(a) (1)  (iii) Ensures an individual’s rights of privacy...

Privacy for individuals in 24 hour residential supports and placement services begins with each individual having clearly defined private living, sleeping and personal care spaces. There should be a lock on the bedroom door, unless otherwise contraindicated and documented through the ISP process or unless the bedroom door leads to an egress.  Even if individuals are sharing a room, there is an expectation that their sleeping area and furniture is their private space.  Staff (Home providers) knock before entering a person’s room. Staff /Home providers encourage and support other people to respect others’ privacy.  Staff  (Home providers) do not enter people’s rooms without permission. This permission can be given prior to entry.  For example, staff obtained permission to enter the bedroom, but needs to step away and return momentarily, and don’t need to ask for permission to reenter when she/he returns.  Staff /Home providers do not open people’s closets or drawers without permission.

Individuals are supported to be alone when they want. They can spend time alone in their rooms, with the door closed, if they choose. They are allowed and even encouraged to close the bedroom door when they want or need privacy. For individuals with roommates, there are opportunities to be alone. Staff facilitate these opportunities and work with roommates to come to agreements that respect and foster privacy of all roommates.	Site visit 

Individual interview/ observation 

Staff interview 

	A sample of sites is reviewed to determine whether there is environmental support for privacy (e.g. private meeting space; private bedrooms).

A sample of staff is interviewed and individuals are interviewed/ observed to determine whether individuals understand that they have privacy in their own personal space. 

A sample of sites is observed to determine whether privacy is supported in practice (i.e., staff knock on doors, individuals are able to be in their rooms).	There is substantial interview and observational evidence that individuals have privacy in their own personal space(s), and the individual has a lockable bedroom door (unless contra-indicated or leading to egress).  

	There is minimal indication through interview and/or observational evidence that individuals are able to have privacy in their own personal spaces and/or the individual does not have a lockable bedroom door.	
(Personal Safety)

 –effective 8/15/18 
L-91 
Incidents are reported and reviewed as mandated by regulation

	 13.02: Reportable Incidents 
(1) A reportable incident is any event or occurrence in the life of an individual that must be reported to the Department. The categories of incidents that are subject to the reporting requirements of 115 CMR 13.00 include, but are not limited to, the following: 
(a) unanticipated or suspicious death; 
(b) inappropriate sexual behavior; 
(c) significant behavioral incident; 
(d) unexpected hospital visit; 
(e) fire; 
(f) suspected mistreatment; 
(g) theft; 
(i) missing person; 
(j) criminal activity; 
(k) transportation accident; 
(l) emergency relocation; 
(m) suicide attempt; 
(n) property damage; 
(o) victim of physical altercation; and 
(p) medical/psychiatric intervention not requiring a hospital visit. 

(2) The Department may modify the categories and definitions of reportable incidents at its discretion, and shall periodically issue such categories and definitions in incident management guidelines. 

13.03: Reporting Requirements 

Providers shall report to the Department: 
(a) any reportable incident involving an individual for whom the provider was responsible for providing care and/or supervision at the time of the incident; 
(b) any reportable incident that occurs in the provider’s program which is licensed or certified by the Department and involves an individual whose services are not funded by the Department, or who are not eligible for DDS services; 
(c) any reportable incident involving a child or the primary caregiver of a child participating in the Children’s Autism Home and Community Based Waiver Program; 
(d) any reportable incident designated by the Department as requiring a major level of review that occurs while an individuals younger than 18 years old is receiving a service funded by the Department; 
(e) any incident involving a fatality, near fatality, or serious bodily injury of a child receiving services from the Department. A fatality includes deaths resulting from automobile accidents, abusive head trauma, gunshot wounds and drug overdose. Serious bodily injury means bodily injury involving a substantial risk of death, extreme physical pain, protracted and obvious disfigurement or protracted loss or impairment of the function of a bodily member, organ or mental faculty;
(f) any reportable incident that is brought to the provider’s attention that involves an individual who, at the time of the incident, was under the care and/or supervision of a person who is not an employee, volunteer or subcontractor of the provider, as soon as the provider learns of the incident.

13.04 (5)
An individual’s guardian(s) shall receive verbal notification that an incident requiring a major level review involving the individual occurred as soon as reasonably practicable after the incident is discovered. Notification of incidents requiring a minor level review shall be made to the guardian(s) in accordance with the preferences expressed by the guardian(s) documented in the individual record. Guardians may request written notification regarding any incident, and shall have access to any Incident Report when finalized.

Guidelines:
All staff need to be knowledgeable concerning what constitutes a reportable incident, and practices and timing for filing, and reporting to supervisory personnel.   

Supervisory staff need to take immediate actions to protect health, safety and welfare of the individual(s) and to ensure that the incident notes the people involved in the incident including any eyewitnesses to the incident.

Guardians need to be informed of all major incidents as soon as reasonably practical after the incident, and of minor incidents in accordance with the preferences of the guardians.	
Policies and procedures for reporting incidents.

Incident reports (HCSIS)

Communication and locations Logs 

Individual Record 

Staff interview

Individual interview	
A review of incidents filed to identify those that have been filed, and the timelines for these.

Notification of all major incidents to all parties, including the guardians is checked. 

A review of a sample of documentation (individual and location) is conducted to assess whether reportable items noted within communication log, individual record, or interview were also filed as incident reports.

Staff interviewed to determine knowledge of what constitutes reportable incidents.
	
Review of incidents indicates that staff are filing, and information shared to all relevant parties through either interview or documentation showed no evidence of unreported incidents.  Initial Incident Reports and Final Incident Reports are submitted to the department within the timelines specified.
	
Review of incidents indicates that staff are not filing, and information shared to all relevant parties through either interview or documentation showed evidence of unreported incidents.  Initial Incident Reports and Final Incident Reports are not submitted to the department within the timelines specified.
Information shared either through interview or documentation shows that an incident went unreported.