Provider:  Commonwealth Enterprises, Inc.					Provider Address:  Town Line Redemption, P.O. Box 689, N. Dighton

Survey Team:  Laura K. O’Connor						Dates of Review:  May 20 – 24, 2013

Mid-Cycle Scope and Results: 	

Service Grouping	
Licensure Level and Duration	# Indicators Std. Met/Std. Rated at Mid-Cycle	
Sanction Status Prior to Mid-Cycle	
Combined Results Post - Mid-Cycle	
Sanction Status Post    Mid-Cycle	
 Employment and Day 
 Supports	 Deferred Licensure	9/15	o	Eligible for New Business	 Two-Year License  
 with Mid-Cycle  
 Review
 49/55  (89.09%)	x	Eligible for New Business
(80% or more std. met; no critical std. not met.)
	
 1 Location 
 4 Audits 	 

 

 
 
 	x	Ineligible for New Business. 	 

 
 	o	Ineligible for New Business
(<=80% std met and/or more critical std. not met.)	

Summary of Ratings

 Organizational Area Needing Improvement on Standard Not Met:	
 Indicator #	
L2	

 Indicator	
Abuse/Neglect reporting.	

 Area Need Improvement	
An issue was identified pertaining to an individual taking money from someone else who lived on WDC grounds, and agency staff making her pay restitution.  This same individual was suspended from work without safeguards in place.  None of these incidents were reported or documented by agency staff, as required.  When identified, agency management agreed to file an investigation report regarding the incidents involving potential financial exploitation.  The agency needs to ensure that all staff are knowledgeable regarding their mandated reporting responsibilities.

 Status at Mid-Cycle	
Staff throughout the agency received training regarding abuse and neglect reporting.  Instances of suspected abuse, neglect or mistreatment have been reported as required.  One investigation has been reported and screened out since the last survey.

 # Met / # Rated at Mid-Cycle	
1/1	

 Rating	
MET	

 	

Employment and Day Supports Areas Needing Improvement on Standards Not Met:	
 Indicator #	
L1	

 Indicator	
Abuse/Neglect training.	

 Area Need Improvement	
Recently dated one page documents in each individual's file lists a Human Rights Officer from another program location and did not contain abuse reporting procedures.  Parents/Guardians were also not provided with annual rights and abuse reporting training information.  The agency needs to ensure that each individual and their families/guardians receive sufficient training and information regarding how to recognize and report potential abuse, neglect or mistreatment, on at least an annual basis, as required.

 Status at Mid-Cycle	
The agency has provided annual and monthly refresher training to individuals regarding rights and how to report potential abuse and neglect.  Packets of information regarding rights and DPPC reporting were also mailed to families/guardians.

 # Met / # Rated at Mid-Cycle	
4/4	

 Rating	
MET	

 	

Employment and Day Supports Areas Needing Improvement on Standards Not Met, cont.	
 Indicator #	
L8	

 Indicator	
Emergency Fact Sheets	

 Area Need Improvement	
The agency needs to monitor to ensure that Emergency Fact Sheet (EFS) include all required elements, including: photograph of the individual, significant medical diagnoses, allergies, and current medications.

 Status at Mid-Cycle	
The four Emergency Fact Sheets that were reviewed contained required elements.	

 # Met / # Rated at Mid-Cycle	
4/4	

 Rating	
MET	

 	

 
 Indicator #	
L10	

 Indicator	
Reduce risk interventions.	

 Area Need Improvement	
The agency indicated that no one at this location was involved in risk management; however, at least two people were actively being followed through the DDS Area Office Risk Management Committee.  One of the individuals whose supports were evaluated as part of this survey has exhibited behaviors that posed risk by taking money from other individuals.  Interventions have been implemented without required safeguards in place.  There were no support protocols in place, such as supervision strategies, to prevent the recurrence of risk behaviors.  All agency staff need to be knowledgeable of how to pro-actively recognize, communicate, and respond to risk behaviors.

 Status at Mid-Cycle	
One man has exhibited behaviors that pose potential risk to himself and others.  A Behavior Plan was in place; however, this plan was intended for use at his home and could not be fully or correctly implemented  at work.  This plan included potential restraint by two staff.  A residential staff person provided one to one support to him at work.  Agency staff were not yet trained in restraint techniques and need additional guidance/supervision regarding their roles and responsibilities if an individual exhibits behaviors that pose potential risk or requires crisis response.  The agency also needs to implement its plans to more accurately and actively identify and monitor when individuals have behaviors or health needs that pose potential risk.  Staff must be trained and knowledgeable regarding their roles and responsibilities, as well.

 # Met / # Rated at Mid-Cycle	
2/3	

 Rating	
NOT MET	

 	

 

 

Employment and Day Supports Areas Needing Improvement on Standards Not Met, cont.	
Indicator #	
L13	

 Indicator	
Clean location.	

 Area Need Improvement	
Multiple issues were identified pertaining to the cleanliness and maintenance of the three buildings.  The agency needs to develop and implement systems to more effectively monitor buildings and advocate for needed repairs within a timely manner.

 Status at Mid-Cycle	
Since the last survey, the individuals and staff that worked at the previous Wredemco location have moved their work supports.  These people are temporarily sharing space with the agency's other Wrentham day supports program, which is located on Route One.  A large new location in Mansfield, MA has been purchased and is in the process of being renovated to become a redemption center.  The North Dighton Town Line Redemption Center location, which was the only one visited for this survey, was generally well- maintained.  The individuals who performed cleaning throughout the building were vigilant about keeping the space as clean as possible.

 # Met / # Rated at Mid-Cycle	
1/1	

 Rating	
MET	

	

	
 Indicator #	
L14	

 Indicator	
Site in good repair.	

 Area Need Improvement	
The main stairs within the Womens' Vocational building needed better lighting, replacement of visual contrast taping, the broken doorknob at the top removed or replaced, and cleaning.  (Corrected)  The rear steps in this building, that served as a second means of egress and led to the basement, also needed additional lighting and cleaning.

 Status at Mid-Cycle	
No issues pertaining to this indicator were identified at the agency's North Dighton location.	

 # Met / # Rated at Mid-Cycle	
1/1	

 Rating	
MET	

 	

Employment and Day Supports Areas Needing Improvement on Standards Not Met, cont.	
  Indicator #	
L21	

 Indicator	
Safe electrical equipment.	

 Area Need Improvement	
Lighting issues on stairs in Women's Building were identified, Round ceiling light fixtures needed to be cleaned from bugs/debris within them, the hole in the wall of the break room in the Mens' vocational building, which showed wires, needs to be fixed.

 Status at Mid-Cycle	
No issues pertaining to this indicator were identified at the agency's North Dighton location.	

 # Met / # Rated at Mid-Cycle	
1/1	

 Rating	
MET	

 	

 Indicator #	
L22	

 Indicator	
Clean appliances.	

 Area Need Improvement	
Microwaves, particularly in the top inside areas, need to be cleaned.  (Corrected)  The agency needs to monitor to ensure that all appliances are continuously maintained in a sanitary matter.

 Status at Mid-Cycle	
No issues pertaining to this indicator were identified at the agency's North Dighton location.	

 # Met / # Rated at Mid-Cycle	
1/1	

 Rating	
MET	

 	

  Indicator #	
L58	

 Indicator	
Behavior Plan component.	

 Area Need Improvement	
One individual had been suspended from work three times and made to pay restitution as a result of behavioral issues.  These interventions were not identified as potential responses to her target behaviors within her plan or otherwise documented/reported to or approved by her ISP team.  There was no criteria for recording or evaluating data towards reducing the restrictiveness of interventions used to address her behavioral issues.  Behavior Plans must be revised, as needed, incorporate all interventions used, and include all required components.  

 Status at Mid-Cycle	
Two of the four Behavior Plans that were reviewed were written for residential services and could not be fully or correctly implemented at work.  The agency needs to review all existing behavioral supports to identify and correct plans, to ensure that they can be implemented correctly by work staff, and that they contain all required components.

 # Met / # Rated at Mid-Cycle	
2/4	

 Rating	
NOT MET	

 	

Employment and Day Supports Areas Needing Improvement on Standards Not Met, cont.	
 Indicator #	
L59	

 Indicator	
Behavior Plan review.	

 Area Need Improvement	
Level II Behavior Plans had not been reviewed by the agency's Human Rights Committee.  The Level I Plan needs significant revisions to address the interventions that have been implemented, which may require reclassification to a Level II Plan.  All Level II Plans also needs to be reviewed by the Peer Review Committee, as required.

 Status at Mid-Cycle	
Two of the four Behavior Plans did not contain required reviews, including a Level II Plan that was not reviewed by the agency's Human Rights Committee.  The agency needs to ensure that Behavior Plans receive all required reviews before they are implemented.

 # Met / # Rated at Mid-Cycle	
2/4	

 Rating	
NOT MET	

 	

 
 Indicator #	
L60	

 Indicator	
Data maintenance.	

 Area Need Improvement	
Minimal data was being taken regarding a backpack that the individual with the Level I Plan carried to/from work.  Interventions were being used, including going into a more quiet area to allow the person to calm down, suspensions from work, and restitution, without any documentation or data in place.  The agency needs to ensure that staff fully understand their roles and responsibilities so that they can more effectively record and maintain data to determine the effectiveness of behavioral interventions.

 Status at Mid-Cycle	
Some data was being taken for some of the Behavior Plans, either through data charts or daily notes from the person's work supervisor.  One person had a one to one residential staff accompany him to work to provide his primary supports, and to track his behavioral data for his residential clinician's use.  Data was being taken regarding another woman's target behaviors, but there was no written plan or monitoring.  The agency needs to implement plans to work with clinicians to develop more effective ways for staff to maintain and use data to determine the efficacy of behavioral interventions.

 # Met / # Rated at Mid-Cycle	
2/4	

 Rating	
NOT MET	

 	

 
 
 Employment and Day Supports Areas Needing Improvement on Standards Not Met, cont.	
 Indicator #	
L78	

 Indicator	
Restrictive Intervention Training	

 Area Need Improvement	
Staff need additional training to ensure that they can proactively recognize when interventions pose restric-tions of individuals’ rights.  Staff also need to be knowledgeable regarding how to consistently implement and document any restrictive interventions.

 Status at Mid-Cycle	
Although staff had been trained regarding existing behavior plans, some of these plans were written for residential services and could not be implemented during working hours.  One plan contained potential escorts and restraint; which staff are not yet trained to do correctly.  NVMAB training for staff is scheduled in June 2013.  The agency's work rules, called "Keys to Vocational Success," contained restrictive elements such as suspension, without explanation of how/when these restrictions would be implemented.  Staff need additional training, supervision, and guidance, regarding various types of behavioral and restrictive inter-ventions, including explanation of their roles/responsibilities when any restrictive interventions are imple-mented.

 # Met / # Rated at Mid-Cycle	
0/1	

 Rating	
NOT MET	

 	

 Indicator #	
L79	

 Indicator	
Restraint training.	

 Area Need Improvement	
One person had a Level II Plan in place that contained restraint as a component of the plan.  Agency staff must be trained and knowledgeable regarding restraint procedures.  The existing behavior plan references  a different type of restraint training than the agency will provide to staff.  The Behavior Plan should be enhanced to cross reference the procedures to be implemented with the agency's restraint training curric-   ulum.

 Status at Mid-Cycle	
Staff from both locations are scheduled to receive NVMAB training in June 2013.  One individual has a level two behavior program that includes potential two person escorts and restraints.  His residential staff, who reportedly received CPI restraint training, provided one to one supports to this individual during working hours.  The agency must confer with the residential staff, clinician, and NVMAB instructor to develop emergency intervention techniques to be used during the day, should this person require restraint.  All agency staff, who could potentially be responsible for crisis interventions including restraint, must receive and maintain current training in this area.

 # Met / # Rated at Mid-Cycle	
0/1	

 Rating	
NOT MET	

 	

Employment and Day Supports Areas Needing Improvement on Standards Not Met, cont.	
 Indicator #	
L80	

 Indicator	
Symptoms of illness.	

 Area Need Improvement	
All staff need to be trained regarding the signs and symptoms of illness.  (Corrected)	

 Status at Mid-Cycle	
Staff have received training regarding the signs and symptoms of illness, as required.	

 # Met / # Rated at Mid-Cycle	
1/1	

 Rating	
MET	

 	

 
 Indicator #	
L85	

 Indicator	
Supervision 	

 Area Need Improvement	
The agency needs to provide additional supervision, guidance, training to staff in the areas of safeguarding individuals’ rights and the fostering and development of transferable skills towards supported employment.

 Status at Mid-Cycle	
Many personnel changes have occurred within the agency, including the retirement of the long-time director and the departure of some other long-term staff.  The new director has begun to network staff by having joint meetings with staff from both locations.  A training day is also scheduled for all staff to focus on team and morale building.  As the agency goes forward, it will be important for the new management staff to become more familiar with the state employee personnel filing, recognition, and disciplinary procedures. 

 # Met / # Rated at Mid-Cycle	
1/1	

 Rating	
MET	

 	

 

Mid-Cycle Detail Report
(For provider and area office use only.  This page elaborates on all of the indicators reviewed at follow-up where the standard was not met.)

Employment and Day Supports	
Indicator	Service Type	Location	Individual	Issue	

 

 

 
 	 L10	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	BJ	B.J. has exhibited behaviors that pose potential risk to himself and others.  A Behavior Plan was in place; however; this plan was intended for use at his home and could not be fully or correctly implemented at work.  This plan included potential restraint by two staff.  A residential staff person provided one to one support to B.J. at work.  Agency staff were not yet trained in restraint techniques and need additional guidance/supervision regarding their roles and responsibilities if B.J. exhibits behaviors that pose potential risk or requires crisis response.

 
 	 L58	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	BJ	B.J. needs a Behavior Plan that contains all required components and can be appropriately utilized during working hours.

 

 	 L58	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	SP	S.P. had behavior guidelines that were designed for her home, not for work.  Data was being taken for target behaviors at work, but a Behavior Plan with all required components, which can be implemented during working hours, must be developed.  

 
 	 L59	Center-Based Employment	455 Somerset Avenue 	BJ	Once a Behavior Plan that can be implemented at work for B.J. is developed, all appropriate reviews must occur.

  	 L59	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	SP	Once a Behavior Plan, to be used at work with S.P., is developed; it must receive required reviews.

 
 
 	 L60	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	BJ	B.J.'s work and residential staff must determine how data will be taken, maintained, and provided to both agencies and his clinician, to determine the efficacy of behavioral interventions.

Mid-Cycle Detail Report/Employment and Day Supports, cont.	
Indicator	Service Type	Location	Individual	Issue	

 
 
 	L60	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	SP	Data was being taken for target behaviors; however; there was no corresponding Behavior Plan in place for work hours.  Clinical oversight/monitoring is also needed to determine the efficacy of any behavioral interventions.  

 

 

 

 

 	L78	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	 

 

 

 

 	Although staff had been trained regarding existing Behavior Plans, some of these plans were written for residential services and could not be implemented during working hours.  One plan contained potential escorts and restraint; which staff are not yet trained to do correctly.  The agency's work rules, called "Keys to Vocational Success," contained restrictive elements such as suspension, without explanation of how/when these restraints would be used.  Staff need additional training, supervision, and guidance, regarding various types of behavioral and restrictive interventions, including explanation of their roles/ responsibilities when any restrictive interventions are implemented.

 

 

 	L79	Center-Based Employment	455 Somerset Avenue,
N. Dighton 	 

 

 
 	NVMAB training for all staff that are medically able   to complete this course is scheduled for June 2013.  The agency needs to ensure that this training occurs and that any potential conflict involving one person's residential staff using different crisis intervention/ restraint techniques (CPI) are resolved, through the Behavior Management Plan to be used during day support hours.