PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
Community Autism Resources
33 James Reynolds Rd
C Swansea, MA 02777    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
June 30, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
Community Autism Resources	

	

	

	

	
Review Dates	

	
6/6/2017 - 6/9/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
6/16/2017	

	

	

	

	

	

	
Survey Team	

	
Ed Sutka (TL)	

	

	

	

	
Citizen Volunteers	

	

	

	

	

		

	

	
Survey scope and findings for Employment and Day Supports	

Service Group Type	
Sample Size	
Licensure Scope	
Licensure Level	
Certification Scope	
Certification Level	

Employment and Day Supports	
1 location(s) 3 audit (s) 	
Full Review	
22 / 26 2 Year License 06/16/2017 -  06/16/2019	
	
19 / 20 Certified 06/16/2017 -  06/16/2019	

Community Based Day Services	
1 location(s) 3 audit (s) 	

Full Review	
13 / 14	

Planning and Quality Management	

	
Full Review	
6 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
Community Autism Resources (CAR) is a non-profit human service agency that provides family support and community based day supports (CBDS) to people with Autism Spectrum Disorders (ASD) and their families throughout southeastern Massachusetts.  The Community Based Day supports consist of the Gotschall Access program (GAP), which provides a college experience at the Bristol Community College (BCC) campus in Fall River for the 14 adults whom GAP supports.  While the agency's family support component has provided services for nearly 25 years, GAP commenced in September 2016 and is still in the first year of providing an educational option that will take the participating students three years to complete.  This program, which consists of both core courses and electives, runs two days per week for three 12-week trimesters spread throughout the year. Starting in year two of the three year program, GAP will offer internships to those it supports based on their interests, with supports tailored to help people transition to the employment opportunities of their choice by the end of the third year.  

This review by the Department of Developmental Services (DDS) consisted of three audits, drawing information from six people supported by CAR who participate in courses offered by GAP at the BCC campus in Fall River.  In total, 14 students currently participate in these classes.  The current review, which represented the first time GAP has undergone the licensing process, included all licensing and certification indicators in the DDS survey tool for CBDS.  In addition to the indicators specifically relevant to CBDS services, the survey process also encompassed a number of indicators that were germane to the agency's organizational systems.  

The agency provides an innovative, atypical Community Based Day Service through the GAP's structured three year program.  As a new class is expected to begin each year, enrollment is projected to reach 45 by the 3rd year.  GAP course offerings included a broad range of subject areas, such as theater, organic farming, paralegal supports, and photography.  Subjects were taught through a combination of classroom work as well as experiential components that took place at various locations on the BCC campus.  Curriculum, such as readings selected for the theater class, were adapted to best meet the individualized interests and abilities of each participant, and students were observed to demonstrate a generally high level of concentration and enthusiasm throughout the day.  In addition to having two CAR staff present at all activities, classroom sessions were led by teachers with appropriate expertise who had been hired by CAR as independent contractors to lead specific course offerings.  The agency's efforts to individualize GAP's course offerings were major factors in its achievement of high scores in certification areas and in organizational planning.  

CAR successfully supported the individuals served by GAP to experience integration and acceptance, particularly within the BCC community.  Support from CAR staff had been helpful in assisting students to access a variety of BCC resources, such as the cafeteria, library, gym, and computer lab.  This involvement has helped GAP students to become better known on campus, develop positive relationships, and gain confidence.  GAP staff reshaped on an on-going basis the combination of course offerings and electives in which people participated to better reflect their preferences and desires.  For instance as the GAP's first year is drawing to a close, staff have already begun the process of connecting with organizations that can be helpful in providing internships for GAP students and eventually facilitating transitions to employment opportunities for people that matched their preferences and aspirations.

During the course of the review, a few areas in licensure were identified where further efforts were needed to meet the intent of DDS regulations. or instance, while improvements were being made to the agency's Human Rights Committee, some additional work remained to be done.  In another example, timelines for submission of Individual Support Plan (ISP) Assessments and Support Strategies had not always been met.  Within the certification areas, the agency had made successful efforts to support people to have an impact on the evaluation of their staff, but further efforts are needed to ensure that they have similar opportunities to impact the hiring of new staff.

Based on the findings of this report, the agency has earned a Two-Year License in Employment/Day Supports for its CBDS services offered through GAP. Licensing indicators were rated 85% Met, and the DDS survey team will conduct a follow-up review in approximately 60 days relative to the Not Met licensing indicators.  The agency is also Certified in Employment/Day Supports with 95% of the certification indicators rated Met.	

	

	

LICENSURE FINDINGS	

	

	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
4/5	
1/5	

Employment and Day Supports	
18/21	
3/21	

    Community Based Day Services

	

Critical Indicators	
2/2	
0/2	

Total	
22/26	
4/26	
85%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
4	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
While the agency had made efforts to improve its Human Rights committee (HRC), the following items need to be addressed: clarifying the definition of quorum in the By-laws, ensuring that requirements relating to the frequency of meetings is met with a quorum present for all meetings, ensuring HRC review of agency policies and procedures concerning human rights, and having HRC members make site visits.  Additionally, the agency needs to expand efforts to support voting members to raise questions and concerns  regarding people's rights and to ensure that this type of activity is reflected in the meeting minutes. 	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 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.	
Consents for release of photographs and medical information need to be further refined.  As the generalized medical information states "you will be consulted before any information is released," this form is not necessary if the consultation referred to is sufficiently specific.  Consent for the use of photographs should be specific to the photo.   	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
For one out of two people reviewed, ISP assessments had not been submitted at least 15 days in advance.  ISP assessments need to be submitted at least 15 days in advance of the ISP meeting.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
For one out of two people, ISP Support Strategies had not been submitted at least 15 days in advance.  Support Strategies need to be submitted at least 15 days in advance of the ISP meeting.	

	

		

	

	

CERTIFICATION FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

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

Employment and Day Supports	
13/14	
1/14	

Community Based Day Services	
13/14	
1/14	

TOTAL	
19/20	
1/20	
95%	

Certified	

	

	

	

	

	
Community Based Day Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

 C40	
Individuals are supported to explore, discover and connect with their personal interest and options for community involvement, personal interest and hobbies.	
 The agency offered a college experience to people enrolled in GAP through a joint effort of the agency and BCC.  The agency is commended for further enhancing this experience by its willingness to reshape course offerings to better match people's preferences, including their future employment aspirations.	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
While the agency had provided opportunities for people to provide feedback regarding the performance of their staff, there needs to be similar opportunities provided for people to have input into the process of hiring staff.	

	

	

		

	

						
	MASTER SCORE SHEET LICENSURE	

						
	Organizational: Community Autism Resources	

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

O	
 L2	
Abuse/neglect reporting	
1/1	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L74	
Screen employees	
1/1	
Met	

 L76	
Track trainings	
2/2	
Met	

 L83	
HR training	
2/2	
Met	

						
Employment and Day Supports:	

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

 L1	
Abuse/neglect training	
I	

3/3	
3/3	
Met	

 L8	
Emergency Fact Sheets	
I	

3/3	
3/3	
Met	

 L9	
Safe use of equipment	
L	

1/1	
1/1	
Met	

 L31	
Communication method	
I	

3/3	
3/3	
Met	

 L32	
Verbal & written	
I	

3/3	
3/3	
Met	

 L37	
Prompt treatment	
I	

3/3	
3/3	
Met	

O	
 L38	
Physician's orders	
I	

1/1	
1/1	
Met	

 L39	
Dietary requirements	
I	

2/2	
2/2	
Met	

 L49	
Informed of human rights	
I	

3/3	
3/3	
Met	

 L50	
Respectful Comm.	
L	

1/1	
1/1	
Met	

 L51	
Possessions	
I	

3/3	
3/3	
Met	

 L52	
Phone calls	
I	

3/3	
3/3	
Met	

 L54	
Privacy	
L	

1/1	
1/1	
Met	

 L55	
Informed consent	
I	

0/3	
0/3	
Not Met
(0 %)	

 L77	
Unique needs training	
I	

3/3	
3/3	
Met	

 L80	
Symptoms of illness	
L	

1/1	
1/1	
Met	

 L81	
Medical emergency	
L	

1/1	
1/1	
Met	

 L85	
Supervision 	
L	

1/1	
1/1	
Met	

 L86	
Required assessments	
I	

1/2	
1/2	
Not Met
(50.0 %)	

 L87	
Support strategies	
I	

1/2	
1/2	
Not Met
(50.0 %)	

 L88	
Strategies implemented	
I	

2/2	
2/2	
Met	

#Std. Met/# 21 Indicator	

	

18/21	

	
Total Score	

	

22/26	

	

	

	
84.62%	

		
						
	MASTER SCORE SHEET CERTIFICATION	

						
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
Met	

 C2	
Data analysis	
1/1	
Met	

 C3	
Service satisfaction	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
1/1	
Met	

 C5	
Measure progress	
1/1	
Met	

 C6	
Future directions planning	
1/1	
Met	

	

	

						
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
0/3	
Not Met (0 %)	

 C8	
Family/guardian communication	
3/3	
Met	

 C13	
Skills to maximize independence 	
3/3	
Met	

 C37	
Interpersonal skills for work	
3/3	
Met	

 C40	
Community involvement interest	
3/3	
Met	

 C41	
Activities participation	
3/3	
Met	

 C42	
Connection to others	
3/3	
Met	

 C43	
Maintain & enhance relationship	
3/3	
Met	

 C44	
Job exploration	
3/3	
Met	

 C45	
Revisit decisions	
3/3	
Met	

 C46	
Use of generic resources	
3/3	
Met	

 C47	
Transportation to/ from community	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

 C54	
Assistive technology	
3/3	
Met