PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
COMMUNITY SYSTEMS INC
3 Cedarhill Park Drive
 Plymouth, MA 02360    	

	

	

	

	

	

	

	

January 17, 2017	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
COMMUNITY SYSTEMS INC	

	

	

	

	
Review Dates	

	
12/12/2016 - 12/16/2016	

	

	

	

	
Service Enhancement 
Meeting Date	

	
1/4/2017	

	

	

	

	

	

	
Survey Team	

	
Margareth Larrieux	

Michael Marchese	

Barbara Mazzella (TL)	

Tina Napolitan	

	

	

	

	

	

	
Citizen Volunteers	

	

	

	

	

	

Survey scope and findings for Residential and Individual Home Supports	

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

Residential and Individual Home Supports	
17 location(s) 17 audit (s) 	
Targeted Review	
DDS 16 / 20
Provider 68 / 68

84 / 88 2 Year License 01/04/2017-  01/04/2019	
	
DDS 56 / 66
Provider 7 / 7

63 / 73 Certified 01/04/2017 -  01/04/2019	

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

DDS Targeted Review	
16 / 22	

Placement Services	
7 location(s) 7 audit (s) 	

DDS Targeted Review	
20 / 22	

Individual Home Supports	
3 location(s) 3 audit (s) 	

DDS Targeted Review	
22 / 23	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
11 / 12	

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) 2 audit (s) 	
Targeted Review	
DDS 5 / 5
Provider 24 / 27

29 / 32 2 Year License 01/04/2017-  01/04/2019	
	
DDS 19 / 20
Provider 0 / 0

19 / 20 Certified 01/04/2017 -  01/04/2019	

Community Based Day Services	
1 location(s) 2 audit (s) 	

DDS Targeted Review	
14 / 14	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
11 / 12	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

Community Systems, Inc. (CSI) is a non-profit entity that has divisions located within the states of Connecticut, Delaware, Virginia, and Massachusetts. CSI Massachusetts was established in 1988 and offers residential supports as well as case management services to individuals with developmental and intellectual disabilities residing in the Cape and Islands, in addition to the Greater Plymouth area that are supported by the Massachusetts Department of Developmental Services and Massachusetts Commission for the Blind.  CSI's mission to 'help persons with disabilities to find happiness in their own homes, in their personal relationships, and as contributing members of their community' continues to serve as the foundation of its delivery system and is noted by the agency to be paramount to all programmatic and organizational decisions. CSI currently supports approximately eighty individuals residing in twenty-four hour staffed homes, sixty-eight individuals who reside in shared living arrangements and/or individual home support settings and sixty-nine individuals who receive case management supports in Plymouth and the Cape and Islands. 

The agency received a two year license for its Residential services in 2014 and was therefore eligible to conduct its own self-assessment and receive a DDS Targeted Licensure and Certification Review for each of its Residential service groupings.  Additionally, in 2016 the agency developed Community Based Day Services for individuals who needed assistance accessing community activities, securing part time employment and exploring opportunities to develop new interests or hobbies. These services were also part of a DDS Targeted Licensure and Certification Review. The Targeted Review is comprised of an evaluation of the eight critical indicators, those Licensure and Certification indicators determined to have been `Not Met' in the previous survey cycle and all new and revised Licensure and Certification indicators established in August 2016. The findings of the DDS evaluations were then combined with the agency's findings from its self-assessment and used to determine the agency's new Licensure and Certification levels. 

The DDS targeted review affirmed the continued presence of systems throughout the agency to support essential safeguards in several domains including personal and environmental safety and health care. Homes were well maintained, comfortable and accommodated the needs of individuals and reflected people's personal preferences and tastes. A continued strength of the agency is its commitment to ensuring that medications are administered properly and oversight systems are in place. In addition, all critical indicators were found to be met across all residential settings.  The agency also placed an emphasis on ensuring that the new Federal expectations were in place for all individuals. The agency demonstrated that through an attestation that they had developed, people remained free from arbitrary eviction. Individuals were also afforded privacy and the agency ensured that bedroom doors may be locked. 

Survey findings also revealed that the agency was committed to ensuring that individuals are supported in environments that foster independence as individuals were encouraged to be independent relative to participation in routines around their homes and encouraged individuals to make choices, particularly around household decisions. It was also noted that across all residential settings the agency incorporated input from individuals regarding the performance of staff. It is also noteworthy that the agency recognized the need to regularly check in with individuals regarding their satisfaction of services and supports. Two individuals who participated in the survey commented positively on the changes that were made to accommodate their requests for alternate living arrangements that reflected their interests and needs. 

While the agency has many systems regarding monitoring and oversight, there were several areas identified that need additional strengthening. Additional guidance needs to be provided to individuals and guardians regarding human rights, including notification of agency grievance procedures and whom to contact if issues arise and ensuring that all required components are in place when restrictive practices are in place including provisions to mitigate so as to not restrict the rights of others. The DDS review also noted the need for increased monitoring of timeframes for submission of assessment and support strategies within Residential services. The agency's self-assessment also recognized the need for increase monitoring of timeframes in both its residential and day/employment supports. 

The DDS review also identified a need for examining broader systemic information in order to more comprehensively gather data and analyze information regarding quality measures to identify patterns and trends.  Although the agency had gathered information regarding several quality measures, documentation and interviews with executive staff revealed that data was not being analyzed across service groupings to identify systemic patterns and trends to enhance service improvement efforts. 

There were also some certification indicators that were in the preliminary stages of development and need additional examination.  The agency will need to assess people's needs for further use of assistive technology that may be of benefit to them across all residential groupings. Supports should also be provided to assist individuals to explore and express their needs and to better understand the spectrum of relationship possibilities as the outcome varied depending upon service type, with individuals in some service models less supported to pursue their interests. Additionally, agency support for people to pursue activities and interests of their choice as well as participate in community activities on a frequent basis needs to be strengthened for individuals receiving twenty-four hours of support.

With regard to the agency's Community Based Day Services, the agency 'Met' all critical licensing indicators. DDS survey findings also revealed that individuals were pleased with the supports provided and acknowledged that they were treated with respect and dignity, and involved in activities of their choosing. Individual's schedules were tailored to meet their interests and afforded opportunities to revisit decisions in order to maximize independence towards securing employment opportunities. 

Based on the results of these combined evaluations, the agency achieved a Two-Year license for its Residential Supports with 95% of all licensing indicators receiving a rating of 'Met' and is certified with 86% of all certification indicators receiving a rating of 'Met.' The agency will be conducting its own follow up on any licensing indicators rated 'Not Met.' The agency also achieved a Two-Year license for its Employment/Day Supports with 91% of all licensing indicators receiving a rating of 'Met' and is certified with 95% of all certification indicators receiving a rating of 'Met.' The agency will be conducting its own follow up on any licensure indicators that received a 'Not Met' for Employment/Day supports.	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

Community Systems, Inc. (CSI) has an internal Program Evaluation System which is a detailed methodology to evaluate the quality of persons' lives, the outcomes they achieve with CSI support, their personal safety, and the safety of their homes.  CSI's utilization of Program Evaluation is supplemented by the use of satisfaction surveys.  There are four elements to the CSI satisfaction survey- survey of persons supported, of staff, of families and responsible parties, and of professional colleagues.  The Performance Evaluation is completed by a multi-state peer review team.  The process is outcome based and tied to the CSI mission and the regulations of The Department of Developmental Services (DDS).  The process allows for the review by people not directly involved in the support.  It is also an opportunity for staff to share resources, successes and ideas across the CSI multi-state teams.   An internal evaluation of the supports in CSI/MA was most recently conducted over a five day span on October 3 - 7, 2016.  The previous evaluation was conducted two years ago in October 2014.

A survey of supports was conducted using the QUEST Evaluation Tool created by DDS and edited to better fit CSI requirements for the internal evaluation process.  A spread sheet is used to track all findings in the survey.  Results are calculated to determine if the five quality of life areas were met.  Our system of evaluating scores is three tiered using achieved, partially achieved, and not achieved.  The survey sample was random within the parameters determined by the Executive Management Team of CSI.  The residential supports provided to 34 persons were surveyed.  The team spent roughly 55 person days on-site to reach their findings and conclusions.

When reviewing the self-assessment tool, we identified some areas not included in our Internal Evaluation process.  We effectively conducted a second round of visits, to assess any indicators that were missed and documented findings.  Senior managers visited homes that were not part of their case load.  This internal review further defines our vision and is an integral part of developing goals going forward.  

In addition to our Internal Evaluation process, we have regular mechanisms in place to self-assess and insure quality and safety.

Fire Drills submitted monthly to office for review and tracked by HR.
On-Call reports generated by nursing and administrator on-call for follow up.
Evacuation Plans reviewed by Human Rights Coordinator to insure they match HCSIS and safety assessments.
Human Rights Coordinator reviews all restraints, incidents monthly to review with the committee for trends.  These findings are reviewed with the Clinical Director and Executive Director.
Program Directors complete a checklist monthly to reflect oversight of key areas, which is backed up by the Manager's monthly checklist. 
Health Care Data Base tracks all medical information and highlights pop up when appointments are overdue.
Safety Committee meets quarterly to assess any safety issues throughout the agency
Business office has identified one person to oversee physical homes for maintenance issues.
Business Office staff review petty cash accounts monthly on-line and physically audited monthly.  All funds for folks supported are physically audited monthly for group homes, quarterly for shared living and case management.  All results are emailed to ED, and appropriate staff for review.
Human Resources maintains an employee data base which tracks staff trainings.  These are reviewed at least monthly in Senior Managers meetings and sent out monthly via email to all managers.
Business Manager meets monthly with Program Directors and Managers to review their individual budgets, results are emailed to Executive Director and entire team.
Annual Budget Meetings are held every spring to seek input from staff on needs of each program so that upcoming needs are provided for whether it be staffing, maintenance issues, or moves.

Below please find some of the Internal Evaluation results for Organizational Outcomes:

Organizational Outcomes

The organization has systems in place to safeguard individuals: 

CSI has policies and procedures in place to ensure people supported are safe.  Staff received training in human rights, reporting of abuse, and significant incidents. The agency has a Human Rights Coordinator and 71 Human Rights Officers (one at each site and multiple within case management.  Management staff are on call to provide supports in emergency situations. Significant incidents are reviewed by Guri Davis, Executive Director, for corrective actions. Incidents may be investigated by trained agency personnel or may be followed up on by DDS Program Monitors or the Disabled Persons Protection Commission (DPPC).

The employee files that were reviewed as part of the training sample had current human rights training on file. When staff were asked what they would do in instances of suspected abuse and/or neglect, staff were able to respond appropriately with the exception of one review.  The number to call DPPC was displayed in all homes.  There is a clear approach assisting the people supported to understand their rights and how to report possible violations. The human rights statement is discussed with and signed by the person supported or their guardian.  Guardians are made aware of the right to appeal.  People learn about their rights through incidental teaching throughout their daily routines.  They exercise their rights by choosing how they receive medical supports, are encouraged to make choices in all areas of their lives and participate in the development of their goals. In most cases, staff were notably attuned to the people they support, understanding and responding respectfully to their style of communication.

Staff has the skills and knowledge to support the quality of life of individuals: 

Staff universally knew the Mission of the organization.  Their knowledge was indicated by their actions as well as by the direct statements from the persons supported.  Staff understand their responsibility in support of the people. The Mission and what it entails is discussed with potential employees during every stage of the interview process and is carried through to new employee training. 

CSI has a comprehensive hiring process.  Applicants undergo a lengthy interview process that ends with the Executive Director having a sit down to discuss the mission of the organization, reviewing the applications and ensuring a determination regarding a match. This is after a panel interview that is inclusive of a Program Manager and a Program Director.  People supported are included in the hiring of staff through meeting the candidate at their home, or as in the case of some supports such as case management, at the office. 

There is a clear recognition of the importance of onboarding and open communication with new employees.  Not only is the hiring process thorough, but during a new employee's first three months, there are scheduled phone calls and meetings with the employees to check in, insure that the hiring and training process is being followed by the Executive Director or Clinical Director.

There are policies in place to address evaluations and staff training. The agency uses Access to maintain employee training completion dates, and hardcopies of all completed training is maintained in the employee's personnel file. Staff are reminded of training needs through bi-weekly printed reports of training due. 

In a physical review of 36 personnel files, it was evident that the hiring process, training and retention of employees is valued.   The sample review showed 100% had performance evaluations, 100% had current CPR and First Aid certifications, 100% had Fire Safety and each home had a staff certified in Formal Fire Safety. Most staff had Medication Administration Program (MAP) training, and Nonviolent Management of Aggressive Behavior (NVMAB)/Crisis Prevention Intervention (CPI) training.    
 
Findings: One staff did not have Medication Administration Certification (MAP) training.  This one staff has since been retrained.  Six staff did not have NVMAB/CPI Training.  Four out of six have since been retrained.  

Commendation: There was a clear commitment to supporting people to be happy in their homes, in their personal relationships and as contributing members of their community.  Several Program Directors have very happy teams and the staff members of those teams bring that happiness to the supports provided. 

For example, all staff interviewed were knowledgeable about the Mission of the organization, the policies of the agency, and their role in the supports of each person.  They truly have learned how to communicate with folks in very person-centered and unique ways.  

The organization promotes growth and change to continually improve its supports to individuals: 

CSI-MA has been smart with growth. The organization is focused on supporting each person to be happy, and that has resulted in the closure of group homes.  CSI has more physical locations with essentially the same number of persons supported compared to two years ago.   Their growth is not for the sake of growth; it is only pursued when it will benefit the people currently supported.  

Many persons have had the opportunity to choose their living situation, and many have chosen to live in Shared Living situations.  The group homes are the home of choice for some as they and their guardians are very happy, and it is a comfortable support for them. The agency continues to make efforts to educate guardians and families about alternate living options. 

It should be recognized that CSI-MA has made an effort to develop an organizational plan to close some of the larger group homes creating a few more shared living supports and smaller group home arrangements.  This plan will decrease the need for direct care staff thereby addressing the shortage of direct care staff in the Massachusetts area.  Some of these moves have already commenced which will in the next two months decrease direct care staff by five fulltime positions.

The agency encourages growth and development of their staff.  Over the past year, all of the management staff attended a three day Leadership Retreat that focused on Inspiring Leaders, Motivation, Effective Onboarding, Teamwork, and Program Evaluation.  Additionally interstate committees were formed to develop the Strategic Plan 2016-2020 to map out the future of CSI in the areas of Diversification of Funds, Visibility, Human Capital, Mission and Board Development.  

CSI also has members of its Leadership who have volunteered and become part of the Great Thinkers Group.  This group is a think tank for advancing a forward thinking culture for CSI.	

	

	

	

		
LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Residential and Individual Home Supports	
74/78	
4/78	

    Residential Services
    Placement Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
84/88	
4/88	
95%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
4	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Employment and Day Supports	
19/22	
3/22	

    Community Based Day Services

	

Critical Indicators	
1/1	
0/1	

Total	
29/32	
3/32	
91%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L49	
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.	
A review of training regarding human rights including an awareness of individuals' rights to file a grievance was conducted with seventeen individuals. Of these, seven individuals did not receive information regarding how to file a grievance or were able to acknowledge whom to contact if they have questions or concerns. The agency needs to ensure that individuals and/or guardians are informed in how to file a grievance and knowledgeable concerning whom to contact if they feel a concern or have questions. 	

 L56	
Restrictive practices intended for one individual that affect all individuals served at a location need to have a written rationale that is reviewed as required and have provisions so as not to unduly restrict the rights of others.	
Restrictive practices were reviewed for six individuals. Of these, two individuals had restrictions such as locks on cabinets, door alarms, and restrictions on sharps which did not include all required components including provisions to mitigate the use of these practices so as to not restrict the rights of others and one individual's restrictions did not include a written rationale. The agency needs to ensure that when restrictive practices are in place all required components are included, and that the restriction in place for one person has been mitigated for others.	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
The agency needs to ensure that required assessments are submitted 15 days prior to the ISP. Nine out of twelve records reviewed did not meet DDS required timeframes. 	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
The agency needs to ensure that required support strategies are submitted 15 days prior to the ISP. Six out of twelve records reviewed did not meet DDS required timeframes. 	

	

	

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

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L59	
Behavior plans have received all the required reviews.	
One plan reviewed for SS was not reviewed within the year.	
CSI will insure that a behaviorist is identified and following SS on a regular basis insuring that a Positive Behavior Support Plan is in place and reviewed within the parameters of the plan.	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
CSI has a data base called One Drive, which is and has been up and running, but has not been used consistently across all settings.  Management needs to better use the systems in place for consistent oversight of assessment submissions.	
Review of Assessments will be done monthly at Senior Managers meetings.  The Program Director Checklists will also be added to One Drive so we have an electronic tracking mechanism to see that the assigned oversight has been completed at each home.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
CSI has a data base called One Drive, which is and has been up and running, but has not been used consistently across all settings.  Management needs to better use the systems in place for consistent oversight of support strategy submissions by adding in this data to the One Drive.	
Review of Support Strategies will be done monthly at Senior Managers meetings.  We are adding Support strategies to our One Drive system.	

	

	

	

	
CERTIFICATION FINDINGS	

	

	

	

	

Reviewed by	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 8/9
Provider 3/3	
11/12	
1/12	

Residential and Individual Home Supports	
DDS 48/57
Provider 4/4	
52/61	
9/61	

Individual Home Supports	
DDS 18/19
Provider 4/4	
22/23	
1/23	

Placement Services	
DDS 17/19
Provider 3/3	
20/22	
2/22	

Residential Services	
DDS 13/19
Provider 3/3	
16/22	
6/22	

Total	
	
63/73	
10/73	
86%	

Certified	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 8/9
Provider 3/3	
11/12	
1/12	

Employment and Day Supports	
DDS 11/11
Provider -3/-3	
8/8	
0/8	

Community Based Day Services	
DDS 11/11
Provider 3/3	
14/14	
0/14	

Total	
	
19/20	
1/20	
95%	

Certified	

	

	

	

	

	

	
	
Planning and Quality Management Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

 C2	
The provider analyzes information gathered from all sources and identifies patterns and trends.	
While the agency collects data on program quality measures such as medication occurrences, restraints and investigations, the information is not analyzed to identify patterns and trends for each service type in order to prioritize areas for service improvement efforts. The agency needs to develop a more effective system to gather and analyze information to identify patterns and trends across all programs. 	

	

	

	

	
Individual Home Supports Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C51	
Staff (Home Providers) are knowledgeable about individuals' satisfaction with services and supports and support individuals to make changes as desired.	
 The agency is commended for its staff knowledge about individuals' satisfaction with services and supports which enabled individuals to make changes as requested. One individual who participated in the survey was assisted to relocate to a larger apartment which afforded him more space and showcase his personal belongings in accordance with his desires. 	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Three individuals were reviewed regarding their need for assistive technology and/or modifications to maximize independence. Of these, two individuals have not been assessed to identify any assistive technology that may be of benefit to maximize independence. The agency needs to ensure that individuals are assessed in order to identify any assistive technology that may be of benefit and/or assistive technology and modifications to maximize independence. 	

	

	

	
Placement Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C51	
Staff (Home Providers) are knowledgeable about individuals' satisfaction with services and supports and support individuals to make changes as desired.	
 The agency is commended for its staff knowledge about individuals' satisfaction with services and supports which enabled individuals to make changes as requested. One individual who participated in the survey was assisted to move to a smaller setting which accommodated his preferences. This change has resulted in increased social contacts and community outings in accordance with his desires. 	

	

	

	
Placement Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
Seven individuals were reviewed regarding how their needs/desires for intimacy and companionship are being explored and/or supported. Of these, two individuals were not assessed regarding their need and interest for intimacy and companionship, and not provided with education in this area so that they could better familiarize themselves with interests and support needs. The agency needs to ensure that individuals are provided with support and education geared to the individual's learning style regarding intimacy and companionship. 	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Seven individuals were reviewed regarding their need for assistive technology and/or modifications to maximize independence. Of these, three individuals have not been assessed to identify any assistive technology that may be of benefit to maximize independence. The agency needs to ensure that individuals are assessed in order to identify any assistive technology that may be of benefit and/or assistive technology and modifications to maximize independence. 	

	

	

	
Residential Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C9	
Staff (Home Providers) provide opportunities to develop and/or increase personal relationships and social contacts.  	
Seven individuals were reviewed regarding opportunities to develop and increase social contacts. Of these, two individuals were not supported to develop and increase opportunities for social contacts on a consistent basis. The agency needs to ensure that staff assess individuals' interests in friendships or social contacts and support individuals to increase opportunities for personal relationships and social contacts. 	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
Seven individuals were reviewed regarding how their needs/desires for intimacy and companionship are being explored and/or supported. Of these, five individuals were not assessed regarding their need and interest for intimacy and companionship, and not provided with education in this area so that they could better familiarize themselves with interests and support needs. The agency needs to ensure that individuals are provided with support and education geared to the individual's learning style regarding intimacy and companionship. 	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Seven individuals were reviewed regarding the provision of community activities that reflect individual's preferences and interests. Of these, two individuals were not supported with opportunities to participate in community activities that reflected their unique preferences and interests. The agency needs to ensure that staff provide opportunities to participate in activities that are based on individual preferences and interests. 	

	
 C48	
Individuals are a part of the neighborhood.	
Seven individuals were reviewed regarding opportunities to develop connections with neighbors. Of these, two individuals were not fully supported to develop connections with neighbors. The agency needs to ensure that staff assess routines and provide opportunities to interact with neighbors throughout the year such as during times of picking up mail, walking in the neighborhood and gardening. 	

	
 C49	
The physical setting blends in with and is a natural part of the neighborhood and community.	
Physical settings were reviewed for seven homes.  Of these, two homes did not blend in with other homes in the neighborhood. These homes were easily distinguishable in the neighborhood.  The agency needs to ensure that homes are a natural part of the neighborhood and community.  	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Seven individuals were reviewed regarding their need for assistive technology and/or modifications to maximize independence. Of these, six individuals have not been assessed to identify any assistive technology that may be of benefit to maximize independence. The agency needs to ensure that individuals are assessed in order to identify any assistive technology that may be of benefit and/or assistive technology and modifications to maximize independence. 	

	

	

	

								
	MASTER SCORE SHEET LICENSURE	

								
	Organizational: COMMUNITY SYSTEMS INC	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
17/18	
Met(94.44 % )	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
Provider	
-	
Met	

 L65	
Restraint report submit	
Provider	
-	
Met	

 L66	
HRC restraint review	
Provider	
-	
Met	

 L74	
Screen employees	
Provider	
-	
Met	

 L75	
Qualified staff	
Provider	
-	
Met	

 L76	
Track trainings	
Provider	
-	
Met	

 L83	
HR training	
Provider	
-	
Met	

								
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
7/7	
3/3	
7/7	

	
17/17	
Met	

 L7	
Fire Drills	
L	
DDS	
7/7	

	

7/7	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L11	
Required inspections	
L	
DDS	
6/7	
1/1	
6/7	

	
13/15	
Met
(86.67 %)	

O	
 L12	
Smoke detectors	
L	
DDS	
7/7	
3/3	
7/7	

	
17/17	
Met	

O	
 L13	
Clean location	
L	
DDS	
7/7	
1/1	
7/7	

	
15/15	
Met	

 L14	
Site in good repair	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L15	
Hot water	
L	
DDS	
7/7	
1/1	
6/7	

	
14/15	
Met
(93.33 %)	

 L16	
Accessibility	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L19	
Bedroom location	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L22	
Clean appliances	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L23	
Egress door locks	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L24	
Locked door access	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L28	
Flammables	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L29	
Rubbish/combustibles	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L30	
Protective railings	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L31	
Communication method	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L33	
Physical exam	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L34	
Dental exam	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L35	
Preventive screenings	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L36	
Recommended tests	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
7/7	
1/1	
4/4	

	
12/12	
Met	

 L39	
Dietary requirements	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L40	
Nutritional food	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L41	
Healthy diet	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L42	
Physical activity	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L43	
Health Care Record	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
7/7	
	
6/6	

	
13/13	
Met	

 L47	
Self medication	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
2/7	
3/3	
5/7	

	
10/17	
Not Met
(58.82 %)	

 L50	
Respectful Comm.	
L	
DDS	
7/7	
3/3	
7/7	

	
17/17	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
7/7	
3/3	
7/7	

	
17/17	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
7/7	
3/3	
7/7	

	
17/17	
Met	

 L55	
Informed consent	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L56	
Restrictive practices	
I	
DDS	
1/4	
	
2/2	

	
3/6	
Not Met
(50.0 %)	

 L57	
Written behavior plans	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L60	
Data maintenance	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L62	
Health protection review	
I	
DDS	
5/5	
	
2/2	

	
7/7	
Met	

 L63	
Med. treatment plan form	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L64	
Med. treatment plan rev.	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L65	
Restraint report submit	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I	
DDS	
7/7	
1/1	
7/7	

	
15/15	
Met	

 L68	
Funds expenditure	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L70	
Charges for care calc.	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L71	
Charges for care appeal	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L82	
Medication admin.	
L	
DDS	
7/7	

	

7/7	
Met	

 L84	
Health protect. Training	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L85	
Supervision 	
L	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
DDS	
0/4	
1/2	
2/6	

	
3/12	
Not Met
(25.00 %)	

 L87	
Support strategies	
I	
DDS	
2/4	
0/2	
4/6	

	
6/12	
Not Met
(50.0 %)	

 L88	
Strategies implemented	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
7/7	
3/3	
7/7	

	
17/17	
Met	

#Std. Met/# 78 Indicator	

	

	

	
74/78	

	
Total Score	

	

	

	
84/88	

	

	

	

	
	
95.45%	

			
								
Employment and Day Supports:	

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

 L1	
Abuse/neglect training	
I 	
Provider	

-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	

-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	

-	
-	
Met	

O	
 L38	
Physician's orders	
I 	
Provider	

-	
-	
Met	

O	
 L46	
Med. Administration	
I 	
Provider	

-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	

2/2	
2/2	
Met	

 L50	
Respectful Comm.	
L	
DDS	

1/1	
1/1	
Met	

 L51	
Possessions	
I 	
Provider	

-	
-	
Met	

 L52	
Phone calls	
I	
DDS	

2/2	
2/2	
Met	

 L54	
Privacy	
L	
DDS	

1/1	
1/1	
Met	

 L57	
Written behavior plans	
I 	
Provider	

-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	

-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	

-	
-	
Not Met

	
 L60	
Data maintenance	
I 	
Provider	

-	
-	
Met	

 L63	
Med. treatment plan form	
I 	
Provider	

-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	

-	
-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	

-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	

-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	

-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	

-	
-	
Met	

O	
 L82	
Medication admin.	
L	
Provider	

-	
-	
Met	

 L85	
Supervision 	
L	
Provider	

-	
-	
Met	

 L86	
Required assessments	
I	
Provider	

-	
-	
Not Met

	
 L87	
Support strategies	
I	
Provider	

-	
-	
Not Met

	
 L88	
Strategies implemented	
I 	
Provider	

-	
-	
Met	

#Std. Met/# 19 Indicator	

	

	
19/22	

	
Total Score	

	

	
29/32	

	

	

	
	
90.62%	

			
								
	MASTER SCORE SHEET CERTIFICATION	

								
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C1	
Provider data collection	
DDS	
1/1	
Met	

 C2	
Data analysis	
DDS	
0/1	
Not Met (0 %)	

 C3	
Service satisfaction	
Provider	
-	
Met	

 C4	
Utilizes input from stakeholders	
DDS	
1/1	
Met	

 C5	
Measure progress	
Provider	
-	
Met	

 C6	
Future directions planning	
Provider	
-	
Met	

	

	

	
								
Community Based Day Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
2/2	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C13	
Skills to maximize independence 	
DDS	
2/2	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C40	
Community involvement interest	
DDS	
2/2	
Met	

 C41	
Activities participation	
DDS	
2/2	
Met	

 C42	
Connection to others	
DDS	
2/2	
Met	

 C43	
Maintain & enhance relationship	
DDS	
2/2	
Met	

 C44	
Job exploration	
Provider	
-	
Met	

 C45	
Revisit decisions	
DDS	
2/2	
Met	

 C46	
Use of generic resources	
DDS	
2/2	
Met	

 C47	
Transportation to/ from community	
DDS	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
2/2	
Met	

 C54	
Assistive technology	
DDS	
2/2	
Met	

Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
3/3	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
3/3	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
3/3	
Met	

 C13	
Skills to maximize independence 	
DDS	
3/3	
Met	

 C14	
Choices in routines & schedules	
DDS	
3/3	
Met	

 C15	
Personalize living space	
DDS	
3/3	
Met	

 C16	
Explore interests	
DDS	
3/3	
Met	

 C17	
Community activities	
DDS	
3/3	
Met	

 C18	
Purchase personal belongings	
DDS	
3/3	
Met	

 C19	
Knowledgeable decisions	
DDS	
3/3	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C21	
Coordinate outreach	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
3/3	
Met	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C48	
Neighborhood connections	
DDS	
3/3	
Met	

 C49	
Physical setting is consistent 	
DDS	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

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

 C53	
Food/ dining choices	
DDS	
3/3	
Met	

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

Placement Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
7/7	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
7/7	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
5/7	
Not Met (71.43 %)	

 C13	
Skills to maximize independence 	
DDS	
7/7	
Met	

 C14	
Choices in routines & schedules	
DDS	
7/7	
Met	

 C15	
Personalize living space	
DDS	
7/7	
Met	

 C16	
Explore interests	
DDS	
7/7	
Met	

 C17	
Community activities	
DDS	
7/7	
Met	

 C18	
Purchase personal belongings	
DDS	
7/7	
Met	

 C19	
Knowledgeable decisions	
DDS	
7/7	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
7/7	
Met	

 C47	
Transportation to/ from community	
DDS	
7/7	
Met	

 C48	
Neighborhood connections	
DDS	
7/7	
Met	

 C49	
Physical setting is consistent 	
DDS	
7/7	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
7/7	
Met	

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

 C53	
Food/ dining choices	
DDS	
7/7	
Met	

 C54	
Assistive technology	
DDS	
4/7	
Not Met (57.14 %)	

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
7/7	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
5/7	
Not Met (71.43 %)	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
2/7	
Not Met (28.57 %)	

 C13	
Skills to maximize independence 	
DDS	
7/7	
Met	

 C14	
Choices in routines & schedules	
DDS	
7/7	
Met	

 C15	
Personalize living space	
DDS	
7/7	
Met	

 C16	
Explore interests	
DDS	
6/7	
Met (85.71 %)	

 C17	
Community activities	
DDS	
5/7	
Not Met (71.43 %)	

 C18	
Purchase personal belongings	
DDS	
7/7	
Met	

 C19	
Knowledgeable decisions	
DDS	
7/7	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
7/7	
Met	

 C47	
Transportation to/ from community	
DDS	
7/7	
Met	

 C48	
Neighborhood connections	
DDS	
5/7	
Not Met (71.43 %)	

 C49	
Physical setting is consistent 	
DDS	
5/7	
Not Met (71.43 %)	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
7/7	
Met	

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

 C53	
Food/ dining choices	
DDS	
7/7	
Met	

 C54	
Assistive technology	
DDS	
1/7	
Not Met (14.29 %)