PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
COMMUNITY SYSTEMS INC
3 Cedarhill Park Drive
 Plymouth, MA 02360    	

	

	

	

	

	

	

	

January 28, 2019	

	

	

	

	

	

	

	

	

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	

	
1/8/2019 - 1/14/2019	

	

	

	

	
Service Enhancement 
Meeting Date	

	
1/28/2019	

	

	

	

	

	

	
Survey Team	

	
Katherine Gregory	

Scott Nolan	

Michelle Boyd	

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	
20 location(s) 20 audit (s) 	
Full Review	
70 / 88 2 Year License 01/28/2019 -  01/28/2021	
	
62 / 73 Certified 01/28/2019 -  01/28/2021	

Residential Services	
8 location(s) 8 audit (s) 	

Full Review	
17 / 22	

Placement Services	
8 location(s) 8 audit (s) 	

Full Review	
19 / 22	

Individual Home Supports	
4 location(s) 4 audit (s) 	

Full Review	
22 / 23	

Planning and Quality Management (For all service groupings)	

	
Full Review	
4 / 6	

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) 	
Full Review	
37 / 41 2 Year License 01/28/2019 -  01/28/2021	
	
17 / 20 Certified 01/28/2019 -  01/28/2021	

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

Full Review	
13 / 14	

Planning and Quality Management (For all service groupings)	

	
Full Review	
4 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
Community Systems, Inc. (CSI) is a non-profit organization that has divisions located within the states of Connecticut, Delaware, Virginia, and Massachusetts. CSI Massachusetts was established in 1988 and offers residential supports, community- based day services (CBDS) as well as case management services to individuals with developmental and intellectual disabilities residing on Cape Cod and the 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 currently supports eighty-three individuals residing in twenty-four hour staffed homes, approximately one hundred individuals who reside in shared living arrangements and/or individual home support settings and eight individuals who receive community-based day support services. 

The scope of this survey conducted by the Office of Quality Enhancement included a full review of all licensing and certification indicators for services within the Residential/Individual Supports service grouping and for community-based day services. 

Within residential services, a number of positive practices were noted in the area of health care coordination.  Individuals are supported to receive routine and preventive health screenings and recommended tests and follow up appointments.  Individuals are encouraged to eat nutritious meals, and follow regular physical exercise routines.  For example, one individual is no longer considered a risk for diabetes noting that staff supported her to maintain a healthy diet and follow ongoing exercise routines. Prescription medications are administered according to a written order of a practitioner and are properly documented on a Medication Treatment Chart. Findings also revealed that staff promoted ongoing connections with individuals and their families within all residential service settings. Several individuals are supported to go home on weekends and family members feel welcomed to visit homes and speak with staff at all levels of the organization. 

Across all settings, staff was observed to be respectful when interacting with individuals, taking time to listen and ensure that individuals were satisfied with their services and supports. Individuals living in shared living settings were supported to maintain long-term relationships with their care providers.  Care providers were knowledgeable about strategies to ensure that the unique needs of individuals' are being addressed.  For example, one individual received support and education from her care provider to understand and make an informed decision regarding a medical procedure which afforded her increased opportunities to access her community. 
 
Within community-based day supports, effective support strategies were developed and implemented.  Staff checked in regularly with individuals who had jobs in the community and staff were aware of the ongoing health care needs of individuals so they could successfully participate in community outings such as the senior center, library and volunteer opportunities.  One individual was supported to attend college classes which enabled her to further explore her love of theater and the arts, while another individual was supported to participate in a local theater group in her community.

This review also identified several licensing areas within the agency's residential supports that need strengthening. Particular focus needs to be placed on ensuring that all protections that impact the rights of individuals' are in place including training for individuals, guardians and staff on reporting potential abuse and neglect as well as training regarding the agency's grievance procedures.   Oversight and monitoring needs to be strengthened to ensure that staff are aware of what constitutes a reportable incident and required timelines for reporting.  Monitoring and guidance is needed to ensure that staff are knowledgeable about restrictive practices and that any restrictions are reviewed annually, and provisions are in place to mitigate these practices for those individuals who do not present as a risk. Staff need to be aware of all required components when supporting individuals who have supports and health protective devices, including provisions for safety checks and receiving required reviews. Lastly, the agency needs to focus on strengthening its Human Rights committee to ensure that membership meets composition requirements and investigations and restraints are reviewed. 
 
The agency also needs to strengthen its practices in assisting individuals with their finances. Practices need to be revised to ensure that money management plans include a component regarding the amount of monies that can be independently managed by individuals as well as how the agency will assist individuals to safeguard their funds.  The agency also needs to revise its charges for care practices to ensure that those who are competitively employed are notified in advance of their charges for care and any adjustments proposed, and that there is full transparency in the receipt and management of charges for care payments. 

Across the agency, in the areas of certification, efforts should be directed toward supporting individuals' to provide feedback on staff performance on an ongoing basis, and to share this information with staff for training purposes.  The agency also needs to provide education and training to staff to help support individuals to explore and define their needs for intimacy and companionship.  Staff also need additional training to better support individuals to assess, identify and utilize assistive technology to maximize their independence at home. 

Based on the findings of this report, the agency has earned a Two Year License for Residential/Individual Home Support Service groupings and a Two Year License for Employment/Community-Based Day Supports service groupings. Licensing scores were 80% of indicators met for Residential Services and 90% of indicators met for Community-Based Day Supports. The DDS will conduct follow up within 60 days for any licensing indicators rated Not Met within its residential services and the agency will conduct its own follow up within 60 days for any licensing indicators rated Not Met within Employment/Community-Based Day supports. The agency is Certified in both Residential and Individual Home Supports and Employment/Community-Based Day Supports service groupings receiving scores of 85% for Residential and Individual Home Supports and 85% for Community-Based Day Supports.	

	

	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
7/10	
3/10	

Residential and Individual Home Supports	
63/78	
15/78	

    Individual Home Supports
    Placement Services
    Residential Services

	

Critical Indicators	
8/8	
0/8	

Total	
70/88	
18/88	
80%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
18	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
7/10	
3/10	

Employment and Day Supports	
30/31	
1/31	

    Community Based Day Services

	

Critical Indicators	
3/3	
0/3	

Total	
37/41	
4/41	
90%	

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.	
Although the agency has a Human Rights Committee, there are a number of areas such as mandated composition, review of investigations, restraints and agency policy and procedures that potentially impact the rights of individuals that the agency needs to strengthen in order to improve its effectiveness. The agency needs to ensure that its Human Rights Committee serves as an effective safeguard for all individuals.	

 L66	
All restraints are reviewed by the Human Rights Committee.	
Nine out of 14 restraints were not reviewed by the Human Rights Committee within required timeframes. The agency needs to ensure that restraints are reviewed by the Human Rights Committee as required. 	

 L83	
Support staff are trained in human rights.	
All agency staff were not trained in the mandated reporting requirements that were required by April 1, 2018.  A Notice of Action was issued.  The agency needs to ensure that all staff are trained in the most current mandated reporting requirements.  	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L1	
Individuals have been trained and guardians are provided with information in how to report alleged abuse/neglect.	
Twenty individuals were interviewed and documentation was reviewed regarding how to report alleged abuse and neglect. Of these, five individuals were not aware of how to report potential abuse and neglect nor was there evidence that training was provided regarding how to report potential abuse and neglect. The agency needs to ensure that all individuals are trained in how to report potential abuse and neglect. 	

 L7	
Fire drills are conducted as required.	
In two locations, fire drills were not conducted as identified in the Emergency Evacuation Safety Plans. The agency needs to ensure that fire drills are conducted as required. 	

 L20	
Exit doors are easily operable by hand from inside without the use of keys.	
Two locations had exit doors which were not easily operable. One home visited had a dead bolt lock requiring a key operation and another home had a door identified as a means of egress missing a handle.  The agency needs to ensure that exit doors are free of inside locks and are easily operable.  	

 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.	
Eleven out twenty individuals were not informed of how to file a grievance. The agency needs to ensure that individuals are informed and trained regarding the agency's  grievance procedures, or to whom they should talk to if they have a concern. 	

 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.	
In eight of eleven instances the agency obtained consent without identifying the purpose or to whom the information would be released and the right to withdraw consent.  The agency needs to ensure that when informed consent is obtained from individuals or guardians, all required information is included. 	

 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 in place for six individuals. All required components such as plans to fade, processes to mitigate the effects so as to not unduly restrict the rights of others and reviews to insure that the restriction is still warranted were not included.    The agency needs to ensure that restrictive practices include all required components 	

 L61	
Supports and health related protections are included in ISP assessments and the continued need is outlined.	
For four of six individuals with supports and health related protections, all required components including frequency and duration of use and procedures for safety checks were not present.  The agency needs to ensure that all required information is in place to ensure proper utilization of such supports. 	

 L62	
Supports and health related protections are reviewed by the required groups.	
In two circumstances, the supportive and health related protections had not been reviewed by all the required groups.  The agency needs to ensure that all the required groups review the identified supportive and health related protections.  	

 L64	
Medication treatment plans are reviewed by the required groups.	
Two medication treatment plans did not receive reviews by the ISP team. The agency needs to ensure that medication treatment plans are reviewed by the required groups.	

 L67	
There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	
For six out of eighteen individuals the money management plan did not include one or more of the following components including the level and type of staff support needed, the amount of monies that can be independently managed by individuals, a training plan when appropriate and agreement to financial plans by guardians. The agency needs to ensure that money management plans include all required components.  	

 L70	
Charges for care are calculated appropriately.	
Charges for care were reviewed for twenty individuals.  In six instances, documentation revealed that either charges for care were incorrectly calculated and not consistent with charges for care notification, or when quarterly adjustments were calculated and individuals were charged additional funds during the next quarter, they were not provided with notification as to how charges had been re-determined.  The agency needs to ensure that any adjustments made to charges for care shall be sent at least 30 days prior to the date payment is due and shall show how the charges were determined and explain the appeal process.	

 L79	
Staff are trained in safe and correct administration of restraint.	
In one location, staff needed to have the requisite training to safely utilize restraint.  All staff had not been trained.  The agency needs to ensure that when the administration of restraint is required all staff are trained. 	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments were not submitted within required time frames for six individuals. The agency needs to ensure that assessments are submitted to the DDS Area Office at least 15 days prior to scheduled 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.	
Support strategies were not submitted within required timeframes for six individuals.  The agency needs to ensure that support strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting. 	

 L91	
Incidents are reported and reviewed as mandated by regulation.	
In three locations there were incidents that were not reported. For seven out of fifteen locations at which reportable incidents had occurred, there were instances in which incident reports had not been submitted and/or finalized within required timelines.  The agency need to ensure that all staff are knowledgeable of the criteria for reportable incidents and that these are reported within required timelines.  	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L79	
Staff are trained in safe and correct administration of restraint.	
There was an identified clinical need for all staff to be safely trained in applying restraint for an individual whose plan included behavioral interventions. The agency needs to ensure this training is in place. 	

			

						
	CERTIFICATION FINDINGS	

						
		
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
4/6	
2/6	

Residential and Individual Home Supports	
58/67	
9/67	

Individual Home Supports	
22/23	
1/23	

Placement Services	
19/22	
3/22	

Residential Services	
17/22	
5/22	

TOTAL	
62/73	
11/73	
85%	

Certified	

	

Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
4/6	
2/6	

Employment and Day Supports	
13/14	
1/14	

Community Based Day Services	
13/14	
1/14	

TOTAL	
17/20	
3/20	
85%	

Certified	

	

						

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

Indicator #	
Indicator	
Area Needing Improvement	

 C2	
The provider analyzes information gathered from all sources and identifies patterns and trends.	
The agency quality management system does not identify patterns and trends within each service which could be beneficial in developing appropriate actions and ongoing strategies to enhance service. The agency needs to utilize data/information gathered to systemically evaluate the quality of services and identify trends and patterns which could assist in identifying areas of additional oversight and monitoring. 	

 C5	
The provider has a process to measure progress towards achieving service improvement goals.	
The agency's growth and development plan does not measure service improvement goals across service types. Additionally, it does not have a process for making mid-course corrections, if necessary.  The agency needs to ensure that it measures progress on an ongoing basis and make mid-course corrections to continually enhance service delivery. 	

	

		

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

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
Two individuals were not provided opportunities to provide feedback on the performance of staff on an ongoing basis. The agency needs to ensure that individuals have opportunities to provide feedback on the performance of staff that support them on an ongoing basis. 	

	

	
Placement 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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
Five individuals were not provided opportunities to provide feedback on an ongoing basis on the performance of care providers that support them. The agency needs to ensure that individuals have opportunities to provide feedback on the performance of staff/care providers that support them. 	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For four out of eight individuals there was no evidence to demonstrate that education was provided to staff to help support individuals in the area of sexuality and intimacy. In addition, an assessment was utilized which did not assess individual's need for intimacy and companionship that was in concert with their unique learning style.  The agency needs to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship. 	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The agency had conducted assessments to identify areas where individuals could benefit from the use of assistive technology and/or modifications to maximize independence,   however, the agency had not identified areas of need or had not implemented strategies which could increase individual's independence.  The agency needs to ensure that areas of need are identified and recommendations are implemented. 	

	

	
Residential 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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
Four individuals were not provided opportunities to provide feedback on the performance of staff at the time of hire or on an ongoing basis. The agency needs to ensure that individuals have opportunities to provide feedback at the time of hire or on the performance of staff that support them on an ongoing basis. 	

 C9	
Staff (Home Providers) act as bridge builders and provide opportunities to develop, and/or increase personal relationships and social contacts.	
Two individuals did not have staff support to develop opportunities which could increase social contacts and personal relationships. The agency needs to develop and implement strategies to increase opportunities for individuals to develop personal relationships. 	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For six out of eight individuals there was no evidence to demonstrate that education was provided to staff to help support individuals in the area of sexuality and intimacy. In addition, an assessment was utilized which did not assess individual's need for intimacy and companionship that was in concert with their unique learning style.  The agency needs to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship. 	

 C48	
Individuals are a part of the neighborhood.	
Staff support was not provided which encouraged interactions with neighbors and participation in neighborhood activities. The agency needs to ensure that opportunities are provided which encourage and support neighborhood connections.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The agency had conducted assessments to identify areas where individuals could benefit from the use of assistive technology and/or modifications to maximize independence, however, the agency had not identified areas of need or had not implemented strategies which could increase individual's independence.  The agency needs to ensure that areas of need are identified and recommendations are implemented. 	

	

	
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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
One individual did not provide feedback on the ongoing performance of his staff. The agency needs to ensure that individuals have opportunities to provide feedback on an ongoing basis on the performance of staff that support them. 	

	

		

					
	MASTER SCORE SHEET LICENSURE	

					
	Organizational: COMMUNITY SYSTEMS INC	

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

O	
 L2	
Abuse/neglect reporting	
21/24	
Met(87.50 % )	

 L3	
Immediate Action	
15/15	
Met	

 L4	
Action taken	
15/15	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
15/18	
Met(83.33 % )	

 L66	
HRC restraint review	
5/14	
Not Met(35.71 % )	

 L74	
Screen employees	
6/6	
Met	

 L75	
Qualified staff	
1/1	
Met	

 L76	
Track trainings	
20/20	
Met	

 L83	
HR training	
0/20	
Not Met(0 % )	

							
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
5/8	
4/4	
6/8	

	
15/20	
Not Met
(75.00 %)	

 L5	
Safety Plan	
L	
7/8	
2/2	
8/8	

	
17/18	
Met
(94.44 %)	

O	
 L6	
Evacuation	
L	
8/8	
2/2	
8/8	

	
18/18	
Met	

 L7	
Fire Drills	
L	
6/8	

	

6/8	
Not Met
(75.00 %)	

 L8	
Emergency Fact Sheets	
I	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L9	
Safe use of equipment	
L	
8/8	
2/2	

	
	
10/10	
Met	

 L10	
Reduce risk interventions	
I	
6/6	
1/1	
2/3	

	
9/10	
Met
(90.0 %)	

O	
 L11	
Required inspections	
L	
8/8	
1/1	
8/8	

	
17/17	
Met	

O	
 L12	
Smoke detectors	
L	
8/8	
1/2	
8/8	

	
17/18	
Met
(94.44 %)	

O	
 L13	
Clean location	
L	
8/8	
1/1	
8/8	

	
17/17	
Met	

 L14	
Site in good repair	
L	
7/8	
1/1	
8/8	

	
16/17	
Met
(94.12 %)	

 L15	
Hot water	
L	
7/8	
1/1	
7/8	

	
15/17	
Met
(88.24 %)	

 L16	
Accessibility	
L	
8/8	
1/1	
8/8	

	
17/17	
Met	

 L17	
Egress at grade 	
L	
8/8	
1/1	
5/5	

	
14/14	
Met	

 L18	
Above grade egress	
L	
2/2	
1/1	
2/2	

	
5/5	
Met	

 L19	
Bedroom location	
L	
7/7	

	

7/7	
Met	

 L20	
Exit doors	
L	
6/8	
1/1	

	
	
7/9	
Not Met
(77.78 %)	

 L21	
Safe electrical equipment	
L	
8/8	
1/1	
8/8	

	
17/17	
Met	

 L22	
Well-maintained appliances	
L	
6/8	
1/1	
8/8	

	
15/17	
Met
(88.24 %)	

 L23	
Egress door locks	
L	
3/4	

	

3/4	
Met	

 L24	
Locked door access	
L	
8/8	

	

8/8	
Met	

 L25	
Dangerous substances	
L	
8/8	

	

8/8	
Met	

 L26	
Walkway safety	
L	
7/8	
1/1	
8/8	

	
16/17	
Met
(94.12 %)	

 L27	
Pools, hot tubs, etc.	
L	
1/1	
1/1	
1/1	

	
3/3	
Met	

 L28	
Flammables	
L	
8/8	

	

8/8	
Met	

 L29	
Rubbish/combustibles	
L	
7/8	
1/1	
6/8	

	
14/17	
Met
(82.35 %)	

 L30	
Protective railings	
L	
7/7	
1/1	
6/6	

	
14/14	
Met	

 L31	
Communication method	
I	
7/8	
4/4	
8/8	

	
19/20	
Met
(95.00 %)	

 L32	
Verbal & written	
I	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L33	
Physical exam	
I	
8/8	
2/2	
8/8	

	
18/18	
Met	

 L34	
Dental exam	
I	
8/8	
2/2	
8/8	

	
18/18	
Met	

 L35	
Preventive screenings	
I	
8/8	
2/2	
7/8	

	
17/18	
Met
(94.44 %)	

 L36	
Recommended tests	
I	
6/7	
2/2	
7/8	

	
15/17	
Met
(88.24 %)	

 L37	
Prompt treatment	
I	
8/8	
2/2	
5/6	

	
15/16	
Met
(93.75 %)	

O	
 L38	
Physician's orders	
I	
4/6	
	
6/6	

	
10/12	
Met
(83.33 %)	

 L39	
Dietary requirements	
I	
4/6	
	
5/5	

	
9/11	
Met
(81.82 %)	

 L40	
Nutritional food	
L	
8/8	
2/2	

	
	
10/10	
Met	

 L41	
Healthy diet	
L	
8/8	
2/2	
7/7	

	
17/17	
Met	

 L42	
Physical activity	
L	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L43	
Health Care Record	
I	
7/8	
4/4	
6/8	

	
17/20	
Met
(85.00 %)	

 L44	
MAP registration	
L	
7/8	

	

7/8	
Met
(87.50 %)	

 L45	
Medication storage	
L	
8/8	

	

8/8	
Met	

O	
 L46	
Med. Administration	
I	
8/8	
	
4/4	

	
12/12	
Met	

 L47	
Self medication	
I	
8/8	
2/2	
8/8	

	
18/18	
Met	

 L49	
Informed of human rights	
I	
2/8	
3/4	
7/8	

	
12/20	
Not Met
(60.0 %)	

 L50	
Respectful Comm.	
L	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L51	
Possessions	
I	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L52	
Phone calls	
I	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L53	
Visitation	
I	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L54	
Privacy	
L	
7/8	
4/4	
8/8	

	
19/20	
Met
(95.00 %)	

 L55	
Informed consent	
I	
1/6	
1/2	
1/3	

	
3/11	
Not Met
(27.27 %)	

 L56	
Restrictive practices	
I	
2/5	
	
1/1	

	
3/6	
Not Met
(50.0 %)	

 L57	
Written behavior plans	
I	
3/3	

	

3/3	
Met	

 L58	
Behavior plan component	
I	
3/3	

	

3/3	
Met	

 L59	
Behavior plan review	
I	
3/3	

	

3/3	
Met	

 L60	
Data maintenance	
I	
3/3	

	

3/3	
Met	

 L61	
Health protection in ISP	
I	
2/5	
	
0/1	

	
2/6	
Not Met
(33.33 %)	

 L62	
Health protection review	
I	
3/5	
	
1/1	

	
4/6	
Not Met
(66.67 %)	

 L63	
Med. treatment plan form	
I	
7/8	
	
4/4	

	
11/12	
Met
(91.67 %)	

 L64	
Med. treatment plan rev.	
I	
3/5	
	
2/2	

	
5/7	
Not Met
(71.43 %)	

 L67	
Money mgmt. plan	
I	
5/8	
1/3	
6/7	

	
12/18	
Not Met
(66.67 %)	

 L68	
Funds expenditure	
I	
8/8	
3/3	
6/6	

	
17/17	
Met	

 L69	
Expenditure tracking	
I	
7/8	
1/2	
5/6	

	
13/16	
Met
(81.25 %)	

 L70	
Charges for care calc.	
I	
7/8	
1/4	
6/8	

	
14/20	
Not Met
(70.0 %)	

 L71	
Charges for care appeal	
I	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L77	
Unique needs training	
I	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L78	
Restrictive Int. Training	
L	
5/5	
	
1/1	

	
6/6	
Met	

 L79	
Restraint training	
L	
0/1	

	

0/1	
Not Met
(0 %)	

 L80	
Symptoms of illness	
L	
8/8	
4/4	
8/8	

	
20/20	
Met	

 L81	
Medical emergency	
L	
8/8	
4/4	
8/8	

	
20/20	
Met	

O	
 L82	
Medication admin.	
L	
8/8	

	

8/8	
Met	

 L84	
Health protect. Training	
I	
4/5	
	
1/1	

	
5/6	
Met
(83.33 %)	

 L85	
Supervision 	
L	
6/8	
4/4	
8/8	

	
18/20	
Met
(90.0 %)	

 L86	
Required assessments	
I	
2/4	
0/2	
5/7	

	
7/13	
Not Met
(53.85 %)	

 L87	
Support strategies	
I	
4/5	
2/4	
4/7	

	
10/16	
Not Met
(62.50 %)	

 L88	
Strategies implemented	
I	
6/8	
3/4	
8/8	

	
17/20	
Met
(85.00 %)	

 L90	
Personal space/ bedroom privacy	
I	
7/8	
2/2	
7/8	

	
16/18	
Met
(88.89 %)	

 L91	
Incident management	
L	
3/8	
0/2	
2/5	

	
5/15	
Not Met
(33.33 %)	

#Std. Met/# 78 Indicator	

	

	

63/78	

	
Total Score	

	

	

70/88	

	

	

	

	
79.55%	

		
							
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	

2/2	
2/2	
Met	

 L8	
Emergency Fact Sheets	
I	

2/2	
2/2	
Met	

 L10	
Reduce risk interventions	
I	

2/2	
2/2	
Met	

 L31	
Communication method	
I	

2/2	
2/2	
Met	

 L32	
Verbal & written	
I	

2/2	
2/2	
Met	

 L37	
Prompt treatment	
I	

2/2	
2/2	
Met	

O	
 L38	
Physician's orders	
I	

1/1	
1/1	
Met	

 L39	
Dietary requirements	
I	

2/2	
2/2	
Met	

O	
 L46	
Med. Administration	
I	

1/1	
1/1	
Met	

 L49	
Informed of human rights	
I	

2/2	
2/2	
Met	

 L50	
Respectful Comm.	
L	

1/1	
1/1	
Met	

 L51	
Possessions	
I	

2/2	
2/2	
Met	

 L52	
Phone calls	
I	

2/2	
2/2	
Met	

 L54	
Privacy	
L	

1/1	
1/1	
Met	

 L56	
Restrictive practices	
I	

1/1	
1/1	
Met	

 L57	
Written behavior plans	
I	

2/2	
2/2	
Met	

 L58	
Behavior plan component	
I	

2/2	
2/2	
Met	

 L59	
Behavior plan review	
I	

2/2	
2/2	
Met	

 L60	
Data maintenance	
I	

2/2	
2/2	
Met	

 L63	
Med. treatment plan form	
I	

2/2	
2/2	
Met	

 L64	
Med. treatment plan rev.	
I	

2/2	
2/2	
Met	

 L77	
Unique needs training	
I	

2/2	
2/2	
Met	

 L78	
Restrictive Int. Training	
L	

1/1	
1/1	
Met	

 L79	
Restraint training	
L	

0/1	
0/1	
Not Met
(0 %)	

 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	

1/1	
1/1	
Met	

 L87	
Support strategies	
I	

1/1	
1/1	
Met	

 L88	
Strategies implemented	
I	

2/2	
2/2	
Met	

 L91	
Incident management	
L	

1/1	
1/1	
Met	

#Std. Met/# 31 Indicator	

	

30/31	

	
Total Score	

	

37/41	

	

	

	
90.24%	

		
							
	MASTER SCORE SHEET CERTIFICATION	

							
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
Met	

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

 C3	
Service satisfaction	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
1/1	
Met	

 C5	
Measure progress	
0/1	
Not Met (0 %)	

 C6	
Future directions planning	
1/1	
Met	

	

	

							
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
1/2	
Not Met (50.0 %)	

 C8	
Family/guardian communication	
2/2	
Met	

 C13	
Skills to maximize independence 	
2/2	
Met	

 C37	
Interpersonal skills for work	
1/1	
Met	

 C40	
Community involvement interest	
2/2	
Met	

 C41	
Activities participation	
2/2	
Met	

 C42	
Connection to others	
2/2	
Met	

 C43	
Maintain & enhance relationship	
2/2	
Met	

 C44	
Job exploration	
1/1	
Met	

 C45	
Revisit decisions	
2/2	
Met	

 C46	
Use of generic resources	
2/2	
Met	

 C47	
Transportation to/ from community	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

 C54	
Assistive technology	
2/2	
Met	

Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
1/3	
Not Met (33.33 %)	

 C8	
Family/guardian communication	
4/4	
Met	

 C9	
Personal relationships	
4/4	
Met	

 C10	
Social skill development	
4/4	
Met	

 C11	
Get together w/family & friends	
4/4	
Met	

 C12	
Intimacy	
3/4	
Met	

 C13	
Skills to maximize independence 	
4/4	
Met	

 C14	
Choices in routines & schedules	
2/2	
Met	

 C15	
Personalize living space	
2/2	
Met	

 C16	
Explore interests	
4/4	
Met	

 C17	
Community activities	
4/4	
Met	

 C18	
Purchase personal belongings	
4/4	
Met	

 C19	
Knowledgeable decisions	
4/4	
Met	

 C20	
Emergency back-up plans	
2/2	
Met	

 C21	
Coordinate outreach	
4/4	
Met	

 C46	
Use of generic resources	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C48	
Neighborhood connections	
2/2	
Met	

 C49	
Physical setting is consistent 	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/4	
Met	

 C52	
Leisure activities and free-time choices /control	
4/4	
Met	

 C53	
Food/ dining choices	
2/2	
Met	

 C54	
Assistive technology	
3/4	
Met	

Placement Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
3/8	
Not Met (37.50 %)	

 C8	
Family/guardian communication	
8/8	
Met	

 C9	
Personal relationships	
6/7	
Met (85.71 %)	

 C10	
Social skill development	
7/7	
Met	

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

 C12	
Intimacy	
4/8	
Not Met (50.0 %)	

 C13	
Skills to maximize independence 	
8/8	
Met	

 C14	
Choices in routines & schedules	
8/8	
Met	

 C15	
Personalize living space	
7/8	
Met (87.50 %)	

 C16	
Explore interests	
7/7	
Met	

 C17	
Community activities	
6/7	
Met (85.71 %)	

 C18	
Purchase personal belongings	
8/8	
Met	

 C19	
Knowledgeable decisions	
8/8	
Met	

 C20	
Emergency back-up plans	
8/8	
Met	

 C46	
Use of generic resources	
7/7	
Met	

 C47	
Transportation to/ from community	
8/8	
Met	

 C48	
Neighborhood connections	
7/7	
Met	

 C49	
Physical setting is consistent 	
5/5	
Met	

 C51	
Ongoing satisfaction with services/ supports	
7/7	
Met	

 C52	
Leisure activities and free-time choices /control	
8/8	
Met	

 C53	
Food/ dining choices	
8/8	
Met	

 C54	
Assistive technology	
3/8	
Not Met (37.50 %)	

Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
4/8	
Not Met (50.0 %)	

 C8	
Family/guardian communication	
8/8	
Met	

 C9	
Personal relationships	
6/8	
Not Met (75.00 %)	

 C10	
Social skill development	
8/8	
Met	

 C11	
Get together w/family & friends	
8/8	
Met	

 C12	
Intimacy	
2/8	
Not Met (25.00 %)	

 C13	
Skills to maximize independence 	
8/8	
Met	

 C14	
Choices in routines & schedules	
8/8	
Met	

 C15	
Personalize living space	
8/8	
Met	

 C16	
Explore interests	
7/8	
Met (87.50 %)	

 C17	
Community activities	
7/8	
Met (87.50 %)	

 C18	
Purchase personal belongings	
7/8	
Met (87.50 %)	

 C19	
Knowledgeable decisions	
8/8	
Met	

 C20	
Emergency back-up plans	
8/8	
Met	

 C46	
Use of generic resources	
8/8	
Met	

 C47	
Transportation to/ from community	
8/8	
Met	

 C48	
Neighborhood connections	
3/8	
Not Met (37.50 %)	

 C49	
Physical setting is consistent 	
7/8	
Met (87.50 %)	

 C51	
Ongoing satisfaction with services/ supports	
8/8	
Met	

 C52	
Leisure activities and free-time choices /control	
8/8	
Met	

 C53	
Food/ dining choices	
8/8	
Met	

 C54	
Assistive technology	
4/8	
Not Met (50.0 %)