SUMMARY OF OVERALL FINDINGS

Provider:  Community Systems, Inc.

Review Dates:  November 5 – 11, 2014

Service Enhancement Meeting Date:  November 21, 2014

Survey Team:  Barbara Mazzella (TL), Sally Hajjar, Michael Marchese, Scott F. Nolan, 
		     and Edward Sutka

 
 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	18 Locations 18 Audits 	Full Review	78 / 85     Two-Year License 11/21/2014 - 11/21/2016	 

 	 

 	
Residential Services	7 Locations   7 Audits 	 
 	 
 	Full Review	14 / 14 Certified	
Placement Services	7 Locations   7 Audits	 
 	 
 	Full Review	14 / 14 Certified	
Individual Home Supports	4 Locations   4 Audits	 
 	 
 	Full Review	15 / 15 Certified	
 Survey Scope and Findings for Planning and Quality Management	
Service Group Type
	Sample Size	Licensure Scope	Licensure Level	Certification Scope	Certification Level	
Planning and Quality Management	N/A	N/A	N/A	Full Review	4/6     Certified	

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 which 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 and Plymouth areas that are supported by the Massachusetts Department of Developmental Services (DDS) and the 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" serves as the foundation of its delivery system and is noted by the agency to be embedded in all organizational and programmatic decisions.

CSI currently supports approximately seventy individuals residing in twenty-four hour staffed homes, sixty-three individuals who reside in shared living arrangements and/or individual home support settings and eighty-three individuals who receive case management supports in Plymouth and the Cape and Islands.  A full Licensure and Certification survey was conducted which included examining essential safeguards in supporting adults with intellectual disabilities within Massachusetts as well as reviewing quality outcomes that fall under Certification areas.  During this review seven audits were conducted on twenty-four hour staffed homes, seven audits were conducted within the home placement model, and four audits were conducted within individual home supports. 

Since the last Licensing and Certification review (October 2012), the agency had increased its focus on ensuring that its mission was clearly rooted in all services and supports provided to individuals as well as visibly demonstrated by staff in all interactions and settings.  Significant time and attention has been directed at its hiring processes to ensure that all candidates appreciate and acknowledge the importance of value-driven supports as evident in administrative interviews and documentation review of staff training.  The Executive Director is now an integral part of the hiring process and meets with all potential candidates prior to any final hiring decision.  Survey visits identified that individuals were happy in their current homes and staff assisted individuals to participate in activities and opportunities that were directly reflective of individual's interests and preferences.  The agency also continues to stress the importance of continuous education/ professional development and have ensured that many staff has participated in retreats offered through other states within the CSI network of supports.  

A fundamental strength of the agency continues to be in the coordination of complex medical support.  Extensive medical oversight systems have been developed and implemented within its residential network to ensure that medical care is provided in a comprehensive and consistent manner.  Wellness plans were reviewed at homes visited during the survey which reflected individuals' unique medical issues and concerns.  For example, in one home, staff stored and maintained a separate set of pots to use for an individual who had severe allergies.  Another area of strength was seen in the promotion and protection of people's rights.  Staff consistently reinforced individual's desires to become contributing members of their communities and fostered relationships that assisted individuals to connect with local clubs and civic activities to participate in volunteer opportunities.  The agency has also focused increased attention on ensuring that its Human Rights Committee (HRC) serves as an integral and effective body.  Survey findings revealed that members questioned if restrictions which impacted individuals' rights were necessary.  HRC members also responded on short notice to conduct a site visit after a significant human rights concern had been raised. 

Given that the agency has experienced significant growth since its inception and continues to strive to ensure the provision of essential safeguards, the agency should review its systems in order to examine 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 a cursory review process for collecting data on quality measures, documentation and interviews with executive staff revealed that data is not being collected across all locations and a quality improvement system has not been fully actualized.  Additionally, the agency should consider the following areas for increased oversight: ensuring that fire drills are conducted as required, monitoring the water temperatures at sinks and showers to ensure compliance within prescribed limits, development of financial plans that include training components when the agency has shared and delegated responsibilities, and ensuring that timeframes established for submission of assessments and support strategies are met.  

Based on the findings of this report, the agency is congratulated for receiving a score of 92% in the Licensing indicators for residential services and for all but two planning/organizational Certification indicators, all residential services, placement services, and individual home supports Certification outcomes were ‘Met.’  The agency has demonstrated that it is committed to providing supports and services that are tailored to meet the unique needs of the individuals they serve and are based on its mission.  The agency will receive a Two-Year License for residential services and will conduct its own follow-up on the ‘Not Met’ indicators.

 
LICENSURE FINDINGS

Met / Rated	
Not Met / Rated	% Met	
Organizational	10/10	0/10		
Residential and  Individual Home Supports	68/75	7/75	
	
  Residential Services
  Placement Services
  Individual Home Supports				
Critical Indicators	8/8	0/8		
Total	78/85	7/85	92%	
Two-Year License				
# Indicators for 60 Day Follow-up	
	7	

 

Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur:	
 
 	Indicator #	Indicator	Area Needing Improvement	

 

 
 	 L7	Fire drills are conducted as required.	Documentation regarding fire drills at two loca-tions indicated that fire drills did not occur at the frequency specified in the safety plan as well as fire drill logs included documentation errors. (Staff were incorrectly recording asleep drills during times designated as awake.)  The agency needs to ensure that fire drills are conducted as specified in the DDS approved Emergency Evacuation Safety Plan and include accurate information regarding times of drills.

 
 
 	 L15	Hot water temperature tests between 110 and 130 degrees.	The agency needs to ensure that hot water temperature at sinks and showers test between 110 and 120. Water temperatures were not within prescribed limits at four residential locations.

	 L56	Restrictive practices intended for one individual that affect all indi-viduals 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.
	The agency needs to ensure that when restric-tive practices are in place, such as locks on cabinets and restrictions on sharps, the agency secures a written rationale as required including provisions to mitigate the use of these practices so as to not restrict the rights of others.  	

 
 	 L62	Supports and health-related protec-tions are reviewed by the required groups.	The agency needs to ensure that when individuals are prescribed supportive and health- related protections all required reviews are in place.	

 
 
  	 L67	There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	When the agency has shared or delegated money management responsibilities, the agency needs to ensure that there is a written plan which includes a training plan to reduce or eliminate the need for assistance.	

 
  	 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.  Eight out of seventeen 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 support strategies are submitted 15 days prior to the ISP.  Ten out of sixteen records reviewed did not include support strategies that met required timeframes.	

CERTIFICATION FINDINGS

  
 	Met / Rated	Not Met / Rated	
Certification - Planning and Quality Management	4/6	2/6	
Residential and Individual Home Supports	

Residential Services	14/14	0/14	
Individual Home Supports	15/15	0/15	
Placement Services	14/14	0/14	

Planning and Quality Management Areas Needing Improvement on Standards Not Met:	
 	Indicator #	Indicator	Area Needing Improvement	

 

 	 C1	The provider collects data regard-ing program quality including but not limited to incidents, investiga-tions, restraints, and medication occurrences.
	Although the agency collects information on investigations and restraints, the agency needs to develop a more systemic approach incorporating all program components regarding quality across all program settings. 	

 
 	 C2	The provider analyzes information gathered from all sources and identifies patterns and trends.	The agency needs to develop a more effective system to gather and analyze information regard-ing quality measures in order to identify patterns and trends. 

  

 

MASTER SCORE SHEET LICENSURE
Organizational: 
	Indicator #	Indicator	Met/Rated	Rating                               (Met, Not Met, Not Rated)	
O	 L2	Abuse/Neglect reporting	18/18	Met	
 	 L3	Immediate Action	14/14	Met	
 	 L4	Action taken	13/13	Met	
 	 L48	Human Rights Committee	1/1	Met	
 	 L65	Restraint Report submit	21/23	Met (91.30%)	
 	 L66	HRC restraint review	9/11	Met (81.82%)	
 	 L74	Screen employees	9/9	Met	
 	 L75	Qualified staff	1/1	Met	
 	 L76	Track trainings	20/20	Met	
 	 L83	Human Rights training	20/20	Met	

Residential and Individual Home Supports:

Ind. #	
Indicator	
Location or Individual
	
Res. Supports	
Ind. 
Home Supports	
Place-ment	
Resp.	
ABI-MFP Res. Sup.	
ABI-MFP Place-ment	
Total Met/ Rated	
Rating	
	 L1	Abuse/Neglect training	I	6/7	4/4	7/7				17/18	Met
(94.44%)	
	 L5	Safety Plan	L	7/7	3/4	7/7				17/18	Met
(94.44%)	
O	 L6	Evacuation	L	6/7	3/4	7/7				16/18	Met
(88.89%)	
	 L7	Fire Drills	L	5/7						5/7	Not Met
(71.43%)	
	 L8	Emergency Fact Sheets	I	7/7	4/4	7/7				18/18	Met	
	 L9	Safe use of equipment	L	7/7	4/4	7/7				18/18	Met	
 	 L10	Reduce risk interventions	I	2/2	  	1/1				3/3	Met	
O	 L11	Required inspections	L	7/7	3/3	7/7				17/17	Met	
O	 L12	Smoke detectors	L	7/7	3/3	6/7				16/17	Met
(94.12%)	
O	 L13	Clean location	L
	7/7	3/3	7/7				17/17	Met	
	 L14	Site in good repair	L	4/4	2/2	7/7				13/13	Met	
	 L15	Hot water	L	6/7	3/4	5/7				14/18	Not Met
(77.78%)	
Residential and Individual Home Supports, cont.

Ind. #	
Indicator	
Location or Individual
	
Res. Supports	
Ind. 
Home Supports	
Place-ment	
Resp.	
ABI-MFP Res. Sup.	
ABI-MFP Place-ment	
Total Met/ Rated	
Rating	
	 L16	Accessibility	L	6/7	3/3	5/5				14/15	Met
(93.33%)	
	 L17	Egress at grade 	L
	7/7	4/4	7/7				18/18	Met	
	 L18	Above grade egress	L	 	1/1	1/1				2/2	Met	
	 L19	Bedroom location	L	7/7	1/1					8/8	Met	
	 L20	Exit doors	L
	7/7	4/4					11/11	Met	
	 L21	Safe electrical equipment	L	7/7	3/3	7/7				17/17	Met	
	 L22	Clean appliances	L	7/7	3/3	6/7				16/17	Met
(94.12%)	
	 L23	Egress door locks	L	5/5						5/5	Met	
	 L24	Locked door access	L	6/6						6/6	Met	
	 L25	Dangerous substances	L	7/7	3/3	7/7				17/17	Met	
	 L26	Walkway safety	L	6/7	3/3	6/7				15/17	Met
(88.24%)	
	 L28	Flammables
	L	5/5	3/3	7/7				15/15	Met	
	 L29	Rubbish/Com-bustibles	L	6/7	2/2	7/7				15/16	Met
(93.75%)	
	 L30	Protective railings	L	4/5	1/1	7/7				12/13	Met
(92.31%)	
	 L31	Communication method	I	7/7	4/4	7/7				18/18	Met	
	 L32	Verbal & written	I
	7/7	4/4	7/7				18/18	Met	
	 L33	Physical exam	I
	7/7	4/4	7/7				18/18	Met	
	 L34	Dental exam	I	6/7	3/3	7/7				16/17	Met
(94.12%)	
	 L35	Preventive screenings	I	7/7	4/4	7/7				18/18	Met	
	 L36	Recommended tests	I	7/7	4/4	7/7				18/18	Met	
	 L37	Prompt treatment	I	7/7	4/4	7/7				18/18	Met	
O	 L38	Physicians’ orders	I	5/7	 	6/6				11/13	Met
(84.62%)	
	 L39	Dietary requirements	I	6/7	3/3	5/5				14/15	Met
(93.33%)	
	 L40	Nutritional food	L	7/7
	4/4	7/7				18/18	Met	
Residential and Individual Home Supports, cont.

Ind. #	
Indicator	
Location or Individual
	
Res. Supports	
Ind. 
Home Supports	
Place-ment	
Resp.	
ABI-MFP Res. Sup.	
ABI-MFP Place-ment	
Total Met/ Rated	
Rating	
	 L41	Healthy diet	L	7/7	4/4	7/7
				18/18	Met	
	 L42	Physical activity	L
	7/7	4/4	7/7				18/18	Met	
	 L43	Health Care Record	I	7/7	4/4	7/7				18/18	Met	
	 L44	MAP Registration	L	7/7						7/7	Met	
	 L45	Medication storage	L	7/7	1/1	  				8/8	Met	
O	 L46	Medication administration	I	6/7	 	5/5				11/12	Met
(91.67%)	
  	 L47	Self- medication	I	5/5	4/4	5/5				14/14	Met	
	 L49	Informed of human rights	I	7/7	4/4	7/7				18/18	Met	
 	 L50	Respectful communication	L	7/7	4/4	7/7				18/18	Met	
	 L51	Possessions	I
	7/7	4/4	7/7				18/18	Met	
	 L52	Phone calls	I
	7/7	4/4	7/7				18/18	Met	
 	 L53	Visitation	I
	7/7	4/4	7/7				18/18	Met	
	 L54	Privacy	L
	7/7	4/4	7/7				18/18	Met	
	 L55	Informed consent	I	1/1		1/1				2/2	Met	
	 L56	Restrictive practices	I	0/2		 				0/2	Not Met
(0%)	
	 L57	Written Behavior Plans	I	4/4		1/1				5/5	Met	
 	 L58	Behavior Plan component	I	4/4	  	1/1				5/5	Met	
	 L59	Behavior Plan review	I	4/4		1/1				5/5	Met
	
	 L60	Data maintenance	I	4/4		1/1				5/5	Met	
	 L61	Health protection in ISP	I	5/6		2/2				7/8	Met
(87.50%)	
	 L62	Health protection review	I	4/5		1/2				5/7	Not Met
(71.43%)	
	 L63	Med. Treatment Plan form	I	6/7	2/3	6/6				14/16	Met
(87.50%)	
	 L64	Med. Treatment Plan review	I	7/7	3/3	6/6				16/16	Met	

Residential and Individual Home Supports, cont.

Ind. #	
Indicator	
Location or Individual
	
Res. Supports	
Ind. 
Home Supports	
Place-ment	
Resp.	
ABI-MFP Res. Sup.	
ABI-MFP Place-ment	
Total Met/ Rated	
Rating	
	 L67	Money Mgmt. Plan	I	3/6	2/2	5/5				10/13	Not Met
(76.92%)	
	 L68	Funds expenditure	I	7/7	2/2	5/5				14/14	Met	
	 L69	Expenditure tracking	I	6/7	2/2	5/5				13/14	Met
(92.86%)	
	 L70	Charges for care calc.	I	6/7	1/1	5/7				12/15	Met
(80%)	
	 L71	Charges for care appeal	I	7/7	0/1	5/6				12/14	Met
(85.71%)	
	 L77	Unique needs training	I	7/7	3/4	7/7				17/18	Met
(94.44%)	
	 L78	Restrictive Int. Training	L	1/1	1/1	3/3				5/5	Met	
	 L79	Restraint training	L	3/3	1/1	2/2				6/6	Met	
	 L80	Symptoms of illness	L	7/7	4/4	7/7				18/18	Met	
	 L81	Medical emergency	L	7/7	4/4	7/7				18/18	Met	
O	 L82	Medication administration	L	7/7						7/7	Met	
 	 L84	Health Protection Training	I	5/6	 	2/2				7/8	Met
(87.50%)	
	 L85	Supervision 	L
	7/7	4/4	7/7				18/18	Met	
	 L86	Required assessments	I	2/7	3/4	4/6				9/17	Not Met
(52.94%)	
	 L87	Support Strategies	I	3/6	1/4	2/6				6/16	Not Met
(37.50%)	
	 L88	Strategies implemented	I	6/6	4/4	7/7				17/17	Met	
# Std. Met/75 Indica-tors									68/75		
Total Score									78/85		

 	 

 	 

 	 
 	91.76%	  	

MASTER SCORE SHEET CERTIFICATION
Certification - Planning and Quality Management:	
Indicator #	Indicator	Met/Rated	Rating	
 C1	Provider data collection	0/1	Not Met (0%)	
 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	1/1	Met	
 C6	Future directions planning	1/1	Met	

Individual Home Supports Reviewed By DDS:	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	4/4	Met	
 C8	Family/Guardian communication	4/4	Met	
 C9	Personal relationships	3/4	Met	
 C10	Social skill development	4/4	Met	
 C11	Get together w/family & friends	4/4	Met	
 C12	Intimacy	4/4	Met	
 C13	Skills to maximize independence 	4/4	Met	
 C14	Choices in routines & schedules	4/4	Met	
 C15	Personalize living space	4/4	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	4/4	Met	
 C21	Coordinate outreach	4/4	Met	

Placement Services Reviewed By DDS:	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	7/7	Met	
 C8	Family/Guardian communication	7/7	Met	
 C9	Personal relationships	7/7	Met	
 C10	Social skill development	7/7	Met	

Placement Services Reviewed By DDS, cont.	
Indicator #	Indicator	Met/Rated	Rating	
 C11	Get together w/family & friends	7/7	Met	
 C12	Intimacy	7/7	Met	
 C13	Skills to maximize independence 	7/7	Met	
 C14	Choices in routines & schedules	7/7	Met	
 C15	Personalize living space	7/7	Met	
 C16	Explore interests	7/7	Met	
 C17	Community activities	7/7	Met	
 C18	Purchase personal belongings	6/6	Met	
 C19	Knowledgeable decisions	7/7	Met	
 C20	Emergency back-up plans	7/7	Met	

Residential Services Reviewed By DDS:	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	7/7	Met	
 C8	Family/Guardian communication	7/7	Met	
 C9	Personal relationships	7/7	Met	
 C10	Social skill development	6/7	Met (85.71%)	
 C11	Get together w/family & friends	7/7	Met	
 C12	Intimacy	7/7	Met	
 C13	Skills to maximize independence 	7/7	Met	
 C14	Choices in routines & schedules	7/7	Met	
 C15	Personalize living space	7/7	Met	
 C16	Explore interests	7/7	Met	
 C17	Community activities	7/7	Met	
 C18	Purchase personal belongings	7/7	Met	
 C19	Knowledgeable decisions	7/7	Met	
 C20	Emergency back-up plans	7/7	Met