Provider:	

COMPREHENSIVE MENTAL HEALTH	

	
Provider Address:	

331R State Road , North Dartmouth	

	

	

	

	
Name of Person
Completing Form:	

Susan Duclos	

	
Date(s) of Review:	

24-JAN-17 to 24-JAN-17	

	

			
Follow-up Scope and results :	

Service Grouping	
Licensure level and duration	
  # Indicators std. met/ std. rated 	

Residential and Individual Home Supports	
2 Year License	

  

	

Summary of Ratings	

		

Residential and Individual Home Supports Areas Needing Improvement on Standard not met - Identified by DDS	

Indicator #	
L47	

Indicator	
Self medication	

Area Need Improvement	
One individual participating in the survey had not had their self-medication skills assessed.  The agency needs to ensure that self-medication assessments are completed for each individual to determine if a teaching plan may be appropriate.	

Process Utilized to correct and review indicator	
CMHS will ensure that all individuals served are assessed on an ongoing basis for their ability to self medicate.	

Status at follow-up	
The individual participating in the survey has been formally assessed by the Agency MAP trainer and a teaching plan is being developed to support his goal of self-administration.	

Rating	
Met	

Indicator #	
L64	

Indicator	
Med. treatment plan rev.	

Area Need Improvement	
One of two Medication Treatment Plans (MTP) reviewed by the ISP team did not contain all of the behavior modifying medications one individual is prescribed.  The agency needs to ensure that all prescribed behavior modifying medications are reviewed by the required groups.	

Process Utilized to correct and review indicator	
All Medication Treatment Plans will be reviewed on an ongoing basis and updated as necessary.	

Status at follow-up	
The Medication Treatment Plan for the individual participating in the survey has been revised to include his pre-sedation medication.	

Rating	
Met	

Indicator #	
L86	

Indicator	
Required assessments	

Area Need Improvement	
Assessments for two out of eight individuals were not submitted within required time frames. The agency needs to ensure that assessments are submitted to the DDS area office, 15 days prior to the ISP.	

Process Utilized to correct and review indicator	
CMHS will follow timeframe notifications issued through HCSIS (Healthcare Record Notification) and the respective service coordinator.	

Status at follow-up	
CMHS is following notifications and submitting to DDS within the required timeframe.	

Rating	
Met	

Indicator #	
L87	

Indicator	
Support strategies	

Area Need Improvement	
Support strategies for two out of eight individuals were not submitted within the required time frames. The agency needs to ensure that strategies are submitted to the DDS area office, 15 days prior to the ISP.	

Process Utilized to correct and review indicator	
CMHS will follow timeframe notifications issued through HCSIS (Healthcare Record Notification) and the respective service coordinator.	

Status at follow-up	
CMHS is following notifications and submitting to DDS within the required timeframe.	

Rating	
Met