PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
Crystal Springs, Inc.
38 Narrows Rd POB 372
 Assonet, MA 02702    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
March 31, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
Crystal Springs, Inc.	

	

	

	

	
Review Dates	

	
3/3/2017 - 3/9/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
3/23/2017	

	

	

	

	

	

	
Survey Team	

	
Barbara Mazzella (TL)	

Scott Nolan	

	

	

	

	

	

	
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	
4 location(s) 6 audit (s) 	
Full Review	
73 / 82 2 Year License 03/23/2017 -  03/23/2019	
	
21 / 28 Certified with Progress Report 03/23/2017 -  03/23/2019	

Residential Services	
4 location(s) 6 audit (s) 	

Full Review	
15 / 22	

Planning and Quality Management	

	
Full Review	
6 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
Crystal Springs, Inc. is a non-profit agency that has been providing services to children and adults with developmental disabilities in Southeastern Massachusetts for over fifty years. The agency's 45 acre campus style setting offers residential and educational options for children and adults. Residential services are offered to adults residing in 14 homes; ten homes are on the campus setting and four homes are located within the surrounding communities. The agency currently provides services to approximately 70 adults, ages 22 and older, and 45 children, ages 3 to 22.  The agency's service delivery system is based on its mission 'to provide individualized programs for children and adults with developmental disabilities while embracing and nurturing each person's pursuit of growth, independence, dignity and choice.' 

A full licensure and certification review was conducted on the agency's residential services and included indicators which were new or revised as of 8/29/16. Services at four homes were reviewed, three of which were on campus and one was in the neighboring community.  The scope of the licensure review addressed indicators related to domains such as health care, environmental safety, funds management and human rights, while the certification review included areas such as individual choice and control, community inclusion and relationships. In addition, organizational certification areas, such as data collection and analysis regarding the quality of services were also reviewed.
 
The findings of the survey team revealed a number of positive outcomes relating to a variety of domains. Homes were found to be in good condition, and mechanisms were in place which afforded staff a process to identify concerns which were prioritized by the maintenance department. Another area of strength was in the area of health care and medical supports provided to individuals.  Individuals with complex health care needs received required medical care as well as timely follow up from specialized practitioners. In one instance, an individual with complex medical needs was exhibiting unusual medical symptoms and staff advocated on his behalf with his physicians to review his current medication regimen and its efficacy resulting in a medication change.  The agency is also recognized for medication systems that included correctly administering medications for each of the six individuals surveyed.
The agency also ensured that all individuals were assessed regarding their swimming abilities to use the campus pool and many individuals enjoyed using the pool on a frequent and ongoing basis. 
 
Within the organizational domains, the agency's staff met all required trainings and many staff participated in specialized training opportunities based on the complex medical needs of individuals' receiving support.  Survey findings also revealed organizational areas that need additional strengthening. The agency needs to ensure that the Human Rights Committee meets composition requirements, conducts regular meetings, reviews restraints and discuss issues that potentially impact individuals' rights.  The agency needs to ensure that restraint reports are submitted within required timelines.
 
Although the survey team noted positive achievements in a number of licensing domains, the agency could benefit from additional focus in a few discrete indicators. For example, there were instances where hot water temperatures were not within allowable limits. There were also instances where the agency was not fully aware of the requirements relating to obtaining agreement to the Medication Treatment Plan as well as including all required components when a restrictive practice is in place. Staff also need to strengthen its implementation and oversight when individuals' require specialized diets.
 
Within organization areas related to certification, the agency gathered data from investigations, HCSIS, medication reviews and incidents to systemically identify patterns and trends. For example, the agency analyzed medication error reports which revealed practices which contributed to documentation errors and utilized consultation from a pharmacist to rectify this situation.  In concert with its strategic plan, the agency developed benchmarks and targeted objectives in response to the strengthened certification indicators regarding community inclusion.  Other areas of strength regarding certification were in relation to individual outcomes. Communication between families and guardians were respectful and encouraged.  The agency has an open door policy and welcomes family input. Individuals were supported to participate in activities and build skills that maximized their independence; these teaching techniques and support strategies were tailored to their unique learning styles. 

There were however, several areas within certification that need additional focus.  Additional assistance needs to be provided to expand supports to explore individualized preferences regarding social and recreational activities.  Access to community activities tended to be infrequent and consistent participation in local events was limited. Most individuals living on campus had minimal interaction with the surrounding neighborhood. There were limited opportunities to come into contact with others in the community who share the individuals interests, and to develop potential relationships with new friends and acquaintances. Another area that would benefit from further focus would be to assist staff to help educate individuals, especially those with a limited understanding of how to more effectively express their feelings regarding intimacy and companionship.
 
Based on the findings of this report, the agency has earned a Two-Year License for Residential/Individual Home Supports, with 89 % of the licensing indicators rated Met and is Certified with a Progress Report in this service grouping with 75 % of the certification indicators receiving a rating of Met. Within approximately 60 days, the DDS office of Quality Enhancement will conduct a follow up review for any licensing indicators that were rated Not Met.  The agency will have one year to address the certification findings and prepare its progress report on the certification indicators that were rated Not Met.	

	

LICENSURE FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
7/10	
3/10	

Residential and Individual Home Supports	
66/72	
6/72	

    Residential Services

	

Critical Indicators	
8/8	
0/8	

Total	
73/82	
9/82	
89%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
9	

	

	

	

	

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 had a human rights committee, there were a number of areas 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. 	

 L65	
Restraint reports are submitted within required timelines.	
Fifteen restraint reports were reviewed. Of these, eleven reports were not finalized within the five day manager review period and three restraints were not created within the three days as well as reviewed by the manager within five days.The agency needs to ensure that restraint reports are created and submitted within required timelines.  	

 L66	
All restraints are reviewed by the Human Rights Committee.	
Ten out of ten restraints were not reviewed within 120 days by the Human Rights Committee as required. The agency needs to ensure that restraints are reviewed within 120 days. 	

		

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L15	
Hot water temperature tests between 110 and 130 degrees.	
The hot water temperature was tested at four locations. The hot water temperature at two of these homes exceeded allowable limits. The agency needs to ensure that hot water temperatures are within allowable limits of 110-120 degrees. 	

 L39	
Special dietary requirements are followed. 	
Specialized dietary requirements were reviewed for six individuals. In two of these instances, staff were not implementing strategies to ensure that specialized dietary requirements were being implemented as prescribed by practitioners. The agency needs to ensure that specialized dietary requirements are being implemented as designed. 	

 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.	
A restrictive practice was in place for one individual. All required components were not in place, including a rationale for the use of this device, least restrictive alternatives utilized, a teaching plan to reduce the need for this device and a plan to reduce or eliminate the need for this intervention. The agency needs to ensure that all restrictive practices include all required components. 	

 L63	
Medication treatment plans are in written format with required components.	
Medication treatment plans were reviewed for six individuals. Of these, three medication treatment plans did not include all required components including data regarding the presence of target behaviors in order to determine the effectiveness of the treatment plan, and the inclusion of all behavior modifying medications.  The agency needs to ensure that Medication Treatment Plans are written with all required components. 	

 L64	
Medication treatment plans are reviewed by the required groups.	
Five out of six Medication Treatment Plans were not reviewed at the ISP. The agency needs to ensure that medication treatment plans are reviewed by the required groups. 	

 L88	
Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	
The implementation of support strategies was reviewed for six individuals. In three instances, strategies agreed upon in the ISP were not being implemented by staff. The agency needs to ensure that support strategies agreed upon in the ISP are being implemented.  	

	

		

	

	

CERTIFICATION FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

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

Residential and Individual Home Supports	
15/22	
7/22	

Residential Services	
15/22	
7/22	

TOTAL	
21/28	
7/28	
75%	

Certified with Progress Report	

	

	

	

	

	
Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C9	
Staff (Home Providers) provide opportunities to develop and/or increase personal relationships and social contacts.  	
Opportunities to develop and/or increase personal relationships were reviewed for six individuals. Of these, four individuals could benefit from additional opportunities to develop and/or 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 individuals, there was no evidence to document that the agency has a curriculum or that education has been provided to staff supporting individuals in the area of sexuality and intimacy. In addition, there were no formal or informal assessments made of an individuals' need for intimacy and companionship in concert with individual's unique learning styles. The agency need to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship. 	

 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Exploration of individuals' interests regarding cultural, social, recreational and spiritual activities was not identified for six individuals on a consistent and ongoing basis. The agency needs to support individuals to explore, discover and encourage participation of integrated cultural, social recreational and spiritual activities on a regular basis. 	

 C17	
Community activities are based on the individual's preferences and interests.	
Six individuals were reviewed regarding their access to community activities that were based on their individual preferences and interests. Four of the six individuals were not provided with frequent opportunities to participate in community activities that aligned with their preferences. Additionally, there was limited evidence of staff knowledge regarding local events and or activities. The agency needs to ensure that staff are knowledgeable about local events and activities that reflect individuals' interests and afford opportunities for individuals to participate in these events. 	

 C48	
Individuals are a part of the neighborhood.	
Six individuals were reviewed regarding their connections with neighbors. Four individuals resided on a campus setting which limited their opportunities to meet neighbors and become active participants in neighborhood activities. The agency needs to ensure that opportunities are provided which encourage and support neighborhood connections. 

	
 C49	
The physical setting blends in with and is a natural part of the neighborhood and community.	
The physical setting of four homes were reviewed. Three homes are situated on a large campus and are not fully integrated in the community. The agency needs to ensure that individuals are supported to live in settings that blend into the neighborhood and are integrated into the community. 	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for six individuals were reviewed, and in three instances assessment of assistive technology needs had not yet gone beyond the initial stages. The agency needs to assess each individual's needs and determine how assistive technology modifications could help people to maximize their independence.	

	

	

		

	

						
	MASTER SCORE SHEET LICENSURE	

						
	Organizational: Crystal Springs, Inc.	

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

O	
 L2	
Abuse/neglect reporting	
4/4	
Met	

 L3	
Immediate Action	
15/15	
Met	

 L4	
Action taken	
13/13	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
1/15	
Not Met(6.67 % )	

 L66	
HRC restraint review	
0/10	
Not Met(0 % )	

 L74	
Screen employees	
1/1	
Met	

 L75	
Qualified staff	
4/4	
Met	

 L76	
Track trainings	
15/15	
Met	

 L83	
HR training	
15/15	
Met	

						
	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	
6/6	

	

6/6	
Met	

 L5	
Safety Plan	
L	
4/4	

	

4/4	
Met	

O	
 L6	
Evacuation	
L	
4/4	

	

4/4	
Met	

 L7	
Fire Drills	
L	
4/4	

	

4/4	
Met	

 L8	
Emergency Fact Sheets	
I	
6/6	

	

6/6	
Met	

 L9	
Safe use of equipment	
L	
4/4	

	

4/4	
Met	

 L10	
Reduce risk interventions	
I	
1/1	

	

1/1	
Met	

O	
 L11	
Required inspections	
L	
4/4	

	

4/4	
Met	

O	
 L12	
Smoke detectors	
L	
4/4	

	

4/4	
Met	

O	
 L13	
Clean location	
L	
4/4	

	

4/4	
Met	

 L14	
Site in good repair	
L	
4/4	

	

4/4	
Met	

 L15	
Hot water	
L	
2/4	

	

2/4	
Not Met
(50.0 %)	

 L16	
Accessibility	
L	
4/4	

	

4/4	
Met	

 L17	
Egress at grade 	
L	
4/4	

	

4/4	
Met	

 L18	
Above grade egress	
L	
1/1	

	

1/1	
Met	

 L19	
Bedroom location	
L	
4/4	

	

4/4	
Met	

 L20	
Exit doors	
L	
4/4	

	

4/4	
Met	

 L21	
Safe electrical equipment	
L	
4/4	

	

4/4	
Met	

 L22	
Clean appliances	
L	
4/4	

	

4/4	
Met	

 L23	
Egress door locks	
L	
4/4	

	

4/4	
Met	

 L24	
Locked door access	
L	
4/4	

	

4/4	
Met	

 L25	
Dangerous substances	
L	
4/4	

	

4/4	
Met	

 L26	
Walkway safety	
L	
4/4	

	

4/4	
Met	

 L27	
Pools, hot tubs, etc.	
L	
2/2	

	

2/2	
Met	

 L28	
Flammables	
L	
4/4	

	

4/4	
Met	

 L29	
Rubbish/combustibles	
L	
4/4	

	

4/4	
Met	

 L30	
Protective railings	
L	
3/3	

	

3/3	
Met	

 L31	
Communication method	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L32	
Verbal & written	
I	
6/6	

	

6/6	
Met	

 L33	
Physical exam	
I	
6/6	

	

6/6	
Met	

 L34	
Dental exam	
I	
6/6	

	

6/6	
Met	

 L35	
Preventive screenings	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L36	
Recommended tests	
I	
6/6	

	

6/6	
Met	

 L37	
Prompt treatment	
I	
6/6	

	

6/6	
Met	

O	
 L38	
Physician's orders	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L39	
Dietary requirements	
I	
4/6	

	

4/6	
Not Met
(66.67 %)	

 L40	
Nutritional food	
L	
4/4	

	

4/4	
Met	

 L41	
Healthy diet	
L	
4/4	

	

4/4	
Met	

 L42	
Physical activity	
L	
4/4	

	

4/4	
Met	

 L43	
Health Care Record	
I	
6/6	

	

6/6	
Met	

 L44	
MAP registration	
L	
4/4	

	

4/4	
Met	

 L45	
Medication storage	
L	
4/4	

	

4/4	
Met	

O	
 L46	
Med. Administration	
I	
6/6	

	

6/6	
Met	

 L49	
Informed of human rights	
I	
6/6	

	

6/6	
Met	

 L50	
Respectful Comm.	
L	
4/4	

	

4/4	
Met	

 L51	
Possessions	
I	
6/6	

	

6/6	
Met	

 L52	
Phone calls	
I	
6/6	

	

6/6	
Met	

 L53	
Visitation	
I	
6/6	

	

6/6	
Met	

 L54	
Privacy	
L	
4/4	

	

4/4	
Met	

 L55	
Informed consent	
I	
4/4	

	

4/4	
Met	

 L56	
Restrictive practices	
I	
0/1	

	

0/1	
Not Met
(0 %)	

 L61	
Health protection in ISP	
I	
6/6	

	

6/6	
Met	

 L62	
Health protection review	
I	
6/6	

	

6/6	
Met	

 L63	
Med. treatment plan form	
I	
3/6	

	

3/6	
Not Met
(50.0 %)	

 L64	
Med. treatment plan rev.	
I	
1/6	

	

1/6	
Not Met
(16.67 %)	

 L67	
Money mgmt. plan	
I	
6/6	

	

6/6	
Met	

 L68	
Funds expenditure	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L69	
Expenditure tracking	
I	
6/6	

	

6/6	
Met	

 L70	
Charges for care calc.	
I	
6/6	

	

6/6	
Met	

 L71	
Charges for care appeal	
I	
6/6	

	

6/6	
Met	

 L77	
Unique needs training	
I	
6/6	

	

6/6	
Met	

 L78	
Restrictive Int. Training	
L	
4/4	

	

4/4	
Met	

 L79	
Restraint training	
L	
4/4	

	

4/4	
Met	

 L80	
Symptoms of illness	
L	
4/4	

	

4/4	
Met	

 L81	
Medical emergency	
L	
4/4	

	

4/4	
Met	

O	
 L82	
Medication admin.	
L	
4/4	

	

4/4	
Met	

 L84	
Health protect. Training	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L85	
Supervision 	
L	
4/4	

	

4/4	
Met	

 L86	
Required assessments	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L87	
Support strategies	
I	
5/6	

	

5/6	
Met
(83.33 %)	

 L88	
Strategies implemented	
I	
3/6	

	

3/6	
Not Met
(50.0 %)	

 L90	
Personal space/ bedroom privacy	
I	
5/6	

	

5/6	
Met
(83.33 %)	

#Std. Met/# 72 Indicator	

	

	

66/72	

	
Total Score	

	

	

73/82	

	

	

	

	
89.02%	

		
						
	MASTER SCORE SHEET CERTIFICATION	

						
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
Met	

 C2	
Data analysis	
1/1	
Met	

 C3	
Service satisfaction	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
1/1	
Met	

 C5	
Measure progress	
1/1	
Met	

 C6	
Future directions planning	
1/1	
Met	

	

	

						
Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
6/6	
Met	

 C8	
Family/guardian communication	
6/6	
Met	

 C9	
Personal relationships	
2/6	
Not Met (33.33 %)	

 C10	
Social skill development	
6/6	
Met	

 C11	
Get together w/family & friends	
6/6	
Met	

 C12	
Intimacy	
0/6	
Not Met (0 %)	

 C13	
Skills to maximize independence 	
6/6	
Met	

 C14	
Choices in routines & schedules	
6/6	
Met	

 C15	
Personalize living space	
4/4	
Met	

 C16	
Explore interests	
0/6	
Not Met (0 %)	

 C17	
Community activities	
2/6	
Not Met (33.33 %)	

 C18	
Purchase personal belongings	
6/6	
Met	

 C19	
Knowledgeable decisions	
6/6	
Met	

 C20	
Emergency back-up plans	
4/4	
Met	

 C46	
Use of generic resources	
5/6	
Met (83.33 %)	

 C47	
Transportation to/ from community	
6/6	
Met	

 C48	
Neighborhood connections	
2/6	
Not Met (33.33 %)	

 C49	
Physical setting is consistent 	
1/4	
Not Met (25.00 %)	

 C51	
Ongoing satisfaction with services/ supports	
6/6	
Met	

 C52	
Leisure activities and free-time choices /control	
6/6	
Met	

 C53	
Food/ dining choices	
5/6	
Met (83.33 %)	

 C54	
Assistive technology	
3/6	
Not Met (50.0 %)