QE5 - PROVIDER REPORT
 
DDS OQM/OQE  

PROVIDER REPORT 
DDS WESTERN REGION 1 (CCS)
195 INDUSTRIAL AVENUE
 NORTHAMPTON, MA 01060    

 
Report Date
October 29, 2010 

COVER PAGE

Provider: DDS WESTERN REGION 1
Review Dates: 9/10/2010 - 9/16/2010
Survey Team:  Martina Pocaterra (TL), Brian Grant, Gregg Shumway, Phyllis Stever, Jill Walulak, 
                          Denise Barci
 
Reviews Completed:
Residential and Individual Home Supports	
Site	
Individual Audits	

           Residential Services	
13	
13 ( 26 ) 	

Employment and Day Supports	
Site	
Individual Audits	

           Community-based Day Services	
N/A	
3 ( 3 ) 	

	

Licensure:
	
Licensure Level	
# Met / # Rated	
Licensure Duration	

Residential Services	
2 Year License	
80/83	
9/29/2010 to 9/28/2012	

Community-based Day Services	
2 Year License	
27/32	
9/29/2010 to 9/28/2012	

Certification:
Performed By: DDS
Certification Results by Service Type
•	
Planning and Quality Management	
5/6 Standard Met	

•                       	
Residential Services	
14/14 Standard Met	

•                       	
Community-based Day Services	
7/8 Standard Met	

 

Executive Summary
DDS Western State Operated Residences, known operationally as Commonwealth Community Services (CCS) is a large state-operated agency that provides 24-hour residential supports to 226 individuals throughout Western Massachusetts. CCS also operates Community Connections, for individuals who are of retirement age or for whom traditional employment options were not appropriate or desired. This community based day service currently supports 29 individuals that the agency also serves residentially. The program focuses on providing community companions, known as community connectors to enable individuals to pursue activities of their interest. For the purpose of this review thirteen audits were conducted at thirteen residential locations, as well as three audits involving participants of the Community Connections program. 

Consistent with findings identified during past survey reviews, CCS' commitment to service improvement continues to be a principle strength that contributes to ensuring positive outcomes for individuals. The organization was proactive in utilizing feedback from various stakeholders to develop strategic goals that directly addressed the needs of individuals. Strengths identified throughout the audits where directly linked to the agency’s strategic planning initiatives. For example, health supports was a significant strength of the agency, as was the competent, skilled workforce CCS employed. Further, it was evident that agency staff are invested in ensuring that all aspects of services and supports are maintained at a high level of quality.   
 
CCS is known for its capacity to serve individuals with complex medical needs, and those who benefit from strong clinical supports to overcome personal behavioral challenges. Current findings continue to identify this as a significant strength of the organization. The presence of well-developed systems assured that people received good healthcare supports through timely medical care, medication administration oversight, and proactive supports for developing healthy living routines. The agency’s capacity to provide nursing support increased the level of expertise and oversight of routine and specialized health care. Effective utilization of other allied health care professionals, in combination with a team of competent direct supporters, also contributed to the provision of high quality individualized supports and services for individuals. Staff at all levels of the organization and across service settings were noted to be well-trained, creative, and continuously engaged in activities, such as active teaching, data collection and problem solving, which promoted individuals’ successes, growth, and presence in their respective communities.

Another defining strength of CCS was its organizational stability. The agency continues to be successful in retaining a large core of long term clinical, management, and direct care supporters who take great pride in the value of their work, are highly committed, and have a great deal of historical knowledge of the individuals they serve.  In addition, CCS demonstrated commitment to enhancing staff training and development in all areas of services and supports. New employees received a comprehensive orientation and solid grounding in essential safeguards for individuals. An agency-wide ‘Advanced Training’ program promoted learning of other skills sets, and encouraged staff to become centered in the people with whom they are working by emphasizing areas such as seeing the value and gifts of all individuals. Findings evidenced the effective implementation of the agency’s strong values-based philosophy that each individual’s worth be affirmed through respectful, dignified interactions and regard for human rights.  

Commonwealth Community Services has demonstrated an ongoing commitment to improving the quality of supports provided to individuals. The agency will be granted a two-year license, with a follow-up review to occur in 60 days

LICENSURE FINDINGS
Organizational
Summary of Ratings
•	Standard Met: 7 / 9
•	Standard Not Met: 2 /9
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.	The agency needs to ensure that human rights committees meet membership requirements.  	
 L65	Restraint reports are submitted within required timelines.	The agency needs to ensure that restraint reports are submitted within timelines. 	

Residential and Individual Home Supports
•	Residential Services
Summary of Ratings
•	Standard Met: 73 / 74	
•	Standard Not Met: 1 / 74	
•	Critical Indicators standards met: 8 / 8	

Rating Detail:
Commendations on Standards Met:	
Indicator#	Indicator	Commendations	
 L36	Recommended tests and appointments with specialists are made and kept. 	The agency's nursing staff are commended for the quality of health care assessments. Consistently, the survey team found very informative and comprehensive assessments, which provided health care professionals and staff with complete information on the individuals’ conditions and needs. The nursing staff also contributed to the effective coordination and communication between the health care providers and the persons' teams. 	
  L85	The agency provides on-going supervision and staff development.	The agency is commended for the continued efforts to enhance the quality of training offered to staff through the Orientation Program and the Advanced Training Program. These initiatives have further contributed to positive outcomes for many of the individuals reviewed. 	

Rating Detail:
Areas Needing Improvement on Standards not met/Follow-up to occur:	
Indicator#	Indicator	Area Needing Improvement	
 L71	Individuals are notified of their appeal rights for their Charges for Care.	The agency needs to ensure that charges for care notifications are sent to individuals/guardians.  

Employment and Day Supports
•	Community-based Day Services
Summary of Ratings
•	Standard Met: 20 / 23	
•	Standard Not Met: 3 / 23	
•	Critical Indicators standards met: 4 / 4	

Rating Detail:
Areas Needing Improvement on Standards not met/Follow-up to occur:	
Indicator#	Indicator	Area Needing Improvement	
 L8	Emergency fact sheets are current and accurate and available on site.	The agency needs to ensure that emergency fact sheets are updated and accurate.  	
 L77	The agency assures that staff are familiar with and trained to support the unique needs of individuals.	The agency needs to ensure that staff are familiar and trained to support the unique needs of individuals.  	
 L88	Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	The agency needs to ensure that strategies identified and agreed upon in the ISP are being implemented. 	

CERTIFICATION FINDINGS
Services Reviewed:
	•	Planning and Quality Management
•	Residential Services
•	Community-based Day Services

Planning and Quality Management	
Summary of Ratings	 	 	
	•	Standard Met: 5/6
	•	Standard Not Met: 1/6	
Areas Needing Improvement on Standards not met	
Indicator #	Indicator	Area Needing Improvement	
 C3	The provider actively solicits and utilizes input from the individuals and families regarding satisfaction with services.	The agency's Community Connections needs to develop a formal system to solicit and utilize input from individuals and families regarding satisfaction with services. 	
Commendations on Standards Met:	
Indicator #	Indicator	Commendations	
 C6	The provider has mechanisms to plane for future directions in service delivery and implements strategies to actualize these plans.	The agency is commended for its continuing efforts and commitment to evaluating the supports it provides and for developing specific goals that directly impact the supports and quality of life for each individual served.	
 
Community-based Day Services	
Summary of Ratings	 	 	
	•	Standard Met: 7/8
	•	Standard Not Met: 1/8	
Areas Needing Improvement on Standards not met	
Indicator #	Indicator	Area Needing Improvement	
 C7	Individuals have opportunities to provide feedback on the performance of staff that supports them. 	The agency needs to provide individuals with opportunities to provide feedback on the performance of staff that supports them.