Department of Mental Retardation
Office of Quality Management, Office of Quality Enhancement 
Licensure and Certification

		Report Date:  February 6, 2008

Agency:  North Central Human Services
Review Dates: 12/11/2007  to  12/21/2007 
Licensure:  1/7/2008  to  1/7/2010
Licensure Level:  Two Year License
Follow-Up Required:  Yes     People maintain good health. (33 % rule)
				 The organization has systems in place to safeguard individuals.
Certification Performed By:  The Department of Mental Retardation for Residential Supports
Certification Completed On:  1/7/2008
Certification Outcome:  Certified with 4 out of 6 Quality of Life Areas Achieved 
Survey Team: Richard Spence (Team Leader)
Citizen Volunteer(s):  None
Number of Individual Reviews Completed:  [ 3 ]	
					[ 3 ] Residential Reviews
			 		[ 0 ] Work/Community Reviews
					[ 0 ] Respite Reviews (Not Rated)
			[ 1 ] Safeguard System Reviews  (Not Rated)

EXECUTIVE SUMMARY

North Central Human Services, Inc. (NCHS) is a large human service organization located in Gardner, MA. Along with a primary focus on mental health services, the agency also provides residential services to thirteen individuals funded by the Department of Mental Retardation (DMR).  For these individuals, the agency operates three homes that provide twenty-four hour support as well as placement services through a shared-living arrangement. For the purpose of this licensing and certification survey, the services provided to three individuals were reviewed, two of whom people received twenty-four hour support and one individual received placement services. Additionally, a Safeguard System Review was conducted at one home that provides twenty-four support.

Since the last review, conducted in December 2005, the agency had improved many of its systems to monitor the safety and well-being of individuals. Each quarter, the agency conducts a comprehensive audit of services and supports at each location that includes a review of home maintenance, funds management support, medication administration, and individual record reviews. Findings of the current survey indicated that many of these systems were effective in assuring positive outcomes for individuals in protecting their health and safety.   

One area of strength for the agency is its commitment to assisting people to be well supported in terms of their health needs.  Each program manager and the shared-living provider was knowledgeable of people’s health and medication needs and, with one exception, was very involved in assuring that people’s medical needs were adequately addressed in a timely manner.

Another positive area for the agency is its attention to improving people’s home environments.  Since the last survey, one program had moved to a new location that was specifically designed, decorated and furnished for the four women living there.  Plans were also underway to renovate a second home, which will be completed later this fiscal year. 

Individuals and their supporters, including guardians and involved families, were supported to understand people’s basic rights. Annual training in human rights was conducted with each person who received services. Additionally, staff received annual training in human rights, and a packet of information on human rights was sent to guardians and families each year. The agency also assured that people were afforded due process protection when certain rights were limited within the context of a behavior plan or support/health-related protection, such as bedrails or lap-belts that limited people’s movement.

As the agency moves forward in improving the quality of its services and supports, the survey team offers the following considerations. Further development of the agency’s human rights committee is needed in order to ensure that safeguards are effective in protecting people’s rights. At the time of the survey, the committee did not include a master’s level clinical among its membership. It was also found that the committee had not met a quarterly during the last two years and that some committee meetings did not have a quorum in attendance.  

The agency is also encouraged to develop effective strategies to support people’s community and social connections. The agency recognized the importance of setting a foundation for achieving outcomes in these areas through training and development of staff. The agency supported each residential manager to complete a ten-session training in community integration. The agency will need to take the next step in applying what has been learned in supporting individuals to develop meaningful ties to their community through greater utilization and involvement with local resources. 

North Central Human Services, Inc. is an agency that is open to feedback and has shown its ability to effectively utilize such feedback in improving services. This was evident in a number of areas subject to review, including strengthened safeguard systems as well as improvements to home environments. As a result of this survey, the agency will receive a Two-Year license and is certified with four out of six Quality of Life Areas achieved. Follow-up will occur on the agency’s systems to safeguard the rights of individuals, with particular attention to the membership and responsibilities of the human rights committee. 

Provider Scoring Summary

Licensure Review 

Quality of Life
Area	
Residential
Supports	Work/
Community
Supports	
Respite
Supports	
Overall Provider
Rating	

Rights & Dignity	
Achieved		
	
Achieved	
Personal Well-
Being	
Achieved		
	
Achieved	
Organizational Outcomes:  The organization has systems in place to safeguard people.
	Partially Achieved	

Certification Review

Quality of Life
Area	
Residential
Supports	Work/
Community
Supports	
Respite
Supports	
Overall Provider
Rating	

Individual Control	
Achieved		
	
Achieved	
Community and
Social Connections	
Partially Achieved		
	
Partially Achieved	
Personal Growth &
Accomplishments	
Partially Achieved		
	
Partially Achieved	
Organizational Outcomes:  Staff have the skills and knowledge to support the quality  
                                               of life of people.	Achieved	
Organizational Outcome:  The organization supports growth and change to continually 
                                              improve its quality of supports	Achieved	

Organizational Combined Rating:  (Based on both the licensure organizational outcome and the two certification quality of life outcomes)	Achieved	

Department of Mental Retardation
Office of Quality Management, Office of Quality Enhancement 
Licensure and Certification

Section I
Licensure Review 

Outcome of Individual Quality Reviews

Rights and Dignity
Personal Well-Being

Outcomes for the Organization

The agency has systems in place to safeguard people.

 
QUALITY OF LIFE AREA
RIGHTS AND DIGNITY
Rating:  Achieved

Principles:  Support and affirmation of individual rights are safeguards for all people as citizens of the United States.  These rights are framed in the Constitution, Bill of Rights, and Federal and State statutes.  They include such freedoms as the rights to privacy, free speech and due process.  The actualization of individual rights is especially important to people with disabilities because they have not always been afforded these most basic of guarantees and may need support to exercise their rights.  In order to have their rights affirmed, individuals first must be respected, valued and treated with positive regard.

QUALITY OF LIFE SCORING SUMMARY

Outcomes 
and Indicators	
Residential Reviews	Work &
Community
Reviews	
Respite
Reviews	
% of Indicators

(Excluding Respite) 	
People are valued:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	Interactions are respectful of people.
	3	0					100%	-	
B.	People are supported to identify themselves as adults.	3	0					100%	-	
C.	People are supported to take pride in themselves and their surroundings.	3	0					100%	-	
D.	People live and work in settings that are typical of other members of the community.	3	0					100%	-	
People’s rights are affirmed:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People and/or those supporting them understand individual rights.	3	0					100%	-	
B.	People’s rights are exercised in their everyday lives.	3	0					100%	-	
C.	People receive the same treatment as other employees.	N/A	N/A					N/A	N/A	
D.	People receive comparable wages and benefits as other employees.	N/A	N/A					N/A	N/A	
People’s rights are protected.
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	All interventions are the least intrusive and are based upon people’s unique needs.	3	0					100%	-	
B.	All interventions are included in a written plan.	1
(2 N/A)	0					100%	-	
C.	People, or their guardians, knowingly and voluntarily give consent and have the opportunity to refuse or withdraw approval.	1
(2 N/A)	0					100%	-	
D.	Safeguards ensure a thorough review and approval process when needed.	1
(2 N/A)	0					100%	-	
E.	All interventions are safely, accurately and    consistently implemented.	1
(2 N/A)	0					100%	-	

QUALITY OF LIFE AREA
PERSONAL WELL-BEING
Rating:  Achieved

Principles:  Being safe, secure and healthy provides a foundation that enables people to have a truly fulfilling life and do the things that are important to them.  As with rights, certain universal things contribute to the well-being of everyone in society, regardless of who they are and their personal circumstance.  These universals include having routine physical examinations, wearing seat belt, or installing smoke detectors.  Beyond the universal safeguards, personal well-being is supported by a recognition of people’s skills and needs as balanced against their lifestyle choices.  Services are designed to assist people to be secure, achieve and/or maintain good health, to make decisions that keep them out of harm’s way, and to ensure a prompt response when people’s safety, security or health are compromised.

QUALITY OF LIFE SCORING SUMMARY

Outcomes 
and Indicators	
Residential Reviews	Work &
Community
Reviews	
Respite
Reviews	
% of Indicators

(Excluding Respite) 	
People are safe at home and work:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People’s home and work place are safe, secure, and in good repair.	3	0					100%	-	
B.	People and their supporters know what to do in an emergency.	3	0					100%	-	
C.	People can safely evacuate from their home or work place in an emergency.	3	0					100%	-	
D.	There are adequate supports for people to be safe in their home and work.	3	0					100%	-	
E.	People use materials and equipment safely.	N/A	N/A					N/A	N/A	
People are free from harm:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	Supports are in place if people make decisions that put them at risk.	0 
(3 N/A)	0					N/A	N/A	
B.	Immediate actions are taken to ensure people’s safety.	0 
(3 N/A)	0					N/A	N/A	
C.	Actions are taken to correct the situation when people have been mistreated.	0 
(3 N/A)	0					N/A	N/A	
D.	Steps are taken to prevent the situation from occurring again.	0 
(3 N/A)	0					N/A	N/A	
E.	People know how or have support to report a situation where they feel they are being or have been mistreated or harmed.	3	0					100%	-	

PERSONAL WELL BEING: - Continued

Outcomes 
and Indicators	
Residential Reviews	Work &
Community
Reviews	
Respite
Reviews	
% of Indicators

(Excluding Respite) 	
People maintain good health:
Achieved (33% rule)	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People are supported to have a health lifestyle.	3	0					100%	-	
B.	People are supported to be active participants in their health care.	3	0					100%	-	
C.	People have needed routine and specialized health care services.	2	1					67%	33%	
D.	Supporters are knowledgeable about people’s health care needs.	3	0					100%	-	
E.	People’s medications are given properly and as prescribed by the practitioner.	3	0					100%	-	
People’s funds are safeguarded:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People receive the support and/or education they need in managing their financial resources.	3	0					100%	-	
B.	People’s funds are managed properly and with their consent.	3	0					100%	-	

OUTCOMES FOR THE ORGANIZATION

Principles:  Positive outcomes for individuals are the result of many factors, not the least of which is a strong, coherent organizational structure.  For positive outcomes for individuals to be sustained over time, across all settings and by all staff, agencies need to create an infrastructure and culture that supports quality and safeguards individuals.

SCORING SUMMARY

Outcome and Indicators	
Agency
Totals	
The organization has systems in place to safeguard individuals:
Partially Achieved	
Finding	% of IndicatorsPresent	
A.	The organization has strategies that proactively ensure that essential safeguards are in place       across settings and over time.	Yes	67%	
B.	The organization has systems in place to affirm and protect the rights and dignity of individuals.	No		
C.	The agency implements procedures that minimize unnecessary risk to individuals.
	Yes		

Department of Mental Retardation
Office of Quality Management, Office of Quality Enhancement 
Licensure and Certification

Section II
Certification Review

Outcome of Individual Quality Reviews

Individual Control
Community and Social Connections
Personal Growth and Accomplishment

Outcome for the Organization

Staff have the skills and knowledge to support the quality of life of people.
The organization improves services as a result of these analyses.

	

QUALITY OF LIFE AREA
INDIVIDUAL CONTROL
Rating:  Achieved

Principles:  Being able to direct the course of one’s life is something for which all people strive.  Self-determination is expressed in all aspects of people’s lives, both in little, everyday things such as deciding when to get up as well as in major life decisions that may have a deep, long lasting effect such as deciding on a certain career or moving to a new community.  The type and amount of support people need to take charge of their lives varies greatly.  For some, even making everyday choices is a new experience and they need much guidance in learning how to make both everyday and major choices.  For others, periodic check-ins and discussions are needed to keep them on course and to make sure they have an understanding of their options and of the consequences of their decisions.  What is important is that people have all the information they need to make decisions, that they are empowered and supported to take action, and that they understand how their decisions affect their lives.

QUALITY OF LIFE SCORING SUMMARY

Outcomes 
and Indicators	
Residential Reviews	Work &
Community
Reviews	
Respite
Reviews	
% of Indicators

(Excluding Respite) 	
People are understood: 
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	Supporters understand what people are expressing.	3	0					100%	-	
B.	Supporters use people’s primary means of communication.	3	0					100%	-	
C.	Supporters assist people to communicate with and be understood by others.	3	0					100%	-	
People make choices in
their everyday lives:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People make choices about their routines and schedules.	2	1					67%	33%	
B.	People make choices about the work and household tasks for which they are responsible.	2
(1 N/A)	0					100%	-	
C.	People spend their leisure time in personally satisfying ways.	3	0					100%	-	
People are the primary decision- 
makers in their lives:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People develop their personal goals.
	2	1					67%	33%	
B.	People influence who provides their supports.	3	0					100%	-	
C.	People control important decisions about their home and home life.	2	1					67%	33%	
D.  People choose where they work or, if they choose not to work, people have options that are meaningful to them.	N/A	N/A					N/A	N/A	

QUALITY OF LIFE AREA
COMMUNITY AND SOCIAL CONNECTIONS
Rating:  Partially Achieved

Principles:  Membership in community life supports people’s sense of belonging and provides opportunities for citizenship, friendship and valued roles in society.  Everyone has unique, identifiable ways that he or she is connected to the community and to other people who are important to them.  Being a part of community life means that people are using all the resources and amenities that others use.  Being connected also means that people have other people in their lives who are important to them, who are there for them when needed and with whom they can share their thoughts and concerns.  It also includes having a place in society, a place that other people recognize and value.  It may mean helping out neighbors and friends when needed or having talents and gifts that are recognized and shared with other people.

QUALITY OF LIFE SCORING SUMMARY

Outcomes 
and Indicators	
Residential Reviews	Work &
Community
Reviews	
Respite
Reviews	
% of Indicators

(Excluding Respite) 	
People are integrated into 
their community:
Partially Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People live and work in communities with the resources they want and need.	2	1					67%	33%	
B.	People use the same community resources as others on a frequent and ongoing basis.	1	2					33%	67%	
People are connected with 
their community:
Partially Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People are supported to explore their personal interests and options for community involvement.	1	2					33%	67%	
B.	People are involved in activities that connect them to other people in the community.	1	2					33%	67%	
People have relationships:
Partially Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People are supported to maintain and enhance relationships with family, friends and co-workers.	2	1					67%	33%	
B.	People are supported to develop new friendships.	1	2					33%	67%	
C.	People are supported to explore, define, and express their need for intimacy.	2	1					67%	33%	

QUALITY OF LIFE AREA
PERSONAL GROWTH AND ACCOMPLISHMENT
Rating:  Partially Achieved

Principles:  While developing one’s own goals is a critical first step in making decisions about one’s life, achieving personal goals and developing the skills to be as independent as possible give individuals a sense of purpose, direction and self-fulfillment in their lives.  The strategies and support used in assisting people to reach their goals takes on many forms and should be tailored to people’s unique skills, needs, preferences and style of learning.  It includes helping people to learn from both planned as well as unanticipated events in their lives.  While there is much to be proud of in acquiring the skills to do things independently, it does not mean that people are independent in everything they do.  There is the joy that people feel in accomplishing things together and the feeling of self-worth that comes with completing something as independently as possible.

QUALITY OF LIFE SCORING SUMMARY

Outcomes 
and Indicators	
Residential Reviews	Work &
Community
Reviews	
Respite
Reviews	
% of Indicators

(Excluding Respite) 	
People accomplish their goals:
Partially Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People’s goals are the basis of actions and supports.	1	2					33%	67%	
B.	There is a match between what people are doing now and what they want to do in the future.	2	1					67%	33%	
C.	People have access to needed resources in order to accomplish their goals.	1	2					33%	67%	
D.	There are supports to get a job that people like.	N/A	N/A					N/A	N/A	
E.	There are supports to succeed at the job.	N/A	N/A					N/A	N/A	
F.	People are supported to advance in their job.	N/A	N/A					N/A	N/A	
People have autonomy:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	People complete day-to-day activities, tasks and chores as independently as possible.	3	0					100%	-	
B.	People have access within their home and workplace.	3	0					100%	-	
People grow through their 
life experiences:
Achieved	
Yes	
No	
Yes	
No	
Yes	
No	
Yes	
No	
A.	Supporters are sensitive and attuned to both small and large events in people’s lives.	3	0					100%	-	
B.	People are encouraged to understand experiences in their lives.	2	1					67%	33%	
C.	People are supported to grow from events in their lives that affect them.	2	1					67%	33%	

OUTCOME FOR THE ORGANIZATION

Principles:  Positive outcomes for individuals are the result of many factors, not the least of which is a strong, coherent organizational structure.  For positive outcomes for individuals to be sustained over time, across all settings and by all staff, agencies need to create an infrastructure and culture that supports quality and safeguards individuals.

SCORING SUMMARY
Staff have the skills and knowledge to support 
the quality of life of individuals:
Achieved	
Finding	% of IndicatorsPresent	
A.	The agency recruits and maintains a competent work force.
	Yes	100%	
B.	The agency has ways to support staff knowledge, effectiveness and creativity.
	Yes		
The organization supports growth and change to continually
improve its supports to individuals:
Achieved	
Finding	% of IndicatorsPresent	
A.	The organization has processes to evaluate the quality of its supports.
	Yes	50%	
B.	The organization improves services as a result of these analyses.
	No