PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
EAST MIDDLESEX ARC
60-D Audubon Road
 Wakefield, MA 01880    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
EAST MIDDLESEX ARC	

	

	

	

	
Review Dates	

	
2/21/2017 - 2/27/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
3/13/2017	

	

	

	

	

	

	
Survey Team	

	
Anne Carey	

Jennifer Conley-Sevier	

John Downing	

Steve Goldberg (TL)	

	

	

	

	

	

	
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	
6 location(s) 11 audit (s) 	
Full Review	
79 / 84 2 Year License 03/13/2017 -  03/13/2019	
	
44 / 51 Certified 03/13/2017 -  03/13/2019	

Residential Services	
3 location(s) 7 audit (s) 	

Full Review	
19 / 22	

Individual Home Supports	
3 location(s) 4 audit (s) 	

Full Review	
20 / 23	

Planning and Quality Management (For all service groupings)	

	
Full Review	
5 / 6	

Survey scope and findings for Employment and Day Supports	

Service Group Type	
Sample Size	
Licensure Scope	
Licensure Level	
Certification Scope	
Certification Level	

Employment and Day Supports	
4 location(s) 9 audit (s) 	
Full Review	
55 / 57 2 Year License 03/13/2017 -  03/13/2019	
	
27 / 42 Certified with Progress Report 03/13/2017 -  03/13/2019	

Community Based Day Services	
1 location(s) 4 audit (s) 	

Full Review	
8 / 14	

Employment Support Services	
3 location(s) 5 audit (s) 	

Full Review	
14 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
5 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
The East Middlesex ARC (EMARC) is a non-profit organization founded in 1954 and providing a range of services to children and adults with developmental disabilities in the Northeast region. Services include family support, recreation, day habilitation, residential, and day/work supports.  A full DDS licensing and certification review of the agency was conducted inclusive of EMARC's 24-hour residential services, Individual Home Supports (IHS), Employment, and Center Based Day Services (CBDS).
Since the previous survey (2015) EMARC had embarked on a strategic planning process to improve and advance various aspects of the organization and its supports. The process included an assessment of the agency, its strengths and weakness, the development of short and long term goals, timelines, and the development of action plans and initiatives in response to the identified objectives. Efforts were made to keep the planning process transparent to all those involved and be inclusive of feedback from EMARC's various stakeholders including individuals, families and guardians. Major efforts included; the closure of the sheltered work program and the development and expansion of CBDS and employment services; a renewed focus on the quality of employee recruitment, training, retention, and supervision; a focus on improving clinical supports; enhancing staff training around recognizing and reporting potential abuse and neglect; and providing supports commensurate with new community based waiver (CMS)standards regarding, for example, people's family, social and community connections. 
The agency had recognized a need to improve its clinical/behavioral supports. In September 2015 Monthly Clinical Coordinator meetings were initiated bringing together staff from across EMARC programs, providing a formal venue for the discussion of "unique" client issues, serving both as a problem solving resource and learning opportunity involved staff. The agency had developed an incident reporting system that enabled managers to identify and respond to patterns or trends. For example, data analysis had resulted in a recent focus on 'falls' prevention. 
In an effort to ensure staff were well trained to support people's unique needs, EMARC revised its "Protocol" books to include information about such as seizure protocols and special dietary requirements, and there was a renewed focus on healthy eating, weight loss and exercise. The agency received a commendation for successfully ensuring that staff were knowledgeable about and effective with the people they supported. For some individuals surveyed, assistive technology was in place to assist people to be as independent as possible. The agency had begun to utilize resources available on the DDS web site to assess people in this regard.  The agency's Healthcare Coordinator provided specialized training to staff as needed, coordinated many appointments and follow-ups, and facilitated hospitalizations and discharges. 
Agency systems ensured that people's workplace, home or apartment was clean and well maintained, and that necessary inspections occurred. People had been supported to decorate their home according to their taste and preferences. The agency, as part of its strategic plan, had looked at the age and condition of its facilities with an eye toward making improvements or finding replacements where necessary. Overall, the agency scored very high in the licensing indicators, reflective of its commitment to maintaining people's overall quality of life, health and well-being.
It was obvious during surveys that staff knew the individuals they supported very well. People were supported to be involved in normative daily tasks and routines, to do so as independently as possible, and be in control of daily decision with support as needed, and positive guidance.  People were supported to engage in known preferred activities and with familiar friends and family. It was noted however, that activities were often EMARC sponsored groups or planned events, and the participants were often other recipients of EMARC services. When the agency utilized external resources, for example classes at a local community college, they were not frequently integrated with the general public. Although the agency supported people to maintain positive existing relationships and activity preferences, the agency also needs to balance these by actively assessing interests, exploring new experiences, and do so in integrated community settings.     
Similarly, for individuals in CBDS, information on their leisure, recreational, community or employment interests had not been fully assessed. The agency had developed an increased number of "volunteer" options for people to choose from. However, these opportunities often lacked defined training goals for participants, there was no task analysis or clear skills development occurring, and in some instances people were doing work for which they could have been paid. The agency was very responsive to addressing this issue when it was identified during the survey. While CBDS staff also appeared knowledgeable about people's current preferences, increased attention needs to be given to exposing people to new experiences, exploring, and pursuing evolving interests that might also promote the development of new relationships and opportunities for community integration. 
In employment supports, vocational preferences, skills assessments, and detailed career plans had not been effectively developed. The agency needs to support career development by initiating a process of assessing interests and skills utilizing a variety of methods and resources, not just those available through EMARC, and developing short and long term career goals and skills training based on people's unique abilities. For those people who are employed, the agency needs to be aware of the employers' practices in regard to benefits and performance evaluation, in order to advocate effectively for the people they support. Throughout the employment experience, the agency should ensure that supports are sufficient to promote success, and planning occurs to minimize supports over time.
Within the Residential Services/Individual Home Supports programs EMARC received a rating of met in 94% of licensing indicators, and all critical indicators were met.  The agency also received a rating of met in 86% of certification indicators reviewed.  As a result, the agency will receive a Two Year License for Residential Services/Individual Home Supports; follow-up on all not met licensing indicators will be conducted by EMARC within 60 days.  Within the Employment and Day Supports program, the agency met 96% of all licensing indicators, including all critical indicators, and met 64% of the certification indicators reviewed.  As a result, the agency will receive a Two Year License and is certified for its Employment and Day Supports program, and follow-up on all not met licensing indicators will also be conducted by EMARC within 60 days.  The agency's employment/work program is certified with a progress report, due within one year of the service enhancement meeting, on those certification indicators that received a not met rating.	

	

	

LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/8	
0/8	

Residential and Individual Home Supports	
71/76	
5/76	

    Residential Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
79/84	
5/84	
94%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
5	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/8	
0/8	

Employment and Day Supports	
47/49	
2/49	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
8/8	
0/8	

Total	
55/57	
2/57	
96%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
2	

	

	

			

	

	
Residential Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

 L77	
The agency assures that staff are familiar with and trained to support the unique needs of individuals.	
 The agency had developed a "unique needs" informational binder for each individual served.  Binders are reviewed by new staff as part of their orientation. They contained comprehensive information about each individual and their support needs, information on current medications, behavioral supports, medical diagnoses, specialized diets, and unique conditions or supports specific to the individual.  In general, staff appeared very knowledgeable about the people they supported. As necessary they had received training from the agency's Health-care Coordinator on special medical conditions and supports, such as diabetes and seizures. Positive outcomes were noted during the survey as several individuals had been supported to lose weight and successfully manage, for example, their diabetes, with a subsequent decrease in medication. The agency is commended for supporting staff to be knowledgeable and well trained regarding the unique needs of the people they support.	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 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.	
At one of two residential locations surveyed, kitchen knives were stored in a locked closet, ostensibly for the safety of one of the individuals. However, there was no written rationale in place describing the need for this restriction, and there had not been a Human Rights Committee review of this practice. For the other individuals in the home, there was no written mitigation plan in place designed to reduce or eliminate the impact of the restriction, and the individuals and/or their guardians have not been informed of this restrictive practice. The agency needs to ensure that restrictive practices receive the required reviews, and that other individuals in the home who do not require restrictions are informed of their presence, and that plans are in place to reduce or eliminate the impact of the restrictions.	

 L58	
All behavior plans contain the required components.	
A behavior plan restricting the individual's telephone use and mealtimes was missing required components, including the rationale based on a functional analysis and less restrictive alternative interventions that have been tried. The agency needs to ensure that behavior plans include all required components.	

 L59	
Behavior plans have received all the required reviews.	
For the one behavior plan that was reviewed as part of the sample, restrictive components within the plan had not been reviewed by the agency's Human Rights Committee as required. The agency needs to ensure that behavior plans that include restrictive practices are reviewed and approved by the individual and/or guardian, the ISP team, and the Human Rights Committee.	

 L63	
Medication treatment plans are in written format with required components.	
For two individuals surveyed who were taking behavior modifying medication, treatment plans did not include all required components. Within the plan, there needs to be a general clinical plan for the use of the medication, such as criteria for re-evaluating or adjusting the medication.  This should be described in specific terms so that the type of data being collected is consistent with the criteria for evaluating the course of treatment.  The analysis of this data should form the basis from which the individual's clinical course is evaluated. The agency needs to ensure that medication treatment plans contain all of the required components. 	

 L64	
Medication treatment plans are reviewed by the required groups.	
For two of the six persons surveyed, there was no evidence of the required review for their medication treatment plan. The agency needs to ensure that medication treatment plans are submitted to and reviewed by the individual's ISP team.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L72	
Sub-minimum wages earned are paid in accordance with Department of Labor (DOL) requirements for compensation.	
For one employment individual surveyed, it was determined the agency was utilizing the site's reception desk as a volunteer and training opportunity.  The agency needs to ensure that individuals performing jobs as volunteers to obtain or enhance their skills must have a specific skills assessment and training plan in place, and the volunteer placement must be time limited. Otherwise, individuals need to be paid according to minimum wage requirements. An Action Required was issued and the agency took successful corrective action.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
For two of the six individuals surveyed, support strategies had not been submitted within the required time-line. Strategies must be submitted to the service coordinator 15 days prior to the ISP meeting.	

		

		

	

	

CERTIFICATION FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
5/6	
1/6	

Residential and Individual Home Supports	
39/45	
6/45	

Individual Home Supports	
20/23	
3/23	

Residential Services	
19/22	
3/22	

TOTAL	
44/51	
7/51	
86%	

Certified	

	

	
	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
5/6	
1/6	

Employment and Day Supports	
22/36	
14/36	

Community Based Day Services	
8/14	
6/14	

Employment Support Services	
14/22	
8/22	

TOTAL	
27/42	
15/42	
64%	

Certified with Progress Report	

	

	

	

	

	
Planning and Quality Management Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C5	
The provider has a process to measure progress towards achieving service improvement goals.	
The agency had developed a strategic plan including an analysis of its strengths, weaknesses, and areas for growth and service improvement. It was evidenced that some goals had been achieved or were being worked upon. However, no measurable benchmarks had been established to assist the agency to monitor efforts or make mid-course changes, if necessary. For example, for EMARC's residential services a goal had been developed to improve the management of people's health-care. Person specific examples were provided, and were evidenced at sites surveyed, but no overall measurable criteria had been utilized to assess, overall, whether there had been agency improvement on the goal. The agency needs to develop a process by which to measure progress on its strategic goals.	

	

	

	

	
Individual Home Supports- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
The agency had developed systems to obtain feedback from individuals on the quality of their supporters, and involve them in the hiring or promotion process. For example, all the individuals surveyed in 24-hour supports had the opportunity to be involved in the hiring and/or evaluation of staff. However, the agency was less successful involving individuals receiving Individual Home Supports (IHS). The agency needs to ensure that IHS participants take greater advantage of this opportunity.	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
None of the individuals surveyed had either formal or informal assessments of their needs and interests in the area of intimacy and companionship.  The agency needs to ensure that staff are knowledgeable of the individuals' needs and interests in this area, and that individuals receive support in these identified areas.  Education provided to individuals should be geared to the individuals' learning style.  The provider must either have appropriately trained staff and use a teaching curriculum, or have access to resources that support learning in this area.

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
The agency did not have a method to periodically assess people's interests, and support the exploration and discovery of new and integrated cultural, spiritual, social and recreational activities. The agency needs to support people to explore and expand upon their current interests on a consistent and sustained basis. Such involvement can also serve to connect people in new ways to new people, relationships and experiences.  	

	

	
Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For five individuals surveyed, neither formal nor informal assessments of the individuals' needs and interests in the area of intimacy and companionship were present.  The agency needs to ensure that staff are knowledgeable of the individuals' needs and interests in this area, and that individuals receive support in these identified areas.  Education provided to individuals should be geared to the individuals' learning style.  The provider must either have appropriately trained staff and use a teaching curriculum, or have access to resources that support learning in this area.

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
For three out of seven individuals surveyed, there was no evidence that the process of exploration, discovery, and participation of integrated cultural, social, recreational and spiritual activities was occurring. The agency needs to ensure that efforts are made to expose individuals to a broad range of activities that contribute to rich and varied lives, and determine which of these activities are of interest to the individual. The agency also needs to ensure that individuals are supported in such a way as to potentially broaden each individual's knowledge of potential options that they may not be aware of beyond EMARC-sponsored activities. 	

 C17	
Community activities are based on the individual's preferences and interests.	
For three out of seven individuals surveyed, there was no evidence that individualized community activities were occurring or had been offered to individuals. The agency needs to ensure that individuals are provided with frequent opportunities to engage in community activities that are in line with the individual's preferences and interests and that staff are knowledgeable about local events and activities.  

	

	

Community Based Day Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C40	
Individuals are supported to explore, discover and connect with their personal interest and options for community involvement, personal interest and hobbies.	
For four out of four individuals surveyed, there was no evidence that the process of exploration, discovery and connection of personal interests and options for community involvement was occurring. While individuals had their interests outlined in their ISP, there was no evidence of individual interest assessments occurring via community based day supports. The agency needs to ensure that each individual's likes and dislikes, interests and preferences are assessed using a variety of means and expose individuals to other options so they might broaden their interests. 	

 C41	
Individuals participate in activities, including those in the community, that reflect their interests and preferences.	
For four out of four individuals surveyed, there was no evidence that community based day activities were based on the individual interests and preference of each person. The agency needs to ensure that once individual interests have been assessed and established, people are supported to realize these preferences and interests in an individualized way.	

 C42	
Individuals are involved in activities that connect them to other people in the community.	
For three out of four individuals surveyed, there was no evidence that community activities provided connected them to other people in the community. The agency needs to ensure that community activities offered allow for frequent contact with the community at large.  	

 C43	
Staff act as bridge builders to support individuals to develop, sustain, and enhance relationships with others. 	
For three out of four individuals surveyed, there was no evidence of staff acting as bridge builders so that individuals could develop personal relationships with people other than paid staff. 
The agency needs to ensure that opportunities for social contact are consistently provided so that staff can support individuals in having a more rich connection with other people who share their interests.	

 C45	
Individual's decisions of what to do during the day are revisited on a regular basis.	
For three out of four individuals, there was no evidence that individuals' decisions of what to do during the day are revisited on a regular basis (at least quarterly). Daily morning meetings on site discussed activity options for the day for each grouping of individuals with their support staff, however, options were not based on the analysis of individual preferences and therefore were limited.
The agency needs to ensure that individual interests, including an interest in employment, are revisited on a regular basis. 	

 C46	
Staff (Home Providers) support individuals to learn about and use generic community resources.	
For four out of four individuals surveyed, the activity calendar included options for volunteerism, including at a local library, however, there was no evidence of wider staff knowledge of generic community resources that could be places of interest for individuals, for example, local gym, swimming pool, parks, libraries, community centers.  The agency needs to ensure that individuals are supported to learn about and use a wide variety of community resources which are then used frequently and based upon individual preferences. 	

	

	
Employment Support Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
The agency had developed systems to obtain feedback from individuals on the quality of their supporters, and many of the individuals surveyed involved in Community Based Day Supports (CBDS) had the opportunity to be involved in the hiring, promotion and/or evaluation of staff. However, the agency was less successful involving individuals receiving employment supports. The agency needs to ensure that all day/work  participants are supported to be involved in the hiring, and on an ongoing basis the performance evaluation of their staff.	

 C22	
Staff have effective methods to assist individuals to explore their job interests.	
For three out of the four individuals surveyed, there was no evidence staff utilized effective methods to assist that individual with explore their job interests. The agency needs to develop an assessment process that allows for the exploration of a broad range of career opportunities.  The exploration process should not only include current employment opportunities, but a variety of other careers to fully insure that individuals have the knowledge to make an informed decision concerning their careers.  	

 C23	
Staff utilize a variety of methods to assess an individual's skills, interests, career goals and training and support needs in employment.	
For three out of the four individuals surveyed, there was no evidence staff utilized a variety of methods to assess skills, interests, career goals, training and support needs. Staff currently use a General Interest Form that lacks specificity.  The agency does not have a comprehensive assessment process for assessing individuals' skills, interests and career goals. The agency needs to use an assessment process with a variety of methods to assess the individual's current skills, areas of interest, and training and support needs related to their career of choice	

 C24	
There is a plan developed to identify job goals and support needs.	
For three out of the four persons surveyed, there was no employment or career plan to identify job goals and support needs. Using the outcomes from the assessment process, the agency needs to develop a comprehensive and detailed plan that identifies job goals and support needs for individuals.	

 C25	
Staff assist individuals to work on skill development for job attainment and success.	
For two out of the four people surveyed, there was no evidence staff assisted individuals to work on skill development for job attainment and success. The agency needs to provide training and skill development to individuals to support them in gaining the skills necessary to obtain the job of choice.	

 C26	
Career planning includes an analysis of how an individual's entitlements can be managed in a way that allows them to work successfully in the community.	
There was no evidence the agency had completed an analysis of how an individual's entitlements can be managed in a way that allows them to work successfully in the community. The agency needs to provide individuals and their families information pertaining to entitlements, and analyze how an individual's entitlements can be managed once they obtain employment.  	

 C33	
Employee benefits and rights are clearly explained to the individual.	
For two of the five individuals surveyed, there was no evidence of them having been informed of their employee benefits and rights.  The agency needs to ensure each individual has been informed of or received a copy of their employee benefits and rights, from their employers.	

 C34	
The agency provides the optimal level of support to promote success with a specific plan for minimizing supports.	
For two of the four individuals surveyed, the agency has not developed a plan for fading supports to allow individuals to perform their jobs with greater independence.  The agency needs to support individuals to have the skills for greater independence in their jobs.	

	

	

		

					
	MASTER SCORE SHEET LICENSURE	

					
	Organizational: EAST MIDDLESEX ARC	

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

O	
 L2	
Abuse/neglect reporting	
15/15	
Met	

 L3	
Immediate Action	
15/15	
Met	

 L4	
Action taken	
12/12	
Met	

 L48	
HRC	
1/1	
Met	

 L74	
Screen employees	
4/4	
Met	

 L75	
Qualified staff	
1/1	
Met	

 L76	
Track trainings	
12/12	
Met	

 L83	
HR training	
12/12	
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	
7/7	
4/4	

	
	
11/11	
Met	

 L4	
Action taken	
L	
1/1	
3/3	

	
	
4/4	
Met	

 L5	
Safety Plan	
L	
3/3	
3/3	

	
	
6/6	
Met	

O	
 L6	
Evacuation	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L7	
Fire Drills	
L	
3/3	

	

3/3	
Met	

 L8	
Emergency Fact Sheets	
I	
7/7	
3/4	

	
	
10/11	
Met
(90.91 %)	

 L9	
Safe use of equipment	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L10	
Reduce risk interventions	
I	
2/2	
1/1	

	
	
3/3	
Met	

O	
 L11	
Required inspections	
L	
3/3	
3/3	

	
	
6/6	
Met	

O	
 L12	
Smoke detectors	
L	
3/3	
3/3	

	
	
6/6	
Met	

O	
 L13	
Clean location	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L14	
Site in good repair	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L15	
Hot water	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L16	
Accessibility	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L17	
Egress at grade 	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L18	
Above grade egress	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L19	
Bedroom location	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L20	
Exit doors	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L21	
Safe electrical equipment	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L22	
Clean appliances	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L23	
Egress door locks	
L	
3/3	

	

3/3	
Met	

 L24	
Locked door access	
L	
3/3	

	

3/3	
Met	

 L25	
Dangerous substances	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L26	
Walkway safety	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L27	
Pools, hot tubs, etc.	
L	
	
1/1	

	
	
1/1	
Met	

 L28	
Flammables	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L29	
Rubbish/combustibles	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L30	
Protective railings	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L31	
Communication method	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L32	
Verbal & written	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L33	
Physical exam	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L34	
Dental exam	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L35	
Preventive screenings	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L36	
Recommended tests	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L37	
Prompt treatment	
I	
7/7	
4/4	

	
	
11/11	
Met	

O	
 L38	
Physician's orders	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L39	
Dietary requirements	
I	
7/7	
1/1	

	
	
8/8	
Met	

 L40	
Nutritional food	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L41	
Healthy diet	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L42	
Physical activity	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L43	
Health Care Record	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L44	
MAP registration	
L	
3/3	

	

3/3	
Met	

 L45	
Medication storage	
L	
3/3	
3/3	

	
	
6/6	
Met	

O	
 L46	
Med. Administration	
I	
7/7	
1/1	

	
	
8/8	
Met	

 L47	
Self medication	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L49	
Informed of human rights	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L50	
Respectful Comm.	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L51	
Possessions	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L52	
Phone calls	
I	
6/7	
4/4	

	
	
10/11	
Met
(90.91 %)	

 L53	
Visitation	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L54	
Privacy	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L55	
Informed consent	
I	
2/2	
4/4	

	
	
6/6	
Met	

 L56	
Restrictive practices	
I	
1/3	

	

1/3	
Not Met
(33.33 %)	

 L57	
Written behavior plans	
I	
1/1	

	

1/1	
Met	

 L58	
Behavior plan component	
I	
0/1	

	

0/1	
Not Met
(0 %)	

 L59	
Behavior plan review	
I	
0/1	

	

0/1	
Not Met
(0 %)	

 L60	
Data maintenance	
I	
1/1	

	

1/1	
Met	

 L61	
Health protection in ISP	
I	
4/4	
1/1	

	
	
5/5	
Met	

 L62	
Health protection review	
I	
4/4	
1/1	

	
	
5/5	
Met	

 L63	
Med. treatment plan form	
I	
4/6	

	

4/6	
Not Met
(66.67 %)	

 L64	
Med. treatment plan rev.	
I	
4/6	

	

4/6	
Not Met
(66.67 %)	

 L67	
Money mgmt. plan	
I	
7/7	
1/1	

	
	
8/8	
Met	

 L68	
Funds expenditure	
I	
7/7	
3/3	

	
	
10/10	
Met	

 L69	
Expenditure tracking	
I	
7/7	
1/1	

	
	
8/8	
Met	

 L70	
Charges for care calc.	
I	
7/7	
2/2	

	
	
9/9	
Met	

 L71	
Charges for care appeal	
I	
7/7	
2/2	

	
	
9/9	
Met	

 L77	
Unique needs training	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L80	
Symptoms of illness	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L81	
Medical emergency	
L	
3/3	
3/3	

	
	
6/6	
Met	

O	
 L82	
Medication admin.	
L	
3/3	

	

3/3	
Met	

 L84	
Health protect. Training	
I	
4/4	
1/1	

	
	
5/5	
Met	

 L85	
Supervision 	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L86	
Required assessments	
I	
6/7	
2/3	

	
	
8/10	
Met
(80.0 %)	

 L87	
Support strategies	
I	
6/6	
2/3	

	
	
8/9	
Met
(88.89 %)	

 L88	
Strategies implemented	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L90	
Personal space/ bedroom privacy	
I	
7/7	
4/4	

	
	
11/11	
Met	

#Std. Met/# 76 Indicator	

	

	

71/76	

	
Total Score	

	

	

79/84	

	

	

	

	
94.05%	

		
							
Employment and Day Supports:	

							
	
Ind. #	
Ind.	
Loc. or Indiv.	
Emp. Sup.	
Cent. Based Work	
Com. Based Day	
Total Met / Rated	
Rating	

 L1	
Abuse/neglect training	
I	
5/5	
	
4/4	
9/9	
Met	

 L4	
Action taken	
L	
1/1	
	
1/1	
2/2	
Met	

 L5	
Safety Plan	
L	
1/1	
	
1/1	
2/2	
Met	

O	
 L6	
Evacuation	
L	
1/1	
	
1/1	
2/2	
Met	

 L7	
Fire Drills	
L	
1/1	
	
1/1	
2/2	
Met	

 L8	
Emergency Fact Sheets	
I	
5/5	
	
4/4	
9/9	
Met	

 L9	
Safe use of equipment	
L	
2/2	
	
1/1	
3/3	
Met	

O	
 L11	
Required inspections	
L	
1/1	
	
1/1	
2/2	
Met	

O	
 L12	
Smoke detectors	
L	
1/1	
	
1/1	
2/2	
Met	

O	
 L13	
Clean location	
L	
1/1	
	
1/1	
2/2	
Met	

 L14	
Site in good repair	
L	
1/1	
	
1/1	
2/2	
Met	

 L15	
Hot water	
L	
1/1	
	
1/1	
2/2	
Met	

 L16	
Accessibility	
L	
1/1	
	
1/1	
2/2	
Met	

 L17	
Egress at grade 	
L	
1/1	
	
1/1	
2/2	
Met	

 L18	
Above grade egress	
L	
1/1	
	
1/1	
2/2	
Met	

 L20	
Exit doors	
L	
1/1	
	
1/1	
2/2	
Met	

 L21	
Safe electrical equipment	
L	
1/1	
	
1/1	
2/2	
Met	

 L22	
Clean appliances	
L	
1/1	
	
1/1	
2/2	
Met	

 L25	
Dangerous substances	
L	
1/1	
	
1/1	
2/2	
Met	

 L26	
Walkway safety	
L	
1/1	
	
1/1	
2/2	
Met	

 L28	
Flammables	
L	
1/1	
	
1/1	
2/2	
Met	

 L29	
Rubbish/combustibles	
L	
1/1	
	
1/1	
2/2	
Met	

 L30	
Protective railings	
L	
1/1	
	
1/1	
2/2	
Met	

 L31	
Communication method	
I	
5/5	
	
4/4	
9/9	
Met	

 L32	
Verbal & written	
I	
5/5	
	
4/4	
9/9	
Met	

 L37	
Prompt treatment	
I	
2/2	
	
4/4	
6/6	
Met	

O	
 L38	
Physician's orders	
I	

1/1	
1/1	
Met	

 L39	
Dietary requirements	
I	

1/1	
1/1	
Met	

 L45	
Medication storage	
L	
1/1	
	
1/1	
2/2	
Met	

O	
 L46	
Med. Administration	
I	

1/1	
1/1	
Met	

 L49	
Informed of human rights	
I	
5/5	
	
4/4	
9/9	
Met	

 L50	
Respectful Comm.	
L	
2/2	
	
1/1	
3/3	
Met	

 L51	
Possessions	
I	
5/5	
	
4/4	
9/9	
Met	

 L52	
Phone calls	
I	
5/5	
	
4/4	
9/9	
Met	

 L54	
Privacy	
L	
2/2	
	
1/1	
3/3	
Met	

 L55	
Informed consent	
I	
3/3	
	
3/3	
6/6	
Met	

 L56	
Restrictive practices	
I	
2/2	

2/2	
Met	

 L67	
Money mgmt. plan	
I	
1/1	

1/1	
Met	

 L68	
Funds expenditure	
I	
1/1	

1/1	
Met	

 L69	
Expenditure tracking	
I	
1/1	

1/1	
Met	

 L72	
DOL requirements	
I	
0/1	

0/1	
Not Met
(0 %)	

 L77	
Unique needs training	
I	
5/5	
	
4/4	
9/9	
Met	

 L80	
Symptoms of illness	
L	
3/3	
	
1/1	
4/4	
Met	

 L81	
Medical emergency	
L	
3/3	
	
1/1	
4/4	
Met	

O	
 L82	
Medication admin.	
L	
1/1	
	
1/1	
2/2	
Met	

 L85	
Supervision 	
L	
3/3	
	
1/1	
4/4	
Met	

 L86	
Required assessments	
I	
2/3	
	
2/2	
4/5	
Met
(80.0 %)	

 L87	
Support strategies	
I	
2/4	
	
2/2	
4/6	
Not Met
(66.67 %)	

 L88	
Strategies implemented	
I	
5/5	
	
4/4	
9/9	
Met	

#Std. Met/# 49 Indicator	

	

47/49	

	
Total Score	

	

55/57	

	

	

	
96.49%	

		
							
	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	
0/1	
Not Met (0 %)	

 C6	
Future directions planning	
1/1	
Met	

	

	

							
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
3/4	
Met	

 C8	
Family/guardian communication	
4/4	
Met	

 C13	
Skills to maximize independence 	
4/4	
Met	

 C37	
Interpersonal skills for work	
4/4	
Met	

 C40	
Community involvement interest	
0/4	
Not Met (0 %)	

 C41	
Activities participation	
0/4	
Not Met (0 %)	

 C42	
Connection to others	
1/4	
Not Met (25.00 %)	

 C43	
Maintain & enhance relationship	
1/4	
Not Met (25.00 %)	

 C44	
Job exploration	
3/4	
Met	

 C45	
Revisit decisions	
1/4	
Not Met (25.00 %)	

 C46	
Use of generic resources	
0/4	
Not Met (0 %)	

 C47	
Transportation to/ from community	
4/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/4	
Met	

 C54	
Assistive technology	
4/4	
Met	

Employment Support Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
0/5	
Not Met (0 %)	

 C8	
Family/guardian communication	
5/5	
Met	

 C22	
Explore job interests	
1/4	
Not Met (25.00 %)	

 C23	
Assess skills & training needs	
1/4	
Not Met (25.00 %)	

 C24	
Job goals & support needs plan	
1/4	
Not Met (25.00 %)	

 C25	
Skill development	
2/4	
Not Met (50.0 %)	

 C26	
Benefits analysis	
0/5	
Not Met (0 %)	

 C27	
Job benefit education	
4/4	
Met	

 C28	
Relationships w/businesses	
3/3	
Met	

 C29	
Support to obtain employment	
3/4	
Met	

 C30	
Work in integrated settings	
5/5	
Met	

 C31	
Job accommodations	
4/4	
Met	

 C32	
At least minimum wages earned	
5/5	
Met	

 C33	
Employee benefits explained	
3/5	
Not Met (60.0 %)	

 C34	
Support to promote success	
2/4	
Not Met (50.0 %)	

 C35	
Feedback on job performance	
4/5	
Met (80.0 %)	

 C36	
Supports to enhance retention	
5/5	
Met	

 C37	
Interpersonal skills for work	
5/5	
Met	

 C47	
Transportation to/ from community	
5/5	
Met	

 C50	
Involvement/ part of the Workplace culture	
5/5	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/5	
Met (80.0 %)	

 C54	
Assistive technology	
4/5	
Met (80.0 %)	

Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
1/4	
Not Met (25.00 %)	

 C8	
Family/guardian communication	
4/4	
Met	

 C9	
Personal relationships	
4/4	
Met	

 C10	
Social skill development	
4/4	
Met	

 C11	
Get together w/family & friends	
4/4	
Met	

 C12	
Intimacy	
1/4	
Not Met (25.00 %)	

 C13	
Skills to maximize independence 	
4/4	
Met	

 C14	
Choices in routines & schedules	
4/4	
Met	

 C15	
Personalize living space	
3/3	
Met	

 C16	
Explore interests	
0/4	
Not Met (0 %)	

 C17	
Community activities	
4/4	
Met	

 C18	
Purchase personal belongings	
4/4	
Met	

 C19	
Knowledgeable decisions	
4/4	
Met	

 C20	
Emergency back-up plans	
3/3	
Met	

 C21	
Coordinate outreach	
4/4	
Met	

 C46	
Use of generic resources	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C48	
Neighborhood connections	
4/4	
Met	

 C49	
Physical setting is consistent 	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/4	
Met	

 C52	
Leisure activities and free-time choices /control	
4/4	
Met	

 C53	
Food/ dining choices	
4/4	
Met	

 C54	
Assistive technology	
4/4	
Met	

Residential Services	

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	

 C11	
Get together w/family & friends	
7/7	
Met	

 C12	
Intimacy	
2/7	
Not Met (28.57 %)	

 C13	
Skills to maximize independence 	
7/7	
Met	

 C14	
Choices in routines & schedules	
7/7	
Met	

 C15	
Personalize living space	
3/3	
Met	

 C16	
Explore interests	
4/7	
Not Met (57.14 %)	

 C17	
Community activities	
4/7	
Not Met (57.14 %)	

 C18	
Purchase personal belongings	
7/7	
Met	

 C19	
Knowledgeable decisions	
7/7	
Met	

 C20	
Emergency back-up plans	
3/3	
Met	

 C46	
Use of generic resources	
7/7	
Met	

 C47	
Transportation to/ from community	
7/7	
Met	

 C48	
Neighborhood connections	
7/7	
Met	

 C49	
Physical setting is consistent 	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
7/7	
Met	

 C52	
Leisure activities and free-time choices /control	
7/7	
Met	

 C53	
Food/ dining choices	
6/7	
Met (85.71 %)	

 C54	
Assistive technology	
7/7	
Met