PROVIDER REPORT FOR
EVERGREEN CENTER
345 Fortune Blvd
 Milford, MA 01757    

September 02, 2016
Version
Provider Web Report

Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

SUMMARY OF OVERALL FINDINGS

Provider	
EVERGREEN CENTER	
	
Review Dates	
8/10/2016 - 8/15/2016	
	
Service Enhancement 
Meeting Date	
8/26/2016	
	
Survey Team	

Melanie McNamara (TL)	
Janina Millet	

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	2 location(s) 4 audit (s) 	Full Review	78 / 81 2 Year License 08/26/2016 - 08/26/2018			
Residential Services	2 location(s) 4 audit (s) 			Full Review	13 / 14 Certified	
 
Survey scope and findings for Planning and Quality Management	
Service Group Type	Sample Size	Scope	Licensure Level	Certification Scope	Certification Level	
Planning and Quality Management	N/A	N/A	N/A	Full Review	6/6 Certified	
 
EXECUTIVE SUMMARY :
Evergreen Center is a nonprofit organization that provides educational and residential supports to children and adults with developmental disabilities. Headquartered in Milford, MA, the agency's adult supports division currently provides twenty-four hour residential services to up to twenty-two individuals who reside in six residential homes located in the Central/West, Metro Boston and Northeast regions of the state.  Evergreen received a Two-Year license during its previous survey conducted in July, 2014. The current survey was a full licensing and full certification review.  

Evergreen effectively addressed organizational planning and development initiatives.  The provider utilized a program improvement plan as the mechanism to identify future directions in service delivery.  Individual and family/guardian satisfaction surveys, as well as input from the executive team, were utilized to develop program improvement projects.  Project areas identified by the agency included focusing on enhancing community membership and social relationship development.  The agency had also targeted the strengthening of data collection and evidence based supports as an area of service improvement.  An administrative calendar was used to track progress toward identified goals and make changes as needed.  

Findings from the current survey proved the agency's oversight systems continued to be both responsive and effective in ensuring service delivery standards were addressed across a full range of service domains.  Evergreen utilized the Human Services Management Corporation to provide oversight and management through a quality assurance and regulatory compliance department.  The agency's management team also closely monitored all aspects of the services provided to individuals at each of the residential sites it operates.  A monthly administrative calendar continues to be effectively used to routinely conduct internal audits, assign oversight responsibility for the completion of required tasks and ensure compliance with regulatory requirements by DDS and Evergreen.

Survey findings also indicate that staff development and competency was an area of strength for Evergreen.  Mandatory staff trainings and training on individual specific needs were present.  Specialized health related trainings were provided by members of the skilled nursing team.  The agency utilized its comprehensive annual support tool to inform decisions about which trainings staff needed for the individuals they support.  In addition, Training On Demand (TOD), an online service, was used as another avenue for providing staff training.  

Evergreen's provision of health care and supports was another area of strength.  Individuals' medical needs were effectively managed by Evergreen's skilled nursing team.  The agency has a health services advisor and a health services director who oversee aspects of individuals' health care and supervise nursing staff.  Community nursing attached to each residential site monitored health and safety, wellness appointments, first aid kits, and provided MAP oversight.  Health care protocols were in place and staff were trained and knowledgeable in the unique health care support needs of individuals.  Each person's health care information was thoroughly documented and readily available to staff at each site.  

In areas subject to certification, the agency demonstrated a commitment to encouraging and supporting individual choice and control.  Findings indicated that people were well supported to make decisions about their daily routines such as what household chores to complete, when to go to sleep,   and how to spend free time.  Individuals were noted to participate in typical activities and routines such as completing laundry tasks and shopping in the community.  Individuals were encouraged and supported to make purchases of personal belongings of their choosing.   
   
This review also identified areas that would benefit from furthe attention on the part of Evergreen Center.  Submission of ISP assessments and provider support strategies need to be timely and medication treatment plans need to have all of the required components.  The agency should also ensure that individuals are provided with opportunities to participate in integrated activities in their community based on their interest and preference.  Based on the current review and findings, Evergreen has received a Two-Year License for its Residential Supports and the agency's certification has also been renewed.	

LICENSURE FINDINGS

	Met / Rated	Not Met / Rated	% Met	
Organizational	8/8	0/8		
Residential and Individual Home Supports	70/73	3/73		
    Residential Services
				
Critical Indicators	8/8	0/8		
Total	78/81	3/81	96%	
2 Year License				
# indicators for 60 Day Follow-up		3		

			
	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 is commended for implementing various mechanisms to ensure staff knowledge of the unique needs of the individuals served.  Based on the outcome of Evergreen's C.A.S.T. (comprehensive annual support tool) and other risk assessments, agency staff were provided with opportunities to receive training.  Necessary health-related trainings are conducted by nursing staff on such topics as vital signs, seizures, PICA and choking.   This information is kept in the postings book for quick reference.  Online training offerings also included topic areas related to health and safety.  In addition, a "Life Style" outline was utilized to ensure that staff were familiar with each individuals' preferences, routines, preferred activities, and key relationships, among other items.	
			
	Residential Areas Needing Improvement on Standards not met/Follow-up to occur:	
	Indicator #	Indicator	Area Needing Improvement	
	 L63	Medication treatment plans are in written format with required components.	The audits sample included three individuals who were administered behavior modifying medications.  For one person, data was not being collected on the targeted behavior to discern the efficacy of the treatment.  The agency needs to ensure that all medication treatment plans include all required elements.  	
	 L86	Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	For three out of three ISPs reviewed, all required assessments were not submitted timely.  They need to be submitted 15 days prior to the ISP.	
	 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 out of three ISPs reviewed, they were not submitted timely.  Provider support strategies need to be submitted 15 days prior to the ISP.	

CERTIFICATION FINDINGS

	Met / Rated	Not Met / Rated	
Certification - Planning and Quality Management	6/6	0/6	
Residential and Individual Home Supports			
Residential Services
	13/14	1/14	

	Summary of Ratings	
	Residential Services- Areas Needing Improvement on Standards not met:	
	Indicator #	Indicator	Area Needing Improvement	
	 C17	Community activities are provided and are based on the individual's preferences and interests. 	The agency needs to ensure that there are mechanisms in place to identify individuals' interests and preferences and ensure that individuals are provided opportunities to explore community activities related to these interests. When necessary, individualized strategies and plans to promote community involvement need to be developed and implemented.	

MASTER SCORE SHEET LICENSURE
Organizational: EVERGREEN CENTER
	Indicator #	Indicator	Met/Rated	Rating(Met,Not Met,NotRated)	
O	 L2	Abuse/neglect reporting	3/3	Met	
	 L3	Immediate Action	1/1	Met	
	 L4	Action taken	1/1	Met	
	 L48	HRC	1/1	Met	
	 L74	Screen employees	3/3	Met	
	 L75	Qualified staff	5/5	Met	
	 L76	Track trainings	2/2	Met	
	 L83	HR training	5/5	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	4/4						4/4	Met	
	 L5	Safety Plan	L	2/2						2/2	Met	
O	 L6	Evacuation	L	2/2						2/2	Met	
	 L7	Fire Drills	L	2/2						2/2	Met	
	 L8	Emergency Fact Sheets	I	4/4						4/4	Met	
	 L9	Safe use of equipment	L	2/2						2/2	Met	
	 L10	Reduce risk interventions	I	3/3						3/3	Met	
O	 L11	Required inspections	L	2/2						2/2	Met	
O	 L12	Smoke detectors	L	2/2						2/2	Met	
O	 L13	Clean location	L	2/2						2/2	Met	
	 L14	Site in good repair	L	1/1						1/1	Met	
	 L15	Hot water	L	2/2						2/2	Met	
	 L16	Accessibility	L	2/2						2/2	Met	
	 L17	Egress at grade 	L	2/2						2/2	Met	

	Ind. #	Ind.	Loc. or Indiv.	Res. Sup.	Ind. Home Sup.	Place.	Resp.	ABI-MFP Res. Sup.	ABI-MFP Place.	Total Met/Rated	Rating	
	 L18	Above grade egress	L	1/1						1/1	Met	
	 L19	Bedroom location	L	2/2						2/2	Met	
	 L20	Exit doors	L	2/2						2/2	Met	
	 L21	Safe electrical equipment	L	2/2						2/2	Met	
	 L22	Clean appliances	L	2/2						2/2	Met	
	 L23	Egress door locks	L	2/2						2/2	Met	
	 L24	Locked door access	L	2/2						2/2	Met	
	 L25	Dangerous substances	L	2/2						2/2	Met	
	 L26	Walkway safety	L	2/2						2/2	Met	
	 L28	Flammables	L	2/2						2/2	Met	
	 L29	Rubbish/combustibles	L	2/2						2/2	Met	
	 L30	Protective railings	L	1/1						1/1	Met	
	 L31	Communication method	I	4/4						4/4	Met	
	 L32	Verbal & written	I	4/4						4/4	Met	
	 L33	Physical exam	I	4/4						4/4	Met	
	 L34	Dental exam	I	4/4						4/4	Met	

	Ind. #	Ind.	Loc. or Indiv.	Res. Sup.	Ind. Home Sup.	Place.	Resp.	ABI-MFP Res. Sup.	ABI-MFP Place.	Total Met/Rated	Rating	
	 L35	Preventive screenings	I	4/4						4/4	Met	
	 L36	Recommended tests	I	4/4						4/4	Met	
	 L37	Prompt treatment	I	4/4						4/4	Met	
O	 L38	Physician's orders	I	4/4						4/4	Met	
	 L39	Dietary requirements	I	4/4						4/4	Met	
	 L40	Nutritional food	L	2/2						2/2	Met	
	 L41	Healthy diet	L	2/2						2/2	Met	
	 L42	Physical activity	L	2/2						2/2	Met	
	 L43	Health Care Record	I	4/4						4/4	Met	
	 L44	MAP registration	L	2/2						2/2	Met	
	 L45	Medication storage	L	2/2						2/2	Met	
O	 L46	Med. Administration	I	4/4						4/4	Met	
	 L47	Self medication	I	4/4						4/4	Met	
	 L49	Informed of human rights	I	4/4						4/4	Met	

	Ind. #	Ind.	Loc. or Indiv.	Res. Sup.	Ind. Home Sup.	Place.	Resp.	ABI-MFP Res. Sup.	ABI-MFP Place.	Total Met/Rated	Rating	
	 L50	Respectful Comm.	L	2/2						2/2	Met	
	 L51	Possessions	I	4/4						4/4	Met	
	 L52	Phone calls	I	4/4						4/4	Met	
	 L53	Visitation	I	4/4						4/4	Met	
	 L54	Privacy	L	2/2						2/2	Met	
	 L56	Restrictive practices	I	1/1						1/1	Met	
	 L57	Written behavior plans	I	1/1						1/1	Met	
	 L58	Behavior plan component	I	1/1						1/1	Met	
	 L59	Behavior plan review	I	1/1						1/1	Met	
	 L60	Data maintenance	I	1/1						1/1	Met	
	 L61	Health protection in ISP	I	3/3						3/3	Met	
	 L62	Health protection review	I	3/3						3/3	Met	
	 L63	Med. treatment plan form	I	1/2						1/2	Not Met
(50.0 %)	
	 L64	Med. treatment plan rev.	I	2/2						2/2	Met	

	Ind. #	Ind.	Loc. or Indiv.	Res. Sup.	Ind. Home Sup.	Place.	Resp.	ABI-MFP Res. Sup.	ABI-MFP Place.	Total Met/Rated	Rating	
	 L67	Money mgmt. plan	I	4/4						4/4	Met	
	 L68	Funds expenditure	I	4/4						4/4	Met	
	 L69	Expenditure tracking	I	4/4						4/4	Met	
	 L70	Charges for care calc.	I	4/4						4/4	Met	
	 L71	Charges for care appeal	I	4/4						4/4	Met	
	 L77	Unique needs training	I	4/4						4/4	Met	
	 L78	Restrictive Int. Training	L	2/2						2/2	Met	
	 L80	Symptoms of illness	L	2/2						2/2	Met	
	 L81	Medical emergency	L	2/2						2/2	Met	
O	 L82	Medication admin.	L	2/2						2/2	Met	
	 L84	Health protect. Training	I	3/3						3/3	Met	
	 L85	Supervision 	L	2/2						2/2	Met	
	 L86	Required assessments	I	0/3						0/3	Not Met
(0 %)	
	 L87	Support strategies	I	1/3						1/3	Not Met
(33.33 %)	

	Ind. #	Ind.	Loc. or Indiv.	Res. Sup.	Ind. Home Sup.	Place.	Resp.	ABI-MFP Res. Sup.	ABI-MFP Place.	Total Met/Rated	Rating	
	 L88	Strategies implemented	I	4/4						4/4	Met	
	#Std. Met/# 73 Indicator									70/73		
	Total Score									78/81		
										96.30%		
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 Reviewed By -DDS	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	4/4	Met	
 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	4/4	Met	
 C13	Skills to maximize independence 	4/4	Met	
 C14	Choices in routines & schedules	4/4	Met	
 C15	Personalize living space	2/2	Met	
 C16	Explore interests	4/4	Met	
 C17	Community activities	1/4	Not Met (25.00 %)	
 C18	Purchase personal belongings	4/4	Met	
 C19	Knowledgeable decisions	4/4	Met	
 C20	Emergency back-up plans	2/2	Met