PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
GROWTHWAYS INC
41 North Pearl St.
 Brockton, MA 02301    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
August 21, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
GROWTHWAYS INC	

	

	

	

	
Review Dates	

	
7/25/2017 - 7/28/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
8/9/2017	

	

	

	

	

	

	
Survey Team	

	
Michael Marchese	

Tina Napolitan (TL)	

Ed Sutka	

	

	

	

	

	

	
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	
9 location(s) 12 audit (s) 	
Targeted Review	
DDS 14 / 15
Provider 74 / 74

88 / 89 2 Year License 08/09/2017-  08/09/2019	
	
DDS 55 / 58
Provider 15 / 15

70 / 73 Certified 08/09/2017 -  08/09/2019	

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

DDS Targeted Review	
21 / 22	

Placement Services	
2 location(s) 3 audit (s) 	

DDS Targeted Review	
20 / 22	

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

DDS Targeted Review	
23 / 23	

Planning and Quality Management	

	
DDS Targeted Review	
6 / 6	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

Growthways, Inc. is a non-profit organization that has been providing education, training, advocacy and support services to people with intellectual and developmental disabilities in the greater Brockton area since 1982.  Growthways provides services to approximately 80 people with intellectual disabilities in programs including supports for people who need 24 hour of support, individuals who reside in their own homes requiring less than 24 hours of support and to individuals who reside in shared living placements.  

In 2015, Growthways achieved a two year license for its residential services and was eligible to conduct its own self-assessment and receive a targeted Licensure and Certification review.  This Department of Developmental Services (DDS) targeted review was comprised of the eight critical Licensure indicators, the Licensure and Certification indicators which were `Not Met' in the previous survey cycle, and the new and strengthened Licensure and Certification indicators from August 2016.   The survey sample included four homes providing 24 hour supports, three individuals receiving less than 24 hours of individual home supports (IHS), and two homes providing placement supports. 

This review of indicators relating to licensing demonstrated a number of positives within the agency's residential settings. In particular, systems to ensure environmental safety and health care such as medication administration were particularly strong.  For example, the agency ensured that staff who are responsible for medication administration in the 24 hour homes were certified and administered medications to individuals in accordance with MAP policies and procedures.  Additionally, Growthways has developed a comprehensive electronic system to ensure that changes in medications and medical protocols are communicated in a timely fashion.  

Another strength evident included the agency's support to promote human rights and self-advocacy.  The human rights of the individuals served and individuals' abilities to self-advocate are assessed yearly and attention is given to protecting their human rights.  For example, at both staff and house meetings a `right of the month' is reviewed. It was particularly noteworthy that staff supported individuals to strengthen their connections with the state wide self-advocacy organization and supported individuals to assume leadership roles.  In addition people's opinions on the staff that support them are solicited prior to hire and on an ongoing basis. 

This review of indicators relating to certification also demonstrated positive outcomes.  People were provided transportation and staffing support to attend community activities of their choice and preference.   Individuals were provided choices and support in decision making.  Individuals and staff meet monthly at `Club 23', a club that was established to discover and communicate to others about which community events are taking place and enable discussion about preferences.  Individuals also look in newspapers, on the computer and relay information they have heard during the day to staff to express their wishes about events they wish to attend. The homes blended in with their neighborhood, and there was a strong commitment to supporting individuals to be included in their neighborhoods and larger communities. People developed friendships with neighbors leading to interactions such as playing bingo, feeding chickens, attending funerals and inviting neighbors to their homes for cookouts. 

The agency is commended for honoring people's requests and interests in community activities for individuals' within both the residential and IHS services. Within the IHS supports, the agency successfully and consistently assisted individuals to maximize their independence as well as increasing individual's participation in community activities.  For example, one individual has been encouraged and supported to take on a leadership role in the Brockton Self-advocates group where he coordinates and performs DJ duties at their monthly dances.   People discuss and explore new activities at monthly house meetings and choose individual specific community activities including events such as day trips to Cape Cod, baseball games, walking in the park, eating out, concerts and dances.  Growthways then actualized these interests by providing transportation and staffing support to selected community activities.  

The agency's efforts to address the strengthened certification indicators were evident in the development of trainings related to assistive technology.  Although the agency made some progress in this area, the agency should continue its efforts to assess all people's needs for further use of technology that may assist them in increasing their independence.   

In another area for further growth, the DDS findings concur with Growthways findings regarding the need to enhance the supports to individuals to develop companionship and/or intimate relationships with others.  The agency demonstrated support to individuals who were able to express their interests and to initiate intimate relationships with others of their choice, however the agency is encouraged to continue to strengthen the support to assist individuals who are unable to communicate their desires in this area to learn about and actualize their interests for greater intimacy.  

The agency successfully met all but one licensure indicator.  In the months leading up to the review, the Human Rights Committee (HRC) has seen some positive improvements.   For example, the agency had recently begun to perform site visits and increased its attention to recruiting multiple committee members with required expertise.   The agency will benefit from giving continued attention to meet the requirements for members with expertise in the medical, legal and clinical fields and engage their active consistent attendance at meetings, to perform ongoing site visits and to review policies and procedures that affect the rights of individuals at least annually.  

Based on the findings of this report, Growthways has earned a two-Year License for Residential and Individual Home Support services.  Within the licensure indicators, Growthways achieved a score of 99% for residential and individual home supports.   The agency will conduct follow up for the one licensing indicator rated Not Met within 60 days.  

The agency is certified in its Residential and IHS services.  The agency achieved a score of 96% of indicators rated Met within the certification indicators in Residential and Individual Home Supports.  

Growthways has presented the following self-assessment.	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

Growthways, Inc.
Overview of Self Assessment Process

Strengthened Infrastructure:
Since our last review Growthways has added oversight and infrastructure positions to strengthen systems and improve supports. We created the Director of Residential &amp; Community Supports with a primary responsibility of quality assurance and compliance. A full time trainer position now allows for many hours of training opportunities and a more comprehensive approach to professional development. The Human Resources and Maintenance departments were each strengthened with an additional position, our nursing component was expanded and reorganized to better serve the individuals' medical needs, and our first (part-time) behavioral clinician was added. 

Environmental and Personal Safety
Monthly quality assurance reviews are conducted by the coordinators who supervise multiple residences or placements, and include the items used by DDS for licensing and certification. The review includes checking the finances, a record review and environmental checks such as cleanliness, maintenance upkeep and water temperature. For this assessment a sample of the QA reviews for the last year was examined.

Maintenance for group residences utilizes a web-based database that allows each site to enter its needs, and can then be centrally monitored by maintenance personnel and administrative staff. Critical safety issues are called in to the Administrator on Call for prompt resolution (all AOC calls are logged for later review). The agency President works closely with the maintenance staff to assess structural needs as well as preventative maintenance, and the agency has a working relationship with a local contractor for larger renovations and modifications for accessibility due to the changing needs of individuals in our programs. The agency has responded to the need for increased accessibility by both modifying and building two homes in the last four years. The maintenance staff are responsible for routine preventative tasks as well as annual safety checks. To assess the environmental indicators for this survey they reviewed each site and each placement home using the chart included in the DDS QE guidelines.

We have a Safety Committee comprised of all levels of the agency including maintenance staff.  It reviews environmental safeguards and issues a bi-monthly newsletter to highlight safety issues for staff.  A monthly Safety Checklist is completed at residential sites and submitted to the committee chair for review. Vehicles receive a safety assessment each month by program staff, and every six months by the Safety Committee. A Workplace Safety sub-committee is being developed to review possible trends in areas such as motor vehicle accidents, staff injuries and incident reports to determine possible preventative and corrective measures. The agency uses a driving review for new employees and computer based driving test as well as a remedial training program for staff involved in a motor vehicle accident or violation. Each vehicle is equipped with a GPS tracker to enhance safety monitoring. 

Fire alarms and safety equipment (such as bed shakers) are checked at least quarterly during practice drills and documentation reviewed by administrative staff. Employees are trained on fire safety and evacuation procedures at the beginning of employment and must review of the site safety plan at least once each year. Individuals are trained in emergency evacuation, and any evacuation concerns are reviewed at house meetings/home visits, with a plan for compliance submitted for any concerns. If declining health interferes with evacuation, it may require home modifications and adaptive equipment, or changes in staffing composition or an increase in the frequency of practice drills. 

For group residences, the smoke detectors and CO2 detectors are checked routinely during QA reviews, and the maintenance staff change the batteries every fall. Fire extinguishers are checked and recharged every August. Malfunction of equipment is reported immediately for resolution and tracked in the agency's on-line maintenance program. Dryer vents are cleaned by the maintenance staff at least annually and furnaces are inspected annually. Plans for handling snowfall are in each residence in the program log. For Placement Services, documentation of furnace inspections, homeowner's and vehicle insurance is kept on file at our Central Office. Staff and home care providers are trained in the proper use and maintenance of equipment and safety protocols, as well as the fire drill and safe evacuation plan.  

Health
Each individual has an on-site reference binder containing current Health Care Records, Emergency Facts Sheets, ISP's, data and daily notes and specific medical information. These documents are checked during routine QA and supervisory meetings and reviewed with new staff.  The Director of Residential Services conducts a thorough record review before the annual ISP meeting.  Environmental and health related protocols are reviewed internally as well as by the Human Rights Committee and are distributed to guardians.

Health and dental appointments are attended by the program manager or home care provider and documented on the health care visit form. Each appointment is reviewed by the coordinator and agency nurse in order to ensure the individual's needs are properly addressed. An on-line system for integrated management of visits, medications, doctor's orders and MARs was implemented in February 2017. The medication lists are updated for use at following appointments, and are used as part of a safety check for medication deliveries. Recommended follow-up care is tracked in the health care database.  Also tracked are dates of annual physical and dental exams, Medication Treatment Plans, and all aspects of MAP administration. Nursing staff are the primary medical contact with outside facilities, provide specific trainings as needed, and are a resource for individuals and families.  They also attend appointments as necessary. A monthly medication review is done by the Residential Coordinator or Shared Living Case Manager, and the nursing staff have started a monthly comprehensive medication review as well as random spot checks. Treatment protocols for conditions such as seizure disorders, bowel regimens and dysphagia diets are in place along with documentation for staff training. Vital signs are taken and documented monthly for review by a nurse. Required nutrition trainings are offered quarterly, and revised menus based on a modified Mediterranean diet are being developed.

The Medication Treatment Plan Committee reviews all plans to ensure accuracy and consistency. Medication or protocol errors are tracked and remedial group training is required based on a point system. 

The Health Care Initiatives committee targets improvement of the health support services. All medication occurrences are called into the AOC and tracked for supervisory follow-up, which includes systematic retraining. We contract with Lise Gervais, OT, who provides dysphagia and swallowing evaluations and trainings. 

Human Rights
Individuals, staff and families receive training on individual's rights and DPPC reporting, and the topic of rights is reviewed at house meetings, staff meetings and quarterly at Human Rights Officer meetings. The Human Rights Committee meets at least quarterly and reviews all Incident and Restraint Reports, as well as DDS &amp; DPPC investigations, and restrictive practices and behavior plans. We are pursuing a strengthened Human Rights Committee by recruiting dual representation for required roles such as legal and medical. Families receive copies of plans, incident reports, restrictive practices and health related practices. Reports of potential abuse and neglect are addressed immediately, and on-going training geared toward prevention and awareness is included routinely at program meetings. Growthways supports a Self Advocacy group, which collaborates with other local groups. Staff assist to support expanded options to express choice and opportunities for growth and relationships. 

We have a comprehensive approach to developing and implementing a Shared Management of Funds plan. We use a combination of debit cards and cash, with all transactions recorded in an on-line system that helps to maximize the individual's ability to access funds, while at the same time safeguarding the assets and ensuring appropriate use. All expenditures are later reviewed by two levels of Central Office staff.

Workforce
After the second interview we require six hours of on-site observation to assess interaction with individuals, as well as to obtain responses from individuals. Only if this observation is positive can the applicant be recommended for hire and begin training. All new hires must pass a test at the end of the introductory trainings. A 75 day review is then held to ensure appropriateness for the position.  Training occurs on-site for program and individual's specific information. Group sessions are held for topics that address job responsibilities and expectations, clinical and teaching skills, health and medication, restraint, safety, agency policy and procedures and rights and dignity. Trainings are documented and tracked.  Staff receive additional training on individual's specific plans every year. Regular meetings are held to review the individuals' and agency updates as well as training topics, and staff supervisions are conducted monthly. Employees are required to pursue additional professional development opportunities beyond required certifications, and quarterly performance incentives are awarded to staff that have excelled in their job responsibilities. Growthways has been phasing in the additional coordinating, training, support and assessing to implement Positive Behavior Supports. Although adoption of PBS is still in progress, we have already seen positive developments. 

Goal Development &amp; Implementation
Based on the vision statement, we work collaboratively to create clear and detailed assessments, plans and Support Strategies. Objectives and teaching steps are then put into in an individualized format for progress notes in order to further support implementation of the support strategies. Monthly summaries are created from the detail and used to evaluate progress. We are evaluating some new assessments to add to plan development in areas such as socialization and intimacy, improved interest surveys and a more comprehensive residential skills assessment.	

	

	

	

		
LICENSURE FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
79/79	
0/79	

    Residential Services
    Placement Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
88/89	
1/89	
99%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
1	

	

	

	

	

Organizational Areas Needing Improvement on Standards not met/Follow-up to occur:
From DDS review:	

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
The agency needs to support its Human Rights Committee to meet the required membership, review agency policies and procedures that potentially impact individual's rights on a annual basis and conduct site visits on a regular basis.  	

	

	

	

	

	

	

	

CERTIFICATION FINDINGS	

	

	

	
Reviewed by	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 1/1
Provider 5/5	
6/6	
0/6	

Residential and Individual Home Supports	
DDS 54/57
Provider 10/10	
64/67	
3/67	

Individual Home Supports	
DDS 19/19
Provider 4/4	
23/23	
0/23	

Placement Services	
DDS 17/19
Provider 3/3	
20/22	
2/22	

Residential Services	
DDS 18/19
Provider 3/3	
21/22	
1/22	

Total	
	
70/73	
3/73	
96%	

Certified	

	

	

	

	

	
Individual Home Supports Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C13	
Staff (Home Providers) provide support for individuals to develop skills to enable them to maximize independence and participation in typical activities and routines. 	
Staff has exhibited noteworthy efforts to support individuals to develop skills that enhance their independent participation in activities and routines.  For example, one individual has been encouraged and supported to take on a leadership role in the Brockton Self-advocates Group where he coordinates and performs DJ duties at their monthly dances.  Staff further strengthened people's independence by targeting support to those areas where refinement was still needed.  Staff is commended for their ongoing efforts to support individuals to develop the skills needed to maximize their independence in this area. 	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Staff made conscientious efforts to identify people's interests and to support them to participate in community activities that they desired.  Examples of these activities included arts and craft classes, swimming at the YMCA, a weight loss group, fishing, and drum lessons.  Staff are commended for their on-going work to ensure that people enjoyed access to community activities of their choice.	

	

	

	
Placement Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For one individual, evidence was lacking that education had been provided to staff and home care providers to support individuals in the area of sexuality and intimacy. In addition, there were no formal or informal assessments of individuals' need for intimacy and companionship based on their unique learning styles. The agency needs to further assess individuals and provide training to staff and providers to support individuals to explore, define and express their need for intimacy and companionship. 

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For three individuals, evidence was lacking that their assistive technology needs to maximize independence had been assessed.  The agency needs to further assess individual's assistive technology needs to determine what modifications or adaptive devices could help them to be as independent as possible in their homes and community.	

	

	

	
Residential Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Staff actively promoted people's interests by fully supporting their involvement in a variety of activities that reflected their interests.  The agency has established a social club which enhances knowledge of community events.  Examples of community activities included Zumba and arts and crafts classes, memberships at the local YMCA, music classes, and participation in a bowling league.  The agency is commended for supporting individuals to actively participate in community interests that are based on their interests and preferences.  	

	

	

	
Residential Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For three individuals, evidence was lacking that education has been provided to staff to support individuals in the area of sexuality and intimacy. In addition, there were no formal or informal assessments of the individuals' need for intimacy and companionship based on their unique learning styles. The agency needs to further assess individuals and provide training to 
staff to support individuals to explore, define and express their need for intimacy and companionship. 

	

	

	

	MASTER SCORE SHEET LICENSURE	

							
	Organizational: GROWTHWAYS INC	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
9/9	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
DDS	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
Provider	
-	
Met	

 L66	
HRC restraint review	
Provider	
-	
Met	

 L74	
Screen employees	
Provider	
-	
Met	

 L75	
Qualified staff	
Provider	
-	
Met	

 L76	
Track trainings	
Provider	
-	
Met	

 L83	
HR training	
Provider	
-	
Met	

							
	Residential and Individual Home Supports:	

							
	
Ind. #	
Ind.	
Loc. or Indiv.	
Reviewed by	
Res. Sup.	
Ind. Home Sup.	
Place.	
Resp.	
ABI-MFP Res. Sup.	
ABI-MFP Place.	
Total Met/Rated	
Rating	

 L1	
Abuse/neglect training	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
4/4	
2/2	
2/2	

	
8/8	
Met	

 L7	
Fire Drills	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L11	
Required inspections	
L	
DDS	
4/4	
2/2	
2/2	

	
8/8	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
3/4	
2/2	
2/2	

	
7/8	
Met
(87.50 %)	

O	
 L13	
Clean location	
L	
DDS	
4/4	
2/2	
2/2	

	
8/8	
Met	

 L14	
Site in good repair	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L15	
Hot water	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L16	
Accessibility	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L19	
Bedroom location	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L22	
Clean appliances	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L23	
Egress door locks	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L24	
Locked door access	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L27	
Pools, hot tubs, etc.	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L28	
Flammables	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L29	
Rubbish/combustibles	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L30	
Protective railings	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L31	
Communication method	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L33	
Physical exam	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L34	
Dental exam	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L35	
Preventive screenings	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L36	
Recommended tests	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
5/5	

	

5/5	
Met	

 L39	
Dietary requirements	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L40	
Nutritional food	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L41	
Healthy diet	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L42	
Physical activity	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L43	
Health Care Record	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
6/6	
	
3/3	

	
9/9	
Met	

 L47	
Self medication	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
6/6	
3/3	
3/3	

	
12/12	
Met	

 L50	
Respectful Comm.	
L	
DDS	
4/4	
2/2	
2/2	

	
8/8	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
6/6	
3/3	
3/3	

	
12/12	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
4/4	
2/2	
2/2	

	
8/8	
Met	

 L55	
Informed consent	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L56	
Restrictive practices	
I	
DDS	
1/1	
	
1/1	

	
2/2	
Met	

 L57	
Written behavior plans	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L60	
Data maintenance	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L63	
Med. treatment plan form	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L64	
Med. treatment plan rev.	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L65	
Restraint report submit	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L70	
Charges for care calc.	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L71	
Charges for care appeal	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

O	
 L82	
Medication admin.	
L	
DDS	
4/4	

	

4/4	
Met	

 L84	
Health protect. Training	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L85	
Supervision 	
L	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L87	
Support strategies	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L88	
Strategies implemented	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
6/6	
3/3	
3/3	

	
12/12	
Met	

#Std. Met/# 79 Indicator	

	

	

	
79/79	

	
Total Score	

	

	

	
88/89	

	

	

	

	
	
98.88%	

			
							
	MASTER SCORE SHEET CERTIFICATION	

							
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C1	
Provider data collection	
Provider	
-	
Met	

 C2	
Data analysis	
Provider	
-	
Met	

 C3	
Service satisfaction	
Provider	
-	
Met	

 C4	
Utilizes input from stakeholders	
DDS	
1/1	
Met	

 C5	
Measure progress	
Provider	
-	
Met	

 C6	
Future directions planning	
Provider	
-	
Met	

	

	

	
							
Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
3/3	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
3/3	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
3/3	
Met	

 C12	
Intimacy	
DDS	
3/3	
Met	

 C13	
Skills to maximize independence 	
DDS	
3/3	
Met	

 C14	
Choices in routines & schedules	
DDS	
3/3	
Met	

 C15	
Personalize living space	
DDS	
2/2	
Met	

 C16	
Explore interests	
DDS	
3/3	
Met	

 C17	
Community activities	
DDS	
3/3	
Met	

 C18	
Purchase personal belongings	
DDS	
3/3	
Met	

 C19	
Knowledgeable decisions	
DDS	
3/3	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C21	
Coordinate outreach	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
3/3	
Met	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C48	
Neighborhood connections	
DDS	
3/3	
Met	

 C49	
Physical setting is consistent 	
DDS	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
3/3	
Met	

 C53	
Food/ dining choices	
DDS	
3/3	
Met	

 C54	
Assistive technology	
DDS	
3/3	
Met	

Placement Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
3/3	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
3/3	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
3/3	
Met	

 C12	
Intimacy	
DDS	
2/3	
Not Met (66.67 %)	

 C13	
Skills to maximize independence 	
DDS	
3/3	
Met	

 C14	
Choices in routines & schedules	
DDS	
3/3	
Met	

 C15	
Personalize living space	
DDS	
2/2	
Met	

 C16	
Explore interests	
DDS	
3/3	
Met	

 C17	
Community activities	
DDS	
3/3	
Met	

 C18	
Purchase personal belongings	
DDS	
3/3	
Met	

 C19	
Knowledgeable decisions	
DDS	
3/3	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
3/3	
Met	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C48	
Neighborhood connections	
DDS	
3/3	
Met	

 C49	
Physical setting is consistent 	
DDS	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
3/3	
Met	

 C53	
Food/ dining choices	
DDS	
3/3	
Met	

 C54	
Assistive technology	
DDS	
0/3	
Not Met (0 %)	

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
6/6	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
6/6	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
4/6	
Not Met (66.67 %)	

 C13	
Skills to maximize independence 	
DDS	
6/6	
Met	

 C14	
Choices in routines & schedules	
DDS	
6/6	
Met	

 C15	
Personalize living space	
DDS	
4/4	
Met	

 C16	
Explore interests	
DDS	
6/6	
Met	

 C17	
Community activities	
DDS	
6/6	
Met	

 C18	
Purchase personal belongings	
DDS	
6/6	
Met	

 C19	
Knowledgeable decisions	
DDS	
6/6	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
6/6	
Met	

 C47	
Transportation to/ from community	
DDS	
6/6	
Met	

 C48	
Neighborhood connections	
DDS	
6/6	
Met	

 C49	
Physical setting is consistent 	
DDS	
4/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
6/6	
Met	

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

 C53	
Food/ dining choices	
DDS	
6/6	
Met	

 C54	
Assistive technology	
DDS	
6/6	
Met