PROVIDER REPORT FOR
HILLTOP CHILD ADULT SERS INC.
171 Park Ave Ste. 105
 West Springfield, MA 01089    

 
 
Version
Provider Web Report

 
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

SUMMARY OF OVERALL FINDINGS
 
Provider	
HILLTOP CHILD ADULT SERS INC.	

Review Dates	
1/30/2013 - 2/5/2013	

Service Enhancement 
Meeting Date	
2/19/2013	

Survey Team	
 
Melanie McNamara	

Martina Pocaterra (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	5 location(s) 9 audit (s) 	Full Review	69 / 76 2 Year License 02/19/2013 - 02/19/2015	 

 	 

 	
Residential Services	2 location(s) 6 audit (s) 	 
 	 
 	DDS Targeted Review	0 / 0 Certified	
Individual Home Supports	3 location(s) 3 audit (s) 	 
 	 
 	DDS Targeted Review	0 / 0 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	DDS Targeted Review	1/1 Certified	

EXECUTIVE SUMMARY :
Hilltop Child &amp; Adult Services, Inc (Hilltop) is a private, non profit organization providing services in the greater Springfield/Westfield area since 1968. Hilltop primarily provides residential services to individuals through contractual agreements with the Department of Developmental Services. Hilltop's residential services include twenty-four hour supports, currently provided to 22 individuals, and 11 individuals who are served through Individual Home Supports arrangements.  

A notable strength of Hilltop lied in its values based organizational culture that guided the direction of Hilltop's service delivery and the actualization of its mission to 'improve the quality of individual's lives and their happiness.' The agency's commitment to its mission was demonstrated across all settings in many ways. It started from a place of high regard and respect for each person, in combination with a comprehensive understanding of individual's personal histories. Hilltop's small organizational structure, under the direction of a long tenured management team, positioned the agency to be knowledgeable about each person's unique support needs. Survey findings evidenced the agency's capacity for providing highly tailored and responsive services to individuals.  

The agency had done a good job in the area of providing quality health care supports. Individuals receiving 24 hour residential services were well supported to attend medical appointments for routine/preventative health care, as well as visits to specialists for specific medical conditions. Several individuals in the sample were provided assistance with ongoing treatment protocols. The agency also promoted strategies across all the programs to encourage healthy lifestyles, emphasizing education and supports that addressed good nutrition and physical activity. Some individuals were noted to have improved health by making better meal choices, leading more active lives, and losing weight. 

Another aspect of Hilltop's services that had a positive impact on the quality of individual's lives was the focus placed on promoting individuals' relationships with significant others. The many years that the management team had been affiliated with Hilltop contributed to the formation of strong bonds amongst staff, individuals and their families. These ties enhanced the lines of communication amongst each other, and created many opportunities for assisting individuals to develop, maintain and strengthen social connections with the important people in their lives. Survey findings showed that the agency was deliberate in its efforts to support individuals to have regular contact with family members and friends. Individuals had regularly scheduled visits with their families, and got together with them for holidays, celebrations and other special events. 

Along with the strengths identified in this report, findings also indicated areas in which Hilltop Child &amp; Adult Services may productively focus its attention.  Among these, the agency will want to strengthen oversight practices that ensure all required components are present in funds management plans and that expenditures are tracked appropriately. The agency needs to ensure timely submission of ISP assessments through better tracking; Steps will also need to be taken to ensure that assessments to address safe use of appliances/equipment at homes are completed for all individuals.	

LICENSURE FINDINGS

 	Met / Rated	Not Met / Rated	% Met	
Organizational	7/7	0/7	 	
Residential and Individual Home Supports	62/69	7/69	 

    Residential Services
    Individual Home Supports	 

 

 	
Critical Indicators	8/8	0/8	 	
Total	69/76	7/76	91%	
2 Year License	 	 	 	
# indicators for 60 Day Follow-up	 
 	7	 

 
 	 	 	 	
 	Organizational Commendations on Standards Met:	
 	Indicator #	Indicator	Commendations	

 

 
 	 L48	The agency has an effective Human Rights Committee.	Hilltop is acknowledged for its ongoing efforts to support its human rights committee to be very familiar with individuals. The well-established system that involves quarterly reports from the appointed human right officer that are submitted regularly to the committee, describes how each individual was supported to address quality of life outcomes. This is a great illustration of the agency¿s commitment to carry out its mission of improving the life of individuals.   	

 	 	 	
 	Residential Commendations on Standards Met:	
 
 	Indicator #	Indicator	Commendations	

 

 

 

 	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 assuring that the staff are familiarized and trained to provide supports that address individuals' unique needs. Program orientation and ongoing training documentation demonstrated that all the staff received person-specific training. The agency recently implemented the use of a Manual of Responsibilities (MOR) at each 24 hour site. These manuals contained relevant information such as person¿s profile, ISP, and health related protocols. In addition, individuals' records were found to be consistently organized with updated information.  	
 	 	 	
 	Residential Areas Needing Improvement on Standards not met/Follow-up to occur:	
 
 	Indicator #	Indicator	Area Needing Improvement	

 	 L7	Fire drills are conducted as required.	The agency needs to ensure that fire drills are conducted in the respective quarters of the calendar year. Additionally,  fire drills' documentation needs to be accurate.  	

 	 L9	Individuals are able to utilize equipment and machinery safely. 	The agency needs to complete skill assessments to identify the person's ability to use equipment/machinery at home.   	

 

 
 	 L55	Informed consent is obtained from individuals or their guardians when required; Individuals or their guardians know that they have the right to withdraw consent.	The agency needs to ensure that informed consent that is secured prior to utilizing the individual's photo has an expiration day of a year after it is signed.	

 

 
 	 L67	There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	Where the agency staff hold an individual's money and provide support in the use of their funds, there needs to be a  plan for the money management responsibilities outlining the details of how the individual will be assisted to manage and spend their funds. The plan needs to include a training component to eliminate or reduce the need for assistance.   There also needs to be agreement to this plan by the individual, guardian or conservator. 	
 
 	 L69	Individual expenditures are documented and tracked.	The agency needs to ensure that individual's expenditures are properly documented and tracked.	

 	 L80	Support staff are trained to recognize signs and symptoms of illness.	The agency needs to ensure that the all staff has access to information regarding how to recognize signs and symptoms of illness. 	

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

 
 
 	 L86	Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	The agency needs to implement a tracking system to ensure that required assessments are submitted within fifteen (15) days prior to the scheduled ISP.	

 
 
CERTIFICATION FINDINGS

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

    Individual Home Supports	0/0	0/0	
    Residential Services	0/0	0/0	

 

 

 

 

 

 

 

 

 

 

 

 
MASTER SCORE SHEET LICENSURE
Organizational: HILLTOP CHILD ADULT SERS INC.
 
 	Indicator #	Indicator	Met/Rated	Rating(Met,Not Met,NotRated)	
O	 L2	Abuse/neglect reporting	5/5	Met	
 	 L3	Immediate Action	5/5	Met	
 	 L4	Action taken	5/5	Met	
 	 L48	HRC	1/1	Met	
 	 L74	Screen employees	2/2	Met	
 	 L76	Track trainings	7/7	Met	
 	 L83	HR training	6/7	Met(85.71 % )	
 
Residential and Individual Home Supports:

 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	

 	 L1	Abuse/neglect training	I	6/6	3/3	 

 
 	9/9	Met	
 
 	 L5	Safety Plan	L	2/2	 

 	2/2	Met	
O	 L6	Evacuation	L	2/2	 	 	 	2/2	Met	
 
 	 L7	Fire Drills	L	0/2	 

 	0/2	Not Met
(0 %)	

 	 L8	Emergency Fact Sheets	I	5/6	3/3	 

 
 	8/9	Met
(88.89 %)	

 	 L9	Safe use of equipment	L	1/2	 

 

 	1/2	Not Met
(50.0 %)	

 
 	 L10	Reduce risk interventions	I	1/1	 

 	 

 	 

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

 

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

 	2/2	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	
O	 L13	Clean location	L	2/2	 

 	2/2	Met	

 	 L14	Site in good repair	L	2/2	 

 

 	2/2	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	

 	 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	1/1	 

 	1/1	Met	

 	 L24	Locked door access	L	2/2	 

 

 	2/2	Met	

 	 L25	Dangerous substances	L	1/1	 

 

 	1/1	Met	
 
 	 L26	Walkway safety	L	2/2	 

 	2/2	Met	
 
 	 L28	Flammables	L	1/1	 

 	1/1	Met	

 	 L29	Rubbish/combustibles	L	2/2	 

 

 	2/2	Met	
 
 	 L30	Protective railings	L	1/1	 

 	1/1	Met	

 	 L31	Communication method	I	6/6	3/3	 

 
 	9/9	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	
 
 	 L32	Verbal & written	I	6/6	 

 	6/6	Met	
 
 	 L33	Physical exam	I	6/6	1/1	 
 	 
 	7/7	Met	
 
 	 L34	Dental exam	I	6/6	0/1	 
 	 
 	6/7	Met
(85.71 %)	
 
 	 L35	Preventive screenings	I	6/6	1/1	 
 	 
 	7/7	Met	
 
 	 L36	Recommended tests	I	3/3	1/1	 
 	 
 	4/4	Met	
 
 	 L37	Prompt treatment	I	6/6	1/1	 
 	 
 	7/7	Met	
O	 L38	Physician's orders	I	5/5	 

 	5/5	Met	

 	 L39	Dietary requirements	I	3/3	 

 

 	3/3	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	6/6	3/3	 

 
 	9/9	Met	
 
 	 L44	MAP registration	L	2/2	 

 	2/2	Met	
 
 	 L45	Medication storage	L	2/2	 

 	2/2	Met	
O	 L46	Med. Administration	I	5/5	 

 

 	5/5	Met	
 
 	 L47	Self medication	I	2/2	 

 	2/2	Met	

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

 
 	9/9	Met	
 
 	 L50	Respectful Comm.	L	2/2	3/3	 
 	 
 	5/5	Met	
 
 	 L51	Possessions	I	6/6	 

 	6/6	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	
 
 	 L52	Phone calls	I	6/6	 

 	6/6	Met	
 	 L53	Visitation	I	6/6	 	 	 	6/6	Met	
 	 L54	Privacy	L	2/2	 	 	 	2/2	Met	
 
 	 L55	Informed consent	I	0/6	 

 	0/6	Not Met
(0 %)	

 	 L61	Health protection in ISP	I	1/1	 

 

 	1/1	Met	

 	 L62	Health protection review	I	1/1	 

 

 	1/1	Met	

 	 L63	Med. treatment plan form	I	3/4	 

 

 	3/4	Met	

 	 L64	Med. treatment plan rev.	I	4/4	 

 

 	4/4	Met	
 
 	 L67	Money mgmt. plan	I	0/6	0/2	 
 	 
 	0/8	Not Met
(0 %)	

 	 L68	Funds expenditure	I	6/6	2/2	 

 
 	8/8	Met	
 
 	 L69	Expenditure tracking	I	6/6	0/2	 
 	 
 	6/8	Not Met
(75.00 %)	

 	 L70	Charges for care calc.	I	6/6	 

 

 	6/6	Met	

 	 L71	Charges for care appeal	I	6/6	 

 

 	6/6	Met	

 	 L77	Unique needs training	I	6/6	2/2	 

 
 	8/8	Met	

 	 L78	Restrictive Int. Training	L	1/1	 

 

 	1/1	Met	
 
 	 L80	Symptoms of illness	L	2/2	0/3	 
 	 
 	2/5	Not Met
(40.0 %)	
 
 	 L81	Medical emergency	L	2/2	3/3	 
 	 
 	5/5	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	
O	 L82	Medication admin.	L	2/2	 

 	2/2	Met	

 	 L84	Health protect. Training	I	1/1	 

 

 	1/1	Met	
 
 	 L85	Supervision 	L	2/2	3/3	 
 	 
 	5/5	Met	

 	 L86	Required assessments	I	3/6	3/3	 

 
 	6/9	Not Met
(66.67 %)	
 
 	 L87	Support strategies	I	5/6	3/3	 
 	 
 	8/9	Met
(88.89 %)	

 	 L88	Strategies implemented	I	6/6	2/3	 

 
 	8/9	Met
(88.89 %)	

 	#Std. Met/# 69 Indicator	 

 

 	 

 

 	62/69	 

 
 	Total Score	 

 	 

 	69/76	 

 	 

 	 

 	 
 	90.79%	 

 
MASTER SCORE SHEET CERTIFICATION
 	Certification - Planning and Quality Management	
 	Indicator #	Indicator	Met/Rated	Rating	
 	 C6	Future directions planning	1/1	Met