PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
Kennedy Donovan Center Inc.
One Commercial Street
 Foxboro, MA 02035    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
December 18, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
Kennedy Donovan Center Inc.	

	

	

	

	
Review Dates	

	
11/27/2018 - 12/3/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
12/18/2018	

	

	

	

	

	

	
Survey Team	

	
Michelle Boyd	

Katherine Gregory	

Michael Marchese	

Barbara Mazzella	

Tina Napolitan	

Scott Nolan (TL)	

Brian Grant	

Laurie Trasatti	

	

	

	

	

	

	
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	
22 location(s) 28 audit (s) 	
Full Review	
75 / 89 2 Year License 12/18/2018 -  12/18/2020	
	
 Certified 12/18/2018 -  12/18/2020	

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

Deemed	

ABI-MFP Residential Services	
1 location(s) 3 audit (s) 	

Deemed	

Placement Services	
14 location(s) 14 audit (s) 	

Deemed	

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

Deemed	

Planning and Quality Management (For all service groupings)	

	
Deemed	

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	
1 location(s) 3 audit (s) 	
Full Review	
28 / 29 2 Year License 12/18/2018 -  12/18/2020	
	
 Certified 12/18/2018 -  12/18/2020	

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

Deemed	

Planning and Quality Management (For all service groupings)	

	
Deemed	

	

	

EXECUTIVE SUMMARY :	

			
The Kennedy-Donovan Center is a Massachusetts based human service organization serving over 10,000 individuals and families in 160 towns across southeast and central Massachusetts and northeast Connecticut. The agency was founded in 1969; it provides a variety of services to children and adults such as early intervention, adult foster care, family support, and day habilitation supports.  The current review completed by the Department of Developmental Services (DDS) survey team encompassed the following service models; Residential Supports consisting of 24 hour residential services, Individualized Home Supports (IHS), and Placement services offered to adults with Intellectual/Developmental Disabilities, and 24 hour residential services for adults with acquired brain injury; and employment supports.. 

The scope of this survey conducted by the Office of Quality Enhancement (OQE) included a full review of all licensing indicators for residential and employment services.  The Kennedy Donovan Center utilized a deemed process (CARF) for the evaluation of certification indicators related to organizational, residential and employment services.

Within residential services, a variety of positive practices were noted in the area of health care coordination.  Individuals were supported to receive routine and preventative health care including; preventative screenings, and recommended tests and follow up appointments.  Findings also revealed that individuals had the necessary supports to manage significant health care conditions. Two individuals, who had significant complex medical issues, were supported by an agency nurse who consulted with specialists or attended appointments to ensure that home providers were providing proper care. 

Additionally, people were encouraged to participate in physical exercise to promote their health and overall well-being.  For example, two individuals attended a local gym to swim, play basketball and join exercise classes; while the agency assisted another individual to secure a grant to create a home gym.

The team identified positive outcomes in the areas of home safety.  Working smoke and carbon monoxide detectors and current inspections of heating equipment were found to be in place. Homes were clean and met the accessibility needs of those who lived there.  
 
Across all services, staff was observed to be respectful when interacting with individuals, taking the time to listen and ensure their privacy when discussing personal matters. Staff provided support so that individuals understood and could communicate in their primary language or other methods of communication.  In one home, a woman was apologizing for her feelings and staff were observed to comfort her and explain that she has a right to her feelings and there was no need for apologies.  Job coaches discretely provided support as needed, and met privately to address their concerns.

Within employment services, effective support strategies were developed and implemented.  Job coaches checked in regularly with individuals at their job sites and provided individualized supports. Individuals have successfully continued their employment with the same employer from five to fifteen years

This review also identified several licensing areas within the agency's residential supports that need strengthening.  A focus needs to be place on ensuring that staff is knowledgeable of and implement strategies for those individuals who are at risk of falling and are prescribed specialized diets. An emphasis should also be placed on ensuring essential strategies are in implemented when supporting people with the use of behavior modifying medications, behavior support plans and support and health related protections.  For instance data needs to be consistently collected regarding the observation of symptoms/target behaviors as outlined in behavior support plans and medication treatment plans. 
 
The agency needs to strengthen its practices when assisting individuals with managing their finances.  Where the agency has shared and/or delegated money management responsibilities, support plans need to include how much money the individual can handle independently while promoting the individual's growth and learning to the fullest extent possible. Tracking mechanisms need to be in place that document all transactions, individual expenditures and balances for all accounts that individuals are assisted to manage. 

There were issues identified across residential services that demonstrated that those providing oversight were not effectively monitoring that systems were in place.  For example within placement services, for six out of eleven individuals, even though monthly visits were conducted by case management staff, issues were identified regarding the management of individuals' funds such as a lack of systems to track expenditures.  Additionally, the monthly monitoring of medication administration did not identify a lack of medication administration recording mechanisms or inconsistencies in documentation at three out of eleven locations.  An emphasis needs to be place on providing staff additional training to fulfill their role to effectively provide oversight of systems and guidance to staff/home providers they oversee.  

Organizationally, the agency's Human Rights Committee (HRC) had been strengthened since the last survey, however continued efforts are needed.  A review of meeting minutes showed that improvements included regular attendance by member with requisite expertise and necessary discussion of items at meetings.  Areas that need to be enhanced include conducting regular review of policies and procedures that impact human rights and ensuring the committee composition meets regulation.

Based on the findings of this report, the agency has earned a Two Year License for Residential and Individual Home Support Services and a Two Year License for Employment Services. The DDS will conduct follow up within 60 days for any licensing indicators rated Not Met in Residential and Individual Home Supports.	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
66/79	
13/79	

    ABI-MFP Residential Services
    Placement Services
    Individual Home Supports
    Residential Services

	

Critical Indicators	
8/8	
0/8	

Total	
75/89	
14/89	
84%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
14	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
19/19	
0/19	

    Employment Support Services

	

Critical Indicators	
2/2	
0/2	

Total	
28/29	
1/29	
97%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
1	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
Although the agency has a Human Rights Committee that meets regularly, there are areas that need to be strengthen in order to improve its effectiveness, such as the review of agency policies and procedures and achieving the requisite membership composition. 	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L23	
There are no locks on bedroom doors that provide access to an egress.	
One home had bedrooms with doors leading to an egress.  The bedroom doors had locks. The agency needs to ensure that there are no locks on bedroom doors that lead to an egress.	

 L39	
Special dietary requirements are followed. 	
Four individuals were prescribed specialized diets.   In two circumstances, individuals were not supported to follow the recommendations of their physicians.  The agency needs to ensure that staff is knowledgeable concerning specialized diets and that supports are individualized to encourage individuals to adhere to physician's recommendations.  	

 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.	
For the two individuals for whom consent to use their photo had been sought, the consent form did not contain all the required information.  The agency need to ensure that  informed consents for the release of photographs include the specific purpose for release, the parties to whom it would be released, and the duration of its use	

 L60	
Data are consistently maintained and used to determine the efficacy of behavioral interventions.	
Six individuals who participated in the survey were supported with behavioral interventions. For three individuals, data was not maintained regularly on target behaviors The agency needs to ensure data is consistently maintained and reviewed to determine the efficacy of behavioral interventions.	

 L61	
Supports and health related protections are included in ISP assessments and the continued need is outlined.	
Four out of eleven individuals requiring supports and health related protections did not have all the necessary safeguards in place such as a written authorization for use by a licensed practitioner or staff implementing safety checks. The agency needs to ensure when a person utilizes supports and health related there is written plan for implementation that contains all the required components.	

 L63	
Medication treatment plans are in written format with required components.	
Six out of nineteen Medication Treatment Plans (MTP's) were reviewed as part of the survey, written plans did not include one or more of the following components: all behavior modifying medications were not included in the plans and/or data was not being collected to be provided to the prescribing practitioner to evaluate the clinical efficacy of the MTP. The agency needs to ensure Medication Treatment Plans include all of the behavior modifying medication(s) an individual is prescribed and is being implemented as written.	

 L64	
Medication treatment plans are reviewed by the required groups.	
Four out of sixteen Medication treatment Plans (MTP's) were not reviewed by the required groups. 	

 L67	
There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	
For ten out of twenty-five individuals the money management plan developed to outline the support needed to manage funds did not include one or more of the following components: level and type of staff support needed, how much money the person could manage independently, and/or all of the accounts/assets the person will manage or receive assistance to manage; and a training plan when appropriate.  The agency needs to ensure that written money management plans clearly outline the individual's level of independence, type of support to be provided and  a training plan to promote the individual's growth and learning to the fullest extent possible. 	

 L69	
Individual expenditures are documented and tracked.	
For ten out of twenty-three individuals for whom that agency had shared or delegated management money management responsibilities, there were issues identified related to the documenting of expenditures. The agency needs to ensure individual expenditures and documented, tracked and monitored	

 L85	
The agency provides ongoing supervision, oversight and staff development.	
At six out of twenty-two locations, a review of practices in place, related to areas such as medication administration and financial management, were not in accordance with agency policies/procedures and/or DDS expectations. Discussion with agency staff and home providers demonstrated a lack of knowledge of standards, and/or when these should apply, and how to monitor compliance.. The agency needs to ensure the supervision, oversight and monitoring provided is adequate to ensure the consistent implementation of systems across all residential services. 	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments for six individuals were not submitted within the 15 day time frame. The agency needs to ensure that assessments are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP 	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Support Strategies for six individuals were not submitted within the 15 day time frame. The agency needs to ensure that Support Strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting. 	

 L91	
Incidents are reported and reviewed as mandated by regulation.	
At one location visited there was an incident that was not reported.  For seven out of sixteen locations visited at which reportable incidents had occurred, there were instances in which incident reports had not been submitted and/or finalized within required timelines.  The agency needs to staff and home care providers are knowledgeable of the criteria for reportable incidents and that these are reported within required timelines.	

	

	MASTER SCORE SHEET LICENSURE	

					
	Organizational: Kennedy Donovan Center Inc.	

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

O	
 L2	
Abuse/neglect reporting	
22/22	
Met	

 L3	
Immediate Action	
15/15	
Met	

 L4	
Action taken	
15/15	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
12/15	
Met(80.0 % )	

 L66	
HRC restraint review	
13/13	
Met	

 L74	
Screen employees	
2/2	
Met	

 L75	
Qualified staff	
6/6	
Met	

 L76	
Track trainings	
18/20	
Met(90.0 % )	

 L83	
HR training	
20/20	
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	
14/14	
	
3/3	
	
28/28	
Met	

 L5	
Safety Plan	
L	
3/3	
3/3	
12/14	
	
1/1	
	
19/21	
Met
(90.48 %)	

O	
 L6	
Evacuation	
L	
3/3	
3/3	
12/14	
	
1/1	
	
19/21	
Met
(90.48 %)	

 L7	
Fire Drills	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L8	
Emergency Fact Sheets	
I	
6/7	
3/4	
14/14	
	
3/3	
	
26/28	
Met
(92.86 %)	

 L9	
Safe use of equipment	
L	
3/3	
4/4	

1/1	
	
8/8	
Met	

 L10	
Reduce risk interventions	
I	
2/4	
2/2	
3/3	
	
1/1	
	
8/10	
Met
(80.0 %)	

O	
 L11	
Required inspections	
L	
3/3	
2/2	
14/14	
	
1/1	
	
20/20	
Met	

O	
 L12	
Smoke detectors	
L	
3/3	
3/3	
14/14	
	
1/1	
	
21/21	
Met	

O	
 L13	
Clean location	
L	
3/3	
2/2	
14/14	
	
1/1	
	
20/20	
Met	

 L14	
Site in good repair	
L	
2/2	
2/2	
13/14	
	
1/1	
	
18/19	
Met
(94.74 %)	

 L15	
Hot water	
L	
2/3	
2/2	
13/14	
	
1/1	
	
18/20	
Met
(90.0 %)	

 L16	
Accessibility	
L	
3/3	
	
13/13	
	
1/1	
	
17/17	
Met	

 L17	
Egress at grade 	
L	
3/3	
	
6/6	
	
1/1	
	
10/10	
Met	

 L18	
Above grade egress	
L	
1/1	
	
5/5	

	
6/6	
Met	

 L19	
Bedroom location	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L20	
Exit doors	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L21	
Safe electrical equipment	
L	
3/3	
2/2	
14/14	
	
1/1	
	
20/20	
Met	

 L22	
Well-maintained appliances	
L	
2/3	
2/2	
13/14	
	
1/1	
	
18/20	
Met
(90.0 %)	

 L23	
Egress door locks	
L	

	
	
0/1	
	
0/1	
Not Met
(0 %)	

 L24	
Locked door access	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L25	
Dangerous substances	
L	
3/3	
2/2	

1/1	
	
6/6	
Met	

 L26	
Walkway safety	
L	
3/3	
2/2	
14/14	
	
1/1	
	
20/20	
Met	

 L27	
Pools, hot tubs, etc.	
L	

3/3	

	
3/3	
Met	

 L28	
Flammables	
L	
3/3	

	
1/1	
	
4/4	
Met	

 L29	
Rubbish/combustibles	
L	
3/3	
2/2	
13/14	
	
1/1	
	
19/20	
Met
(95.00 %)	

 L30	
Protective railings	
L	
2/2	
2/2	
11/11	
	
1/1	
	
16/16	
Met	

 L31	
Communication method	
I	
7/7	
4/4	
14/14	
	
3/3	
	
28/28	
Met	

 L32	
Verbal & written	
I	
7/7	
4/4	
14/14	
	
3/3	
	
28/28	
Met	

 L33	
Physical exam	
I	
7/7	
3/3	
14/14	
	
3/3	
	
27/27	
Met	

 L34	
Dental exam	
I	
7/7	
3/3	
14/14	
	
3/3	
	
27/27	
Met	

 L35	
Preventive screenings	
I	
6/7	
3/3	
14/14	
	
3/3	
	
26/27	
Met
(96.30 %)	

 L36	
Recommended tests	
I	
7/7	
3/3	
14/14	
	
3/3	
	
27/27	
Met	

 L37	
Prompt treatment	
I	
7/7	
2/2	
13/13	
	
3/3	
	
25/25	
Met	

O	
 L38	
Physician's orders	
I	
5/6	
	
9/9	
	
3/3	
	
17/18	
Met
(94.44 %)	

 L39	
Dietary requirements	
I	
0/3	
	
5/6	

	
5/9	
Not Met
(55.56 %)	

 L40	
Nutritional food	
L	
3/3	
3/3	

1/1	
	
7/7	
Met	

 L41	
Healthy diet	
L	
3/3	
4/4	
14/14	
	
1/1	
	
22/22	
Met	

 L42	
Physical activity	
L	
3/3	
4/4	
14/14	
	
1/1	
	
22/22	
Met	

 L43	
Health Care Record	
I	
6/7	
4/4	
14/14	
	
3/3	
	
27/28	
Met
(96.43 %)	

 L44	
MAP registration	
L	
3/3	
2/2	

1/1	
	
6/6	
Met	

 L45	
Medication storage	
L	
3/3	
2/2	

1/1	
	
6/6	
Met	

O	
 L46	
Med. Administration	
I	
5/7	
1/1	
10/12	
	
3/3	
	
19/23	
Met
(82.61 %)	

 L47	
Self medication	
I	
7/7	
4/4	
14/14	
	
3/3	
	
28/28	
Met	

 L49	
Informed of human rights	
I	
7/7	
4/4	
14/14	
	
3/3	
	
28/28	
Met	

 L50	
Respectful Comm.	
L	
3/3	
4/4	
14/14	
	
1/1	
	
22/22	
Met	

 L51	
Possessions	
I	
7/7	
4/4	
13/14	
	
3/3	
	
27/28	
Met
(96.43 %)	

 L52	
Phone calls	
I	
7/7	
4/4	
14/14	
	
3/3	
	
28/28	
Met	

 L53	
Visitation	
I	
7/7	
4/4	
14/14	
	
3/3	
	
28/28	
Met	

 L54	
Privacy	
L	
2/3	
4/4	
14/14	
	
1/1	
	
21/22	
Met
(95.45 %)	

 L55	
Informed consent	
I	
0/2	

	

0/2	
Not Met
(0 %)	

 L56	
Restrictive practices	
I	
1/1	
	
2/2	

	
3/3	
Met	

 L57	
Written behavior plans	
I	
4/4	
1/1	

1/1	
	
6/6	
Met	

 L58	
Behavior plan component	
I	
4/4	
1/1	

1/1	
	
6/6	
Met	

 L59	
Behavior plan review	
I	
3/4	
1/1	

1/1	
	
5/6	
Met
(83.33 %)	

 L60	
Data maintenance	
I	
2/4	
1/1	

0/1	
	
3/6	
Not Met
(50.0 %)	

 L61	
Health protection in ISP	
I	
1/5	
	
3/3	
	
3/3	
	
7/11	
Not Met
(63.64 %)	

 L62	
Health protection review	
I	
5/5	
	
3/3	
	
3/3	
	
11/11	
Met	

 L63	
Med. treatment plan form	
I	
5/7	
2/3	
4/6	
	
2/3	
	
13/19	
Not Met
(68.42 %)	

 L64	
Med. treatment plan rev.	
I	
5/5	
0/3	
5/5	
	
2/3	
	
12/16	
Not Met
(75.00 %)	

 L67	
Money mgmt. plan	
I	
5/7	
1/4	
8/13	
	
1/1	
	
15/25	
Not Met
(60.0 %)	

 L68	
Funds expenditure	
I	
7/7	
3/4	
12/13	
	
1/1	
	
23/25	
Met
(92.00 %)	

 L69	
Expenditure tracking	
I	
5/7	
3/4	
5/11	
	
0/1	
	
13/23	
Not Met
(56.52 %)	

 L70	
Charges for care calc.	
I	
7/7	
1/1	
13/13	
	
3/3	
	
24/24	
Met	

 L71	
Charges for care appeal	
I	
5/7	
1/1	
13/13	
	
3/3	
	
22/24	
Met
(91.67 %)	

 L77	
Unique needs training	
I	
7/7	
4/4	
14/14	
	
3/3	
	
28/28	
Met	

 L78	
Restrictive Int. Training	
L	
2/3	
1/1	

1/1	
	
4/5	
Met
(80.0 %)	

 L79	
Restraint training	
L	
2/2	
2/2	

	
	
4/4	
Met	

 L80	
Symptoms of illness	
L	
3/3	
4/4	
13/14	
	
1/1	
	
21/22	
Met
(95.45 %)	

 L81	
Medical emergency	
L	
3/3	
4/4	
14/14	
	
1/1	
	
22/22	
Met	

O	
 L82	
Medication admin.	
L	
3/3	
2/2	

1/1	
	
6/6	
Met	

 L84	
Health protect. Training	
I	
4/5	
	
3/3	
	
3/3	
	
10/11	
Met
(90.91 %)	

 L85	
Supervision 	
L	
2/3	
3/4	
10/14	
	
1/1	
	
16/22	
Not Met
(72.73 %)	

 L86	
Required assessments	
I	
3/6	
1/3	
11/12	

	
15/21	
Not Met
(71.43 %)	

 L87	
Support strategies	
I	
4/6	
0/2	
11/12	

	
15/20	
Not Met
(75.00 %)	

 L88	
Strategies implemented	
I	
4/7	
4/4	
13/14	
	
3/3	
	
24/28	
Met
(85.71 %)	

 L89	
Complaint and resolution process	
L	

	
	
1/1	
	
1/1	
Met	

 L90	
Personal space/ bedroom privacy	
I	
7/7	
3/3	
13/14	
	
3/3	
	
26/27	
Met
(96.30 %)	

 L91	
Incident management	
L	
0/3	
1/2	
8/10	
	
0/1	
	
9/16	
Not Met
(56.25 %)	

#Std. Met/# 79 Indicator	

	

	

66/79	

	
Total Score	

	

	

75/89	

	

	

	

	
84.27%	

		
							
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	
3/3	

3/3	
Met	

 L8	
Emergency Fact Sheets	
I	
3/3	

3/3	
Met	

 L10	
Reduce risk interventions	
I	
1/1	

1/1	
Met	

 L31	
Communication method	
I	
3/3	

3/3	
Met	

 L32	
Verbal & written	
I	
3/3	

3/3	
Met	

 L37	
Prompt treatment	
I	
3/3	

3/3	
Met	

O	
 L38	
Physician's orders	
I	
1/1	

1/1	
Met	

 L49	
Informed of human rights	
I	
3/3	

3/3	
Met	

 L50	
Respectful Comm.	
L	
1/1	

1/1	
Met	

 L51	
Possessions	
I	
3/3	

3/3	
Met	

 L52	
Phone calls	
I	
3/3	

3/3	
Met	

 L54	
Privacy	
L	
1/1	

1/1	
Met	

 L77	
Unique needs training	
I	
3/3	

3/3	
Met	

 L80	
Symptoms of illness	
L	
1/1	

1/1	
Met	

 L81	
Medical emergency	
L	
1/1	

1/1	
Met	

 L85	
Supervision 	
L	
1/1	

1/1	
Met	

 L86	
Required assessments	
I	
3/3	

3/3	
Met	

 L87	
Support strategies	
I	
3/3	

3/3	
Met	

 L88	
Strategies implemented	
I	
3/3	

3/3	
Met	

#Std. Met/# 19 Indicator	

	

19/19	

	
Total Score	

	

28/29	

	

	

	
96.55%	

		
							
	MASTER SCORE SHEET CERTIFICATION