PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
LIFESTREAM INC
PO BOX 50487
 New Bedford, MA 02745    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
September 21, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
LIFESTREAM INC	

	

	

	

	
Review Dates	

	
8/30/2018 - 9/5/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
9/21/2018	

	

	

	

	

	

	
Survey Team	

	
Katherine Gregory	

Michael Marchese	

Tina Napolitan	

Scott Nolan	

Laura O'Connor	

Ed Sutka (TL)	

Barbara Mazzella	

	

	

	

	

	

	
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	
17 location(s) 20 audit (s) 	
Targeted Review	
DDS 13 / 14
Provider 75 / 75

88 / 89 2 Year License 09/21/2018-  09/21/2020	
	
DDS 74 / 76
Provider 18 / 18

92 / 94 Certified 09/21/2018 -  09/21/2020	

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

DDS Targeted Review	
22 / 22	

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

DDS Targeted Review	
21 / 22	

Placement Services	
5 location(s) 6 audit (s) 	

DDS Targeted Review	
21 / 22	

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

DDS Targeted Review	
22 / 22	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 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	
2 location(s) 6 audit (s) 	
Targeted Review	
DDS 15 / 15
Provider 47 / 48

62 / 63 2 Year License 09/21/2018-  09/21/2020	
	
DDS 22 / 24
Provider 18 / 18

40 / 42 Certified 09/21/2018 -  09/21/2020	

Community Based Day Services	
1 location(s) 3 audit (s) 	

DDS Targeted Review	
14 / 14	

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

DDS Targeted Review	
20 / 22	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

LifeStream, Inc. (LifeStream) is a private, non-profit human service agency, which was founded in 1976 by a group of concerned parents.  While the agency has grown significantly in size over the years, it has continued to concentrate its services in the New Bedford and Fall River areas.  Supports offered by LifeStream encompass a broad spectrum of services for adults and children with intellectual disabilities and individuals with Acquired Brain Injury.  The current review focused on services provided to adults and included the following residential service types: twenty-four hour supports, less than twenty-four hour supports, and shared living supports.  Day support services that were evaluated included two service types: employment supports and community based day supports (CBDS). 
 
As LifeStream had earned a Two-Year License for its day and residential supports during the previous review, the agency was eligible to conduct a self-assessment, which it elected to do.  In conjunction with the agency's self-assessment, DDS conducted a "Targeted Review" which consisted of the eight licensing indicators considered "critical" as well as any licensing or certification indicators which were new or which had been strengthened since the last review.  The results of the current survey represent a combination of the DDS targeted review and the agency's self-assessment.

A number of strengths were found in the agency's residential services.  For instance, within the licensing requirements, homes were found to be safe and in good repair.  Requirements relating to the Medication Administration Program (MAP) were found to be consistently in place.  Staff were aware of their roles as reporters of abuse, neglect and mistreatment, and could articulate these responsibilities.  

Within the certification indicators, a number of commendable practices were noted in relation to residential supports.  For instance, consistent efforts were made, particularly within Acquired Brain Injury (ABI) services, to assist people to participate in community activities that matched their interests.  Efforts to involve people in the hiring and evaluation of their staff were consistently seen, and were particularly effective within 24 hour residential supports and shared living.  Supports provided through the shared living model had also been helpful in assisting people to explore their needs for intimacy and companionship.  

Additionally, staff's assistance to support informed decision making had been of benefit to people in several areas, including helping them to exercise increased choice and control over their leisure time activities.  Staff were also helpful to individuals in providing input that helped them make major life decisions.  For example, one woman was provided with information and guidance in making a decision about the care of her toddler, while another individual who was active in a faith community chose to be baptized after discussing his wishes with staff. 

A number of positive outcomes were seen in the agency's day supports that related to the licensing domains of personal and environmental safety.  Requirements, such as ensuring working smoke detectors and maintaining a safe environment, were found to be consistently in place.  

A focus of the agency's CBDS activities was to facilitate opportunities for individuals to use generic resources and to develop relationships with community partners, such as the library, the YMCA, or local restaurants.  Some of the individuals participating in CBDS were also involved in volunteer activities that were of interest to them.  In addition, people receiving CBDS regularly participated in community activities, some of which were offered twice a week to give people an additional opportunity to enjoy preferred events that they would have otherwise missed due to their employment schedules.         

Individuals who received employment supports earned minimum wage and commented that they were excited to work at jobs they enjoyed.  Staff support was tailored to encouraging independence while providing assistance to the extent needed.  Assessments were in place which identified skills and interests that assisted in developing career paths.  While people who participated in employment supports were generally experiencing success, a need was identified to more fully explain benefit protection strategies for people who are employed or who are pursuing employment.  As well, it is recommended that further efforts be made to assist people who receive employment supports to use assistive technology in ways that would enhance their independence.  

Based on the findings of this report, LifeStream has earned a Two-Year License and is Certified for both the Residential Supports group and the Employment and Day Supports group.  Residential scores were 99% in licensing and 96% in certification; day support scores were 98% for licensing and 95% for certification.   Within sixty days, the agency will conduct its own follow-up on any licensing indicators rated Not Met and submit the results to the DDS Office of Quality Enhancement.  The agency's description of its self-assessment process follows.	

	

	

	

Description of Self Assessment Process:	

	

	

LifeStream, Inc. has developed a quality assurance program to ensure compliance with all regulations and the provision of quality supports across the agency. The tool used to evaluate services across the organization is based on DDS licensure standards as well as best practices across the organization. All programs are audited internally at least twice a year by Program Coordinators and/or Program Directors along with Nursing Coordinators and Director of Quality Assurance. The result of the audits along with action plans for any findings are reviewed by Program Directors. Action plans include timeline for implementation and completion. The Agency added a Quality Assurance Consultant to complete additional off- cycle audits of LifeStream systems.

LifeStream's Program Review Committee is comprised of members of the Board of Directors and Senior Management. The committee's purpose is to develop a system that monitors the ongoing performance of all aspects of LifeStream's programs and services. The committee looks at agency progress by yearly comparison of specific benchmarks and against industry statistics. The committee presents to the Board of Directors quarterly to review incident management, investigations, medication administration occurrences and human resources statistics along with employee and consumer satisfaction. During each review the committee evaluates changes and trends in organizational performance and identifies areas needing improvement.

In addition to our standardized Quality Assurance Reviews, LifeStream has several other quality assurance systems in place:

* Health and Safety:  Nursing staff review all medication administration documentation monthly at the program site. This review occurs at the end of the month to ensure accuracy of current medication administration and carry over to the next month. Nursing staff along with management also review all PRN medication and documentation during this review. RN Coordinators act as a liaison for all hospitalization admissions and discharges, write quarterly medical assessments and review all physician encounters to address any concerns or follow-up required. Assessing RNs are available to help with hospital discharges and to provide person-specific trainings for new equipment or doctor's orders as needed. Lab work is also tracked by our nursing department.  An RN Coordinator is on call 24/7.

* Property and Vehicle Safety: LifeStream's Director of Facilities and Asset Management oversees our Facility Department. The Facilities Manager is on call 24/7. Structural systems such as HVAC, fire alarms, sprinklers, generators and lift systems are inspected annually by licensed technicians in the respective areas. Annual inspections are conducted and work orders generated based on inspection findings. Work orders are submitted electronically as needed for routine corrective and preventive maintenance. Vehicles are inspected monthly by a third party vendor to ensure safety.

* Staff Development: LifeStream's Education and Training Division is certified by the Commonwealth as a private business school. Our Training Department maintains a training database that tracks all required training. This information is distributed to all managers on a monthly and/or as needed basis to ensure on-going training compliance. All employees attend an extensive orientation program that includes: Introduction to Developmental Services, Human Rights and Mandated Reporting, CPR, First Aid, Medication Administration, Vital Signs, Universal Precautions, Body Mechanics, NVMAB, Nutrition, Dysphasia and Meal Preparation, Positive Behavior Supports, Formal Fire Safety, Human Service Worker Safety 1 and 2 and agency Policies and Procedures. Site-specific and consumer-specific training occurs at the program location. LifeStream is an approved testing site for the Medication Administration Program. Registered Nurses provide training in g-tube nutrition, flushes and medication administration. LifeStream maintains a Staff Training and Development Course Catalog with over 100 training topics offered on an as- needed basis. LifeStream has trainers on staff in the following areas: Medication Administration, Certified Nursing Aide, NVMAB, Positive Behavior Supports, CPR, First Aid, Human Rights, Abuse Prevention, Dysphagia, Human Service Worker Safety and Nutrition. LifeStream employs 7 registered nurses who are all trained MAP consultants. LifeStream actively participates on the New Bedford and regional training committees.
* Interdisciplinary Team: LifeStream's Interdisciplinary Team (IDT) members include nursing, quality assurance, therapy services, psychology, management and direct care support. DDS personnel are invited to participate in LifeStream's IDT meetings. This IDT team meets twice a month to review individuals at risk medically or behaviorally. LifeStream employs 3 master's level clinicians and 2 doctorate level consultants within our Psychology Department.

* Human Rights: LifeStream's Human Rights Committee meets 10 times yearly and has a full complement of required membership. The Human Rights Committee reviews incidents, restraints, restrictive procedures, behavior plans, investigations, human rights complaints and supportive and protective devices. In addition, the committee reviews Agency analytics throughout the year including significant incident trends, satisfaction surveys etc. The Human Rights Committee conducts annual site visits to a sample of residential homes, meets with individuals and staff and shares findings and recommendations with the Agency. LifeStream mails a Human Rights newsletter to individuals and family quarterly along with the LifeStream grievance policy and specific information on abuse and DPPC annually. The Senior Director of Clinical Services meets with all human rights officers two times a year to provide on-going education. Individuals meet with their Human Rights Officer monthly to review information regarding their rights. LifeStream also has a Human Rights Complaint Form that can be completed and submitted to the Human Rights Committee. A telephone hot line is also in place to assist those who would like to submit a complaint privately. Only the Senior Director of Clinical Services and Human Rights Chair have access to retrieve messages from the Human Rights hotline.

* Standards Committee: LifeStream's Standards Committee includes representation across the agency with expertise in several disciplines. The committee meets monthly to develop standardized forms, procedures and to ensure implementation of systems throughout the agency. The Standards Committee keeps apprised of new initiatives and regulations and updates agency procedures as needed. This committee also audits programs to ensure consistent use and implementation of standardized procedures, protocols and forms.

* Safety Committee: LifeStream's Safety Committee meets monthly to review all work-related injuries and safety concerns. The committee has initiated several programs to ensure safe practices throughout the agency. Protocols such as 'safe lifting' and 'transportation safety' have been developed and implemented by the Safety Committee. The committee conducts audits to ensure compliance with safe practices through unannounced van inspections and 1:1 observation of wheelchair securement procedures for transportation. The committee attends house meetings to discuss program- specific safety concerns as needed and provides education as it relates to safety procedures. Safety Concern forms are available at each location for individual and employee use. All completed forms are forwarded to the Safety Committee for review and recommendation.

LifeStream received a Two-Year License during its last DDS Licensing and Certification Survey, meeting 100% of all indicators for residential supports and 97% for day supports.  LifeStream has chosen to conduct a self-assessment audit.

The Chief Operating Officer, Senior Director of Clinical Services, Director of Quality Assurance and Quality Assurance Consultant, along with the leadership of each program, utilized the DDS Licensure Tool along with the Office of Quality Management, Office of Quality Enhancement's 45 day letter to develop the sample size and conduct each individual survey. The surveys were conducted between July 4th and July 9th of 2018.  The Director of Quality Assurance, Therapy Services Director, Senior Director of Clinical Services, Nursing Coordinators and Program Directors worked in teams to conduct each individual survey. This approach ensured expertise in psychology, nursing and program management for each survey conducted. All program locations audited were given a 7 day notice.  However, individuals being surveyed were only identified on the day of the audit.

LifeStream used 80% as the threshold to determine if an indicator was Met or Not Met. All audits included interviews with staff/care provider and individuals along with documentation reviews and visits to the home/work location:

* 32% of 24/7 Residential Programs were surveyed. One home under each Program Coordinator was randomly selected allowing for a sampling across several different management teams. This approach was taken to ensure agency systems are in place throughout the organization. In total, 9 residential homes were audited, including 9 individuals from Cluster A and 7 individuals from Cluster B.
* 5 Individual/Home Support service locations were audited. Individuals chosen represented a sample across management in the New Bedford and Fall River areas.

* 25% of Placement services or 6 individuals were selected. The audit included interviews with the caregiver and the individual served along with documentation reviews and visits to the home location.

* Three individuals from Supported Employment and three individuals from Community-Based Day Support were audited. A combination of individuals from Cluster A and Cluster B were audited. 

* Each audit team was responsible for reviewing all data and determining what indicators were met or not met for each individual audited. 

* This information was given to the Chief Operating Officer for review and inclusion into the Provider Assessment Report.
All indicators at the Organizational level were reviewed by the Chief Operating Officer along with the Director of Quality Assurance and the Quality Assurance Consultant. 

* All Organizational Licensing and Certification indicators were identified as MET.

* There was one unmet licensing indicator in Residential and Home Supports.

L91 (Incident Management) 
Incident reports were filed appropriately but initial and final reports were not submitted within timelines. 

   *  There was one unmet licensing indicator in Employment and Day Supports: 

L8 (Emergency Fact Sheets). Diagnoses did not match health care records in 2 of 9 records reviewed.

   * There was one unmet certification indicator in Residential Services:

C 17 (Community Activities) People could have been offered more opportunities to have meaningful interaction with their communities.	

	

	

	

LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Residential and Individual Home Supports	
78/79	
1/79	

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

	

Critical Indicators	
8/8	
0/8	

Total	
88/89	
1/89	
99%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
1	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Employment and Day Supports	
52/53	
1/53	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
8/8	
0/8	

Total	
62/63	
1/63	
98%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
1	

	

	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L91	
Incidents are reported and reviewed as mandated by regulation.	
For all 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 ensure that required timelines to submit and/or finalize Incident Reports are adhered to.	

	

	

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

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L8	
Emergency fact sheets are current and accurate and available on site.	
Diagnoses on Emergency Fact Sheets for two out of the nine individuals reviewed did not match the individual's health care record.	
LifeStream reviewed all emergency fact sheets of individuals in Employment and Day Supports and ensured that they matched their Health Care Records. All emergency fact sheets are in compliance at this time.	

	

	
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 73/75
Provider 13/13	
86/88	
2/88	

ABI-MFP Placement Services	
DDS 0/0	
0/0	
0 / 0	

ABI-MFP Residential Services	
DDS 18/19
Provider 3/3	
21/22	
-2/22	

Individual Home Supports	
DDS 18/18
Provider 4/4	
22/22	
-4/22	

Placement Services	
DDS 18/19
Provider 3/3	
21/22	
-2/22	

Residential Services	
DDS 19/19
Provider 3/3	
22/22	
-3/22	

Total	
	
92/94	
2/94	
98%	

Certified	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

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

Employment and Day Supports	
DDS 21/23
Provider 13/13	
34/36	
2/36	

Community Based Day Services	
DDS 11/11
Provider 3/3	
14/14	
-3/14	

Employment Support Services	
DDS 10/12
Provider 10/10	
20/22	
-8/22	

Total	
	
40/42	
2/42	
95%	

Certified	

	

	

	

	

	

	
ABI-MFP Residential Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Staff provided ongoing support to ensure that individuals are actively engaging in religious, cultural and social activities of their interest and preference.  In a number of instances these supports have been commendable for the level of effort and involvement by staff.  For example, two individuals have been supported to attend weekly religious services, one of whom has reconnected with his local church/parish in the city where he previously lived.  Staff bring him to Sunday mass each week and to many of the parish's cultural/religious events.  As a result he has reestablished old relationships with the church's pastor and fellow parishioners.  The other individual has connected with a fellow parishioner that has resulted in the possibility of becoming a volunteer speaker to local youth groups.  For another individual, staff has supported his interest in rock n' roll music.  Through their efforts to arrange the necessary accommodations, despite his extensive physical challenges, he has been able to attend numerous concerts at venues such as Gillette Stadium, and Xfinity Center.  The agency is commended for its commitment to ensure that individuals are supported to fully participate in activities on a consistent and sustained basis.       	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C48	
Individuals are a part of the neighborhood.	
For three individuals there was no evidence that staff had provided them with opportunities to explore a possible connection with a neighbor who engaged in an area of potential interest.  The agency needs to support individuals to develop connections with neighbors through regular opportunities.     	

	

	

	

Placement Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
The agency implemented a comprehensive process for ensuring that individuals were actively involved in the selection of placement providers to ensure that their lifestyle choices and unique needs were accommodated. For example, one individual commented that this was the first living arrangement that supported and respected her choices while offering her opportunities to provide feedback on an ongoing basis. The agency is commended for its processes for involving individuals in the selection of placement providers and for soliciting their input on satisfaction with providers on an on-going basis. 	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
The agency is commended for providing ongoing opportunities which created a means for individuals to develop and maintain close relationships. Individuals were supported to visit with companions at their homes and enjoy a variety of community activities. In one instance, an individual was also supported to explore gender identify and potential inclusive communities.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Six individuals were reviewed regarding their need for assistive technology to maximize their independence. Of these, two individuals were not assessed to determine if any assistive technology and/or modifications could maximize their abilities to do things with greater independence. The agency needs to ensure that assessments are completed and strategies implemented to support individuals to use assistive technology to enhance independence. 	

	

	

	
Residential Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
Staff used a variety of formats based upon people's learning and communication styles to elicit people's feedback relating to the hiring and evaluation of their staff.  For instance, one person's intended questions for prospective staff were programmed into an App in his iPad, so that it could be activated during the interview process.  Staff are commended for their comprehensive efforts in this area.   	

	
 C19	
The provider assists individuals to make knowledgeable decisions. 	
Staff provided people with education and encouragement based on their learning and communication styles, while respecting their right to be the ultimate decision makers.  For instance, staff recognized that one gentleman could make decisions more effectively when presented with a small menu of items rather than a large one.  Staff are commended for their effectiveness in assisting people to make knowledgeable decisions.	

	
 C52	
Individuals have choice and control over their leisure and non-scheduled activities.	
Staff supported people to have control over their leisure time and to enjoy activities that matched their personal preferences to the maximum extent possible.  For instance, one woman was supported to enjoy a variety of hobbies of her choosing, including making necklaces with beads and putting together 300 piece puzzles.  A special area was set up to facilitate her work on these projects.  This woman's request to buy many of the items relating to these hobbies was also respected.  Staff are commended for their on-going support in assisting people to exercise choice and control over their leisure activities.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 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.	
An analysis of how future earnings could potentially impact benefits was not done for two out of three individuals. The agency needs to ensure that an analysis regarding individuals' future earnings could impact entitlements is conducted with individuals and guardians. 	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Three individuals were reviewed regarding their need for assistive technology to maximize their independence. Although one individual was assessed regarding her need for assistive technology in the workplace, strategies and or interventions to increase her independence were not identified. 	

	

	

	

	MASTER SCORE SHEET LICENSURE	

								
	Organizational: LIFESTREAM INC	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
19/19	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
Provider	
-	
Met	

 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	

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

O	
 L6	
Evacuation	
L	
DDS	
7/7	
4/4	
5/5	
	
1/1	
	
17/17	
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	
7/7	
	
4/5	
	
1/1	
	
12/13	
Met
(92.31 %)	

O	
 L12	
Smoke detectors	
L	
DDS	
7/7	
4/4	
4/5	
	
1/1	
	
16/17	
Met
(94.12 %)	

O	
 L13	
Clean location	
L	
DDS	
7/7	
	
5/5	
	
1/1	
	
13/13	
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	
Well-maintained 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	
7/7	
2/2	
3/3	
	
3/3	
	
15/15	
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	
7/7	
3/3	
1/2	
	
3/3	
	
14/15	
Met
(93.33 %)	

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

 L49	
Informed of human rights	
I	
DDS	
7/7	
4/4	
6/6	
	
3/3	
	
20/20	
Met	

 L50	
Respectful Comm.	
L	
DDS	
7/7	
4/4	
5/5	
	
1/1	
	
17/17	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
7/7	
4/4	
6/6	
	
3/3	
	
20/20	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
7/7	
4/4	
5/5	
	
1/1	
	
17/17	
Met	

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

 L56	
Restrictive practices	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
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	

 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	
7/7	
1/1	

1/1	
	
9/9	
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	

 L89	
Complaint and resolution process	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
7/7	
4/4	
6/6	
	
3/3	
	
20/20	
Met	

 L91	
Incident management	
L	
DDS	
0/7	
0/4	
0/4	
	
0/1	
	
0/16	
Not Met
(0 %)	

#Std. Met/# 79 Indicator	

	

	

	
78/79	

	
Total Score	

	

	

	
88/89	

	

	

	

	
	
98.88%	

			
								
Employment and Day Supports:	

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

 L1	
Abuse/neglect training	
I 	
Provider	
	
-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	

1/1	
1/1	
Met	

 L7	
Fire Drills	
L 	
Provider	
	
-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
	
-	
-	
-	
Not Met

	
 L9	
Safe use of equipment	
L 	
Provider	
	
-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L11	
Required inspections	
L	
DDS	

1/1	
1/1	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	

1/1	
1/1	
Met	

O	
 L13	
Clean location	
L	
DDS	

1/1	
1/1	
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	

 L20	
Exit doors	
L 	
Provider	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
	
-	
-	
-	
Met	

 L22	
Well-maintained appliances	
L 	
Provider	
	
-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
	
-	
-	
-	
Met	

 L26	
Walkway safety	
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	

 L37	
Prompt treatment	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	

3/3	
3/3	
Met	

 L39	
Dietary requirements	
I 	
Provider	
	
-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	

3/3	
3/3	
Met	

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

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

 L51	
Possessions	
I 	
Provider	
	
-	
-	
-	
Met	

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

 L54	
Privacy	
L	
DDS	
1/1	
	
1/1	
2/2	
Met	

 L56	
Restrictive practices	
I 	
Provider	
	
-	
-	
-	
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	

 L63	
Med. treatment plan form	
I	
DDS	

2/2	
2/2	
Met	

 L64	
Med. treatment plan rev.	
I	
DDS	

2/2	
2/2	
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	
1/1	
	
1/1	
2/2	
Met	

 L85	
Supervision 	
L 	
Provider	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
	
-	
-	
-	
Met	

 L87	
Support strategies	
I	
Provider	
	
-	
-	
-	
Met	

 L88	
Strategies implemented	
I 	
Provider	
	
-	
-	
-	
Met	

 L91	
Incident management	
L	
DDS	

1/1	
1/1	
Met	

#Std. Met/# 52 Indicator	

	

	
52/53	

	
Total Score	

	

	
62/63	

	

	

	
	
98.41%	

			
								
	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	

	

	

	
								
ABI-MFP Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider 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	
1/1	
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	
0/3	
Not Met (0 %)	

 C49	
Physical setting is consistent 	
DDS	
1/1	
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	
2/2	
Met	

Community Based Day Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
3/3	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C13	
Skills to maximize independence 	
DDS	
3/3	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C40	
Community involvement interest	
DDS	
3/3	
Met	

 C41	
Activities participation	
DDS	
3/3	
Met	

 C42	
Connection to others	
DDS	
3/3	
Met	

 C43	
Maintain & enhance relationship	
DDS	
3/3	
Met	

 C44	
Job exploration	
Provider	
-	
Met	

 C45	
Revisit decisions	
DDS	
3/3	
Met	

 C46	
Use of generic resources	
DDS	
3/3	
Met	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

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

 C54	
Assistive technology	
DDS	
3/3	
Met	

Employment Support Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
3/3	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C22	
Explore job interests	
Provider	
-	
Met	

 C23	
Assess skills & training needs	
DDS	
3/3	
Met	

 C24	
Job goals & support needs plan	
Provider	
-	
Met	

 C25	
Skill development	
Provider	
-	
Met	

 C26	
Benefits analysis	
DDS	
1/3	
Not Met (33.33 %)	

 C27	
Job benefit education	
DDS	
3/3	
Met	

 C28	
Relationships w/businesses	
DDS	
1/1	
Met	

 C29	
Support to obtain employment	
Provider	
-	
Met	

 C30	
Work in integrated settings	
DDS	
3/3	
Met	

 C31	
Job accommodations	
Provider	
-	
Met	

 C32	
At least minimum wages earned	
Provider	
-	
Met	

 C33	
Employee benefits explained	
DDS	
3/3	
Met	

 C34	
Support to promote success	
DDS	
3/3	
Met	

 C35	
Feedback on job performance	
Provider	
-	
Met	

 C36	
Supports to enhance retention	
Provider	
-	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C50	
Involvement/ part of the Workplace culture	
DDS	
3/3	
Met	

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

 C54	
Assistive technology	
DDS	
2/3	
Not Met (66.67 %)	

Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
4/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
4/4	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
4/4	
Met	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C14	
Choices in routines & schedules	
DDS	
4/4	
Met	

 C15	
Personalize living space	
DDS	
4/4	
Met	

 C16	
Explore interests	
DDS	
4/4	
Met	

 C17	
Community activities	
DDS	
4/4	
Met	

 C18	
Purchase personal belongings	
DDS	
4/4	
Met	

 C19	
Knowledgeable decisions	
DDS	
4/4	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C21	
Coordinate outreach	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
4/4	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

 C48	
Neighborhood connections	
DDS	
4/4	
Met	

 C49	
Physical setting is consistent 	
Provider	
-	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
4/4	
Met	

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

 C53	
Food/ dining choices	
DDS	
4/4	
Met	

 C54	
Assistive technology	
DDS	
3/4	
Met	

Placement Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider 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	
6/6	
Met	

 C13	
Skills to maximize independence 	
DDS	
6/6	
Met	

 C14	
Choices in routines & schedules	
DDS	
6/6	
Met	

 C15	
Personalize living space	
DDS	
5/5	
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	
5/5	
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	
4/6	
Not Met (66.67 %)	

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
7/7	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
7/7	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
7/7	
Met	

 C13	
Skills to maximize independence 	
DDS	
7/7	
Met	

 C14	
Choices in routines & schedules	
DDS	
7/7	
Met	

 C15	
Personalize living space	
DDS	
7/7	
Met	

 C16	
Explore interests	
DDS	
7/7	
Met	

 C17	
Community activities	
DDS	
7/7	
Met	

 C18	
Purchase personal belongings	
DDS	
7/7	
Met	

 C19	
Knowledgeable decisions	
DDS	
7/7	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
7/7	
Met	

 C47	
Transportation to/ from community	
DDS	
7/7	
Met	

 C48	
Neighborhood connections	
DDS	
7/7	
Met	

 C49	
Physical setting is consistent 	
DDS	
7/7	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
7/7	
Met	

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

 C53	
Food/ dining choices	
DDS	
6/6	
Met	

 C54	
Assistive technology	
DDS	
7/7	
Met