PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
Living Hope Services Inc.
85 Crescent Avenue
 Chelsea, MA 02150    	

	

	

	

	

	

	

	

April 24, 2017	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
Living Hope Services Inc.	

	

	

	

	
Review Dates	

	
3/16/2017 - 3/20/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
3/28/2017	

	

	

	

	

	

	
Survey Team	

	
Lisa MacPhail	

Raymond Edi-Osagie (TL)	

	

	

	

	

	

	

	

	

		

	

	
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	
36 / 39 2 Year License 03/28/2017 -  03/28/2019	
	
17 / 20 Certified 03/28/2017 -  03/28/2019	

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

Full Review	
11 / 14	

Planning and Quality Management	

	
Full Review	
6 / 6	

	

	

			
EXECUTIVE SUMMARY:	

			
Living Hope Services Inc. is a Human Services agency that operates Community Based Day Services (CBDS) in Chelsea, Massachusetts.  Living Hope was established as its own provider in July of 2014 in order to continue the provision of services to individuals who had been attending CBDS under a different agency that no longer provides services.  The agency currently serves 19 individuals of varying ages with intellectual and developmental disabilities.  It has retained most of the same individuals and staff since its inception. Living Hope supports a diverse population, and has a diverse staff body.  For this Department of Developmental Services (DDS) licensing and certification survey, the agency underwent reviews of its administrative systems, and three individual audits in its CBDS program.  

Living Hope continues to develop systems and resources to become recognized as a provider of services within the greater Boston area. Living Hope was awarded a transportation contract and purchased a new van; it provides day program transportation for seven individuals, and increased community access for all participants. Living Hope has long term tenured staff, including a Director who has been with most of the individuals and currently served since 1998. The agency just completed its two year strategic plan that included goals such as the purchasing of a new vehicle, which occurred and the renovation of the CBDS building, which is ongoing at this time without disruption to services. The agency has added three volunteer staff, including a retired staff and a former firefighter; and contracted with a relief agency to provide staffing coverage as needed.  Volunteer staff bring a wealth of knowledge and experiences regarding the local community.  The agency conducted satisfaction surveys that included mailings to individuals, families and staff.  Feedback received from the surveys resulted in a number of initiatives such as the development of a Spanish/English group learning model, to improve communication with the one Spanish speaking individual.

The review at the CBDS revealed that the agency continues to use creative ways to ensure quality day programming supports. This was especially evident in the way people with physical and cognitive challenges were supported to engage in the day activities at the program location such as janitorial work, cleaning, meal preparation and packing, and filing.  For many of these jobs, individuals were compensated monetarily.  The agency's long tenured staff had good understanding of the communication styles and support needs of individuals.  Additionally, Living Hope provided comprehensive trainings in all areas of individuals common and unique needs.  For example, Living Hope brought in an orientation and mobility specialist from the Massachusetts Commission for the Blind to consult with and train staff on ambulation and mobility supports for a visually impaired man. During the survey, individuals were observed participating in activities such as the `'talking sticks group'', where people gave their ideas for future activities. The agency supported meaningful ISP objectives that were well implemented and tracked; and people had many successes in meeting their ISP objectives. Living Hope identified people's aspirations, and is taking steps to meet these aspirations:  e.g. a woman in the CBDS program is being prepared for transition to a work program, in order to fulfil her dream of having gainful employment.

Living Hope's ultimate goal is to support individuals to have a greater presence within the greater Boston community. The people's interests were apparent to the staff through comprehensive assessments of community and social interests that were completed for every individual served by the agency. Some individuals were independently involved with the neighborhood, accessing neighborhood stores and having relationships with those vendors. Neighborhood vendors were in regular communication with the CBDS program, reporting on the activities of individuals visiting their establishments.  For those served who were not able to access the community independently, community participation was far less frequent.  In house, individuals were supported to engage in volunteering efforts, such as the Hope of Life ministries homelessness initiative. The ministry provides food and supplies that are then packaged and distributed to the homeless by individuals, supported at Living Hope with the support of staff and the church pastor. 

The review of Living Hope services and systems showed that the agency has made significant progress as a provider of CBDS services within the Boston area. However, the survey highlighted a few areas in which the agency needs to pay greater attention in order to be in full compliance with regulations. In the area of human rights, the agency needs to ensure that its newly constituted human rights committee meets as required.  Environmentally, the agency needs to develop systems for ensuring consistent compliance with water temperature requirements. In the area of community access, the agency needs to ensure that when people's interests for community activities are identified, staff support these activities to occur.  Additionally, work interests need to be more fully assessed and steps need to be taken to teach skills related to these expressed work interests. Furthermore, given the agency's evolving demographics, the agency needs to develop and implement systems for supporting people whose behaviors may pose a risk to themselves or others.

In summary, Living Hope made great strides in improving the quality of CBDS services that it provides to the individuals. The result of this DDS survey of its CBDS program showed that the agency scored 92% for licensing and 85% for certification indicators. As a result of these scores, the agency will receive a two year license for its CBDS services. The agency will conduct its own follow-up for licensing indicators that were Not Met during this survey, and submit the results to the DDS Office of Quality Enhancement within 60 days of the Service Enhancement Meeting (SEM).	

	

	

LICENSURE FINDINGS	

	

	

	

	
	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
2/3	
1/3	

Employment and Day Supports	
34/36	
2/36	

    Community Based Day Services

	

Critical Indicators	
4/4	
0/4	

Total	
36/39	
3/39	
92%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

	

	

	

	
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 put in a lot of effort creating its own human rights committee, it remains a work in progress. The agency needs to ensure that it maintains a fully constituted human rights committee, and that it meets for the required number of times within each calendar year.	

		

	

	
Employment/Day Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

 L88	
Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	
The agency had an effective system for ensuring that individual's ISP objectives were monitored and tracked. People had objectives that were very relevant to their quality of life needs and promoted independence; and, staff were very thorough in supporting individuals to actualize their objectives. 	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L8	
Emergency fact sheets are current and accurate and available on site.	
The emergency fact sheets for two of the three audits contained the required information; but for one individual, it was missing the list of medications. The agency needs to ensure that when individuals take medication, the medications are listed on the emergency fact sheets.	

 L15	
Hot water temperature tests between 110 and 130 degrees.	
The water temperature for the CBDS site was outside the required range; it registered at 129 degrees for the sink. The agency needs to ensure that water temperature is maintained within the required range for CBDS programs. 	

			

		

	

	

CERTIFICATION FINDINGS	

	

	

	
	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
6/6	
0/6	

Employment and Day Supports	
11/14	
3/14	

Community Based Day Services	
11/14	
3/14	

TOTAL	
17/20	
3/20	
85%	

Certified	

	

	

	

	

	
Community Based Day Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

 C51	
Staff (Home Providers) are knowledgeable about individuals' satisfaction with services and supports and support individuals to make changes as desired.	
The agency's staff had great knowledge of the people they support in great part due to staff's long tenure and the longevity of the individuals at the program.  Staff displayed considerable knowledge of people's interests and satisfaction with the supports they received.	

	

	
Community Based Day Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C41	
Individuals participate in activities, including those in the community, that reflect their interests and preferences.	
The agency performed interest inventory assessments for all the people it supports. However, for three individuals surveyed, there was no indication that they were being supported to participate in community activities that matched their interests. The agency needs to ensure that activities that have been identified as matching people's interests are actualized, and that people are active in the community.	

 C42	
Individuals are involved in activities that connect them to other people in the community.	
The agency purchased a van and did interest assessments for the people it supports.  For two individuals surveyed however, there was little indication of connections to people in their immediate community. Through involvement in community activities, the agency needs to ensure that people are given the opportunity to meet people and form relationships.  	

 C43	
Staff act as bridge builders to support individuals to develop, sustain, and enhance relationships with others. 	
For two individuals surveyed, there was little evidence of staff consistently reaching out to connect people to community resources and people who share their interests. The agency needs to train its staff to become better bridge builders between individuals and with people within the community. 	

	

	

		

	

						
	MASTER SCORE SHEET LICENSURE	

						
	Organizational: Living Hope Services Inc.	

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

 L48	
HRC	
0/1	
Not Met(0 % )	

 L76	
Track trainings	
3/3	
Met	

 L83	
HR training	
3/3	
Met	

						
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	

 L5	
Safety Plan	
L	

1/1	
1/1	
Met	

O	
 L6	
Evacuation	
L	

1/1	
1/1	
Met	

 L7	
Fire Drills	
L	

1/1	
1/1	
Met	

 L8	
Emergency Fact Sheets	
I	

2/3	
2/3	
Not Met
(66.67 %)	

 L9	
Safe use of equipment	
L	

1/1	
1/1	
Met	

O	
 L11	
Required inspections	
L	

1/1	
1/1	
Met	

O	
 L12	
Smoke detectors	
L	

1/1	
1/1	
Met	

O	
 L13	
Clean location	
L	

1/1	
1/1	
Met	

 L14	
Site in good repair	
L	

1/1	
1/1	
Met	

 L15	
Hot water	
L	

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

 L16	
Accessibility	
L	

1/1	
1/1	
Met	

 L17	
Egress at grade 	
L	

1/1	
1/1	
Met	

 L20	
Exit doors	
L	

1/1	
1/1	
Met	

 L21	
Safe electrical equipment	
L	

1/1	
1/1	
Met	

 L22	
Clean appliances	
L	

1/1	
1/1	
Met	

 L25	
Dangerous substances	
L	

1/1	
1/1	
Met	

 L26	
Walkway safety	
L	

1/1	
1/1	
Met	

 L28	
Flammables	
L	

1/1	
1/1	
Met	

 L29	
Rubbish/combustibles	
L	

1/1	
1/1	
Met	

 L30	
Protective railings	
L	

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	

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/# 36 Indicator	

	

34/36	

	
Total Score	

	

36/39	

	

	

	
92.31%	

		
						
	MASTER SCORE SHEET CERTIFICATION	

						
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
Met	

 C2	
Data analysis	
1/1	
Met	

 C3	
Service satisfaction	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
1/1	
Met	

 C5	
Measure progress	
1/1	
Met	

 C6	
Future directions planning	
1/1	
Met	

	

	

						
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
3/3	
Met	

 C8	
Family/guardian communication	
3/3	
Met	

 C13	
Skills to maximize independence 	
3/3	
Met	

 C37	
Interpersonal skills for work	
2/2	
Met	

 C40	
Community involvement interest	
3/3	
Met	

 C41	
Activities participation	
0/3	
Not Met (0 %)	

 C42	
Connection to others	
1/3	
Not Met (33.33 %)	

 C43	
Maintain & enhance relationship	
1/3	
Not Met (33.33 %)	

 C44	
Job exploration	
2/2	
Met	

 C45	
Revisit decisions	
3/3	
Met	

 C46	
Use of generic resources	
3/3	
Met	

 C47	
Transportation to/ from community	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

 C54	
Assistive technology	
3/3	
Met