PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
LIVING INDEPENDENTLY FOREVER
550 Lincoln Rd Ext
 Hyannis, MA 02601    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
October 26, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
LIVING INDEPENDENTLY FOREVER	

	

	

	

	
Review Dates	

	
9/27/2017 - 10/2/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
10/18/2017	

	

	

	

	

	

	
Survey Team	

	
Michael Marchese (TL)	

Tina Napolitan	

Laura O'Connor	

	

	

	

	

	

	
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) 7 audit (s) 	
Targeted Review	
DDS 21 / 22
Provider 50 / 52

71 / 74 2 Year License 10/18/2017-  10/18/2019	
	
DDS 39 / 44
Provider 7 / 7

46 / 51 Certified 10/18/2017 -  10/18/2019	

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

DDS Targeted Review	
21 / 22	

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

DDS Targeted Review	
20 / 23	

Planning and Quality Management (For all service groupings)	

	
Full Review	
5 / 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) 	
Full Review	
43 / 50 2 Year License 10/18/2017-  10/18/2019	
	
31 / 42 Certified with Progress Report 10/18/2017 -  10/18/2019	

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

Full Review	
11 / 14	

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

Full Review	
15 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
5 / 6	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

Living Independently Forever (LIFE), Inc. is a private, not for profit human service organization that has been serving adults with learning and intellectual disabilities for more than 25 years.  The agency offers residential, individual home, and/or community based day and employment supports to 136 people through its various service locations on Cape Cod and the greater Plymouth area.  Since their last survey in 2015, the agency has expanded its service area with its offering of Individual Home Supports in Plymouth, and in 2016 the agency was licensed to provide Community Based Day (CBDS) and Employment Support (CBDS) services.

The current survey consisted of a combination of full and targeted Licensure and Certification reviews.  In 2015 the agency received a two year license for its Residential and Individual Home Support services and was therefore eligible to conduct a self-assessment and receive a targeted licensure and certification review of this service grouping. The findings of the Department of Developmental Services (DDS) evaluations were combined with the agency's self-assessment findings and used to determine the current Licensure and Certification levels for the agency's Residential and Individual Home Supports A full Licensure and Certification review of the agency's Employment and CBDS services was conducted due to this being a new service grouping, since their 2015 survey.  The findings of this evaluation were used to determine the agency's Licensure and Certification levels for their new Employment and Day Support services.

The Department of Developmental Services (DDS) targeted review of the agency's Residential and Home Support services confirmed that across all residential settings there were systems in place, promoting the presence of key safeguards.  All critical licensure indicators, including areas such as the implementation of health care protocols, medication administration, and the care and maintenance of people's homes were identified as met.

Practices in place promoted the affirmation of people's rights.  Staff was observed to interact with individuals in a respectful manner, and there was a consistent theme of encouraging individuals to feel positive about themselves and their accomplishments.  People supported were found to be informed and knowledgeable of their human rights.  Also in the human rights domain, the agency addressed an area of needed strengthening by revising its informed consent form, and was successful in properly obtaining consent from individuals or their guardians in instances when their image and/or personal information had been disclosed.  One area found to require addition attention was with the timely submission of ISP assessments.  This finding was identified by the agency during their self-assessment process and a corrective action plan has been developed.

Within the Residential and Home Supports' certification domains success was observed in the following areas.  Staff promoted people living an active and healthy lifestyle.  The agency has recently enhanced its efforts in this area, and it was reflected in people's utilization of fitness and nutrition classes and the use of fitness facilities, both on site and in the community.  Staff was also observed to be supporting people to make healthy dietary choices.  Another area was the support provided to people to increase their independent living skills.  Through the agency's "Hybrid Program", people are provided additional staff supports in order to successfully transition from 24-hour residential to individual home support settings.  People were also supported to participate in a wide variety of recreational and social activities that were personally meaningful to them.

For Employment and Day Supports, a host of positive outcomes were demonstrated, including all rated critical licensure indicators were met.  The Hyannis campus facilities were found to be safe and in good condition.  Treatment protocols and specialized diets were in place and staff was knowledgeable of them.  Staff interacted with individuals respectfully, and was observed to encourage them to self-direct choices related to vocational, recreational and social activities and interests.  Again, individuals were found to be knowledgeable of their human rights, and informed consent was obtained by the agency when disclosing people's personal information and/or images.

A clear area of strength of the agency's Employment and Day Supports was the agency's efforts and success in supporting people to succeed in integrated work settings.  All of the people participating in the review were employed in jobs within the local community and in many instances were earning above minimum wage.  It was also noted that timely supports were provided to people during periods of employment transition.
 
Organizationally, the agency employs an effective system for tracking staff training, and all required trainings were found to be place, including specialized trainings in people's unique needs.

Areas the agency should focus on strengthening in its Employment and Day Supports include enhancing its assessment processes, and enhancing staff's knowledge regarding people's employment benefits and the impact of earnings on people's monthly benefits.  For instance,  developing a more comprehensive and formal process for assessing people's skills in a broader range for employment industries, and training and support needs in this area would be beneficial.  It is also recommended that further attention focus on training staff so they able to more effectively educate and support people and their guardians on the impact of employment income on their entitlements.

The survey team identified a few areas where more effective monitoring and staff development is needed to promote consistent outcomes for all people across all services.  For instance, while staff performance feedback from people supported was evident in 24-hour residential services, there was no evidence that it was occurring across the other service groupings.  The agency is encouraged to focus on efforts to implement this process throughout the agency.  Another area needing additional attention is related to assistive technology.  While some people were observed to be using technological devices, there was no evidence that there assistive technology needs had been assessed, or a plan had been developed to utilize technology to enhance their independence.  Additionally, requirements relating to the use of supportive and protective devices had not been fully addressed.

Based on the results of the DDS and agency self-assessment reviews, the agency has received a two year license for its Residential and Individual Home Supports with 96% of all licensing indicators receiving a rating of 'Met', and is certified with 90% of certification indicators receiving a rating of 'Met'.  The agency will conduct its own follow-up for the licensing indicators rated 'Not Met' within 60 days.  The agency also received a two year license for its Employment and Day Supports with 86% of all indicators receiving a rating of 'Met', and is certified with 74% of all certification indicators receiving a rating of 'Met'.  DDS will conduct a follow-up on the licensing indicators in 60 days, and the agency will complete a Certification Progress Report for its Employment and Day Supports within one year of the Service Enhancement Meeting, noting efforts taken to meet the 'Not Met' certification indicators.

Living Independently Forever, Inc. presented the following self-assessment including a description of the organizations ongoing quality assurance systems.	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

LIFE's Self-Assessment Process

The Self-Assessment team visited eight locations in September, meeting with individuals and staff, conducting site inspections, reviewing case books, Physician's Orders and day to day activities in each location.  The Provider Self-Assessment Report was completed for over 23 individuals.  The self-assessment conducted provides both a snapshot of services in a distinct period of time and the results of ongoing Quality Assurance systems in place.

Personal Safety was assessed by confirming abuse and neglect trainings, reviewing fire drills, checking Emergency Fact Sheets, and where appropriate, reviewing evacuations and trainings in risk interventions.  The team found that through regular Community Council meetings and case time, staff discuss safe transportation training, home alone safety, and other personal safety topics.

Environmental Safety was assessed through site inspections of several locations and confirmed by LIFE's Maintenance Supervisor who has a requisition system in place and conducts annual inspections which monitor the exterior and interior of buildings and homes.  Because water temperature was an issue for our last survey, the Maintenance Supervisor and Self-Assessment Members have been repeatedly monitoring temperatures and have found them consistently within acceptable ranges.

Communication
Individuals are communicated with in their primary language.  In our self-assessment we found a communication need identified and appropriate agencies contacted to develop a plan to meet the communication needs of the individual through adaptive technology and visual prompts.
In addition, the team reviewed the correspondence section in the Case Books, witnessed Community Council Meetings, watched staff help individuals to understand and complete surveys, applications and more.

Health
Physical: Most individuals at LIFE administer their own medications.  Group home staff members responsible for dispensing medications are required to be MAP certified.  Staff follow-up with medical appointments and undertake physicals, dental exams, and follow up medical appointments. AED equipment is mounted in each fitness center.  The Self-Assessment team reviewed staffing to insure MAP staff administered medications; spot-checked AED equipment inspections; reviewed medications against Physician's Orders; and reviewed Case Books for required assessments.

The Assessment team discovered that an individual missed medical appointments due to staff miscommunication.  We are addressing this by adding appointments in the department to Outlook so they are communicated and followed up on promptly.

Exercise and Nutrition: Weekly nutrition classes at each campus are well attended. We have a fitness center at each site, managed by staff who also run Fitness Challenges.  LIFE also utilizes local YMCAs.  Customized plans are developed for participants.  With our growth we found it necessary to increase our fitness staff to meet demand.  LIFE's focus on fitness was evident throughout our assessment as we visited fitness centers and viewed activity logs.

Mental and Spiritual: Support to exercise access to religion of choice, therapy, grief counseling, medical specialists or any desired or needed are provided.  The Self-Assessment team assessed this through Case Book review and discussions with staff and individuals.

Human Rights: The Self-Assessment team reviewed training logs, parent/guardian communication and Case Books to confirm that all receive training on individual's rights and DPPC reporting.  The topic of rights was reviewed at Community and staff meetings, witnessed Human Rights and DPPC flyers in homes, reviewed incidents and investigations to confirm that reports of potential abuse and neglect are addressed immediately with a plan of action and resolution. On-going training geared toward prevention and awareness is part of the LIFE culture. We observed that individuals are communicated with respectfully, are able to maintain their own possessions, receive phone calls, visitors, and have privacy.

Where LIFE struggled with Informed Consent in the last survey, we have revised our Publicity Release form with input from the Survey and Certification team to be specific to the photo the used, the location where it will be used, the anticipated duration of the photo in use, and the right to withdraw consent at any time.  Case Books were reviewed to insure the presence of the updated Consent Forms.

The team observed through Case Books and in group homes that when Behavior Plans are in place, staff serving the individual(s) are familiar with and trained in the administration of the plan.  Health protections in the ISP are also reviewed by staff, with many requiring staff sign off.

The Self-Assessment Team's review of Case Books found that Medication Treatment Plans are in place when needed, and Money Management Plans in place with the required components.  We confirmed with our Finance Department that the Charges for Care letters are sent annually.  Site inspections revealed that Group Home residents have a privacy lock on their bedroom doors except when the door leads to an egress.

Competent Workforce
All staff who have direct client involvement are required to be certified in CPR, AED, First Aid, and Human Rights. All staff working in the Group Homes who dispense medications are required to be MAP certified.  Mandated training is tracked and was reviewed by the Self-Assessment team.

The Self-Assessment team reviewed training books to insure that direct care staff is trained in the following areas: signs and symptoms of illness, responding to emergencies, fire safety, healthy diets, positive behavioral supports, and human service worker safety.  Direct care staff is also expected to know the unique support needs, health protections and goals of the individuals they serve. We observed various approaches to insure this including spreadsheets of all ISP goals, and sign offs on ISP plans.  LIFE prohibits restraints.

Goal Development and Implementation 
LIFE recognizes that timely filing of required assessments and support strategies is critical to a successful ISP meeting.  The Self-Assessment team reviewed input from DDS and HCSIS alerts for timely filing and found that deadlines were not consistently met.  We assessed this standard as not met, with less than 80% of locations reporting in a timely fashion.
To address this LIFE recently granted HCSIS access to several additional staff, and has undertaken training in ISP and HCSIS Incident Report Writing.  In addition, staff who are new to HCSIS have reviewed the DDS training videos available online.  To insure future timely filing of required assessments and support strategies, LIFE's COO sends Outlook Calendar reminders of deadlines in advance, and follows up as deadlines approach.

Personal Safety
Allegations of abuse and neglect are reported as mandated.  An assessment of our orientation practices show that the role of staff as mandated reporters is reviewed with the Human Resources Director on the first day of employment, and the employee is required to sign an acknowledgement that they have received the training.  Additionally, staff is trained annually in Human Rights and DPPC.  When LIFE is made aware of a complaint, immediate action is taken to insure the safety of the alleged victim, along with any recommended follow up action.

Human Rights
LIFE's Human Rights Committee meets at least quarterly, as assessed through meeting notes.  All individuals, staff and families receive training on individual's rights and DPPC reporting as assessed through training tracking.  LIFE has a policy prohibiting restraints.

Competent Workforce
In order to hire a competent workforce at LIFE, recruitment ads are placed stating the skills and background required, and resumes are reviewed by Human Resources and hiring managers to determine suitability for open positions.  Interviews with prospective staff are conducted by hiring Managers, and are often preceded by a phone screening interview conducted by the Human Resources Director. If the candidate is deemed a good match for LIFE, references are checked and a CORI is run by Human Resources Director.  Upon a reference check, a firm job offer is made, pending results of fingerprints, CORI clearance and driving record. An Orientation appointment is set up with the candidate and the Human Resources Director. A fingerprint background check will be performed on all LIFE employees. The new employee shadows in the position until fingerprinting results are in, or for an agreed upon time before working on their own in the new position.
Once hired, new staff members attend an Orientation consisting of several training modules.  A review of employee files insured we are meeting this standard.

Communication
This year, LIFE formed a committee of LIFE participants representing each location, which developed a new survey for residents and have agreed to help in the interviewing process.  The results of this survey are available in the binder provided to the Survey Team.  The Self-Survey Team confirmed individual participation in interviews of potential staff through direct observation and discussion with staff.

LIFE honors individual desires in its support of a participant's communication with guardians and family members.  In addition, there is a continuous flow of communication between guardians, family members, and staff.  Examples of opportunities of communication between staff and family or guardian include our annual Family Weekend, annual ISP Meetings, our monthly newsletters, and on a daily basis as need arises. In our assessment we found that choice is strongly encouraged in all aspects of an individual's life: employment, religion, socialization and community participation and wellness.

Supporting and Enhancing Relationships
The Self-Assessment team visited homes and reviewed activities to assess that LIFE staff coordinate between campuses and across agencies to help the individuals they serve forge relationships.  We found examples of staff hosting events where individuals were encouraged to invite others, providing transportation to movie dates and beach BBQs to help those we serve foster relationships, and more.  The Self-Assessment, the team found staff working daily on the softer social skills needed to develop and maintain meaningful relationships. We found examples of staff creating opportunities through social events, by insuring privacy, and by providing extra staff to allow for dating opportunities in an effort to allow for intimacy and the development of romantic relationships.

Choice, Control and Growth
The Self-Assessment team reviewed ISP goals to confirm that staff often tie goals to things like safe use of equipment, cooking, and other life skills. In our assessment we found check lists for daily cleaning chores in homes.  One Group Home Manager is planning a cooking club/community meal and is enlisting other group homes to facilitate community and progress toward independent cooking.

Our Self-Assessment we found that staff is well versed on individual preference for activities, schedules, and the staff who serve them. We found all Individual rooms decorated according to preference. Assistive technology is in use throughout, including noise cancelling head phones, iPhone, and computers.

Access and Integration
Review of ISP goals and activities reveals LIFE staff encourages use of local transportation, participation in organizations and clubs, and other skills that foster independence and allow for increased integration in the community.  LIFE purchases high quality homes in established neighborhoods to insure integration of the home in the community.	

	

	

	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
7/8	
1/8	

Residential and Individual Home Supports	
64/66	
2/66	

    Residential Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
71/74	
3/74	
96%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
7/8	
1/8	

Employment and Day Supports	
36/42	
6/42	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
6/6	
0/6	

Total	
43/50	
7/50	
86%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
7	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
The agency's Human Rights Committee meets member composition and attendance requirements, but the Committee has not been provided with the necessary information to complete some of its required responsibilities and duties.  The agency needs to provide the Human Rights Committee with the necessary information, such as investigations and follow-up action plans, so that it can properly conduct its required duties and responsibilities.	

	

	

	

	

	

	

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

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
We found that we submitted required assessments within 15 days of the ISP meeting less than 80% of the time.	
We have recently granted HCSIS access to several additional staff, and have undertaking training in ISP writing, as well as HCSIS incident report writing.  Staff new to HCSIS have reviewed on-line DDS training videos.  To ensure timely filing of required assessments, LIFE COO sends outlook calendar reminders of deadlines in advance, and follow up as those deadlines approach.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
We found that we submitted support strategies within 15 days of the ISP meeting less than 80% of the time.	
We have recently granted HCSIS access to several additional staff, and have undertaken training in ISP writing as well as HCSIS incident report writing.  Staff new to HCSIS have reviewed on-line DDS training videos.  To ensure timely filing of support strategies, LIFE COO sends Outlook calendar reminders of these deadlines in advance, and follow up as those deadlines approach.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L27	
If applicable, swimming pools and other bodies of water are safe and secure according to policy.	
Individuals at one of the agency's Employment and Day Supports locations have unrestrictive access to a non-lifeguarded swimming pool.  There was no evidence that water safety policies and procedures were in place.  The agency needs to develop water safety policies and procedures that cover the necessary safeguards, including supervision requirements, individual skill assessments and water safety training for staff in accordance with the DDS policy.	

 L61	
Supports and health related protections are included in ISP assessments and the continued need is outlined.	
For one individual, there was no evidence that written protocols were not in place for three of her four supportive protective devices.  The agency needs to ensure that protocols are developed for all supports and health related protections that include parameters for use, cleaning and care of the device, and documentation of use.	

 L62	
Supports and health related protections are reviewed by the required groups.	
For one individual, the agency's Human Rights Committee (HRC) had not reviewed one of her supportive protective devices which may impose limitation of movement.  The agency needs to ensure that the HRC reviews all supports and health related protections if they limit the individual's movement. 	

 L84	
Staff are trained in the correct utilization of health related protections per regulation.	
For one individual, there was no evidence of staff training and knowledge of two of the individual's four supportive protective devices.  The agency needs to ensure that staff is trained and familiar with all supports and health related protections.  	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Two individuals' support strategies were not submitted within 15 days of their scheduled ISP meeting date.  The agency needs to ensure that all support strategies are submitted within 15 days of the ISP meeting.  	

 L88	
Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	
For two of five individuals, there was no evidence that data was being collected to document progress towards achievement of their employment and day support goals.  The agency needs to ensure that staff implement all components of agreed upon support strategies including the collection of data documenting progress towards the accomplishment of ISP goals and objectives.	

	

	

	

	

	
CERTIFICATION FINDINGS	

	

	

	

	

Reviewed by	
Met / Rated	
Not Met / Rated	
% Met	

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

Residential and Individual Home Supports	
DDS 34/38
Provider 7/7	
41/45	
4/45	

Individual Home Supports	
DDS 16/19
Provider 4/4	
20/23	
3/23	

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

Total	
	
46/51	
5/51	
90%	

Certified	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

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

Community Based Day Services	
DDS	
11/14	
3/14	

Employment Support Services	
DDS	
15/22	
7/22	

Total	
	
31/42	
11/42	
74%	

Certified with Progress Report	

	

	

	

	

	

	
	
Planning and Quality Management Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

 C2	
The provider analyzes information gathered from all sources and identifies patterns and trends.	
While the agency collects and reviews program quality related data from a number of sources, there was limited evidence that this information is analyzed to determine if patterns or trends exist which may result in systemic quality improvement planning.  The agency needs to develop a system to review service quality information that includes identifying patterns and trends as a step towards the development of service improvement policies and procedures.	

	

	

	

	

Individual Home Supports- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
While some individuals have had the opportunity to observe new staff when shadowing, their feedback had not been included in the hiring process.  In addition, there was no evidence that individuals have had the opportunity to provide input on the ongoing work performance of staff who support them.  The agency needs to strengthen the processes which individuals are able to provide feedback on their staff.   	

	
 C48	
Individuals are a part of the neighborhood.	
Staff supported individuals to be active and encouraged them to have connections with others in the LIFE campus nearest to them.  However, two of the four people who participated in the survey could benefit from additional staff support and opportunities to connect with other neighbors, who do not receive supports from the agency. The agency needs to expand their supports to ensure that each individual is consistently supported to become part of their greater neighborhood.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Three of the four individuals have not yet been assessed to determine which assistive technology and/or modifications could increase their independence. Staff needs additional training and resources to enable them to properly assess each individual's skills and needs in this area, towards helping them to be as independent as possible.	

	

	

	

Residential 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. 	
Two of three individuals had not been assessed to determine if assistive technology and/or modifications would increase their level of independence in their home and community.  The agency needs to ensure that staff are trained and have the resources to properly assess individual's needs and skills in this area, and develop plans to introduce assistive technology and/or modifications to maximize independence.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
While some individuals have had the opportunity to observe new staff when shadowing, their feedback has not been included in the hiring process.  In addition, there was no evidence that individuals had the opportunity to provide input on the ongoing  work performance of staff who support them.  The agency needs to strengthen the processes which individuals are able to provide feedback on their staff.   	

	
 C47	
Individuals have full access to the community through transportation available and/or provided.	
One individual receiving Community Based Day Supports expressed a strong interests in learning more about travel training to increase her independence and so that her family would not have to drive her to and from work.  Staff needs to support this individual to sign up and receive travel training and to research other options besides public transportation, due to its limited availability.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Three individuals had not yet been assessed to determine which assistive technology and/or modifications could increase their independence. Staff needs additional training and resources to enable them to properly assess each individual's skills and needs in this area, towards helping them to be as independent as possible.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire and on an ongoing basis on the performance of staff that support them.	
While some individuals have had the opportunity to observe new staff when shadowing, their feedback has not been included in the hiring process.  In addition, there was no evidence that individuals had the opportunity to provide input on the ongoing  work performance of staff who provide them employment supports.  The agency needs to strengthen the processes which individuals are able to provide feedback on their staff.   	

	
 C23	
Staff utilize a variety of methods to assess an individual's skills, interests, career goals and training and support needs in employment.	
While all three individuals who participated in the survey for employment supports had received some assessments as part of their intake and orientation process, these were not updated to reflect their unique job skills, training needs and/or proficiencies related to his or her current job(s) and interests. The agency needs to use a variety of methods to assess each individual's job skills, training needs and proficiencies that are relevant to his or her field of interest.	

	
 C24	
There is a plan developed to identify job goals and support needs.	
There were no written plans in place, to address the three individuals' employment goals and support needs.  These plans need to be developed based on identifying his or her current interests, strengths, and needs.	

	
 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.	
Staff recently supported one individual to resign from part of his job, based on fears that his earned wages would negatively impact his entitlements. The agency needs to ensure that staff is trained and knowledgeable regarding how to support individuals and/or their guardians to receive accurate information regarding how to best manage their entitlements while staying gainfully employed.	

	
 C33	
Employee benefits and rights are clearly explained to the individual.	
While all three of the individuals who participated in the survey for employment supports were aware of their hourly wages, neither they nor their support staff were knowledgeable regarding employee benefits such as how sick time was accrued or how this time could be requested for use.  The agency needs to ensure that employment support staff is knowledgeable regarding the types of benefits that individuals earn and how to access/use these.	

	
 C47	
Individuals have full access to the community through transportation available and/or provided.	
One individual expressed a strong desire to receive additional transportation training and to explore other options in the event he ever wanted to change employment beyond his current job that he could walk to/from.  Employment staff needs to support individuals to receive transportation training towards increasing their independence and options for work.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Two of three individuals had not been assessed to determine if assistive technology and/or modifications would increase their level of independence in their home and at their job.  The agency needs to ensure that staff are trained and have the resources to properly assess individual's needs and skills in this area, and develop plans to introduce assistive technology and/or modifications to maximize independence.  	

	

	

	

	MASTER SCORE SHEET LICENSURE	

										
	Organizational: LIVING INDEPENDENTLY FOREVER	

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

O	
 L2	
Abuse/neglect reporting	
1/1	
Met	

 L3	
Immediate Action	
7/8	
Met(87.50 % )	

 L4	
Action taken	
7/7	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L74	
Screen employees	
4/4	
Met	

 L75	
Qualified staff	
1/1	
Met	

 L76	
Track trainings	
5/5	
Met	

 L83	
HR training	
5/5	
Met	

										
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
-	
-	

-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
1/1	
4/4	

	
	
5/5	
Met	

 L7	
Fire Drills	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

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

	
	
3/3	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
1/1	
3/3	

	
	
4/4	
Met	

O	
 L13	
Clean location	
L	
DDS	
1/1	
2/2	

	
	
3/3	
Met	

 L14	
Site in good repair	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L15	
Hot water	
L	
DDS	
1/1	
2/2	

	
	
3/3	
Met	

 L16	
Accessibility	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L19	
Bedroom location	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L22	
Clean appliances	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L23	
Egress door locks	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L24	
Locked door access	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 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	
3/3	
2/2	

	
	
5/5	
Met	

 L39	
Dietary requirements	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L40	
Nutritional food	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L41	
Healthy diet	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L42	
Physical activity	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L43	
Health Care Record	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
3/3	

	

3/3	
Met	

 L47	
Self medication	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
3/3	
4/4	

	
	
7/7	
Met	

 L50	
Respectful Comm.	
L	
DDS	
1/1	
4/4	

	
	
5/5	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
3/3	
4/4	

	
	
7/7	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
1/1	
4/4	

	
	
5/5	
Met	

 L55	
Informed consent	
I	
DDS	
3/3	
2/2	

	
	
5/5	
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	

 L80	
Symptoms of illness	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L82	
Medication admin.	
L	
DDS	
1/1	

	

1/1	
Met	

 L85	
Supervision 	
L	
Provider	
-	
-	

-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
-	
-	

-	
-	
-	
Not Met

	
 L87	
Support strategies	
I	
Provider	
-	
-	

-	
-	
-	
Not Met

	
 L88	
Strategies implemented	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
3/3	
4/4	

	
	
7/7	
Met	

#Std. Met/# 64 Indicator	

	

	

	
64/66	

	
Total Score	

	

	

	
71/74	

	

	

	

	
	
95.95%	

			

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	
6/6	
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	
3/3	
	
2/3	
5/6	
Met
(83.33 %)	

 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	

1/1	
1/1	
Met	

 L16	
Accessibility	
L	

1/1	
1/1	
Met	

 L17	
Egress at grade 	
L	

1/1	
1/1	
Met	

 L18	
Above grade egress	
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	

 L27	
Pools, hot tubs, etc.	
L	

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

 L28	
Flammables	
L	

1/1	
1/1	
Met	

 L29	
Rubbish/combustibles	
L	

1/1	
1/1	
Met	

 L31	
Communication method	
I	
3/3	
	
3/3	
6/6	
Met	

 L32	
Verbal & written	
I	
3/3	
	
3/3	
6/6	
Met	

O	
 L38	
Physician's orders	
I	
2/2	
	
2/2	
4/4	
Met	

 L39	
Dietary requirements	
I	

2/2	
2/2	
Met	

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

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

 L51	
Possessions	
I	
3/3	
	
3/3	
6/6	
Met	

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

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

 L55	
Informed consent	
I	
1/1	
	
2/2	
3/3	
Met	

 L61	
Health protection in ISP	
I	

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

 L62	
Health protection review	
I	

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

 L77	
Unique needs training	
I	
3/3	
	
3/3	
6/6	
Met	

 L80	
Symptoms of illness	
L	
1/1	
	
1/1	
2/2	
Met	

 L81	
Medical emergency	
L	
1/1	
	
1/1	
2/2	
Met	

 L84	
Health protect. Training	
I	

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

 L85	
Supervision 	
L	
1/1	
	
1/1	
2/2	
Met	

 L86	
Required assessments	
I	
2/2	
	
2/3	
4/5	
Met
(80.0 %)	

 L87	
Support strategies	
I	
2/2	
	
1/3	
3/5	
Not Met
(60.0 %)	

 L88	
Strategies implemented	
I	
1/2	
	
2/3	
3/5	
Not Met
(60.0 %)	

#Std. Met/# 42 Indicator	

	

36/42	

	
Total Score	

	

43/50	

	

	

	
86.00%	

				
										
	MASTER SCORE SHEET CERTIFICATION	

										
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
	
Met/Rated	
Rating	

 C1	
Provider data collection	
	
1/1	
Met	

 C2	
Data analysis	
	
0/1	
Not Met (0 %)	

 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	
	
0/3	
Not Met (0 %)	

 C8	
Family/guardian communication	
	
3/3	
Met	

 C13	
Skills to maximize independence 	
	
3/3	
Met	

 C37	
Interpersonal skills for work	
	
3/3	
Met	

 C40	
Community involvement interest	
	
3/3	
Met	

 C41	
Activities participation	
	
3/3	
Met	

 C42	
Connection to others	
	
3/3	
Met	

 C43	
Maintain & enhance relationship	
	
3/3	
Met	

 C44	
Job exploration	
	
3/3	
Met	

 C45	
Revisit decisions	
	
3/3	
Met	

 C46	
Use of generic resources	
	
3/3	
Met	

 C47	
Transportation to/ from community	
	
2/3	
Not Met (66.67 %)	

 C51	
Ongoing satisfaction with services/ supports	
	
3/3	
Met	

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

Employment Support Services	

Indicator #	
Indicator	
	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
	
0/3	
Not Met (0 %)	

 C8	
Family/guardian communication	
	
3/3	
Met	

 C22	
Explore job interests	
	
3/3	
Met	

 C23	
Assess skills & training needs	
	
0/3	
Not Met (0 %)	

 C24	
Job goals & support needs plan	
	
0/3	
Not Met (0 %)	

 C25	
Skill development	
	
3/3	
Met	

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

 C27	
Job benefit education	
	
3/3	
Met	

 C28	
Relationships w/businesses	
	
1/1	
Met	

 C29	
Support to obtain employment	
	
3/3	
Met	

 C30	
Work in integrated settings	
	
3/3	
Met	

 C31	
Job accommodations	
	
3/3	
Met	

 C32	
At least minimum wages earned	
	
3/3	
Met	

 C33	
Employee benefits explained	
	
0/3	
Not Met (0 %)	

 C34	
Support to promote success	
	
3/3	
Met	

 C35	
Feedback on job performance	
	
3/3	
Met	

 C36	
Supports to enhance retention	
	
3/3	
Met	

 C37	
Interpersonal skills for work	
	
3/3	
Met	

 C47	
Transportation to/ from community	
	
2/3	
Not Met (66.67 %)	

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

 C51	
Ongoing satisfaction with services/ supports	
	
3/3	
Met	

 C54	
Assistive technology	
	
1/3	
Not Met (33.33 %)	

Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
1/4	
Not Met (25.00 %)	

 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	
3/4	
Met	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C14	
Choices in routines & schedules	
DDS	
4/4	
Met	

 C15	
Personalize living space	
DDS	
3/3	
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	
2/4	
Not Met (50.0 %)	

 C49	
Physical setting is consistent 	
DDS	
4/4	
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	
3/4	
Met	

 C54	
Assistive technology	
DDS	
1/4	
Not Met (25.00 %)	

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
3/3	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
3/3	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
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	
3/3	
Met	

 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	
1/3	
Not Met (33.33 %)