Provider	
MAB COMMUNITY SERVICES	
	
Provider Address	
200 Ivy St , Brookline	

Survey Team	
Hayes, Leslie; Lisa MacPhail	
	
Date(s) of Review	
15-AUG-16 to 16-AUG-16	

	

Follow-up Scope and results :	

Service Grouping	
Licensure level and duration	
# Critical Indicators std. met/ std. rated at follow-up 	
  # Indicators std. met/ std. rated at follow-up	
Sanction status prior to Follow-up	
Combined Results post- Follow-up; for Deferred, License level	
Sanction status post Follow-up	

Employment and Day Supports	
2 Year License	
	
5/7	
x	
Eligible for new business
(Two Year License)	
2 Year License	
x	
Eligible for New Business
(80% or more std. met; no critical std. not met)	

2 Locations 
5 Audits 	

	
o	
Ineligible for new business. (Deferred Status: Two year mid-cycle review License)	
	
o	
Ineligible for New Business
(<=80% std met and/or more critical std. not met)	

	

		
Summary of Ratings	

		
Employment and Day Supports Areas Needing Improvement on Standard not met - Identified by DDS	

Indicator #	
L1	

Indicator	
Abuse/neglect training	

Area Need Improvement	
For three of the four individuals surveyed, there was no evidence that they were trained annually in how to report abuse/neglect. There was also no evidence that guardians were sent information on how to report abuse/neglect. The agency needs to ensure that individuals and guardians are given this information annually.	

Status at follow-up	
For three out of the three individuals surveyed at follow-up, the agency has put a tracking system in place to ensure trainings are completed and/or guardians are sent information on how to report abuse/neglect.	

#met /# rated at follow-up	
3/3	

Rating	
Met	

Indicator #	
L8	

Indicator	
Emergency Fact Sheets	

Area Need Improvement	
For two of the four individuals surveyed, the Emergency Fact Sheets did not reflect current medication information. The agency needs to ensure that Emergency Fact Sheets are kept current.	

Status at follow-up	
For two out of the two individuals surveyed at follow-up, Emergency Fact Sheets were complete and contained the correct information on diagnoses and medications.	

#met /# rated at follow-up	
2/2	

Rating	
Met	

Indicator #	
L9	

Indicator	
Safe use of equipment	

Area Need Improvement	
For one of the two individuals surveyed, the section of the Safety Assessment addressing the utilization of equipment and machinery was not completed.  The agency needs to ensure that the Safety Assessment including the section on the utilization of equipment and machinery is completed at the time of the ISP.	

Status at follow-up	
This indicator is Not Met/Not Rated. For the individual surveyed at follow-up, the agency states that they have been unable to meet with the individual for two years. Therefore, they have been unable to complete this assessment.	

#met /# rated at follow-up	
1/1	

Rating	
Not Rated	

Indicator #	
L49	

Indicator	
Informed of human rights	

Area Need Improvement	
In three out of the four individuals surveyed, there was no evidence that individuals and guardians had been informed of their human rights, how to file a grievance or to whom they should talk if they have a concern. The agency needs to ensure that individuals and guardians are given this information annually.	

Status at follow-up	
For three out of the three individuals surveyed at follow-up, the agency has put a tracking system in place to ensure individuals and guardians are informed of their human rights, how to file a grievance and who to talk to with concerns.	

#met /# rated at follow-up	
3/3	

Rating	
Met	

Indicator #	
L56	

Indicator	
Restrictive practices	

Area Need Improvement	
The program needs to ensure that the rationale for restrictive practices is reviewed annually by the Human Right Committee. The agency needs to ensure that restrictive practices have a written rationale along with a plan to reduce the restriction and are reviewed by the Human Rights Committee annually.	

Status at follow-up	
The agency has eliminated the restrictive practice (door alarms) that was in place at the time of survey (6/6/16).	

#met /# rated at follow-up	
0/0	

Rating	
Not Rated	

Indicator #	
L86	

Indicator	
Required assessments	

Area Need Improvement	
For two out of the three individuals surveyed, the required ISP assessments were not submitted to the service coordinator within the required timelines. The agency needs to ensure that the required ISP assessments are submitted within the required timelines.	

Status at follow-up	
For one out of the two individuals surveyed at follow-up, the agency did not submit the ISP assessments within the required timelines.	

#met /# rated at follow-up	
1/2	

Rating	
Not Met	

Indicator #	
L87	

Indicator	
Support strategies	

Area Need Improvement	
For two of the three individuals surveyed, the required ISP support strategies were not submitted to the service coordinator within the required timelines. The agency needs to ensure that the required ISP support strategies are submitted within the required timelines.	

Status at follow-up	
For two out of the two individuals surveyed at follow-up, the agency submitted the ISP support strategies within the required time lines.	

#met /# rated at follow-up	
2/2	

Rating	
Met	

	

Indicator #	
L88	

Indicator	
Strategies implemented	

Area Need Improvement	
For three of the four individuals surveyed, there was not sufficient evidence that the services and support strategies agreed upon at the ISP were being implemented. The agency needs to ensure that ISP support strategies agreed upon at the ISP are being implemented according to the support strategies.	

Status at follow-up	
For two out of the three individuals surveyed, there continues to be insufficient evidence that the services and supports strategies agreed upon in the ISP are being implemented.  The agency must ensure that all documentation relating to ISP objectives reflect the support strategies set forth in the ISP.	

#met /# rated at follow-up	
1/3	

Rating	
Not Met	

Administrative Areas Needing Improvement on Standard not met - Identified by DDS	

Indicator #	
L48	

Indicator	
HRC	

Area Need Improvement	
There is no evidence that the Ethics Commission has approved having an RN working for another MAB service as a voting member of the Human Rights Committee. In addition, there was no evidence that there were the appropriate number of individuals/family members/advocates attending the Human Rights Committee meetings over the past two years. The agency needs to ensure that there is a fully constituted Human Right Committee in place that complies with regulations. 	

Status at follow-up	
The agency has had one Human Rights Committee meeting since the survey (6/6/16). This meeting included two self-advocates and a family member. The agency reports they continue to actively recruit self-advocates/guardians/family members.	

#met /# rated at follow-up	
1/1	

Rating	
Met	

Indicator #	
L65	

Indicator	
Restraint report submit	

Area Need Improvement	
Three of the six reported restraints were not submitted within the required timelines. The agency needs to ensure that restraint reports are submitted within the required timelines.	

Status at follow-up	
There have been no new restraints reported since the survey (6/6/16).	

#met /# rated at follow-up	
0/0	

Rating	
Not Rated