PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
MAY INSTITUTE (THE)
41 Pacella Park Drive
 Randolph, MA 02368    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
May 1, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
MAY INSTITUTE (THE)	

	

	

	

	
Review Dates	

	
4/9/2018 - 4/12/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
5/1/2018	

	

	

	

	

	

	
Survey Team	

	
Ed Sutka (TL)	

Katherine Gregory	

Janina Millet	

Barbara Mazzella	

Scott Nolan	

Mark Boghoian	

John Downing	

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	
23 location(s) 25 audit (s) 	
Targeted Review	
DDS 14 / 19
Provider 67 / 67

81 / 86 2 Year License 05/01/2018-  05/01/2020	
	
DDS 48 / 58
Provider 15 / 15

63 / 73 Certified 05/01/2018 -  05/01/2020	

Residential Services	
20 location(s) 20 audit (s) 	

DDS Targeted Review	
18 / 22	

Placement Services	
2 location(s) 2 audit (s) 	

DDS Targeted Review	
19 / 22	

Individual Home Supports	
1 location(s) 3 audit (s) 	

DDS Targeted Review	
20 / 23	

Planning and Quality Management	

	
DDS Targeted Review	
6 / 6	

	

	

	

EXECUTIVE SUMMARY :	

	

	

The May Institute, a nonprofit organization that was founded in 1955, provides educational, rehabilitative and behavioral health services to children and adults with autism spectrum disorder, brain injury, mental illness, and other developmental disabilities.  The agency has grown in size over the years and now provides services throughout Massachusetts as well as in other states.  The current review by the Department of Developmental Services (DDS) survey team encompassed the following service models: 24 hour residential supports, less than 24 hour residential supports, and shared living.  As the agency had elected to complete a self-assessment for all supports under evaluation, the portion of the review completed by DDS was targeted to a limited number of indicators, including those considered critical and those rated Not Met during the previous survey.  The scores for the licensure and certification review as a whole reflected a combination of the DDS targeted review and ratings from the agency's self-assessment.

The review by the DDS survey team highlighted a number of strengths in terms of indicators related to licensure.  For instance, systems to monitor medical protocols and medication administration were found to be effective, and staff training in medication administration was found to be consistently in place.  Fire drills were conducted regularly and according to regulation, and smoke detectors were found to be in good working order.  Staff were knowledgeable regarding their responsibilities to report abuse, neglect, and mistreatment.  

The certification indicators also revealed a number of strengths across all service types.  For instance, supports provided to individuals had generally been helpful to them in making gains in increasing their independent living skills. One individual was excited about sharing her recently gained culinary skills as she made cookies during the review. This woman has retired, and her access to the community throughout the day has been enhanced by the availability of agency vans. People were encouraged to exercise choice and control over their leisure time activities.  For instance, one individual is supported to enjoy her longtime interest in horseback riding.  Homes were attractive and blended in with the surrounding neighborhoods.  

For individuals who received less than 24 hour supports, strengths were seen in the agency's ability to promote choice and community involvement, and individuals were found to exercise a high degree of independence and choice making in their daily lives.  For instance, individuals were supported to self-determine their schedule of activities and routines.  Consistent with their preferences and interests, individuals were regularly involved in their communities and utilized generic resources as needed, either with staff or on their own. 

Within licensing, some indicators were identified where improvements were needed.  One of these was the indicator that addresses the safeguards that need to be in place when restrictive practices, such as door alarms and locked cleaning or hygiene supplies, were in effect.  When restrictions of this sort were used, required safeguards were not consistently in place, e.g., a rationale for the current use of the restrictions, and plans to fade the restrictions and mitigate their impact on others within the home who did not need them.  

For some of the indicators within the certification portion of the review, further efforts were needed to meet the intended outcomes, and initiatives associated with certain indicators were still in the early stages and needed enhancement.  For example, while some efforts to help people benefit from the use of assistive technology were seen, assessments were not in place, and strategies to address people's needs in this area were not consistently present.  Another area where further assessment was needed was in identifying people's needs to better understand the spectrum of relationship possibilities, including an exploration of intimate relationships.  For the certification indicators relating to community involvement, additional approaches and strategies were needed to assist people to explore and participate in options for community activities based on their interests.

Based upon the combination of the DDS review and the agency's self-assessment, the findings resulted in scores of 94% for licensing and 86% for certification.  The agency has earned a Two-Year License and Certification for the Residential/Individual Home Support services grouping and will conduct its own sixty day follow-up for any licensing indicators that were rated Not Met.  A description of the provider's self-assessment process follows.	

	

	

	

Description of Self Assessment Process:	

	

	

May Institute utilizes an ongoing quality improvement process that ensures that quality services are being delivered. Some components of this process are: satisfaction surveys to all stakeholders; research; extensive training; quality monitoring audits of residential sites (these reviews are completed by the Quality Improvement (QI) Department and Program Supervisors using a tool created by the agency); external reviews by an independent environmental specialist; outcome reports measuring performance in effectiveness, efficiency, access, and satisfaction; and dashboard data systems to monitor program indicators.   

Our performance improvement program provides a planned systematic organization-wide approach to designing, measuring, and improving processes, systems and outcomes of the various programs of the May Institute.  The plan is comprehensive and interdisciplinary and covers critical functions; stakeholder input, health and safety, individual-centered service planning, access to services, human rights, outcome management, , and strategic planning. 
May Institute has multiple levels of oversight to insure the integrity of our services. Steering Committee, Human Rights Committees, Peer Review systems, Quality Improvement Safety and Compliance meetings and organization wide Safety Committee. These layers of support provide input from various levels of the organization and the community to ensure oversight, direction and management of systems in the areas of access to services, clinical integrity and follow up data.

We have a comprehensive safety /risk program that manages the various components of safety through internal monitoring and tracking of data. The QI Department reviews several components of the Safety and Risk Management status of each program monthly at Program Management Meetings and QI Department Meetings. Components of this system include: Infection Control; Medication Management; Life Safety; Incident Management; Allegations of Abuse and Neglect; Mortality Reviews; Environmental Safety; Individuals At Risk; Pharmacy Reviews; Privacy; and Security. It is the policy of the May Institute to learn from significant incidents through systematic investigation of the circumstances and contributory factors, and where possible, to implement improvements to reduce the risk of recurrence.  This is accomplished through incident reporting and quality improvement processes. Data is analyzed and benchmarked against previous rates, trends are identified and addressed.

The Organization has a Healthcare Forum in which the nurses and healthcare representatives from all programs meet regularly to address areas of concern, initiatives, policies, new systems, and best practices. In addition, there is a Significant Medication Occurrence Review Committee that evaluates root causes and trends in medication occurrence reports that will inform subsequent program and organizational action plans for improvement which may include but is not limited to employee training, employee discipline, and program improvements. 

There is an Adult Services Records Committee which includes the leadership of the Division, Quality Improvement and other key representatives that are invited to attend depending on the topics being addressed at the meeting.  The committee works to unify and standardize systems while utilizing best practices. Some activities include: review and approval of programmatic policy and Standard Operating Practices (SOP), creating and approving divisional documents and forms, incorporating new and revised regulations or laws, sharing best practices, identifying or implementing performance improvement initiatives, and preparation for licensing or certification reviews. 

The Facilities Department regularly monitors smoke/fire and CO2 alarms as well as water temperatures at all sites. They provide ongoing seasonal maintenance and repairs are addressed through a centralized reporting system called Angus Anywhere. The Department also manages all annual site inspections, pest control contracts and the organizations fleet of vehicles.  The Fleet Manager chairs the Vehicle Accident Review Committee which reviews every vehicle accident and makes safety recommendations regarding policies, practices and training for the organization.

The targeted review for the residential self-assessment was conducted from March 14, 2018 through March 30, 2017 using the 24hr residential audit worksheet revised 9/17/17, from the DDS Licensing and Certification Manual, fifth edition. The Quality Improvement Department determined the sample size based on the DDS sample size listed on the 45-day letter, which resulted in 20 sites with 24hr supports and 3 sites with less than 24hr supports. Sites were divided amongst the three service centers as follows: Western Massachusetts - 4 sites (24hr) and 2 less than 24hr, Cape Cod and Southeastern Massachusetts - 7 sites (24hr), Eastern Massachusetts - 9 sites (24hr), and another less than 24hr site. Specific sites within each service center were randomly selected via computer using a random number selection program. Review teams consisted of a combination of reviewers from the regional center's leadership team and the QI department ensuring that there was a balanced team that did not only include supervisors that directly oversee the program being reviewed. 

At each site one individual was selected for review of cluster A and a different individual was selected for review of cluster B. Using the DDS tools, the teams: reviewed documentation, individual records, and logs. In addition, team members conducted observations of the environment, conducted interviews; and used thermometers to test water temperatures at each site location. Programs received immediate feedback at the end of each review on the rating for each indicator, upon which the programs began the process of rectifying any deficiencies noted.

The organizational indicators were reviewed centrally by the Quality Improvement Department using existing processes and systems for a number of the indicators. For the Employee file review, we utilized the QE Centralized Training Review Checklist and followed the OQE sampling rubric guidelines. Files and training grids for 20 employees were reviewed as well as qualifications were verified for 10 new hires and credentials for 3 licensed employees were reviewed to ensure they were current. Reviewers from the Quality Improvement Department, Corporate Human Resources Department, and each center participated. The centers exchanged files with another region to ensure that representatives were reviewing another center's employee files to ensure objectivity.

The QI Department compiled the scores from all reviewers into the final report. The results of the organizational and residential audits determined that 83 out of 86 licensure indicators were met for a total of 97% compliance. An indicator had to be met at 80% or better to be considered met across all sites. All critical indicators were above 80% across all sites. Overall the programs were at 96% compliance with all certification indicators rated, 27 out of 28 indicators rated were met.	

	

	

	

LICENSURE FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/10	
2/10	

Residential and Individual Home Supports	
73/76	
3/76	

    Residential Services
    Placement Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
81/86	
5/86	
94%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
5	

	

	

	

	

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.	
For one of the agency's three Human Rights Committees, a doctor or nurse had participated in fewer than half the meetings, and minutes presented information about interventions under review as part of a broad summary from which the specific interventions that had been reviewed or approved could not be determined.  Additionally, minutes are not consistently submitted to the Office of Human Rights as required.  The agency needs to meet all requirements related to the human rights committees.	

 L65	
Restraint reports are submitted within required timelines.	
A review of restraint documentation revealed that only 74% met timelines for entering the restraint information into HCSIS and/or completing the review by the Restraint Manager.  The agency needs to complete all requirements related to reporting restraint information in a timely manner.	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L56	
Restrictive practices intended for one individual that affect all individuals served at a location need to have a written rationale that is reviewed as required and have provisions so as not to unduly restrict the rights of others.	
In four out of eighteen instances, restrictive practices, e.g., alarms on egress doors, locked cleaning supplies and hygiene products, lacked necessary components, e.g., plans to fade the restriction, plans to mitigate the effects of the restrictions on others, or a rationale for the restriction.  The agency needs to ensure that when restrictions are in place, all requirements are met. 	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Although the agency received the required 30-day notice from the DDS Area Office regarding the dates of the individuals' ISP meetings, the agency did not submit the required assessments within the 15 day time frame for nine individuals. The agency needs to ensure that assessments are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Although the agency received the required 30-day notice from the DDS Area Office regarding the dates of the individuals' ISP meetings, the agency did not submit the required Support Strategies within the 15 day time frame for eleven individuals. The agency needs to ensure that Support Strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting.	

	

	
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 47/57
Provider 10/10	
57/67	
10/67	

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

Placement Services	
DDS 16/19
Provider 3/3	
19/22	
3/22	

Residential Services	
DDS 15/19
Provider 3/3	
18/22	
4/22	

Total	
	
63/73	
10/73	
86%	

Certified	

	

	

	

	
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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For all three individuals, feedback was not documented at the time of hire nor incorporated into annual staff performance reviews.  The agency needs to support individuals to have increased input into the hiring and evaluation of their staff. 	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For all three individuals, the agency had not assessed or provided education relevant to exploring or expressing possible needs relating to intimacy and companionship.  The agency needs to undertake the assessment process and provide appropriate supports based on these assessments.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For all three individuals, the agency had not assessed individuals' needs for using assistive technology to increase their independence.  The agency needs to undertake the assessment process and provide appropriate supports based on these assessments.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
One of the two individuals needed additional supports to develop his interests through participating in cultural, social, recreational and/or spiritual activities. 	

	
 C17	
Community activities are based on the individual's preferences and interests.	
One individual who participated in the survey was very independent in this area. However, the other individual needed additional supports to more consistently participate in community based activities, based on his interests and preferences. 	

	
 C48	
Individuals are a part of the neighborhood.	
In one instance, an individual was not supported to make connections within his neighborhood or offered supports to develop connections with neighbors. The agency needs to ensure that individuals are supported to become familiar with their neighbors and to be part of their neighborhood.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For fifteen individuals there was no evidence to document that the agency has a curriculum or that education has been provided to staff supporting individuals in the area of sexuality and intimacy. In addition, there were no formal or informal assessments made of the individuals' need for intimacy and companionship in concert with individuals' unique learning styles. The agency needs to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship.	

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Seven out of twenty-one individuals were not fully supported to explore and discover community organizations and activities that could connect them with their culture, social and spiritual interests. The agency needs to assist individuals to make these connections.  	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Five of the twenty-one individuals were not provided with frequent opportunities to participate in community activities that aligned with their preferences. Additionally, there was limited evidence of staff knowledge regarding local events and activities. The agency needs to ensure that staff are knowledgeable about local events and activities that reflect individuals' interests and afford opportunities for individuals to participate in these events.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Individualized assessments regarding assistive technology and/or modifications were not completed for ten individuals. The agency needs to ensure that assistive technology and/or modification needs are assessed and actualized for each individual.  	

	

	

	

	MASTER SCORE SHEET LICENSURE	

							
	Organizational: MAY INSTITUTE (THE)	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
23/23	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
DDS	
2/3	
Not Met(66.67 % )	

 L65	
Restraint report submit	
DDS	
119/161	
Not Met(73.91 % )	

 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	
19/19	
1/1	
2/2	

	
22/22	
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	
20/20	
1/1	
2/2	

	
23/23	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
20/20	
1/1	
2/2	

	
23/23	
Met	

O	
 L13	
Clean location	
L	
DDS	
20/20	
	
2/2	

	
22/22	
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	

 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	
18/18	
2/2	

	
	
20/20	
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	
21/21	
2/2	
2/2	

	
25/25	
Met	

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

 L49	
Informed of human rights	
I	
DDS	
21/21	
3/3	
2/2	

	
26/26	
Met	

 L50	
Respectful Comm.	
L	
DDS	
20/20	
1/1	
2/2	

	
23/23	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
20/21	
3/3	
2/2	

	
25/26	
Met
(96.15 %)	

 L53	
Visitation	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
20/20	
1/1	
2/2	

	
23/23	
Met	

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

 L56	
Restrictive practices	
I	
DDS	
11/15	
3/3	

	
	
14/18	
Not Met
(77.78 %)	

 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	
DDS	
19/21	
1/1	
0/1	

	
20/23	
Met
(86.96 %)	

 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	
20/20	
1/1	

	
	
21/21	
Met	

 L84	
Health protect. Training	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L85	
Supervision 	
L	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
DDS	
10/16	
0/1	
0/2	

	
10/19	
Not Met
(52.63 %)	

 L87	
Support strategies	
I	
DDS	
9/17	
0/1	
0/2	

	
9/20	
Not Met
(45.00 %)	

 L88	
Strategies implemented	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
19/21	
	
2/2	

	
21/23	
Met
(91.30 %)	

#Std. Met/# 76 Indicator	

	

	

	
73/76	

	
Total Score	

	

	

	
81/86	

	

	

	

	
	
94.19%	

			
							
	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	

	

	

	

Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

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

 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	
0/3	
Not Met (0 %)	

 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	

 C21	
Coordinate outreach	
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	
0/3	
Not Met (0 %)	

Placement Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
2/2	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
2/2	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
2/2	
Met	

 C12	
Intimacy	
DDS	
2/2	
Met	

 C13	
Skills to maximize independence 	
DDS	
2/2	
Met	

 C14	
Choices in routines & schedules	
DDS	
2/2	
Met	

 C15	
Personalize living space	
DDS	
2/2	
Met	

 C16	
Explore interests	
DDS	
1/2	
Not Met (50.0 %)	

 C17	
Community activities	
DDS	
1/2	
Not Met (50.0 %)	

 C18	
Purchase personal belongings	
DDS	
2/2	
Met	

 C19	
Knowledgeable decisions	
DDS	
2/2	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
2/2	
Met	

 C47	
Transportation to/ from community	
DDS	
2/2	
Met	

 C48	
Neighborhood connections	
DDS	
1/2	
Not Met (50.0 %)	

 C49	
Physical setting is consistent 	
DDS	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
2/2	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
2/2	
Met	

 C53	
Food/ dining choices	
DDS	
2/2	
Met	

 C54	
Assistive technology	
DDS	
2/2	
Met	

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
17/21	
Met (80.95 %)	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
18/21	
Met (85.71 %)	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
21/21	
Met	

 C12	
Intimacy	
DDS	
6/21	
Not Met (28.57 %)	

 C13	
Skills to maximize independence 	
DDS	
21/21	
Met	

 C14	
Choices in routines & schedules	
DDS	
21/21	
Met	

 C15	
Personalize living space	
DDS	
20/20	
Met	

 C16	
Explore interests	
DDS	
14/21	
Not Met (66.67 %)	

 C17	
Community activities	
DDS	
16/21	
Not Met (76.19 %)	

 C18	
Purchase personal belongings	
DDS	
20/21	
Met (95.24 %)	

 C19	
Knowledgeable decisions	
DDS	
21/21	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
20/21	
Met (95.24 %)	

 C47	
Transportation to/ from community	
DDS	
21/21	
Met	

 C48	
Neighborhood connections	
DDS	
20/21	
Met (95.24 %)	

 C49	
Physical setting is consistent 	
DDS	
20/20	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
21/21	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
21/21	
Met	

 C53	
Food/ dining choices	
DDS	
21/21	
Met	

 C54	
Assistive technology	
DDS	
11/21	
Not Met (52.38 %)