PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
NEW ENGLAND VILLAGE
664 School St
 Pembroke, MA 02359    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
August 9, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
NEW ENGLAND VILLAGE	

	

	

	

	
Review Dates	

	
7/12/2017 - 7/18/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
7/27/2017	

	

	

	

	

	

	
Survey Team	

	
Margareth Larrieux	

Barbara Mazzella (TL)	

Scott Nolan	

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	
6 location(s) 9 audit (s) 	
Targeted Review	
DDS 17 / 18
Provider 71 / 71

88 / 89 2 Year License 07/27/2017-  07/27/2019	
	
DDS 32 / 39
Provider 12 / 12

44 / 51 Certified 07/27/2017 -  07/27/2019	

Residential Services	
4 location(s) 6 audit (s) 	

DDS Targeted Review	
17 / 22	

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

DDS Targeted Review	
21 / 23	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

Survey scope and findings for Employment and Day Supports	

Service Group Type	
Sample Size	
Licensure Scope	
Licensure Level	
Certification Scope	
Certification Level	

Employment and Day Supports	
3 location(s) 8 audit (s) 	
Targeted Review	
DDS 13 / 13
Provider 62 / 62

75 / 75 2 Year License 07/27/2017-  07/27/2019	
	
DDS 18 / 21
Provider 21 / 21

39 / 42 Certified 07/27/2017 -  07/27/2019	

Community Based Day Services	
1 location(s) 4 audit (s) 	

DDS Targeted Review	
13 / 14	

Employment Support Services	
2 location(s) 4 audit (s) 	

DDS Targeted Review	
20 / 22	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

New England Village, Inc. (NEV), which was incorporated in 1972, is a non-profit agency that provides residential and day supports to individuals with intellectual and developmental disabilities in southeastern Massachusetts. NEV operates 17 homes which provide services to approximately 80 individuals. The agency's day services provide 64 individuals with a combination of employment supports for those individuals who want to be competitively employed, and community based day supports (CBDS) for those individuals whose main focus is enrichment, volunteerism and skills training toward employment. Options for those who wish to earn competitive wages include agency operated businesses such as an organic farm or a cleaning crew as well as jobs in community businesses such as Trader Joe's and Marshalls. The agency's CBDS programs are provided at two locations; Hanson and Pembroke. The Hanson program provides skill building opportunities toward career exploration as well as community-based experiences based on individual interests.  Pembroke is specifically geared towards those individuals who have retired from working or those who wish to spend time in a slower paced setting. This option known as The Living Center (TLC) enrichment program offers opportunities to participate in the arts, music, fitness and community outings.  The agency also provides day habilitation services at locations in Kingston and Pembroke. 

The current review, is a DDS Targeted Licensure and Certification Review. In 2015, the agency received a two year license for its Residential and Day/Employment services and was therefore eligible to conduct its own self-assessment and receive a DDS Targeted Licensure and Certification Review of both Residential and Day Service groupings. The targeted review is comprised of an evaluation of the eight critical indicators, those Licensure and Certification indicators determined to have been `Not Met' in the previous survey cycle and all new and revised Licensure and Certification indicators established in August 2016. The findings of the DDS evaluations were then combined with the agency's findings from its self-assessment and used to determine the agency's new Licensure and Certification levels.  The DDS survey sample included four homes that are staffed 24 hours a day, three individuals who received less than 24 hours of support per day, four people who were receiving employment supports and four audits of individuals who were receiving CBDS. 

Since the last survey, the agency has made significant efforts to ensure that person centered choices and activities are embedded in all aspects of individual's supports. Findings revealed that individuals receiving both residential and day supports participated in numerous activities that reflected individualized interests and hobbies and are provided in off campus locations.  It was observed that there were increased efforts by residential staff to promote people's participation in activities that expanded their opportunities for community integration. One individual was extremely proud of her accomplishment; she was a participant in a community chorus and performed publicly. Several individuals at the CBDS program went to a local community coffee shop on a regular basis and have developed relationships with individuals who work at these local establishments. Laugh Yoga provided at the YMCA was also noted to be a favorite activity of many CBDS participants.  

The review also demonstrated a number of additional positive strengths within the agency's residential and day services. Homes were well maintained and reflected personal preferences and tastes. Staff ensured that all systems regarding the administration of medications were in compliance with MAP procedures in both 24 hour residential settings and at the CBDS location in which staff were administering medications to individuals. The agency also acknowledged that many individuals have resided at NEV for many years and their healthcare needs are reflective of those who are aging.  A system to ensure oversight and monitoring of healthcare such as the presence of falls assessments, and implementation of physician ordered protocols by staff was present in all residential and day support locations.  Staff were also observed to be respectful of individual's privacy and individuals within both residential and day services were aware of their human rights officer and with whom to speak to regarding any issues involving respect and dignity.  A revised handbook for families and Individuals who receive employment and CBDS supports was distributed in 2017.  This document provides individuals and families comprehensive and understandable information regarding program policies, benefits and grievance procedures. 
The agency has also demonstrated increased efforts to obtain competitive employment for individuals. Findings revealed that individuals who were employed, had jobs that paid competitive wages and reflected their interests.  

While this review identified significant areas of success within the agency's residential supports, additional attention should be focused on ensuring that when restrictive practices are in place provisions are made to mitigate the effect of this restriction on others. Additionally, although the agency had taken initial steps toward inventories of people's current use of assistive technology, it needs to continue its efforts and train staff to assess people's needs for further use of technology that may be of benefit to them at home and at day/employment locations.  The agency also needs to provide support for people to explore, define and express their need for intimacy and companionship within its residential network of supports. This was also identified in the agency's self-assessment as an area that the agency will be continuing to refine and strengthen. 

While the agency has made gains to promote fuller access to individualized activities within the community, several of the new and revised certification indicators require further efforts to more fully address community integration.  Residentially, all the homes are located in close proximity to one another in a campus-based setting.  The agency needs to expand individuals' opportunities to meet neighbors, become active participants in neighborhood activities, and be part of the surrounding Pembroke neighborhood.  With regard to employment, the agency needs to concentrate on pursuing and promoting integrated employment opportunities in the community. 

Based on the findings of this report, the agency has earned a Two-Year License for both its day and residential services. Licensing scores were 99% for residential supports and 100% for day supports. The agency will conduct its own follow-up for the licensing indicators rated Not Met within approximately 60 days. The agency is Certified in Residential and Individual Home supports with 86% of the Certification indicators receiving a rating of Met and Certified in Employment and Day supports with 93% of the Certification indicators receiving a rating of Met.  New England Village, Inc. has presented the following self-assessment inclusive of a description of the organization's ongoing quality assurance systems.	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

To consistently continue to meet DDS standards, NEV evaluated all locations/individuals using L&amp;C indicators as revised in August 2016. Internal audits occur regularly, with the last being completed in the month prior to the DDS targeted review. Tools used as part of the process include: site visit forms, clinical audit tool, training records, MAP Technical Assistance tool, medical encounter forms, HCSIS review and HRC meeting minutes. Utilizing these measures ensures adherence to providing person centered and quality supports to the individuals whom we serve.

Employment and Day Supports audited a sample size of 25% for both ES and CBDS; data was reviewed for 11 individuals from ES and 14 individuals from CBDS. For all critical indicators and those indicators rated as "Not Met" from the 2015 survey 100% of individuals served were reviewed. For Residential Services 15 of 15 physical sites and all clinical records, etc. were audited. The criteria determining "standard met" was based on a compliance factor of 85% or higher.

Personal Safety: All direct support staff are actively trained in mandates to prevent and report instances of suspected abuse, and all instances are reported to DPPC and immediately acted upon to assure the safety of individuals. Complaints and restraints are actively reviewed by the agency Human Rights Committee, as well as internal administrative review. Evacuation Plans are submitted as necessary to all involved Area Offices for review and approval; fire drills are conducted as required for each physical location. Emergency Fact Sheets are kept current and are minimally updated every six months to reflect ongoing changes. The ability of individuals to safely use physical equipment is assessed through the annual ISP and staff are trained to support the individual to gain greater personal independence. In the ES/CBDS settings a participant handbook is distributed and routinely reviewed during participant meetings. Individuals who may pose a risk to themselves or others are assessed through clinical supports, and guidelines to reduce elements of risk while minimizing impact on personal independence are put into place.

Environmental Safety: To promote environmental safety and identify emerging needs, NEV has an active Safety Committee (which includes review of falls or other physical accidents). Required inspections are conducted by vendors (i.e.: septic, HVAC, fire alarms, etc.) and appropriate local authorities; these are coordinated by the Facilities Manager. Program Directors in turn work directly with Facilities to coordinate action appropriate to areas of concern. There is emphasis throughout NEV on quality and aesthetically attractive facilities, and this emphasis is promoted by and to all personnel. There is a maintenance request order system in place to address any issues which may require expertise. There is an annual walk through with the ED to identify capital improvements. Inspection checklists are completed by Residential Program Managers to assure quality of the physical home; vehicle checklists are completed monthly. Within the last two years, emergency generators have been installed at all residential programs; these are tested and serviced regularly.

Communication: There has been increased emphasis on the ability of direct support staff to understand how the individual communicates. This is reflected through: training in ASL or other modalities, increasing use of adaptive means to assist the person to communicate their wants and needs. There is increased focus on improving communications between divisions in order to enhance and improve the quality of service provided. There is ongoing attention to assure that all communications and interactions promote the respect and dignity of the person. Individuals now participate and provide input into hiring staff and performance reviews. 

Health: NEV employs 6 nurses across all settings; they meet monthly to review medical service needs, provide support and promote communication. Residential RN provides oversight to the ES/CBDS setting, including MAP supervision and auditing. Medical Awareness training is required for all staff, and provided through the Orientation process. Additionally, specialized medical trainings (i.e.: health related protections) are offered at staff meetings on an as needed basis. Within Residential services, Nursing and Program Managers meet to review appointments, required follow-up, training needs and other emerging issues. Program Managers partner to complete regular peer MAP audits of programs and individual audits of their own homes; Residential nursing completes deeper "spot" MAP audits of programs. Residential nursing has created a system for tracking ongoing appointments and has created and updated policies and procedures to meet the needs of individuals served. 

Human Rights: NEV remains committed to providing person centered quality care in the most dignified and respectful manner possible. Staff receive training on Human Rights and Abuse Prevention and Reporting. Individuals served are regularly educated and informed of their rights, as well as means to file complaints and grievances. Human Rights officers are assigned and all staff are encouraged to act as advocates at all times. Information regarding Abuse Prevention and Reporting is shared with families and guardians of individuals served via an annual mailing. In March 2016 NEV began including a self-advocate in Orientation as a Human Rights trainer. NEV supports an active, vocal Human Rights Committee, and encourages its members to be an effective oversight; minutes of the HRC meetings are distributed to the appropriate Area Offices and HR Specialists. The HRC reviews restrictive practices to reduce the level of impact on the person and others. Behavior plans prepared by clinicians contain all required components. Plans are reviewed by the HRC and in the ISP and informed consent is gathered for all parties; data for Level 2 plans is collected and reviewed monthly. Locking doorknobs have been placed on all bedroom doors; individuals are encouraged to use locks for privacy according to their own needs. 

Competent Workforce: Since 2015 Orientation has been expanded to a 5 day course, including relevant requirements (Med Awareness, CPR/FA, Safety Care, PCP and PBS, etc.). Applicants are screened as part of the hiring process. Audits of required trainings are completed periodically. The agency continues to implement the eAcademy training system to expand learning opportunities and to track progress. Supervisory feedback occurs on a regular basis, at least monthly. Team meetings occur weekly, bi-weekly, and monthly depending on the focus of the program. Program specific updates are communicated bi-weekly at Senior Leadership with the ED. 

Goal Development &amp; Implementation: Periodic HCSIS reviews are performed to assure required assessments and support strategies are completed within submission timelines; tracking systems are in place. Monitoring occurs at the programmatic level to assure that objectives, once agreed upon, are implemented for the individual.  

Planning &amp; Quality Improvement: See New Initiatives for greater detail. NEV actively seeks to measure progress towards outcomes through objective measures, utilizing input from stakeholders to inform decision making. As part of Person Centered implementation, NEV engaged the "IQMA team", a consultancy group, to develop satisfaction surveys for individuals served, as well as staff and families. Staff and family surveys were completed in FY17. Surveys of individuals served will be ongoing into FY18. 

Supporting &amp; Enhancing Relationships: People are supported to develop and build upon new and existing relationships with family and friends. NEV responds to individual needs regarding intimacy based on what is suitable to each person. Within this area NEV has identified education of staff as needing further development. 

Choice, Control &amp; Growth: People are supported to maximize personal control of their lives according to the demands of their own person. Use of person centered "Personal Passports" to supplement the ISP and empower self-direction has been introduced.  Choices in routines, schedules, personalized living spaces, purchase of personal items, and control over leisure activities, companionship, food /dining choices and satisfaction with service are subjects of continuing focus. The role of assistive technology in increasing personal control is being assessed and investigated, and has been identified as requiring further development

Access &amp; Integration: See New Initiatives, below, for greater detail. People are supported to explore and expand their interests within the greater community. Along with regular use of generic community resources, there is continuing emphasis for people to become active members of their community (joining local art guilds, chorale groups, faith groups, etc.). Tracking mechanisms have been put into place to measure progress in this area in order to inform future supports.

Meaningful &amp; Satisfying Day Activities: People are supported to explore opportunities and interests as they relate to employment in a way that is person centered and customized. Within the ES/CBDS setting individualized leisure and job interest surveys have been implemented. In the CBDS setting people structure their preferences for day to day options through daily check in meetings, and set weekly schedules for themselves. 

New Initiatives/Projects since 2015: In 2015 - 2016, NEV engaged in a process to develop a strategic plan to identify core values. The plan outlined seven priorities for the period of 2016 - 2018: 1) developing a Person Centered philosophy, including training and systems to assure success 2) increasing opportunities for meaningful integration and membership in the surrounding community including integration with non-disabled members of that community 3) expanding visibility in the greater community 4) enhancing programming while developing new opportunities to serve other populations; 5) promoting a positive culture of change and innovation by training employees, creating new professional opportunities and re-structuring NEV to accomplish its strategic goals 6) investing in a modernized IT infrastructure to provide for enhanced communication, measurement and reporting while securing assistive technology for individuals as needed 7) diversifying revenue streams to grow NEV's ability to provide high quality services and maintain facilities in order to better serve the needs of people with disabilities. These areas of focus allow division directors to set programmatic goals on an annual basis. Progress towards goals is objectively measured (as outlined within the strategic plan) and additional feedback is sought from all stakeholders in order to inform NEV's ongoing direction.	

	

	

	

		
LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Residential and Individual Home Supports	
78/79	
1/79	

    Residential Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
88/89	
1/89	
99%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
1	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Employment and Day Supports	
65/65	
0/65	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
8/8	
0/8	

Total	
75/75	
0/75	
100%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
0	

	

	

		

	

	
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.	
A restrictive practice of utilizing auditory alarms on all egress doors was reviewed at one home. Provisions were not included to mitigate the effect of this restriction on others. The agency needs to ensure that restrictive practices include provisions so as to not unduly restrict the rights of others.	

	

	

	
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 31/38
Provider 7/7	
38/45	
7/45	

Individual Home Supports	
DDS 17/19
Provider 4/4	
21/23	
2/23	

Residential Services	
DDS 14/19
Provider 3/3	
17/22	
5/22	

Total	
	
44/51	
7/51	
86%	

Certified	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

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

Employment and Day Supports	
DDS 17/20
Provider 16/16	
33/36	
3/36	

Community Based Day Services	
DDS 10/11
Provider 3/3	
13/14	
1/14	

Employment Support Services	
DDS 7/9
Provider 13/13	
20/22	
2/22	

Total	
	
39/42	
3/42	
93%	

Certified	

	

	

	

	

Individual Home Supports- 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 two individuals, there was no evidence 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 an individual's need for intimacy and companionship in concert with individual's 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. 	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for three individuals were reviewed, and in one instance an assessment of assistive technology needs had not yet been conducted. The agency needs to assess each individual's needs and determine how assistive technology/modifications can help people to maximize their independence.	

	

	

	
Residential 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.	
Six individuals were reviewed regarding opportunities to provide ongoing feedback on the performance of staff.  In two instances, there was no evidence to demonstrate that opportunities were provided at the time of hire and on an ongoing basis to provide feedback on the performance of staff. The agency needs to ensure that individuals have ongoing opportunities to provide feedback on the performance of their staff. 

	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For four individuals, there was no evidence 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 an individual's need for intimacy and companionship in concert with individual's 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. 	

	
 C48	
Individuals are a part of the neighborhood.	
Six individuals were reviewed regarding their connections with their neighbors. All of these individuals resided on a campus setting, which limited their opportunities to meet and interact with their neighbors on a regular basis. The agency needs to ensure that additional opportunities are provided, which encourage and support individuals to become connected with their neighbors and actively participate in local neighborhood events and activities.	

	
 C49	
The physical setting blends in with and is a natural part of the neighborhood and community.	
The physical setting of four homes was reviewed. All of these homes are situated on a large campus and are not fully integrated in the community. The agency needs to ensure that individuals are supported to live in settings that blend into the neighborhood and are integrated into the community.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for six individuals were reviewed, and in three instances, assessments of assistive technology did not determine which devices or modifications would be beneficial to each individual. The agency needs to assess each individual's needs and determine how assistive technology/modifications can help people to maximize their independence.	

	

	

	
Community Based Day 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. 	
Four individuals were reviewed regarding their need for assistive technology/modifications. Assistive technology assessments were started for three individuals, however, these assessments were not yet completed and/or the findings were not being implemented. The agency needs to ensure that individuals are supported to determine how assistive technology/modifications could be used to help increase their independence, based on the findings and/or recommendations derived from assessments.	

	

	

	
Employment Support Services Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

	
 C27	
Individuals and families are encouraged and supported to understand the benefits of integrated employment.	
The agency is commended for providing resources and education to individuals and families regarding the benefits of integrated employment. Information was distributed utilizing web-based programs/links as well as resource booklets developed by agencies specializing in employment benefits to ensure that families were familiar with current social security work incentives which promoted integrated employment opportunities. 	

	

	

	
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.	
Four individuals were reviewed regarding opportunities to provide ongoing feedback on the performance of staff.  In two instances, there was no evidence to demonstrate that opportunities were provided at the time of hire and on an ongoing basis to provide feedback on the performance of staff. The agency needs to ensure that individuals have ongoing opportunities to provide feedback on the performance of their staff. 	

	
 C30	
Individuals are supported to work in integrated job settings.	
Four individuals were reviewed regarding their opportunity to work in integrated work settings. Two of these individuals worked in jobs that were primarily within the agency's campus community. The agency needs to ensure that individuals are supported to work in integrated job settings. 	

	

	

	

	

								
	MASTER SCORE SHEET LICENSURE	

								
	Organizational: NEW ENGLAND VILLAGE	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
8/8	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
Provider	
-	
Met	

 L65	
Restraint report submit	
Provider	
-	
Met	

 L66	
HRC restraint review	
Provider	
-	
Met	

 L74	
Screen employees	
Provider	
-	
Met	

 L75	
Qualified staff	
Provider	
-	
Met	

 L76	
Track trainings	
Provider	
-	
Met	

 L83	
HR training	
Provider	
-	
Met	

								
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
-	
-	

-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
4/4	
1/1	

	
	
5/5	
Met	

 L7	
Fire Drills	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I	
DDS	
6/6	
3/3	

	
	
9/9	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L11	
Required inspections	
L	
DDS	
4/4	
1/1	

	
	
5/5	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
3/4	
1/1	

	
	
4/5	
Met
(80.0 %)	

O	
 L13	
Clean location	
L	
DDS	
4/4	
1/1	

	
	
5/5	
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	
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	

 L27	
Pools, hot tubs, etc.	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L28	
Flammables	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L29	
Rubbish/combustibles	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L30	
Protective railings	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L31	
Communication method	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L33	
Physical exam	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L34	
Dental exam	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L35	
Preventive screenings	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L36	
Recommended tests	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
6/6	

	

6/6	
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	
6/6	

	

6/6	
Met	

 L47	
Self medication	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

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

	
	
9/9	
Met	

 L50	
Respectful Comm.	
L	
DDS	
4/4	
2/2	

	
	
6/6	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
6/6	
3/3	

	
	
9/9	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
4/4	
2/2	

	
	
6/6	
Met	

 L55	
Informed consent	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L56	
Restrictive practices	
I	
DDS	
0/1	

	

0/1	
Not Met
(0 %)	

 L57	
Written behavior plans	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L58	
Behavior plan component	
I	
DDS	
2/2	

	

2/2	
Met	

 L59	
Behavior plan review	
I	
DDS	
2/2	

	

2/2	
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	

 L65	
Restraint report submit	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L70	
Charges for care calc.	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L71	
Charges for care appeal	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
-	
-	

-	
-	
-	
Met	

O	
 L82	
Medication admin.	
L	
DDS	
4/4	

	

4/4	
Met	

 L84	
Health protect. Training	
I 	
Provider	
-	
-	

-	
-	
-	
Met	

 L85	
Supervision 	
L	
Provider	
-	
-	

-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L87	
Support strategies	
I	
Provider	
-	
-	

-	
-	
-	
Met	

 L88	
Strategies implemented	
I	
DDS	
5/6	
3/3	

	
	
8/9	
Met
(88.89 %)	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
6/6	
3/3	

	
	
9/9	
Met	

#Std. Met/# 79 Indicator	

	

	

	
78/79	

	
Total Score	

	

	

	
88/89	

	

	

	

	
	
98.88%	

			
								
Employment and Day Supports:	

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

 L1	
Abuse/neglect training	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L2	
Abuse/neglect reporting	
L	
Provider	
	
-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
	
-	
-	
-	
Met	

 L5	
Safety Plan	
L	
DDS	
1/1	
	
1/1	
2/2	
Met	

O	
 L6	
Evacuation	
L	
DDS	
1/1	
	
1/1	
2/2	
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	
1/1	
	
1/1	
2/2	
Met	

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

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

 L20	
Exit doors	
L 	
Provider	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
	
-	
-	
-	
Met	

 L22	
Clean appliances	
L 	
Provider	
	
-	
-	
-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
	
-	
-	
-	
Met	

 L26	
Walkway safety	
L 	
Provider	
	
-	
-	
-	
Met	

 L27	
Pools, hot tubs, etc.	
L 	
Provider	
	
-	
-	
-	
Met	

 L28	
Flammables	
L 	
Provider	
	
-	
-	
-	
Met	

 L29	
Rubbish/combustibles	
L 	
Provider	
	
-	
-	
-	
Met	

 L30	
Protective railings	
L 	
Provider	
	
-	
-	
-	
Met	

 L31	
Communication method	
I 	
Provider	
	
-	
-	
-	
Met	

 L32	
Verbal & written	
I 	
Provider	
	
-	
-	
-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	

4/4	
4/4	
Met	

 L39	
Dietary requirements	
I 	
Provider	
	
-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	

4/4	
4/4	
Met	

 L49	
Informed of human rights	
I	
DDS	
4/4	
	
4/4	
8/8	
Met	

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

 L51	
Possessions	
I 	
Provider	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
4/4	
	
4/4	
8/8	
Met	

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

 L55	
Informed consent	
I 	
Provider	
	
-	
-	
-	
Met	

 L56	
Restrictive practices	
I 	
Provider	
	
-	
-	
-	
Met	

 L57	
Written behavior plans	
I 	
Provider	
	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
	
-	
-	
-	
Met	

 L60	
Data maintenance	
I 	
Provider	
	
-	
-	
-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
	
-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
	
-	
-	
-	
Met	

 L63	
Med. treatment plan form	
I 	
Provider	
	
-	
-	
-	
Met	

 L64	
Med. treatment plan rev.	
I 	
Provider	
	
-	
-	
-	
Met	

 L65	
Restraint report submit	
L 	
Provider	
	
-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
	
-	
-	
-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
	
-	
-	
-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
	
-	
-	
-	
Met	

 L72	
DOL requirements	
I 	
Provider	
	
-	
-	
-	
Met	

 L73	
DOL certificate	
L 	
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	
1/1	
	
1/1	
2/2	
Met	

 L84	
Health protect. Training	
I 	
Provider	
	
-	
-	
-	
Met	

 L85	
Supervision 	
L 	
Provider	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
	
-	
-	
-	
Met	

 L87	
Support strategies	
I	
Provider	
	
-	
-	
-	
Met	

 L88	
Strategies implemented	
I 	
Provider	
	
-	
-	
-	
Met	

#Std. Met/# 65 Indicator	

	

	
65/65	

	
Total Score	

	

	
75/75	

	

	

	
	
100%	

			
								
	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	

	

	

	
								
Community Based Day Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
4/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C40	
Community involvement interest	
DDS	
3/4	
Met	

 C41	
Activities participation	
DDS	
3/4	
Met	

 C42	
Connection to others	
DDS	
4/4	
Met	

 C43	
Maintain & enhance relationship	
DDS	
4/4	
Met	

 C44	
Job exploration	
Provider	
-	
Met	

 C45	
Revisit decisions	
DDS	
4/4	
Met	

 C46	
Use of generic resources	
DDS	
4/4	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

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

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

Employment Support Services	

	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
2/4	
Not Met (50.0 %)	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C22	
Explore job interests	
Provider	
-	
Met	

 C23	
Assess skills & training needs	
Provider	
-	
Met	

 C24	
Job goals & support needs plan	
Provider	
-	
Met	

 C25	
Skill development	
Provider	
-	
Met	

 C26	
Benefits analysis	
Provider	
-	
Met	

 C27	
Job benefit education	
DDS	
4/4	
Met	

 C28	
Relationships w/businesses	
DDS	
1/1	
Met	

 C29	
Support to obtain employment	
Provider	
-	
Met	

 C30	
Work in integrated settings	
DDS	
2/4	
Not Met (50.0 %)	

 C31	
Job accommodations	
Provider	
-	
Met	

 C32	
At least minimum wages earned	
Provider	
-	
Met	

 C33	
Employee benefits explained	
Provider	
-	
Met	

 C34	
Support to promote success	
DDS	
4/4	
Met	

 C35	
Feedback on job performance	
Provider	
-	
Met	

 C36	
Supports to enhance retention	
Provider	
-	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

 C50	
Involvement/ part of the Workplace culture	
DDS	
2/2	
Met	

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

 C54	
Assistive technology	
DDS	
3/4	
Met	

Individual Home Supports	

	

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	
1/3	
Not Met (33.33 %)	

 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	
2/3	
Not Met (66.67 %)	

Residential Services	

	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
4/6	
Not Met (66.67 %)	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
5/6	
Met (83.33 %)	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
6/6	
Met	

 C12	
Intimacy	
DDS	
2/6	
Not Met (33.33 %)	

 C13	
Skills to maximize independence 	
DDS	
6/6	
Met	

 C14	
Choices in routines & schedules	
DDS	
6/6	
Met	

 C15	
Personalize living space	
DDS	
4/4	
Met	

 C16	
Explore interests	
DDS	
5/6	
Met (83.33 %)	

 C17	
Community activities	
DDS	
6/6	
Met	

 C18	
Purchase personal belongings	
DDS	
6/6	
Met	

 C19	
Knowledgeable decisions	
DDS	
6/6	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
6/6	
Met	

 C47	
Transportation to/ from community	
DDS	
6/6	
Met	

 C48	
Neighborhood connections	
DDS	
0/6	
Not Met (0 %)	

 C49	
Physical setting is consistent 	
DDS	
0/4	
Not Met (0 %)	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
6/6	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
6/6	
Met	

 C53	
Food/ dining choices	
DDS	
6/6	
Met	

 C54	
Assistive technology	
DDS	
3/6	
Not Met (50.0 %)