PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
NORTH SUFFOLK MHA
301 Broadway St
 Chelsea, MA 02150    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
NORTH SUFFOLK MHA	

	

	

	

	
Review Dates	

	
5/15/2017 - 5/18/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
6/2/2017	

	

	

	

	

	

	
Survey Team	

	
Jennifer Conley-Sevier	

Anne Carey	

Sarah Flibotte (TL)	

	

	

	

	

	

	
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	
8 location(s) 8 audit (s) 	
Full Review	
77 / 86 2 Year License 06/02/2017 -  06/02/2019	
	
41 / 45 Certified 06/02/2017 -  06/02/2019	

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

Full Review	
19 / 22	

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

Full Review	
16 / 17	

Planning and Quality Management	

	
Full Review	
6 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
North Suffolk Mental Health Association (NSMHA), founded in 1959 in the Greater Boston Area, is a non-profit organization providing a range of services and supports to adults in the Northeast and Metro Regions with developmental disabilities, dual diagnoses, deaf/blind services and mental health issues. The agency currently provides supports to 99 individuals served by DDS who live in twenty-four hour supervised residential settings in 16 community residences and to six individuals residing in their own apartments receiving services through Individual Home Supports (IHS).

The scope of this survey conducted by the Office of Quality Enhancement (OQE) was a full review of all licensing and certification indicators within the agency's Residential Services/Individual Home Supports program including indicators which were new or revised in August 2016.

Since the last survey the agency has developed systems to ensure improvement in many of the indicators that were previously rated 'not met'. For example, surveyors noted that individuals were able to evacuate safely during quarterly fire drills, medical protocols were being developed and followed, individuals were following a healthy diet and behavioral data was collected and analyzed to make any necessary changes to behavioral plans. The individuals' money was being tracked and documented in accordance with regulations.  In addition, ISP Assessments and Support Strategies were submitted within the required timeframes. Staff had been trained and reviews had been held for the use of Health Related Supports and Protections for individuals. 

Throughout the course of the survey, it was noted that the agency had met many of the new and strengthened standards recently implemented by DDS in August 2016.  For example, the agency had successfully installed locks on all bedroom doors and afforded individuals choice regarding the use and type of lock 'key versus push pin" to ensure privacy. The agency had also demonstrated through an attestation that they have developed residency agreements with individuals.    

The agency had a variety of systems in place to assure safety.   For example, the agency's manager daily walk-through system insured that homes were clean and well-maintained.  Nursing oversight systems assisted with developing medical support plans, conducting MAP audits/consultation and helped to ensure medications were administered appropriately and staff had been trained in the signs and symptoms of illness.  This addition was notable as medical protocols, healthy diets and staff training and review of supports and health related protections were found to be in place during this survey cycle 

The agency successfully ensured that all staff were current in mandated trainings, and promoted the education, knowledge and advancement of staff through many opportunities for additional trainings and growth.  The agency has an effective system to track Orientation training and required staff trainings.  The agency uses a training center data base called Virtual Training Assistant (VTA) which is an on-line system.  All completed trainings for staff are tracked in this system by the agency's Human Resources department and reports are created monthly and forwarded to the appropriate work locations. In addition to required trainings, the agency provides a wide array of training opportunities to all staff to consistently meet the ever changing needs of the individuals served, such as: Positive Behavioral Supports (PBS), Falls Prevention, Total Communication, American Sign Language, Identifying/Reporting Clinical Risk, Alzheimer's disease, Substance Abuse Disorders and Hearing voices while utilizing internal and external resources available to the agency. Many of the individuals have behavioral and health related needs unique to them which staff were aware of the supports required to meet those needs.

The agency developed a system to train and ensure the competence of an internal relief pool to use to fill in when there are vacancies and call-ins.  It was evident to the survey team that staff who were working with individuals knew them well and it was difficult to discern relief staff from permanent staff as all DDS Division homes had consistent methodology of trainings, residential, behavioral, data collection forms, color coding of binders, individual information etc. which ultimately resulted in individuals being served by familiar staff who knew their unique needs.
Overall, the agency employed several practices to support human rights, including the dissemination of human rights materials to guardians, trainings for staff and individuals and Human Rights Training was held at house meetings.  Individuals and family members were informed of the process to file a grievance, as well as reporting suspected mistreatment or abuse to the Disabled Persons Protection Commission. The agency was committed to ensuring that individuals were well respected in all facets of their lives. Throughout the survey, staff was observed to be respectful about the individuals when engaged in conversation with them, their family members and outside resources. The survey team observed staff knocking on bedroom and bathroom doors before entering, ensuring that individuals were given the utmost privacy and respect when dealing with personal care issues. 

Regarding the certification domain of choice, the agency also demonstrated success in a number of areas. Choice of dining options including where and with whom individuals would like to eat their meals was fully supported. It was observed that some individuals preferred to eat with others while some preferred a quiet, intimate dining setting with his own table without others. Individuals were supported to make choices about their daily household routines, purchasing personal belongings and decorating their personal living space.  It was evident that staff was knowledgeable regarding the individuals they support, as well as the community resources available. Surveyors observed that staff were assisting individuals and actively working on skill development through ISP goals, behavior plans, and general daily activities. Individuals appeared to have choices in such things as was documented for example:  personal and household schedules, participating in hiring and evaluating staff and individuals were encouraged to safely use their community alone time.

There are a few areas that the agency has just begun to assess and implement.  As noted in its Strategic Plan, the agency is working to increase Assistive Technology in all homes and to develop an Assistive Technology Assessment Tool to further assist individuals to maximize their independence.  While the agency had recently completed Community/Leisure Activity Surveys with individuals to learn of individuals' community interests, the outcomes of these surveys are still in the infancy stages of becoming fully implemented and are intended to be used by the agency to identify and plan activities based on individual preference and choice.  

Some areas requiring further attention were identified during the survey. For example, on the organizational level the agency needs to have a Human Rights Committee which has full participation by all voting members.  Review of restraints needs to be completed within regulatory timelines.  

For the Residential/Individual Homes Supports some licensure areas need further attention.  In the area of health care, follow-up appointments need be scheduled and occur as recommended by the individuals' health care practitioners.  Medication treatment plans need to include all required components and need to be integrated within the ISP and reviewed by the Human Rights Committee.  Specific media/photo/image and news release consent forms should only be obtained when needed, specifically outlining the scope, dated and signed by the individual or guardian if applicable. 

In the area of certification, the agency needs to further assess individuals  needs or desires in the area of sexuality, intimacy and companionship so that education could be provided and geared to each person's individualized needs/preferences and learning styles. As previously noted, the agency needs to ensure that individuals are using the community in ways which are of interest to them.  

As a result of this review, North Suffolk's Residential Services/Individual Homes Supports received a rating of met in 90% of licensing indicators with all critical indicators met, and therefore received a Two Year License. The agency received a rating of met in 91% of certification indicators reviewed in residential and individual home support services, and as a result, the agency is Certified for Residential Services/Individual Home Supports.  Follow-up on all not met licensing indicators will be conducted by North Suffolk within 60 days.	

	

LICENSURE FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
7/10	
3/10	

Residential and Individual Home Supports	
70/76	
6/76	

    Residential Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
77/86	
9/86	
90%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
9	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
The agency's Human Rights Committee meetings did not include the attendance of a legal representative for six of nine meetings. In addition, attendance at three of the meetings did not meet quorum according to the agency's established by-laws. The Human Rights Committee needs to meet regulatory requirements for membership and maintain quorum in accordance with the committee by-laws.	

 L65	
Restraint reports are submitted within required timelines.	
Three out of the six restraint reports were not created and submitted within required timelines. The agency needs to ensure restraint reports are created within three days of the restraint and reviewed by the restraint manager within five days of the event date in accordance with DDS regulatory requirements.	

 L74	
The agency screens prospective employees per requirements.	
For two of the five newly hired employees reviewed, the application/resume did not indicate required experience to be hired for the position had been met according to job description. The agency needs to ensure that its screening process screens out prospective employees who do not meet provider and DDS qualifications before hire. 	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L24	
Locks on doors not providing egress can be opened by the individuals from the inside and staff carry a key to open in an emergency.	
At two of the five locations, there were locks in place on bathroom doors which, when locked from the inside, could not be opened by staff from the outside in case of emergency. The agency needs to ensure that locks on doors not providing egress only have a lock if they can be opened by the individuals and that staff are able to open locked doors in an emergency.	

 L36	
Recommended tests and appointments with specialists are made and kept. 	
For two out of the eight individuals surveyed, there was no evidence to indicate that all of their medical appointments had been scheduled and kept as recommended by health care practitioners. The agency needs to ensure that arrangements for coordinated medical care, including recommended initial and ongoing follow-up appointments with specialists, are made and kept.	

 L55	
Informed consent is obtained from individuals or their guardians when required; Individuals or their guardians know that they have the right to withdraw consent.	
For eight out of eight individuals surveyed, informed consent forms did not include event specific information and was in many cases obtained for use when a picture/image had not yet been taken. The agency needs to ensure that consents are specific to each situation in which the individuals' picture or information is being shared. 	

 L63	
Medication treatment plans are in written format with required components.	
For three out of six individuals surveyed who were taking behavior modifying medication, medication treatment plans did not include all required components. The agency needs to ensure the following: target behaviors are objectively defined in measurable terms; plans describe a general clinical plan or course for use of the medication such as criteria for re-evaluating and/or adjusting the medication based on the treatment data; data collection is occurring in terms of the criteria established within the plan.	

 L64	
Medication treatment plans are reviewed by the required groups.	
For four out of six individuals surveyed, there was no evidence of the required review for their medication treatment plan. The agency needs to ensure that medication treatment plans are submitted to and reviewed by the individual's ISP team.	

 L67	
There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	
For two out of seven individuals for whom the agency has shared or delegated money management responsibilities, money management plans were lacking required components. The agency needs to ensure that teaching plans are in place for all individuals for whom the agency has shared or delegated money management responsibilities, and that it obtains agreement to the plan from the individual's guardian/conservator.	

	

		

	

	

CERTIFICATION FINDINGS	

	

	

	
Met / Rated	
Not Met / Rated	
% Met	

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

Residential and Individual Home Supports	
35/39	
4/39	

Individual Home Supports	
16/17	
1/17	

Residential Services	
19/22	
3/22	

TOTAL	
41/45	
4/45	
91%	

Certified	

	

	

	

	

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

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.	
For two out of two individuals surveyed, there was no evidence that the individuals were provided the opportunity to give feedback on the staff that supports them.  The agency needs to ensure that Individuals served in the Individual Home Supports Division are afforded the opportunity to provide feedback on the staff who support them.	

	

	
Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For three out of six individuals surveyed,  there was no evidence that individuals' needs or desires in the area of sexuality, intimacy and companionship had been assessed so that education could be provided and geared to each person's preferences and learning styles. The agency needs to ensure that staff are knowledgeable of each individual's needs and/or desires and subsequent appropriate support provided.	

 C17	
Community activities are based on the individual's preferences and interests.	
For four out of six individuals surveyed, there was no evidence that individualized community activities were occurring or had been offered to individuals based on their personal preferences and interests. The agency needs to ensure that individuals are provided with frequent opportunities to engage in community activities that are in line with the individual's preferences and interests.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For three out of six individuals surveyed, there was no evidence that individuals had been assessed, either formally or informally, for their need for assistive technology which could maximize their independence. The agency needs to ensure that they review and assess each individual's needs to determine whether an individual would benefit from any assistive tools and devices to maximize independence in home routines and activities.	

	

	

		

	

						
	MASTER SCORE SHEET LICENSURE	

						
	Organizational: NORTH SUFFOLK MHA	

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

O	
 L2	
Abuse/neglect reporting	
7/8	
Met(87.50 % )	

 L3	
Immediate Action	
15/15	
Met	

 L4	
Action taken	
10/10	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
3/6	
Not Met(50.0 % )	

 L66	
HRC restraint review	
6/6	
Met	

 L74	
Screen employees	
3/5	
Not Met(60.0 % )	

 L75	
Qualified staff	
2/2	
Met	

 L76	
Track trainings	
1/1	
Met	

 L83	
HR training	
1/1	
Met	

						
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
6/6	
1/1	

	
	
7/7	
Met	

 L5	
Safety Plan	
L	
6/6	

	

6/6	
Met	

O	
 L6	
Evacuation	
L	
6/6	

	

6/6	
Met	

 L7	
Fire Drills	
L	
6/6	

	

6/6	
Met	

 L8	
Emergency Fact Sheets	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L9	
Safe use of equipment	
L	
6/6	
2/2	

	
	
8/8	
Met	

 L10	
Reduce risk interventions	
I	
2/2	

	

2/2	
Met	

O	
 L11	
Required inspections	
L	
4/5	

	

4/5	
Met
(80.0 %)	

O	
 L12	
Smoke detectors	
L	
5/5	

	

5/5	
Met	

O	
 L13	
Clean location	
L	
5/5	

	

5/5	
Met	

 L14	
Site in good repair	
L	
5/5	

	

5/5	
Met	

 L15	
Hot water	
L	
5/5	

	

5/5	
Met	

 L16	
Accessibility	
L	
6/6	

	

6/6	
Met	

 L17	
Egress at grade 	
L	
5/5	
1/1	

	
	
6/6	
Met	

 L18	
Above grade egress	
L	
5/5	

	

5/5	
Met	

 L19	
Bedroom location	
L	
6/6	

	

6/6	
Met	

 L20	
Exit doors	
L	
6/6	
1/1	

	
	
7/7	
Met	

 L21	
Safe electrical equipment	
L	
6/6	
1/1	

	
	
7/7	
Met	

 L22	
Clean appliances	
L	
6/6	
1/1	

	
	
7/7	
Met	

 L23	
Egress door locks	
L	
6/6	

	

6/6	
Met	

 L24	
Locked door access	
L	
3/5	

	

3/5	
Not Met
(60.0 %)	

 L25	
Dangerous substances	
L	
5/5	

	

5/5	
Met	

 L26	
Walkway safety	
L	
5/5	

	

5/5	
Met	

 L27	
Pools, hot tubs, etc.	
L	
1/1	

	

1/1	
Met	

 L28	
Flammables	
L	
6/6	

	

6/6	
Met	

 L29	
Rubbish/combustibles	
L	
6/6	

	

6/6	
Met	

 L30	
Protective railings	
L	
6/6	

	

6/6	
Met	

 L31	
Communication method	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L32	
Verbal & written	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L33	
Physical exam	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L34	
Dental exam	
I	
5/5	
2/2	

	
	
7/7	
Met	

 L35	
Preventive screenings	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L36	
Recommended tests	
I	
4/6	
2/2	

	
	
6/8	
Not Met
(75.00 %)	

 L37	
Prompt treatment	
I	
6/6	
2/2	

	
	
8/8	
Met	

O	
 L38	
Physician's orders	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L39	
Dietary requirements	
I	
5/5	
2/2	

	
	
7/7	
Met	

 L40	
Nutritional food	
L	
6/6	
1/1	

	
	
7/7	
Met	

 L41	
Healthy diet	
L	
6/6	
2/2	

	
	
8/8	
Met	

 L42	
Physical activity	
L	
6/6	
2/2	

	
	
8/8	
Met	

 L43	
Health Care Record	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L44	
MAP registration	
L	
6/6	

	

6/6	
Met	

 L45	
Medication storage	
L	
6/6	

	

6/6	
Met	

O	
 L46	
Med. Administration	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L47	
Self medication	
I	
5/6	
2/2	

	
	
7/8	
Met
(87.50 %)	

 L49	
Informed of human rights	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L50	
Respectful Comm.	
L	
6/6	
1/1	

	
	
7/7	
Met	

 L51	
Possessions	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L52	
Phone calls	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L53	
Visitation	
I	
6/6	
1/1	

	
	
7/7	
Met	

 L54	
Privacy	
L	
6/6	
1/1	

	
	
7/7	
Met	

 L55	
Informed consent	
I	
0/6	
0/2	

	
	
0/8	
Not Met
(0 %)	

 L56	
Restrictive practices	
I	
3/4	

	

3/4	
Met	

 L57	
Written behavior plans	
I	
1/1	

	

1/1	
Met	

 L58	
Behavior plan component	
I	
1/1	

	

1/1	
Met	

 L59	
Behavior plan review	
I	
1/1	

	

1/1	
Met	

 L60	
Data maintenance	
I	
1/1	

	

1/1	
Met	

 L61	
Health protection in ISP	
I	
6/6	

	

6/6	
Met	

 L62	
Health protection review	
I	
6/6	

	

6/6	
Met	

 L63	
Med. treatment plan form	
I	
3/6	

	

3/6	
Not Met
(50.0 %)	

 L64	
Med. treatment plan rev.	
I	
2/6	

	

2/6	
Not Met
(33.33 %)	

 L67	
Money mgmt. plan	
I	
4/6	
1/1	

	
	
5/7	
Not Met
(71.43 %)	

 L68	
Funds expenditure	
I	
6/6	

	

6/6	
Met	

 L69	
Expenditure tracking	
I	
6/6	

	

6/6	
Met	

 L70	
Charges for care calc.	
I	
6/6	

	

6/6	
Met	

 L71	
Charges for care appeal	
I	
6/6	

	

6/6	
Met	

 L77	
Unique needs training	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L78	
Restrictive Int. Training	
L	
4/4	

	

4/4	
Met	

 L80	
Symptoms of illness	
L	
6/6	
2/2	

	
	
8/8	
Met	

 L81	
Medical emergency	
L	
6/6	
2/2	

	
	
8/8	
Met	

O	
 L82	
Medication admin.	
L	
6/6	

	

6/6	
Met	

 L84	
Health protect. Training	
I	
6/6	

	

6/6	
Met	

 L85	
Supervision 	
L	
6/6	
2/2	

	
	
8/8	
Met	

 L86	
Required assessments	
I	
5/5	

	

5/5	
Met	

 L87	
Support strategies	
I	
5/5	

	

5/5	
Met	

 L88	
Strategies implemented	
I	
6/6	
2/2	

	
	
8/8	
Met	

 L90	
Personal space/ bedroom privacy	
I	
6/6	
2/2	

	
	
8/8	
Met	

#Std. Met/# 76 Indicator	

	

	

70/76	

	
Total Score	

	

	

77/86	

	

	

	

	
89.53%	

		
						
	MASTER SCORE SHEET CERTIFICATION	

						
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C1	
Provider data collection	
1/1	
Met	

 C2	
Data analysis	
1/1	
Met	

 C3	
Service satisfaction	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
1/1	
Met	

 C5	
Measure progress	
1/1	
Met	

 C6	
Future directions planning	
1/1	
Met	

	

	

						
Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
0/2	
Not Met (0 %)	

 C8	
Family/guardian communication	
2/2	
Met	

 C9	
Personal relationships	
1/1	
Met	

 C11	
Get together w/family & friends	
1/1	
Met	

 C13	
Skills to maximize independence 	
1/1	
Met	

 C16	
Explore interests	
1/1	
Met	

 C17	
Community activities	
1/1	
Met	

 C19	
Knowledgeable decisions	
2/2	
Met	

 C20	
Emergency back-up plans	
2/2	
Met	

 C21	
Coordinate outreach	
2/2	
Met	

 C46	
Use of generic resources	
1/1	
Met	

 C47	
Transportation to/ from community	
2/2	
Met	

 C48	
Neighborhood connections	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

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

 C53	
Food/ dining choices	
2/2	
Met	

 C54	
Assistive technology	
1/1	
Met	

Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
6/6	
Met	

 C8	
Family/guardian communication	
6/6	
Met	

 C9	
Personal relationships	
5/6	
Met (83.33 %)	

 C10	
Social skill development	
6/6	
Met	

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

 C12	
Intimacy	
3/6	
Not Met (50.0 %)	

 C13	
Skills to maximize independence 	
5/6	
Met (83.33 %)	

 C14	
Choices in routines & schedules	
6/6	
Met	

 C15	
Personalize living space	
6/6	
Met	

 C16	
Explore interests	
6/6	
Met	

 C17	
Community activities	
2/6	
Not Met (33.33 %)	

 C18	
Purchase personal belongings	
6/6	
Met	

 C19	
Knowledgeable decisions	
6/6	
Met	

 C20	
Emergency back-up plans	
6/6	
Met	

 C46	
Use of generic resources	
6/6	
Met	

 C47	
Transportation to/ from community	
6/6	
Met	

 C48	
Neighborhood connections	
6/6	
Met	

 C49	
Physical setting is consistent 	
6/6	
Met	

 C51	
Ongoing satisfaction with services/ supports	
6/6	
Met	

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

 C53	
Food/ dining choices	
6/6	
Met	

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