PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
PEOPLE INC
4 South Main St
 Fall River, MA 02721    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
June 5, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
PEOPLE INC	

	

	

	

	
Review Dates	

	
5/16/2018 - 5/21/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
6/5/2018	

	

	

	

	

	

	
Survey Team	

	
Scott Nolan	

Katherine Gregory	

Michael Marchese	

Barbara Mazzella	

Laura O'Connor	

Ed Sutka	

Tina Napolitan (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	
14 location(s) 17 audit (s) 	
Targeted Review	
DDS 16 / 22
Provider 65 / 66

81 / 88 2 Year License 06/05/2018-  06/05/2020	
	
DDS 60 / 77
Provider 18 / 18

78 / 95 Certified 06/05/2018 -  06/05/2020	

Residential Services	
8 location(s) 8 audit (s) 	

DDS Targeted Review	
16 / 22	

ABI-MFP Residential Services	
1 location(s) 3 audit (s) 	

DDS Targeted Review	
15 / 22	

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

DDS Targeted Review	
19 / 22	

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

DDS Targeted Review	
22 / 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 16 / 18
Provider 47 / 48

63 / 66 2 Year License 06/05/2018-  06/05/2020	
	
DDS 17 / 21
Provider 21 / 21

38 / 42 Certified 06/05/2018 -  06/05/2020	

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

DDS Targeted Review	
12 / 14	

Employment Support Services	
2 location(s) 5 audit (s) 	

DDS Targeted Review	
20 / 22	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

	

	

	

EXECUTIVE SUMMARY :	

	

	

People Incorporated, founded in 1968, is a human service agency which provides a variety of services to children and adults including early intervention, foster care, family advocacy, diabetes education, health and nutritional guidance, educational support for high school students and elder services.  The agency provides services within the greater Fall River, New Bedford and Taunton areas.   The current review by the Department of Developmental Services (DDS) survey team encompassed the following service models supporting adults with developmental disabilities: 24 hour residential supports, Individualized Home Supports (IHS), placement, and acquired brain injury supports at 85 locations and Community Based Day Supports (CBDS) and Employment Supports to 103 individuals. 

As the agency had elected to complete a self-assessment for all supports under evaluation, the portion of this review completed by the DDS survey team was targeted to a limited number of indicators.  The scores for the complete licensure and certification review of the agency's day and residential services reflected a combination of the DDS targeted review and ratings from the agency's self-assessment.

The review by the DDS survey team identified a number of strengths.  Licensing requirements regarding environmental safety, such as working smoke and carbon monoxide detectors and current inspections, were found to be in place. Staff supported individuals to evacuate within required time frames and conducted fire drills in accordance with safety plans.  Homes were clean, spacious and offered opportunities for individuals to meet privately with visitors which fostered ongoing contacts and connections with family and friends.  Individual's rooms were decorated in a manner that reflected personalized interests and tastes. One individual was pleased to share her love of dream catchers and how they tastefully decorated her bedroom.

Findings also revealed that the agency continues to maintain systems to ensure that individuals receiving residential services, had the necessary supports to manage significant health care conditions and properly be administered medication.  Staff were aware of individuals' significant health care conditions and provided any unique supports that were needed.  Medications were administered according to the written order of a practitioner and were properly documented on a Medication Treatment Chart. All staff administering medications were certified to do so.

Across all services, staff was observed to be respectful when interacting with individuals; taking the time to listen and process what individuals were expressing, addressing people by first name and asking questions of them.  

The agency's Employment and CBDS programs also had several strengths.  Individuals were employed in integrated work settings and paid minimum wage or better. In efforts to identify and develop new employment opportunities, staff frequently reached out to potential employers and attended job fairs.  Additionally, the agency is a part of the local Chamber of Commerce. One individual had just become unemployed the week prior to the survey and staff supported him to update his resume and begin exploring new employment opportunities within two days.  

Findings revealed that at the employment and CBDS location regular fire drills were conducted in accordance with safety plans and afforded individuals a clean, spacious environment to participate in many activities. 

Positive outcomes were observed within the certification areas across residential, employment and day services.  Residentially, individuals were supported to get together with family and friends.  There were multiple examples of the agency providing transportation to individuals to visit with family/friends.   One individual experiences significant anxiety when visiting with family and the agency was observed to help him develop coping strategies to be able to promote the ongoing relationship with family members. 

Individuals were offered choices for leisure activities and staff demonstrated respected and fostered choice.  In many homes weekly menus were prepared with the residents. Staff was observed to also offer choices each day to ensure individuals were eating what they wished that day.  

Within the CBDS program people were offered multiple choices regarding their schedule.  Several activities were offered daily.  Efforts were made to ensure that community activities offered were within integrated settings and were meaningful such as volunteerism and fitness related. 

Licensing areas involving human rights could benefit from further attention within residential supports.  These areas include the need to develop and inform individuals and guardians of how to file a grievance, ensure that restrictive practices include all the required components, further refine the process for securing consent to  use a person's photo and ensuring people are offered privacy. 
  
Additional efforts are also needed to promote positive outcomes in a few certification areas.  In the area of intimacy and companionship the agency is encouraged to continue this effort to help staff to support individuals. The agency will benefit from finalizing their process to include individual's feedback on staff performance on a regular basis and to share this information with staff for training purposes.  Individuals need further support to assess, identify and utilize assistive technology or modifications to maximize their independence at home. 

Within the employment and day programs, staff need to strengthen their implementation and oversight when individuals require specialized diets.  

Based on the findings of this report, People Inc. has earned a Two Year License for both Residential Supports and Employment and Day Support programs.  Additionally, the agency is certified for both Residential and Employment/Day Supports.  Within residential supports, People Inc. met 92% of all licensing indicators and met for 82% of the certification indicators.  For the Day and Employment programs, People Inc. met 95% of the licensing indicators and met 90% of the certification indicators.  The agency will conduct a follow up for licensing indicators rated Not Met within 60 days.  

People Inc. has presented the following self-assessment.	

	

	

	

Description of Self Assessment Process:	

	

	

People Incorporated (PI) has made a concerted effort to continue on with enhancing our quality improvement systems over the course of the last 2 years. PI recognizes the importance of remaining vigilant when it comes to safety and providing premier services. We have made the commitment to not fall prey to complacency, and to build upon current systems and practices that have proven to be beneficial. 
We see the value in the creation of new tools and providing resources for all staff. Our goal is to have adequate measurement systems to ensure these tools are in fact being utilized. It is not only important they are utilized, but are user-friendly, effective with regard to achieving the desired outcome, and are in line with expectations put forth from all involved stakeholders. Aside from the standard review of documentation, it is necessitous to perform full audits at all locations. The word audit naturally comes with a negative connotation associated with it, but we are working to erase that mind set and replace it with a positive, learning experience where great ideas can be shared. We also are breaking down silos by aligning involved departments. For example, if we are conducting an audit at one of our 24 hour supported Residential sites, our Facilities Team is made aware of the date and location. They accompany the team to the site to perform an environmental review. In addition, we work closely with our Director of MAP Training and Compliance to assess all pertinent information.   

Immediately following that 2016 QE survey, the Residential Team embarked on an ambitious goal to formulate a team to maintain momentum. This team consists of Residential Leadership, Program Operations Managers (POMs), and Assistant Program Operations Managers (APOMs). It is important that we incorporated one or two staff at these audits that do not have direct connection with these sites. Although we do consider ourselves one team with one common goal, each Assistant Residential Director has a caseload of their own. Incorporating someone that is not in that "chain of command" is important to objectivity. Although we used a similar 80 % threshold to consider an area met, our goal is always to achieve 100% compliance. 
At each audit, we utilize three tools. The first is a detailed Home and Safety Worksheet. This worksheet involves over one hundred areas that are assessed for safety and hygiene. The next two forms we use are derived directly from DDS licensure indicators. The first of the two we refer to as "Mandatory Standards". The second tool is the "QE Standards". Management is sent a schedule encompassing several months. There are unannounced visits in between in which staff will participate in a much more abbreviated auditing of a selected item, such as a confidential file. We rely on empirical data and follow up has changed to incorporate an evidence-based mentality. Timelines are established and if needed, a follow-up at the site will be performed. We now conduct our Nursing Team's medication assessments to be in concert with all site audits. 

Our Day Services Division uses a monthly checklist that consists of DDS licensing Environmental Safety indicators, CARF regulations, and OSHA mandates to ensure full compliance. The Program Manager uses this checklist to document that all inspections are current, monthly fire drills are conducted, water temperatures are regulated and that an inspection of the physical site is completed. The checklist is reviewed by Program Directors and Vice President of Day Services. Case files are reviewed quarterly and at the time of the ISP. Emergency fact sheets, health care records, consent forms, safety assessments, ISP goals are all audited during this review. When an individual has medication to address behavioral issues, staff are responsible to ensure there is a written treatment plan and as applicable a Roger's monitor.  As part of the case record review process, staff ensures there is current health care information, to include special diets and protocols. The Nursing staff then provides training to ensure protocols are understood and followed. The completed case record review form is sent to the Program Director; corrective actions are completed within two weeks. 
The Assistant Director of Shared Living/AFC, the Community Health Worker, and Shared Living Case Manager continue to review the individuals in Shared Living we provide supports to, using the DDS Licensure/Certification Guidelines in conjunction with Placement Services Licensure and Certification Information. A biannual review of our shared living individuals, has proven to be an effective measure to ensure compliance for the individuals we support. 

We have implemented a revised orientation format that includes on-site training at the staff's home location. This promotes an increased level of comfort for new staff. Couple that with an extensive 10 Day Training Packet for Direct Care Professionals, and staff are immediately provided with necessary training. Also, we invested a very significant dollar amount in the fall of 2017, to recognize Direct Care Professionals and Certified Nursing Assistants for a job well done. We also realize that training and professional development is an ongoing endeavor. As a result, we have a Human Resources Team that attends meetings regularly, hosts meetings, and makes themselves available to all employees for feedback sessions and professional development. Finally, we have a wonderful training platform known as eAcademy. This is open to all staff. It encompasses not only mandatory trainings, but also elective courses that cover a wide array of topics that will enhance the competency of our workforce. 

All of the aforementioned practices are wonderful if they work in theory, but there must be systems and discussions to monitor progress. In the instances where staff are out of compliance with required trainings, there is a system to monitor that as well. Our Residential sector is by far the largest of the organization involving more than four hundred employees. We meet every Monday to review recruitment efforts to minimize vacancies. We also discuss corrective action plans that are needed as a follow up for positive discipline along with staff that are out of compliance or are approaching their anniversary date of a mandatory training. After reminders have been exhausted, staff will be put on administrative leave until full compliance is achieved. We are happy to report we are approaching our 100% compliance rate. In addition to required trainings, the totality of information needed to work at various sites can prove to be intimidating at times. Along with regularly scheduled trainings and meetings, we have required all employees to be trained in the 10 Day Packet. This document encompasses the necessary information surrounding site-based requirements (evacuation plans), along with all individual specific trainings.
Meetings are instrumental in maintaining ongoing communications. There are weekly meetings for each division. These meetings involve critical incident reviews that may have occurred over the previous week, individuals that may be at risk, staff vacancies, restraint reporting, along with a number of other topics that could potentially have an impact on the individuals and staff alike. We have incorporated an All-Cluster meeting which incorporates management at all levels from Residential sites. We conduct bi-weekly meetings with our Chief Operating Officer, Behavior Services Division, Residential Leadership, and Day Services Leadership. We meet at least quarterly with DDS ABI. We conduct monthly Risk meetings with Fall River DDS. This is in addition to other impromptu meetings that may come about. We conduct quarterly Safety Committee meetings with sixteen staff members from different departments. 

PI always feels we are prepared for any audit, any time. With that being said, we constructed several teams to cover all areas of the survey. All teams were instructed that we have a minimum compliance level of 80% to rate an indicator as met. Prior to this survey, we had representation from QE at a meeting with all involved parties so everyone fully understood the process. The tools provided in the 45 Day Notification were used. 

The process used to self-assess Day Services: A case record review team is comprised of Employment Specialists, a Case Manager and Program Director. The case record review team ensures all records are up to date and all necessary information is in the file. A building inspection team consists of the Vice President of Day Services and Director of Transportation. The building team ensures all inspections are up to date, all emergency systems are working, fire extinguisher are charged, evacuation routes are clean, cleaning supplies are locked, emergency drills are completed, and there is a current evacuation plan. The third team is comprised of the Registered Nurse, Licensed Practical Nurse, Vice President of Day Services and Vocational Program Director to review medication orders, dietary restrictions and  staff trainings. 9 individuals were involved in the survey for Community Based Day Services, while 5 individuals were involved for Employment Support Services.

The process used to self-assess Adult Foster Care (AFC)/Shared Living: During the week of 4/23, the Assistant Director for AFC/Shared Living, the Community Health Worker and Registered Nurse conducted the self-assessment utilizing the Placement Services Licensure and Certification Information 9/1/17 and the DDS Licensure/ Certification Guidelines. 2 individuals were involved in the survey.  The process used to self-assess Residential Services: As part of the audit process, teams were compiled consisting of the VP of Residential Services, the Residential Director, 2 Assistant Directors, the POM and APOM of the site, the Director of MAP Training and Compliance, along with an Administrative staff. We ensured, to the best of our ability, there was a party involve that does not have direct involvement at the sites. In all but one instance, an Assistant Director was involved, which did not have the site being audited on their caseload. In total, we visited 8, 24 hour supported locations, 1 ABI/MFP location along with 4 individuals that receive IHS. The 24 hour locations all had individuals identified as A and B totaling 16 individuals. We audited all 4 individuals from the ABI site. In addition, another team consisting of Assistant Directors, POMs, Assessment Nurses, and Administrative staff conducted sub-audits at 8 additional locations. Also, the remaining sites used a "buddy system" in which 2 houses were paired and audited each location. The sub-audits and "buddy" sites are not reflective in the report. We felt it was important to review all sites once again to ensure there were not pervasive themes that needed to be addressed.	

	

	

	

LICENSURE FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Residential and Individual Home Supports	
71/78	
7/78	

    Residential Services
    ABI-MFP Residential Services
    Placement Services
    Individual Home Supports

	

Critical Indicators	
8/8	
0/8	

Total	
81/88	
7/88	
92%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
7	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
10/10	
0/10	

Employment and Day Supports	
53/56	
3/56	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
8/8	
0/8	

Total	
63/66	
3/66	
95%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L49	
Individuals and guardians have been informed of their human rights and know how to file a grievance or to whom they should talk if they have a concern.	
Thirteen out of seventeen individuals were not informed of how to file a grievance.  The agency needs to ensure that individuals and guardians are informed of how to file a grievance, or to whom they should talk to if they have a concern.	

 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.	
Documents used to obtain informed consent was reviewed for three individuals.  In two instances, the agency obtained consent without identifying the specific purpose or time-frames for distribution.  When obtaining consent it should also be specified that it can be withdrawn before a new release of an image takes place.  The agency needs to ensure that when informed consent is obtained from individuals or their guardians, all required components need to be in place. 	

 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.	
Restrictive practices were reviewed for three individuals.  In two instances, one or more of the following required components were not present: criteria to reduce or eliminate the restriction, information regarding less restrictive interventions utilized or strategies to mitigate the impact of the restriction on others.  The agency needs to ensure that requirements for the use of restrictive practices are in place.	

 L64	
Medication treatment plans are reviewed by the required groups.	
Medication treatment plans were reviewed for eleven individuals.  Of these, seven were not included within individuals' ISP.  The agency needs to ensure that Medication treatment plans are reviewed by the required groups.  	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
The agency did not submit the Support Strategies within the 15 day time frame for 5 individuals.  The agency needs to ensure Support Strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting.  	

 L90	
Individuals are able to have privacy in their own personal space.	
Fourteen individuals were reviewed regarding their right to privacy in their own personal space.  Of these, three individuals did not have lockable bedroom doors.  The agency needs to ensure that individuals are afforded privacy in their own personal space.  	

	

	

	

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

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Residential Services did not meet the 80% threshold; 73% compliance rate.	
We will be using an evidence based approach when Assistant Directors are reviewing ISP action items with Program Operations Managers. All related documentation must be provided and verified on HCSIS. This will be added to agendas for weekly meetings beginning on 5/21/2018.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L39	
Special dietary requirements are followed. 	
One individual had a dietary recommendation, however there was not an effective strategy in place to track or monitor that the person was being supported to follow the doctor's order. The agency needs to ensure special dietary requirements are followed.	

 L87	
Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	
Support strategies were reviewed for six individuals. In three instances, support strategies were not submitted within 15 days of the ISP. The agency needs to ensure that strategies are submitted within required time-frames.	

	

	

	

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

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L15	
Hot water temperature tests between 110 and 120 degrees (as of 1/2014).	
The hot water ranges from 112 to 119 degrees.	
The facilities department is looking into correcting and should have a resolution the week of 5/14/2018.	

	

	

	
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 59/76
Provider 13/13	
72/89	
17/89	

ABI-MFP Residential Services	
DDS 12/19
Provider 3/3	
15/22	
7/22	

Individual Home Supports	
DDS 18/19
Provider 4/4	
22/23	
1/23	

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

Residential Services	
DDS 13/19
Provider 3/3	
16/22	
6/22	

Total	
	
78/95	
17/95	
82%	

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 16/20
Provider 16/16	
32/36	
4/36	

Community Based Day Services	
DDS 9/11
Provider 3/3	
12/14	
2/14	

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

Total	
	
38/42	
4/42	
90%	

Certified	

	

	

	

	

	
ABI-MFP 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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For three individuals, there was no evidence that the provider solicited these individuals' feedback on an ongoing performance of the staff who support them. The agency needs to expand its existing systems to ensure that individuals have opportunities to provide feedback on staff performance on an ongoing basis and that feedback is shared with staff for evaluation and training purposes.	

	
 C9	
Staff (Home Providers) act as bridge builders and provide opportunities to develop, and/or increase personal relationships and social contacts.	
For three individuals, there was insufficient evidence that staff have offered them opportunities to develop, and/or increase personal relationships and social contacts.  	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For three individuals, staff had not assessed their interests and need for intimacy and companionship. The agency needs to ensure that staff have an understanding of the individual's interest in the area of intimacy an companionship, and support them in this area.	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Three individuals were not consistently provided opportunities to explore and participate in community activities based on their preference and interests.  The agency needs to ensure that individuals are supported to participate in preferred activities on an on-going basis.  	

	
 C46	
Staff (Home Providers) support individuals to learn about and use generic community resources.	
One individual had not been provided opportunities to learn about and utilize generic community resources.  The agency needs to ensure that people are supported to use generic resources on a frequent and on-going basis.	

	
 C48	
Individuals are a part of the neighborhood.	
For three individuals reviewed there was no evidence that opportunities were provided to connect with their neighbors or participate in neighborhood activities or community groups.  The agency needs to provide opportunities for people to become part of their neighborhoods.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For two individuals, plans were not developed to support them to explore and implement the use of assistive devices and/or modify existing technology to maximize their independence.  	

	
Individual Home Supports- 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. 	
For two out of four individuals participating in the survey, an assistive technology assessment was not completed or a strategy to assess assistive technology to address an identified need was not developed.  The agency needs to conduct assistive technology evaluations with each individual to determine which modifications or adaptive devices could help them to be as independent as possible.	

	

	

	
Placement 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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For one out of two individuals, there was no evidence that the provider solicited these individuals' feedback on an ongoing performance of the staff who support them. The agency needs to expand its existing systems to ensure that individuals have opportunities to provide feedback on staff performance on an ongoing basis and that feedback is shared with staff for evaluation and training purposes.	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For one out of two individuals reviewed, staff had not assessed their interests and need for intimacy and companionship. The agency needs to ensure that staff have an understanding of individuals' interest in the area of intimacy and companionship, and support them in this areas.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For two individuals, an assessment to identify any areas that assistive technology and/or modifications could be made to enable them to be more self-sufficient was not completed. The agency needs to assist individuals' to identify areas of need and support them to use assistive technology and/or make modifications that would 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 / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For eight individuals, there was no evidence that the provider solicited these individuals' feedback on an ongoing performance of the staff who support them. The agency needs to expand its existing systems to ensure that individuals have opportunities to provide feedback on staff performance on an ongoing basis and that feedback is shared with staff for evaluation and training purposes.	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For six out of eight individuals, staff had not assessed their interests and need for intimacy and companionship. The agency needs to ensure that staff have an understanding of individuals' interest in the area of intimacy and companionship, and support them in this area.	

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Two individuals were not provided sufficient opportunities to connect with their interests for cultural, social, recreational and spiritual activities.  The agency needs to ensure that people are supported to explore and connect with such interests.	

	
 C17	
Community activities are based on the individual's preferences and interests.	
Two individuals were not consistently provided opportunities to explore and participate in community activities based on their preference and interests. 	

	
 C48	
Individuals are a part of the neighborhood.	
For two individuals reviewed there was no evidence that opportunities were provided to connect with their neighbors or participate in neighborhood activities or community groups.  The agency needs to provide opportunities to become part of their neighborhoods.  	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For six individuals, plans were not developed to support them to explore and implement the use of assistive devices and/or modify existing technology to maximize their independence.  The agency needs to conduct assistive technology evaluations with each individual to determine which modifications or adaptive devices could help them to be as independent as possible.   	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For three individuals, there was no evidence that the provider solicited these individuals' feedback on an ongoing performance of the staff who support them. The agency needs to expand its existing systems to ensure that individuals have opportunities to provide feedback on staff performance on an ongoing basis and that feedback is shared with staff for evaluation and training purposes.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For three individuals, the agency had not implemented a process to assess how individuals may benefit from the use of assistive technology or modifications to maximize their independence in various settings. The agency needs to conduct assistive technology evaluations with each individual to determine which modifications or adaptive devices could help them to be as independent as possible.

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
For five individuals, the agency did not have a process for individuals to provide feedback at the time of hire and on an ongoing basis to share feedback regarding employees performance. The agency needs to ensure that individuals have opportunities to provide input during hiring and the ongoing evaluation of staff performance.	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For five individuals, the agency had not implemented a process to assess how individuals may benefit from the use of assistive technology or modifications to maximize their independence in various settings. The agency needs to conduct assistive technology evaluations with each individual to determine which modifications or adaptive devices could help them to be as independent as possible.	

	

	

	

	MASTER SCORE SHEET LICENSURE	

								
	Organizational: PEOPLE INC	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
16/16	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
Provider	
-	
Met	

 L65	
Restraint report submit	
DDS	
112/140	
Met(80.0 % )	

 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	
8/8	
3/3	
2/2	
	
1/1	
	
14/14	
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	
8/8	
1/1	
2/2	
	
1/1	
	
12/12	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
8/8	
2/2	
2/2	
	
1/1	
	
13/13	
Met	

O	
 L13	
Clean location	
L	
DDS	
8/8	
2/2	
2/2	
	
1/1	
	
13/13	
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	

 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	
7/8	
1/1	

3/3	
	
11/12	
Met
(91.67 %)	

 L39	
Dietary requirements	
I	
DDS	
5/6	
	
1/1	
	
2/2	
	
8/9	
Met
(88.89 %)	

 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	
8/8	
2/2	
1/1	
	
3/3	
	
14/14	
Met	

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

 L49	
Informed of human rights	
I	
DDS	
1/8	
1/4	
1/2	
	
1/3	
	
4/17	
Not Met
(23.53 %)	

 L50	
Respectful Comm.	
L	
DDS	
8/8	
3/3	
2/2	
	
1/1	
	
14/14	
Met	

 L51	
Possessions	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
8/8	
4/4	
2/2	
	
3/3	
	
17/17	
Met	

 L53	
Visitation	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L54	
Privacy	
L	
DDS	
7/8	
3/3	
2/2	
	
1/1	
	
13/14	
Met
(92.86 %)	

 L55	
Informed consent	
I	
DDS	
0/1	
1/1	
0/1	

	
1/3	
Not Met
(33.33 %)	

 L56	
Restrictive practices	
I	
DDS	
1/3	

	

1/3	
Not Met
(33.33 %)	

 L57	
Written behavior plans	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I	
DDS	
2/2	

	

2/2	
Met	

 L60	
Data maintenance	
I	
DDS	
2/2	

	

2/2	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L63	
Med. treatment plan form	
I	
DDS	
6/7	
2/2	
0/1	
	
1/1	
	
9/11	
Met
(81.82 %)	

 L64	
Med. treatment plan rev.	
I	
DDS	
4/7	
0/2	
0/1	
	
0/1	
	
4/11	
Not Met
(36.36 %)	

 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	
8/8	
2/2	

1/1	
	
11/11	
Met	

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

 L85	
Supervision 	
L	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
-	
-	
-	
	
-	
-	
-	
Not Met

	
 L87	
Support strategies	
I	
DDS	
3/7	
2/2	
1/1	
	
2/3	
	
8/13	
Not Met
(61.54 %)	

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

 L89	
Complaint and resolution process	
L 	
Provider	
-	
-	
-	
	
-	
-	
-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
6/8	
1/1	
1/2	
	
3/3	
	
11/14	
Not Met
(78.57 %)	

#Std. Met/# 77 Indicator	

	

	

	
71/78	

	
Total Score	

	

	

	
81/88	

	

	

	

	
	
92.05%	

			
								
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	

 L5	
Safety Plan	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	

1/1	
1/1	
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	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	

1/1	
1/1	
Met	

O	
 L13	
Clean location	
L	
DDS	

1/1	
1/1	
Met	

 L14	
Site in good repair	
L 	
Provider	
	
-	
-	
-	
Met	

 L15	
Hot water	
L 	
Provider	
	
-	
-	
-	
Not Met

	
 L16	
Accessibility	
L 	
Provider	
	
-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
	
-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L	
DDS	

1/1	
1/1	
Met	

 L22	
Well-maintained appliances	
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	

 L37	
Prompt treatment	
I 	
Provider	
	
-	
-	
-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
1/1	
	
2/2	
3/3	
Met	

 L39	
Dietary requirements	
I	
DDS	

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

 L44	
MAP registration	
L 	
Provider	
	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
3/3	
	
1/1	
4/4	
Met	

 L49	
Informed of human rights	
I	
DDS	
5/5	
	
3/3	
8/8	
Met	

 L50	
Respectful Comm.	
L	
DDS	
2/2	
	
1/1	
3/3	
Met	

 L51	
Possessions	
I 	
Provider	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
5/5	
	
3/3	
8/8	
Met	

 L54	
Privacy	
L	
DDS	
2/2	
	
1/1	
3/3	
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	

 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	
2/2	
	
1/1	
3/3	
Met	

 L84	
Health protect. Training	
I 	
Provider	
	
-	
-	
-	
Met	

 L85	
Supervision 	
L 	
Provider	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
DDS	
2/3	
	
3/3	
5/6	
Met
(83.33 %)	

 L87	
Support strategies	
I	
DDS	
1/3	
	
2/3	
3/6	
Not Met
(50.0 %)	

 L88	
Strategies implemented	
I	
DDS	
5/5	
	
3/3	
8/8	
Met	

#Std. Met/# 55 Indicator	

	

	
53/56	

	
Total Score	

	

	
63/66	

	

	

	
	
95.45%	

			
								
	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	

	

	

	
								
ABI-MFP Residential Services	

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	
0/3	
Not Met (0 %)	

 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	
0/3	
Not Met (0 %)	

 C18	
Purchase personal belongings	
DDS	
3/3	
Met	

 C19	
Knowledgeable decisions	
DDS	
3/3	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
2/3	
Not Met (66.67 %)	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C48	
Neighborhood connections	
DDS	
0/3	
Not Met (0 %)	

 C49	
Physical setting is consistent 	
DDS	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
3/3	
Met	

 C53	
Food/ dining choices	
DDS	
3/3	
Met	

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

Community Based Day Services	

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	

 C13	
Skills to maximize independence 	
DDS	
3/3	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C40	
Community involvement interest	
DDS	
3/3	
Met	

 C41	
Activities participation	
DDS	
3/3	
Met	

 C42	
Connection to others	
DDS	
3/3	
Met	

 C43	
Maintain & enhance relationship	
DDS	
3/3	
Met	

 C44	
Job exploration	
Provider	
-	
Met	

 C45	
Revisit decisions	
DDS	
3/3	
Met	

 C46	
Use of generic resources	
DDS	
3/3	
Met	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

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

Employment Support Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
0/5	
Not Met (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	
5/5	
Met	

 C28	
Relationships w/businesses	
DDS	
2/2	
Met	

 C29	
Support to obtain employment	
Provider	
-	
Met	

 C30	
Work in integrated settings	
DDS	
4/4	
Met	

 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	
5/5	
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	
5/5	
Met	

 C50	
Involvement/ part of the Workplace culture	
DDS	
5/5	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
5/5	
Met	

 C54	
Assistive technology	
DDS	
0/5	
Not Met (0 %)	

Individual Home Supports	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
4/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
4/4	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
4/4	
Met	

 C12	
Intimacy	
DDS	
3/4	
Met	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C14	
Choices in routines & schedules	
DDS	
4/4	
Met	

 C15	
Personalize living space	
DDS	
3/3	
Met	

 C16	
Explore interests	
DDS	
4/4	
Met	

 C17	
Community activities	
DDS	
4/4	
Met	

 C18	
Purchase personal belongings	
DDS	
4/4	
Met	

 C19	
Knowledgeable decisions	
DDS	
4/4	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C21	
Coordinate outreach	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
4/4	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

 C48	
Neighborhood connections	
DDS	
4/4	
Met	

 C49	
Physical setting is consistent 	
DDS	
3/3	
Met	

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

 C52	
Leisure activities and free-time choices /control	
DDS	
4/4	
Met	

 C53	
Food/ dining choices	
DDS	
4/4	
Met	

 C54	
Assistive technology	
DDS	
2/4	
Not Met (50.0 %)	

Placement Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
1/2	
Not Met (50.0 %)	

 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	
1/2	
Not Met (50.0 %)	

 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	
2/2	
Met	

 C17	
Community activities	
DDS	
2/2	
Met	

 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	
2/2	
Met	

 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	
0/2	
Not Met (0 %)	

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
0/8	
Not Met (0 %)	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
8/8	
Met	

 C10	
Social skill development	
Provider	
-	
Met	

 C11	
Get together w/family & friends	
DDS	
8/8	
Met	

 C12	
Intimacy	
DDS	
2/8	
Not Met (25.00 %)	

 C13	
Skills to maximize independence 	
DDS	
7/8	
Met (87.50 %)	

 C14	
Choices in routines & schedules	
DDS	
8/8	
Met	

 C15	
Personalize living space	
DDS	
8/8	
Met	

 C16	
Explore interests	
DDS	
6/8	
Not Met (75.00 %)	

 C17	
Community activities	
DDS	
6/8	
Not Met (75.00 %)	

 C18	
Purchase personal belongings	
DDS	
7/7	
Met	

 C19	
Knowledgeable decisions	
DDS	
8/8	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
8/8	
Met	

 C47	
Transportation to/ from community	
DDS	
8/8	
Met	

 C48	
Neighborhood connections	
DDS	
6/8	
Not Met (75.00 %)	

 C49	
Physical setting is consistent 	
DDS	
8/8	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
8/8	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
8/8	
Met	

 C53	
Food/ dining choices	
DDS	
8/8	
Met	

 C54	
Assistive technology	
DDS	
2/8	
Not Met (25.00 %)