PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
REACH
20 Middle Street
 Plymouth, MA 02360    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
February 10, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

				
	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
REACH	

	

	

	

	
Review Dates	

	
1/9/2017 - 1/13/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
1/30/2017	

	

	

	

	

	

	
Survey Team	

	
Sally Hajjar (TL)	

Margareth Larrieux	

Barbara Mazzella	

Ed Sutka	

	

	

	

	

	

	
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	
7 location(s) 11 audit (s) 	
Full Review	
84 / 87 2 Year License 01/30/2017 -  01/30/2019	
	
50 / 51 Certified 01/30/2017 -  01/30/2019	

Residential Services	
3 location(s) 7 audit (s) 	

Full Review	
21 / 22	

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

Full Review	
23 / 23	

Planning and Quality Management (For all service groupings)	

	
Full 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	
2 location(s) 2 audit (s) 	
Full Review	
59 / 64 2 Year License 01/30/2017 -  01/30/2019	
	
20 / 20 Certified 01/30/2017 -  01/30/2019	

Community Based Day Services	
2 location(s) 2 audit (s) 	

Full Review	
14 / 14	

Planning and Quality Management (For all service groupings)	

	
Full Review	
6 / 6	

	

	

			
EXECUTIVE SUMMARY :	

			
Reach, Inc. is a private, non-profit human service agency that provides residential and day supports to adults with developmental disabilities throughout the greater Plymouth area. The agency has been providing services since 1987 and is committed to ensuring that its mission 'to assist adults with developmental disabilities reach their full potential towards independence, self-determination, and happiness at home, at work, and in their community' serves as the cornerstone of its delivery system. 

Reach, Inc. is currently funded by the Department of Developmental Services (DDS) to provide residential supports to sixty-two individuals.  The agency offers both twenty-four hour supports in agency operated homes and less than twenty-four hours of support at individuals' homes.  Community Based Day Supports are also availed to twenty-six individuals.  

This licensure and certification review included the new and revised indicators developed in response to requirements set forth by the Centers for Medicare and Medicaid (CMS).  The scope of the licensure review addressed indicators related to domains such as health care, environmental safety, funds management and human rights. The scope of the certification included areas such as individual choice, community membership and personal relationships. Additionally, organizational certification areas such as data collection and analysis regarding the quality of services provided was examined.  

The review by the DDS survey team identified a number of accomplishments on the part of the agency which resulted in positive individual outcomes for individuals receiving residential supports.  In the area of health care, people were supported to receive annual physical and dental examinations, preventative screenings as well as supported to follow recommendations provided by health care practitioners. Another area of strength was noted in the environmental domain; homes were well maintained, comfortable and reflected the personal preferences and tastes of the people who lived there. Two individuals who participated in the survey were excited to showcase their unique collections of memorabilia and possessions. Another positive finding concerned written communication reflecting staffs' understanding of individuals' unique needs. Daily progress notes were thorough, well written, neutral and informative.  

Medication Treatment Plans contained all of the required components and the data collection was thorough and on-going.  It was noted that the data was regularly presented to the treating clinicians and was utilized to chart an appropriate treatment course.  For example, in some cases the medications were either decreased or for one individual who participated in the survey, the medication was discontinued.  In another situation, staff noted and promptly presented clinical concerns of tremors to the prescribing physician which were quickly addressed.  

Within certification, the agency is recognized for providing ongoing opportunities for individuals who received residential supports to provide feedback on the performance of staff at the time of hire and during annual evaluations. The agency encouraged individuals to submit their own questions for inclusion in these feedback mechanisms. Several individuals who participated in the survey were happy to share their questions with surveyors and commented on the agency's willingness to listen and make changes based on individuals' feedback.  It is also noteworthy that the agency recognized the importance of supporting individuals to explore, discover and connect with their cultural interests. For instance, one individual was assisted to develop a PowerPoint presentation about his Native American heritage.  He shared how proud he was to present this PowerPoint and educate others, in the greater community, about his heritage through venues such as the DDS Regional training committee.  

This review also identified a number of areas within the agency's residential supports that need additional strengthening and oversight.  The agency needs to ensure that all required components are in place when a restrictive practice is in place, including a written rationale outlining the need for the restriction, as well as plans to reduce or eliminate the need for the restriction and plans describing how the restriction will not unduly impact others. The agency also needs to ensure that Medication Treatment Plans are reviewed at an individuals' Individual Support Plan meeting.

Within the agency's CBDS program, individuals were supported to explore leisure activities as well as employment options.  Skills training, such as money management was provided to many individuals in concert with identified goals.  Individuals expressed their overall happiness with their services, in particular with the various choices of activities offered. Individuals were supported to have control and independence throughout their day. For example, individuals developed their own daily schedules and were afforded opportunities to independently access local businesses and community amenities during lunchtime or break time. The setting was clean and showcased individuals' creative abilities as many of their artistic creations were displayed within the program and were for sale in the Oh My Gallery, the agency's owned and operated retail store. 

The agency needs to strengthen its CBDS program by enhancing its oversight and monitoring in several areas such as ensuring that specialized dietary requirements are followed, and staff are knowledgeable and implement specialized dietary recommendations as prescribed. Additionally, senior management staff need to ensure that individuals who work for the agency are either paid minimum wage or if less than minimum wage, are paid in accordance with the Department of Labor requirements. 

With regard to the organizational indicators, the agency continues to collect and analyze data to improve service delivery.  However, emphasis should be placed on strengthening the effectiveness of the agency's Human Rights Committee (HRC) to ensure that advocates consistently attend meetings and that the HRC reviews policies and procedures that may potentially impact the rights of individuals supported.  

Based on the findings of this survey, the agency is congratulated for receiving a score of 97% in the Licensing indicators for Residential and Individual Home Support services and is Certified with 98% of all residential / individual home support certification indicators receiving a rating of `Met.'  

With regards to the agency's Day Supports, the agency received a Two-year license. The agency is congratulated for receiving a 92% in the Licensing indicators "Met."  Follow up by the agency will occur within 60 days on all indicators that received a `Not Met'. The agency is Certified with 100% of all employment / day service certification indicators receiving a rating of `Met.'	

	

	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
75/77	
2/77	

    Individual Home Supports
    Residential Services

	

Critical Indicators	
8/8	
0/8	

Total	
84/87	
3/87	
97%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
3	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
50/54	
4/54	

    Community Based Day Services

	

Critical Indicators	
8/8	
0/8	

Total	
59/64	
5/64	
92%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
5	

	

	

	

	

	

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.	
While the agency maintained an active Human Rights Committee (HRC), there were areas such as required composition, soliciting on-going feedback from Committee members and reviewing required items on a timely basis that need improvement.  The agency needs to support an effective Human Rights Committee.	

		

	

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

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.	
Restrictive practices for seven individuals were reviewed.  Of these, one individual's plan did not include a written rationale for the need for the restriction nor a plan to reduce or eliminate the restriction.  For three other individuals there were no strategies in place to mitigate the impact of these restrictions.  The agency needs to insure that written plans include a rationale for the need for the restriction including a plan to reduce or eliminate the need for the restriction; and, the notification to those who the restriction effects, the agency needs to ensure that that all restrictive practices include provisions as not to unduly restrict the rights of others.  	

 L64	
Medication treatment plans are reviewed by the required groups.	
 All seven Medication Treatment Plans reviewed were not reviewed by the individuals' ISP teams.  The agency needs to ensure the Medication Treatment Plans are reviewed by the required groups.  	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L8	
Emergency fact sheets are current and accurate and available on site.	
One out of two emergency fact sheets reviewed did not document an allergy.  The agency needs to ensure that emergency fact sheets are accurate.  	

 L39	
Special dietary requirements are followed. 	
Dietary requirements for two individuals were reviewed. For one person, there was no evidence of staff knowledge regarding sodium limits.  For the second person, there was evidence of staff training; however, not all staff correctly implemented physician's orders calling for a finely chopped diet. Agency needs to ensure that all special dietary requirements are followed.  	

 L72	
Sub-minimum wages earned are paid in accordance with Department of Labor (DOL) requirements for compensation.	
There was evidence that individuals who were employed by the agency, working in retail were not earning minimum wage nor were individuals earning sub-minimum wages in accordance to the Department of Labor (DOL).  The agency needs to ensure that individuals working are paid in accordance with the DOL requirements for compensation.  	

 L73	
The provider has a current DOL certificate.	
Although the agency was paying sub-minimum wages there was no DOL certificate in place.  	

			

		

	

	

CERTIFICATION FINDINGS	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

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

Residential and Individual Home Supports	
44/45	
1/45	

Individual Home Supports	
23/23	
0/23	

Residential Services	
21/22	
1/22	

TOTAL	
50/51	
1/51	
98%	

Certified	

	

	
	
Met / Rated	
Not Met / Rated	
% Met	

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

Employment and Day Supports	
14/14	
0/14	

Community Based Day Services	
14/14	
0/14	

TOTAL	
20/20	
0/20	
100%	

Certified	

	

	

	

	

	

	
Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
For three out of seven people reviewed, there was no informal or formal assessment regarding assistive technology that could benefit the person to maximize their independence. The agency needs to ensure that individuals' are assessed to determine if assistive technology and or/modifications are needed to maximize individuals' independence. 	

	

	

		

	

						
	MASTER SCORE SHEET LICENSURE	

						
	Organizational: REACH	

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

O	
 L2	
Abuse/neglect reporting	
8/8	
Met	

 L3	
Immediate Action	
6/6	
Met	

 L4	
Action taken	
4/4	
Met	

 L48	
HRC	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
1/1	
Met	

 L66	
HRC restraint review	
1/1	
Met	

 L74	
Screen employees	
5/5	
Met	

 L75	
Qualified staff	
2/2	
Met	

 L76	
Track trainings	
12/12	
Met	

 L83	
HR training	
12/12	
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	
7/7	
4/4	

	
	
11/11	
Met	

 L5	
Safety Plan	
L	
3/3	
4/4	

	
	
7/7	
Met	

O	
 L6	
Evacuation	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L7	
Fire Drills	
L	
3/3	

	

3/3	
Met	

 L8	
Emergency Fact Sheets	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L9	
Safe use of equipment	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L10	
Reduce risk interventions	
I	
4/4	
2/2	

	
	
6/6	
Met	

O	
 L11	
Required inspections	
L	
3/3	
3/3	

	
	
6/6	
Met	

O	
 L12	
Smoke detectors	
L	
3/3	
2/2	

	
	
5/5	
Met	

O	
 L13	
Clean location	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L14	
Site in good repair	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L15	
Hot water	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L16	
Accessibility	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L17	
Egress at grade 	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L18	
Above grade egress	
L	
2/2	
2/2	

	
	
4/4	
Met	

 L19	
Bedroom location	
L	
	
1/1	

	
	
1/1	
Met	

 L20	
Exit doors	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L21	
Safe electrical equipment	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L22	
Clean appliances	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L23	
Egress door locks	
L	
2/2	

	

2/2	
Met	

 L24	
Locked door access	
L	
3/3	

	

3/3	
Met	

 L25	
Dangerous substances	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L26	
Walkway safety	
L	
2/3	
3/3	

	
	
5/6	
Met
(83.33 %)	

 L28	
Flammables	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L29	
Rubbish/combustibles	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L30	
Protective railings	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L31	
Communication method	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L32	
Verbal & written	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L33	
Physical exam	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L34	
Dental exam	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L35	
Preventive screenings	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L36	
Recommended tests	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L37	
Prompt treatment	
I	
7/7	
4/4	

	
	
11/11	
Met	

O	
 L38	
Physician's orders	
I	
4/4	
2/2	

	
	
6/6	
Met	

 L39	
Dietary requirements	
I	
3/3	
1/2	

	
	
4/5	
Met
(80.0 %)	

 L40	
Nutritional food	
L	
3/3	
3/3	

	
	
6/6	
Met	

 L41	
Healthy diet	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L42	
Physical activity	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L43	
Health Care Record	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L44	
MAP registration	
L	
3/3	
1/1	

	
	
4/4	
Met	

 L45	
Medication storage	
L	
3/3	
1/1	

	
	
4/4	
Met	

O	
 L46	
Med. Administration	
I	
7/7	
2/2	

	
	
9/9	
Met	

 L47	
Self medication	
I	
7/7	
3/4	

	
	
10/11	
Met
(90.91 %)	

 L49	
Informed of human rights	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L50	
Respectful Comm.	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L51	
Possessions	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L52	
Phone calls	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L53	
Visitation	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L54	
Privacy	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L55	
Informed consent	
I	
3/3	
1/1	

	
	
4/4	
Met	

 L56	
Restrictive practices	
I	
3/7	

	

3/7	
Not Met
(42.86 %)	

 L57	
Written behavior plans	
I	
4/4	
1/1	

	
	
5/5	
Met	

 L58	
Behavior plan component	
I	
4/4	
1/1	

	
	
5/5	
Met	

 L59	
Behavior plan review	
I	
4/4	
1/1	

	
	
5/5	
Met	

 L60	
Data maintenance	
I	
4/4	
1/1	

	
	
5/5	
Met	

 L61	
Health protection in ISP	
I	
	
1/1	

	
	
1/1	
Met	

 L62	
Health protection review	
I	
	
1/1	

	
	
1/1	
Met	

 L63	
Med. treatment plan form	
I	
7/7	
1/1	

	
	
8/8	
Met	

 L64	
Med. treatment plan rev.	
I	
0/6	
0/1	

	
	
0/7	
Not Met
(0 %)	

 L65	
Restraint report submit	
L	
1/1	

	

1/1	
Met	

 L67	
Money mgmt. plan	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L68	
Funds expenditure	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L69	
Expenditure tracking	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L70	
Charges for care calc.	
I	
7/7	
2/2	

	
	
9/9	
Met	

 L71	
Charges for care appeal	
I	
7/7	
1/2	

	
	
8/9	
Met
(88.89 %)	

 L77	
Unique needs training	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L78	
Restrictive Int. Training	
L	
2/2	
2/2	

	
	
4/4	
Met	

 L79	
Restraint training	
L	
2/2	

	

2/2	
Met	

 L80	
Symptoms of illness	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L81	
Medical emergency	
L	
3/3	
4/4	

	
	
7/7	
Met	

O	
 L82	
Medication admin.	
L	
3/3	
2/2	

	
	
5/5	
Met	

 L84	
Health protect. Training	
I	
	
1/1	

	
	
1/1	
Met	

 L85	
Supervision 	
L	
3/3	
4/4	

	
	
7/7	
Met	

 L86	
Required assessments	
I	
3/4	
4/4	

	
	
7/8	
Met
(87.50 %)	

 L87	
Support strategies	
I	
3/4	
4/4	

	
	
7/8	
Met
(87.50 %)	

 L88	
Strategies implemented	
I	
7/7	
4/4	

	
	
11/11	
Met	

 L90	
Personal space/ bedroom privacy	
I	
7/7	
4/4	

	
	
11/11	
Met	

#Std. Met/# 77 Indicator	

	

	

75/77	

	
Total Score	

	

	

84/87	

	

	

	

	
96.55%	

		
							
Employment and Day Supports:	

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

 L1	
Abuse/neglect training	
I	

2/2	
2/2	
Met	

 L5	
Safety Plan	
L	

1/1	
1/1	
Met	

O	
 L6	
Evacuation	
L	

1/1	
1/1	
Met	

 L7	
Fire Drills	
L	

1/1	
1/1	
Met	

 L8	
Emergency Fact Sheets	
I	

1/2	
1/2	
Not Met
(50.0 %)	

 L9	
Safe use of equipment	
L	

2/2	
2/2	
Met	

 L10	
Reduce risk interventions	
I	

1/1	
1/1	
Met	

O	
 L11	
Required inspections	
L	

1/1	
1/1	
Met	

O	
 L12	
Smoke detectors	
L	

1/1	
1/1	
Met	

O	
 L13	
Clean location	
L	

1/1	
1/1	
Met	

 L14	
Site in good repair	
L	

1/1	
1/1	
Met	

 L15	
Hot water	
L	

1/1	
1/1	
Met	

 L16	
Accessibility	
L	

1/1	
1/1	
Met	

 L17	
Egress at grade 	
L	

1/1	
1/1	
Met	

 L20	
Exit doors	
L	

1/1	
1/1	
Met	

 L21	
Safe electrical equipment	
L	

1/1	
1/1	
Met	

 L22	
Clean appliances	
L	

1/1	
1/1	
Met	

 L25	
Dangerous substances	
L	

1/1	
1/1	
Met	

 L26	
Walkway safety	
L	

1/1	
1/1	
Met	

 L29	
Rubbish/combustibles	
L	

1/1	
1/1	
Met	

 L30	
Protective railings	
L	

1/1	
1/1	
Met	

 L31	
Communication method	
I	

2/2	
2/2	
Met	

 L32	
Verbal & written	
I	

2/2	
2/2	
Met	

 L37	
Prompt treatment	
I	

2/2	
2/2	
Met	

O	
 L38	
Physician's orders	
I	

2/2	
2/2	
Met	

 L39	
Dietary requirements	
I	

0/2	
0/2	
Not Met
(0 %)	

 L44	
MAP registration	
L	

1/1	
1/1	
Met	

 L45	
Medication storage	
L	

1/1	
1/1	
Met	

O	
 L46	
Med. Administration	
I	

1/1	
1/1	
Met	

 L49	
Informed of human rights	
I	

2/2	
2/2	
Met	

 L50	
Respectful Comm.	
L	

2/2	
2/2	
Met	

 L51	
Possessions	
I	

2/2	
2/2	
Met	

 L52	
Phone calls	
I	

2/2	
2/2	
Met	

 L54	
Privacy	
L	

2/2	
2/2	
Met	

 L55	
Informed consent	
I	

2/2	
2/2	
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	

 L67	
Money mgmt. plan	
I	

2/2	
2/2	
Met	

 L68	
Funds expenditure	
I	

2/2	
2/2	
Met	

 L69	
Expenditure tracking	
I	

2/2	
2/2	
Met	

 L72	
DOL requirements	
I	

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

 L73	
DOL certificate	
L	

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

 L77	
Unique needs training	
I	

2/2	
2/2	
Met	

 L78	
Restrictive Int. Training	
L	

1/1	
1/1	
Met	

 L79	
Restraint training	
L	

1/1	
1/1	
Met	

 L80	
Symptoms of illness	
L	

2/2	
2/2	
Met	

 L81	
Medical emergency	
L	

2/2	
2/2	
Met	

O	
 L82	
Medication admin.	
L	

1/1	
1/1	
Met	

 L85	
Supervision 	
L	

2/2	
2/2	
Met	

 L86	
Required assessments	
I	

1/1	
1/1	
Met	

 L87	
Support strategies	
I	

1/1	
1/1	
Met	

 L88	
Strategies implemented	
I	

2/2	
2/2	
Met	

#Std. Met/# 54 Indicator	

	

50/54	

	
Total Score	

	

59/64	

	

	

	
92.19%	

		
							
	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	

	

	

							
Community Based Day Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
2/2	
Met	

 C8	
Family/guardian communication	
2/2	
Met	

 C13	
Skills to maximize independence 	
2/2	
Met	

 C37	
Interpersonal skills for work	
2/2	
Met	

 C40	
Community involvement interest	
2/2	
Met	

 C41	
Activities participation	
2/2	
Met	

 C42	
Connection to others	
2/2	
Met	

 C43	
Maintain & enhance relationship	
2/2	
Met	

 C44	
Job exploration	
2/2	
Met	

 C45	
Revisit decisions	
2/2	
Met	

 C46	
Use of generic resources	
2/2	
Met	

 C47	
Transportation to/ from community	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

 C54	
Assistive technology	
2/2	
Met	

Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
4/4	
Met	

 C8	
Family/guardian communication	
4/4	
Met	

 C9	
Personal relationships	
4/4	
Met	

 C10	
Social skill development	
4/4	
Met	

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

 C12	
Intimacy	
4/4	
Met	

 C13	
Skills to maximize independence 	
4/4	
Met	

 C14	
Choices in routines & schedules	
4/4	
Met	

 C15	
Personalize living space	
3/3	
Met	

 C16	
Explore interests	
4/4	
Met	

 C17	
Community activities	
4/4	
Met	

 C18	
Purchase personal belongings	
4/4	
Met	

 C19	
Knowledgeable decisions	
4/4	
Met	

 C20	
Emergency back-up plans	
4/4	
Met	

 C21	
Coordinate outreach	
4/4	
Met	

 C46	
Use of generic resources	
4/4	
Met	

 C47	
Transportation to/ from community	
4/4	
Met	

 C48	
Neighborhood connections	
4/4	
Met	

 C49	
Physical setting is consistent 	
4/4	
Met	

 C51	
Ongoing satisfaction with services/ supports	
4/4	
Met	

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

 C53	
Food/ dining choices	
4/4	
Met	

 C54	
Assistive technology	
4/4	
Met	

Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
7/7	
Met	

 C8	
Family/guardian communication	
7/7	
Met	

 C9	
Personal relationships	
7/7	
Met	

 C10	
Social skill development	
7/7	
Met	

 C11	
Get together w/family & friends	
7/7	
Met	

 C12	
Intimacy	
6/7	
Met (85.71 %)	

 C13	
Skills to maximize independence 	
7/7	
Met	

 C14	
Choices in routines & schedules	
7/7	
Met	

 C15	
Personalize living space	
3/3	
Met	

 C16	
Explore interests	
7/7	
Met	

 C17	
Community activities	
7/7	
Met	

 C18	
Purchase personal belongings	
7/7	
Met	

 C19	
Knowledgeable decisions	
7/7	
Met	

 C20	
Emergency back-up plans	
3/3	
Met	

 C46	
Use of generic resources	
7/7	
Met	

 C47	
Transportation to/ from community	
7/7	
Met	

 C48	
Neighborhood connections	
7/7	
Met	

 C49	
Physical setting is consistent 	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
7/7	
Met	

 C52	
Leisure activities and free-time choices /control	
7/7	
Met	

 C53	
Food/ dining choices	
7/7	
Met	

 C54	
Assistive technology	
4/7	
Not Met (57.14 %)