PROVIDER REPORT FOR
REHABILITATIVE RESOURCES INC
1 Picker Road - P.O. Box 38
 Sturbridge, MA 01566    

 
 
Version
Provider Web Report

 
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

SUMMARY OF OVERALL FINDINGS
 
Provider	
REHABILITATIVE RESOURCES INC	

Review Dates	
6/5/2013 - 6/11/2013	

Service Enhancement 
Meeting Date	
6/25/2013	

Survey Team	
 
Melanie McNamara	

Janina Millet	

Scott Nolan	

Martina Pocaterra	

Phyllis Stever (TL)	

Citizen Volunteers	
 
Marion Julian	

	

	
 
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	13 location(s) 23 audit (s) 	Full Review	82 / 85 2 Year License 06/25/2013 - 06/25/2015	 

 	 

 	
Residential Services	11 location(s) 23 audit (s) 	 

 
 	DDS Targeted Review	0 / 0 Certified	
Placement Services	2 location(s) 23 audit (s) 	 
 	 
 	DDS Targeted Review	1 / 1 Certified	
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	1 location(s) 3 audit (s) 	Full Review	22 / 27 2 Year License 06/25/2013 - 06/25/2015	 

 	 

 	
Employment Support Services	1 location(s) 3 audit (s) 	 
 	 
 	DDS Targeted Review	0 / 0 Certified	
 Survey scope and findings for Planning and Quality Management	
Service Group Type	Sample Size	Scope	Licensure Level	Certification Scope	Certification Level	
Planning and Quality Management	N/A	N/A	N/A	DDS Targeted Review	0/0 Certified	

EXECUTIVE SUMMARY

Rehabilitative Resources, Inc.(RRI) is a large nonprofit organization providing an array of supports to individuals with developmental disabilities, since 1975.  Services subject to this licensure review included residential supports and supported employment. Transportation, day habilitation, and other services available at RRI were not part of this audit process.  The agency had requested permission to conduct a self assessment for this DDS licensure review cycle.  RRI was eligible to make this request based on the positive results of the agency's last review, conducted in 2011.  However, due to significant events at RRI over the past two years, a full licensure and targeted certification review was conducted in lieu of the self assessment process.

Over the past two years, key personnel changes occurred in response to events at the organization.  A new Chief Executive Officer started six months ago, and a new Director of Residential Services is in place.  RRI as an organization is embracing and presenting the changes at the leadership level as a positive opportunity for enhancing the responsiveness of the agency in ensuring the on-going provision of consistent, high quality services.  

RRI continues to have well established, functional systems in place to address service provision requirements relative to health and safety, safeguarding human rights, and involvement in individualized service planning processes.  Well defined policies and procedures continue to permeate the organization.  To strengthen internal compliance with agency policies and procedures, several initiatives were implemented.  The quality assurance department started conducting comprehensive audits at each residential location last fall, and this is now part of the layered oversight systems in place.  Efforts were made to more closely align training provided to staff with the relevant agency policy/procedure.  The agency has also continued to use multidisciplinary internal review boards/committees to proactively address medication occurrences, safety and clinical issues.

The agency has historically allocated significant resources to develop and support staff working at the organization.  RRI provides a comprehensive orientation to new staff, as well as on-going educational opportunities both within and outside of the agency.  With the addition of two full time board certified behavioral analysts to the organization (previously utilized 30 hour consultant), a greater emphasis is being made to train staff on target behavior and data collection procedures utilized for individuals requiring behavior modifying medications.  The agency had also increased available nursing and medication administration personnel, to augment direct services as well as staff training for individuals' health care needs.

Several areas that the agency needs to provide further attention to were identified during the review. The agency's Human Rights Committee needs to continue recruitment efforts to replace the legal member of the committee that left in November 2012.  Systems to ensure restraint reports are reported and reviewed within required timelines and tracking of ISP assessments and support strategy submission to the ISP team for individuals in employment services also need to be strengthened.

LICENSURE FINDINGS

 	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/10	
2/10	

Residential and Individual Home Supports	
74/75	
1/75	

 	

    Residential Services
    Placement Services	

 

 	

Critical Indicators	
8/8	
0/8	

Total	
82/85	
3/85	
96%	

2 Year License	

 	

# indicators for 60 Day Follow-up	

3	

	 

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/10	
2/10	

Employment and Day Supports	
14/17	
3/17	

    Employment Support Services	

 

 	

Critical Indicators	
1/1	
0/1	

Total	
22/27	
5/27	
81%	

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.	The agency needs to ensure the Human Rights Committee membership meets the composition requirements stated in the DDS regulations.  The committee was lacking a member with legal expertise.	

 
 	 L65	Restraint reports are submitted within required timelines.	The agency needs to ensure restraint reports are entered into the DDS HCSIS electronic data base within 3 days of occurrence, and that the restraint manager has reviewed the event within 5 days of occurrence.	
 	Residential Areas Needing Improvement on Standards not met/Follow-up to occur:	
 
 	Indicator #	Indicator	Area Needing Improvement	

 

 	 L67	There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	The agency needs to ensure that when there is a shared or delegated management of funds arrangement in place, a training plan is present as well as agreement to the written funds management plan.	
 	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.	The agency needs to ensure each individual has a current and complete emergency fact sheet available.	

 
 
 	 L86	Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	The agency needs to ensure required assessments for the ISP are submitted 15 days prior to the scheduled ISP meeting (ISPs held prior to February 2013 the timeline for submission was 10 days prior to the meeting).	

 

 	 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 needs to ensure required support strategies for the ISP are submitted 15 days prior to the scheduled ISP meeting (ISPs held prior to February 2013 the timeline for submission was 15 days after the meeting).	

 
CERTIFICATION FINDINGS

 
 	
Met / Rated	
Not Met / Rated	

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

Residential and Individual Home Supports	

 

    Placement Services	
1/1	
0/1	

    Residential Services	
0/0	
0/0	

 
 	
Met / Rated	
Not Met / Rated	

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

Employment and Day Supports	

    Employment Support Services	
0/0	
0/0	

MASTER SCORE SHEET LICENSURE
Organizational: REHABILITATIVE RESOURCES INC
 
 	Indicator #	Indicator	Met/Rated	Rating(Met, Not Met, Not Rated)	
O	 L2	Abuse/neglect reporting	13/13	Met	
 	 L3	Immediate Action	15/15	Met	
 	 L4	Action taken	15/15	Met	
 	 L48	HRC	0/1	Not Met(0 % )	
 	 L65	Restraint report submit	6/17	Not Met(35.29 % )	
 	 L66	HRC restraint review	14/15	Met(93.33 % )	
 	 L74	Screen employees	18/18	Met	
 	 L75	Qualified staff	3/3	Met	
 	 L76	Track trainings	19/20	Met(95.00 % )	
 	 L83	HR training	20/20	Met	
 
Residential and Individual Home Supports:

 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	

 	 L1	Abuse/neglect training	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	
 
 	 L5	Safety Plan	L	11/11	 
 	2/2	 
 	13/13	Met	
O	 L6	Evacuation	L	11/11	 	2/2	 	13/13	Met	
 
 	 L7	Fire Drills	L	10/11	 

 	10/11	Met
(90.91 %)	

 	 L8	Emergency Fact Sheets	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	

 	 L9	Safe use of equipment	L	11/11	 
 
 	2/2	 
 
 	13/13	Met	

 
 	 L10	Reduce risk interventions	I	5/5	 

 	 

 	 

 	5/5	Met	
O	 L11	Required inspections	L	6/6	 
 
 	2/2	 
 
 	8/8	Met	
O	 L12	Smoke detectors	L	6/6	 
 	2/2	 
 	8/8	Met	
O	 L13	Clean location	L	6/6	 
 	2/2	 
 	8/8	Met	

 	 L14	Site in good repair	L	5/5	 
 
 	2/2	 
 
 	7/7	Met	

 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	
 
 	 L15	Hot water	L	10/11	 
 	2/2	 
 	12/13	Met
(92.31 %)	
 
 	 L16	Accessibility	L	6/7	 
 	1/1	 
 	7/8	Met
(87.50 %)	
 
 	 L17	Egress at grade 	L	8/8	 
 	2/2	 
 	10/10	Met	

 	 L18	Above grade egress	L	1/1	 

 

 	1/1	Met	
 
 	 L19	Bedroom location	L	7/7	 

 	7/7	Met	
 	 L20	Exit doors	L	7/7	 	 	 	7/7	Met	

 	 L21	Safe electrical equipment	L	6/6	 
 
 	2/2	 
 
 	8/8	Met	
 
 	 L22	Clean appliances	L	6/6	 
 	2/2	 
 	8/8	Met	
 
 	 L23	Egress door locks	L	8/8	 

 	8/8	Met	

 	 L24	Locked door access	L	8/8	 

 

 	8/8	Met	

 	 L25	Dangerous substances	L	11/11	 
 
 	2/2	 
 
 	13/13	Met	
 
 	 L26	Walkway safety	L	10/10	 
 	2/2	 
 	12/12	Met	
 
 	 L28	Flammables	L	9/9	 
 	1/1	 
 	10/10	Met	

 	 L29	Rubbish/combustibles	L	7/7	 
 
 	2/2	 
 
 	9/9	Met	
 
 	 L30	Protective railings	L	4/4	 
 	2/2	 
 	6/6	Met	

 	 L31	Communication method	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	
 
 	 L32	Verbal & written	I	10/10	 
 	2/2	 
 	12/12	Met	
 
 	 L33	Physical exam	I	11/11	 
 	2/2	 
 	13/13	Met	
 
 	 L34	Dental exam	I	11/11	 
 	2/2	 
 	13/13	Met	
 
 	 L35	Preventive screenings	I	10/10	 
 	2/2	 
 	12/12	Met	
 
 	 L36	Recommended tests	I	11/11	 
 	2/2	 
 	13/13	Met	
 
 	 L37	Prompt treatment	I	11/11	 
 	2/2	 
 	13/13	Met	

 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	
O	 L38	Physician's orders	I	9/9	 

 	9/9	Met	

 	 L39	Dietary requirements	I	7/8	 

 

 	7/8	Met
(87.50 %)	
 
 	 L40	Nutritional food	L	10/10	 
 	2/2	 
 	12/12	Met	
 
 	 L41	Healthy diet	L	11/11	 
 	2/2	 
 	13/13	Met	
 
 	 L42	Physical activity	L	11/11	 
 	2/2	 
 	13/13	Met	

 	 L43	Health Care Record	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	
 
 	 L44	MAP registration	L	11/11	 

 	11/11	Met	
 
 	 L45	Medication storage	L	11/11	 

 	11/11	Met	
O	 L46	Med. Administration	I	11/11	 
 
 	1/1	 
 
 	12/12	Met	
 
 	 L47	Self medication	I	5/5	 
 	1/1	 
 	6/6	Met	

 	 L49	Informed of human rights	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	
 
 	 L50	Respectful Comm.	L	11/11	 
 	2/2	 
 	13/13	Met	
 
 	 L51	Possessions	I	11/11	 
 	2/2	 
 	13/13	Met	
 
 	 L52	Phone calls	I	11/11	 
 	2/2	 
 	13/13	Met	
 	 L53	Visitation	I	11/11	 	2/2	 	13/13	Met	
 	 L54	Privacy	L	11/11	 	2/2	 	13/13	Met	
 
 	 L55	Informed consent	I	1/1	 

 	1/1	Met	
 
 	 L56	Restrictive practices	I	3/3	 

 	3/3	Met	

 	 L57	Written behavior plans	I	2/2	 

 

 	2/2	Met	

 	 L58	Behavior plan component	I	2/2	 

 

 	2/2	Met	

 	 L59	Behavior plan review	I	2/2	 

 

 	2/2	Met	

 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	

 	 L60	Data maintenance	I	2/2	 

 

 	2/2	Met	

 	 L61	Health protection in ISP	I	10/10	 

 

 	10/10	Met	

 	 L62	Health protection review	I	10/10	 

 

 	10/10	Met	

 	 L63	Med. treatment plan form	I	10/11	 
 
 	2/2	 
 
 	12/13	Met
(92.31 %)	

 	 L64	Med. treatment plan rev.	I	9/9	 
 
 	2/2	 
 
 	11/11	Met	
 
 	 L67	Money mgmt. plan	I	6/11	 
 	2/2	 
 	8/13	Not Met
(61.54 %)	

 	 L68	Funds expenditure	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	
 
 	 L69	Expenditure tracking	I	11/11	 
 	2/2	 
 	13/13	Met	

 	 L70	Charges for care calc.	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	

 	 L71	Charges for care appeal	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	

 	 L77	Unique needs training	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	

 	 L78	Restrictive Int. Training	L	3/3	 

 

 	3/3	Met	
 
 	 L79	Restraint training	L	2/2	 

 	2/2	Met	
 
 	 L80	Symptoms of illness	L	10/11	 
 	2/2	 
 	12/13	Met
(92.31 %)	
 
 	 L81	Medical emergency	L	11/11	 
 	2/2	 
 	13/13	Met	
O	 L82	Medication admin.	L	11/11	 

 	11/11	Met	

 	 L84	Health protect. Training	I	10/10	 

 

 	10/10	Met	
 
 	 L85	Supervision 	L	11/11	 
 	2/2	 
 	13/13	Met	

 	 L86	Required assessments	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	

 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	
 
 	 L87	Support strategies	I	11/11	 
 	2/2	 
 	13/13	Met	

 	 L88	Strategies implemented	I	11/11	 
 
 	2/2	 
 
 	13/13	Met	

 	#Std. Met/# 75 Indicator	 

 

 	 

 

 	74/75	 

 
 	Total Score	 

 	 

 	82/85	 

 
 
 	Indicator #	Indicator	Location or Individual indicator	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/Rated	Rating	

 	 

 	 

 	96.47%	 

Employment and Day Supports:

 
 	Indicator #	Indicator	Location or Individual indicator	Employment Support	Center Based Work	Community Based Day Support	Total Met / Rated	Rating	
 
 	 L1	Abuse/neglect training	I	3/3	 
 	 
 	3/3	Met	
 
 	 L8	Emergency Fact Sheets	I	2/3	 
 	 
 	2/3	Not Met
(66.67 %)	
 
 	 L31	Communication method	I	3/3	 
 	 
 	3/3	Met	
 
 	 L32	Verbal & written	I	3/3	 
 	 
 	3/3	Met	
 
 	 L37	Prompt treatment	I	3/3	 
 	 
 	3/3	Met	
 
 	 L49	Informed of human rights	I	3/3	 
 	 
 	3/3	Met	
 
 	 L50	Respectful Comm.	L	1/1	 
 	 
 	1/1	Met	
 	 L51	Possessions	I	3/3	 	 	3/3	Met	
 	 L52	Phone calls	I	3/3	 	 	3/3	Met	
 	 L54	Privacy	L	1/1	 	 	1/1	Met	
 
 	 L77	Unique needs training	I	2/2	 
 	 
 	2/2	Met	
 
 	 L80	Symptoms of illness	L	1/1	 
 	 
 	1/1	Met	
 
 	 L81	Medical emergency	L	1/1	 
 	 
 	1/1	Met	
 	 L85	Supervision 	L	1/1	 	 	1/1	Met	

 
 	Indicator #	Indicator	Location or Individual indicator	Employment Support	Center Based Work	Community Based Day Support	Total Met / Rated	Rating	
 
 	 L86	Required assessments	I	1/3	 
 	 
 	1/3	Not Met
(33.33 %)	
 
 	 L87	Support strategies	I	1/3	 
 	 
 	1/3	Not Met
(33.33 %)	
 
 	 L88	Strategies implemented	I	3/3	 
 	 
 	3/3	Met	

 	#Std. Met/# 17 Indicator	 

 

 	 

 
 	14/17	 

 
 	Total Score	 

 	 
 	 
 	22/27	 
 	
 	 	 	 	 	 	 	81.48%	 	

MASTER SCORE SHEET CERTIFICATION
 
Placement Services Reviewed By -DDS	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	2/2	Met