PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
ROAD TO RESPONSIBILITY
1831 Ocean Street
 Marshfield, MA 02050    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
November 20, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

	

	

	

	

	

	

	SUMMARY OF OVERALL FINDINGS	

				

	

	

Provider	

	
ROAD TO RESPONSIBILITY	

	

	

	

	
Review Dates	

	
10/30/2018 - 11/5/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
11/20/2018	

	

	

	

	

	

	
Survey Team	

	
Michelle Boyd	

Katherine Gregory	

Michael Marchese	

Barbara Mazzella	

Tina Napolitan (TL)	

Scott Nolan	

Laura O'Connor	

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	
15 location(s) 18 audit (s) 	
Full Review	
80 / 89 2 Year License 11/20/2018 -  11/20/2020	
	
85 / 94 Certified 11/20/2018 -  11/20/2020	

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

Full Review	
21 / 22	

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

Full Review	
19 / 22	

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

Full Review	
19 / 22	

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

Full Review	
20 / 22	

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	
5 location(s) 9 audit (s) 	
Full Review	
59 / 64 2 Year License 11/20/2018 -  11/20/2020	
	
 Certified 11/20/2018 -  11/20/2020	

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

Deemed	

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

Deemed	

Planning and Quality Management (For all service groupings)	

	
Full Review	
6 / 6	

	

	

EXECUTIVE SUMMARY :	

			
Road to Responsibility, Inc. (RTR) is an organization that provides services throughout the Southeastern and Metropolitan Boston area of Massachusetts.  Services are offered to adults with Intellectual and Developmental Disabilities, Acquired Brain Injuries and Autism.  An array of residential services are provided including 24 hour residential supports, Individualized Home Supports (IHS) and Placement (Shared Living).  The agency also provides day supports including Community Based Day Supports (CBDS) and Employment.  RTR provides residential supports to approximately 190 individuals and day supports to approximately 500 people. 
 
The scope of this survey conducted by the Office of Quality Enhancement (OQE) included a full review of all licensing and certification indicators for the residential services funded by the Department of Developmental Services (DDS).  RTR utilizes a deemed process (CARF) to report on certification indicators within the day and employment services, thus this review by OQE was exclusive to licensing indicators. Organizationally, both licensing and certification outcomes were reviewed.  

The agency had mechanisms to ensure key safeguards were in place.  The agency has two Human Rights Committees (HRC) that address issues potentially impacting the rights of individuals receiving services.  Comprehensive HRC meeting minutes demonstrate that the committees review agency policies and procedures, incidents, investigations and restraints and members conduct site visits.  The agency had many systems in place, including on-going quality assurance reviews, to collect data and complete trends analysis in an effort to improve services.  The agency demonstrated a commitment to ensuring staff was provided comprehensive training upon hire and continued professional development to promote continuity across all service locations.

Among strengths observed within residential services, of particular note was the support provided to assist individuals to maximize their overall well-being.  Individuals were supported to receive routine and preventative health care; attend follow up appointments, and receive routine screenings and lab work.  There was consistent oversight and training for individuals and staff to promote adherence to physicians' recommendations.  Individuals were supported to lead healthy lifestyles.  Several homes visited had exercise equipment within the home.  People were actively engaged in menu planning and exercise classes such as Yoga, swimming, weight lifting and two individuals had personal trainers.  People were supported to maintain healthy lifestyles overall by attending self- help groups and specialized therapy programs.  

Individuals were supported to access their communities and enjoy relationships with people that were important to them.  For example, one person developed a relationship with a local post master and a store owner after being a frequent customer.  In one home, individuals invited others to their home to create artwork together.  People were supported to connect with family and friends to maintain their relationships through telephone calls and visits. 
  
A focus was placed on supporting individuals to increase their independence at home and within the community.  At most homes, where 24 hour residential services were provided, modifications were made and/or devices were utilized to maximize individuals' ability to household activities as independent as possible.  Within ABI services, independence was fostered in the kitchen where the men living in the home are responsible for menu planning and assisting with the preparation of meals.  For example, one man living in the home loves to use their outdoor grill to cook dinner for his housemates a couple of evenings a week.  Within IHS, people were supported to be independent utilizing public transportation to increase participation in community activities and attendance at medical appointments. 

Since the last survey, the agency completed numerous renovations at its day service locations which increased accessibility and better met the needs of the individuals supported.  For example, one CBDS/Employment site was remodeled to include a fully accessible kitchen area.  The agency was able to maximize the use of the space which resulted in increased ability to respect privacy, provide less stimulating areas for people who prefer a quiet environment and space to address the clinical needs of people receiving services.   

Across all services, staff was observed to be respectful when interacting with individuals and supported them to express themselves.  In one residential home, staff was trained in sign language to support an individual's total communication.  Within Placement, the care provider worked with two individuals living together to negotiate between themselves in planning for their preferred outings.  An individual within the CBDS program was observed to approach administrative staff and express concerns she had with a new staff.  

In regards to licensing, some areas requiring further attention were identified during the survey.  Within the residential services, the agency needs to clarify if individuals are approving or declining consent to use their image; strengthen medication treatment plans by ensuring these have all required components; and ensure staff are trained in and following agency policy regarding the management of individual's money. Lastly, across all models, the agency will benefit from enhancing it systems to meet required timelines for the submission of restraint and incident reports.

Within residential supports, the agency will benefit from continuing its efforts to increase support to individuals to explore and express their need for intimacy and companionship and assist people to be connected to their neighborhood.

As a result of this review, RTR has received a two year license for both its residential and day supports. RTR is certified in residential supports.	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
71/79	
8/79	

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

	

Critical Indicators	
8/8	
0/8	

Total	
80/89	
9/89	
90%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
9	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
50/54	
4/54	

    Community Based Day Services
    Employment Support 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	

 L65	
Restraint reports are submitted within required timelines.	
The submission of restraint information into HCSIS and/or completing the review by the Restraint Manager was completed within required timelines for 63% of the instances.  The agency needs to ensure that all requirements related to reporting restraint information are met.	

		

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 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.	
Forms used to obtain consent to use an individual's image was reviewed for three individuals. In all instances, the signed consent to utilize a photo on the agency's website did not indicate whether or not consent was given. The agency needs to ensure that clarification is sought regarding consent prior to the use of an individual's photo.         	

 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 eight individuals. Restrictive practices included the use of door alarms and locking of sharps. These restrictions impacted individuals residing in the homes, however provisions to fade or reduce limitations were lacking. Another restrictive practice was being utilized outside the parameters identified in a plan. The agency needs to ensure that all restrictive practices include all required components and are implemented as designed. 	

 L58	
All behavior plans contain the required components.	
Seven behavior support plans were reviewed.  There were issues identified with two plans, including the lack of identification of the clinician providing oversight for a Level II plan and clear parameters regarding the longevity of a restriction.  The agency needs to ensure that behavioral plans contain all the required components.  

	
 L63	
Medication treatment plans are in written format with required components.	
Medication treatment plans were reviewed for thirteen individuals. Of these, five medication treatment plans did not include all required components such as a description of the observable symptoms for which the medications are being prescribed or the collection of data which is submitted to the prescribing practitioner to evaluate the effectiveness of the medications. The agency needs to ensure that medication treatment plans include all required components. 	

 L69	
Individual expenditures are documented and tracked.	
Expenditures were reviewed for fourteen individuals. For three individuals, expenditures were not being tracked according to agency policy including documentation of all withdrawals and deposits and maintaining required receipts. The agency needs to ensure that all expenditures are documented and tracked. 	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments for four individuals were not submitted within the 15 day time frame. The agency needs to ensure that assessments are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting. 	

 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 for five individuals were not submitted within the 15 day time frame. The agency needs to ensure that Support Strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting. 	

 L91	
Incidents are reported and reviewed as mandated by regulation.	
For eight out of twelve locations visited at which reportable incidents had occurred, there were instances in which incident Reports had not been submitted and/or finalized within required timelines. The agency needs to ensure that required timelines to submit and/or finalize Incident Reports are adhered to. 	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments for three individuals were not submitted within the 15 day time frame. The agency needs to ensure that assessments are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting.	

 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 for four individuals were not submitted within the 15 day time frame. The agency needs to ensure that Support Strategies are submitted to the DDS Area Office at least 15 days prior to the scheduled ISP meeting. 	

 L88	
Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	
In two out of nine reviews, ISP goals were not being implemented as designed. The agency needs to ensure that services and supports are provided as agreed upon in the ISP. 	

 L91	
Incidents are reported and reviewed as mandated by regulation.	
For three out of five locations visited at which reportable incidents had occurred, there were instances in which incident Reports had not been submitted and/or finalized within required timelines. The agency needs to ensure that required timelines to submit and/or finalize Incident Reports are adhered to. 	

			

	CERTIFICATION FINDINGS	

						
		
Met / Rated	
Not Met / Rated	
% Met	

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

Residential and Individual Home Supports	
79/88	
9/88	

ABI-MFP Residential Services	
19/22	
3/22	

Individual Home Supports	
20/22	
2/22	

Residential Services	
21/22	
1/22	

Placement Services	
19/22	
3/22	

TOTAL	
85/94	
9/94	
90%	

Certified	

	

Met / Rated	
Not Met / Rated	
% Met	

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

Employment and Day Supports	

	

TOTAL	

	

Certified	

	

						

ABI-MFP Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
Although the agency had begun a process to evaluate individual's needs regarding intimacy and companionship, this was not fully implemented across all settings.  The agency needs to continue to assess, educate, and support individuals in the areas of human sexuality. The agency also needs to provide training opportunities to support staff in this area.	

 C48	
Individuals are a part of the neighborhood.	
Supports for three individuals were reviewed regarding their connections with neighbors. In all instances there was limited staff support to provide opportunities which encourage interactions with neighbors and participation in neighborhood activities. The agency needs to ensure that opportunities are provided which encourage and support neighborhood connections.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The agency had conducted assessments to identify areas where individuals could benefit from the use of assistive technology and/or modifications to maximize independence for all three individuals visited.  For one individual, however the agency had not implemented strategies based on areas of need.  The agency needs to ensure all individuals have been assessed to identify and utilized assistive technology and/or modifications that may be of benefit to maximize independence in their homes and/or community.	

	

	
Individual Home Supports Commendations on Standards Met:	

Indicator #	
Indicator	
Commendations	

 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Staff provided ongoing support to ensure individuals participated in social and recreational activities of their interest. The individuals were supported to participate on several integrated tennis, softball and bowling teams. Staff ensured each individual's interest in social and recreational activities were explored. For example, one individual attended a weekly chorus group and summer camp. For another individual, she was supported to attend the prom at a local country club and local outdoor concerts with her friends. The agency is commended for assisting the individuals with participation in community activities on a consistent basis. 	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For both individuals visited, the agency needs to continue its efforts to assess, educate, and support individuals in the areas of intimacy and companionship. The agency also needs to provide training opportunities to support staff in this area.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The agency had not reviewed the need for the use of assistive technology and/or modifications to maximize the independence for one out of two individuals.  The agency needs to ensure individuals have been supported to identify and utilize assistive technology/ and or modification that may be of benefit to maximize independence in their homes and/or community.	

	

	
Placement Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
Although the agency had begun a process to evaluate individual's needs regarding intimacy and companionship, this was not fully implemented across all settings.  The agency needs to continue to assess, educate, and support individuals in the areas of human sexuality. The agency also needs to provide training opportunities to support staff in this area.	

 C46	
Staff (Home Providers) support individuals to learn about and use generic community resources.	
One out of two individuals had limited opportunities to learn about and use local community resources.  The agency needs to ensure staff support individuals to use varied community resources on a frequent and ongoing basis.	

 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The agency had conducted assessments to identify areas where individuals could benefit from the use of assistive technology (AT) and/or modifications to maximize independence. Strategies for one of two individuals, to utilize AT based areas of need had not been implemented.  The agency needs to ensure individuals have been assessed to identify and utilize assistive technology/ and or modification that may be of benefit to maximize independence in their homes and/or community.	

	

	
Residential Services- Areas Needing Improvement on Standards not met:	

Indicator #	
Indicator	
Area Needing Improvement	

 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For six out of eleven individuals, the agency needs to continue its efforts to assess, educate, and support individuals in the areas of intimacy and companionship. The agency also needs to provide training opportunities to support staff in this area.	

	

		

	MASTER SCORE SHEET LICENSURE	

					
	Organizational: ROAD TO RESPONSIBILITY	

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

O	
 L2	
Abuse/neglect reporting	
19/19	
Met	

 L3	
Immediate Action	
9/9	
Met	

 L4	
Action taken	
8/8	
Met	

 L48	
HRC	
2/2	
Met	

 L65	
Restraint report submit	
74/117	
Not Met(63.25 % )	

 L66	
HRC restraint review	
69/81	
Met(85.19 % )	

 L74	
Screen employees	
18/18	
Met	

 L75	
Qualified staff	
4/4	
Met	

 L76	
Track trainings	
20/20	
Met	

 L83	
HR training	
20/20	
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	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L5	
Safety Plan	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

O	
 L6	
Evacuation	
L	
11/11	
1/1	
1/1	
	
1/1	
	
14/14	
Met	

 L7	
Fire Drills	
L	
11/11	

	
1/1	
	
12/12	
Met	

 L8	
Emergency Fact Sheets	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L9	
Safe use of equipment	
L	
11/11	
1/1	

1/1	
	
13/13	
Met	

 L10	
Reduce risk interventions	
I	
6/6	
1/1	
2/2	

	
9/9	
Met	

O	
 L11	
Required inspections	
L	
11/11	
	
2/2	
	
1/1	
	
14/14	
Met	

O	
 L12	
Smoke detectors	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

O	
 L13	
Clean location	
L	
11/11	
	
2/2	
	
1/1	
	
14/14	
Met	

 L14	
Site in good repair	
L	
10/10	
	
2/2	
	
1/1	
	
13/13	
Met	

 L15	
Hot water	
L	
9/11	
	
2/2	
	
1/1	
	
12/14	
Met
(85.71 %)	

 L16	
Accessibility	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

 L17	
Egress at grade 	
L	
11/11	
1/1	

1/1	
	
13/13	
Met	

 L18	
Above grade egress	
L	
8/8	
1/1	

	
	
9/9	
Met	

 L19	
Bedroom location	
L	
6/6	

	
1/1	
	
7/7	
Met	

 L20	
Exit doors	
L	
11/11	
1/1	

1/1	
	
13/13	
Met	

 L21	
Safe electrical equipment	
L	
11/11	
	
2/2	
	
1/1	
	
14/14	
Met	

 L22	
Well-maintained appliances	
L	
10/11	
	
2/2	
	
1/1	
	
13/14	
Met
(92.86 %)	

 L23	
Egress door locks	
L	
11/11	

	
1/1	
	
12/12	
Met	

 L24	
Locked door access	
L	
11/11	

	
1/1	
	
12/12	
Met	

 L25	
Dangerous substances	
L	
11/11	

	
1/1	
	
12/12	
Met	

 L26	
Walkway safety	
L	
11/11	
	
2/2	
	
1/1	
	
14/14	
Met	

 L27	
Pools, hot tubs, etc.	
L	

1/1	

	
1/1	
Met	

 L28	
Flammables	
L	
11/11	

	
1/1	
	
12/12	
Met	

 L29	
Rubbish/combustibles	
L	
10/11	
	
2/2	
	
1/1	
	
13/14	
Met
(92.86 %)	

 L30	
Protective railings	
L	
9/9	
	
2/2	
	
1/1	
	
12/12	
Met	

 L31	
Communication method	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L32	
Verbal & written	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L33	
Physical exam	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L34	
Dental exam	
I	
10/10	
2/2	
2/2	
	
3/3	
	
17/17	
Met	

 L35	
Preventive screenings	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L36	
Recommended tests	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L37	
Prompt treatment	
I	
11/11	
2/2	
1/1	
	
3/3	
	
17/17	
Met	

O	
 L38	
Physician's orders	
I	
9/10	
	
2/2	
	
3/3	
	
14/15	
Met
(93.33 %)	

 L39	
Dietary requirements	
I	
5/5	
	
2/2	

	
7/7	
Met	

 L40	
Nutritional food	
L	
11/11	
1/1	

1/1	
	
13/13	
Met	

 L41	
Healthy diet	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

 L42	
Physical activity	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

 L43	
Health Care Record	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L44	
MAP registration	
L	
11/11	

	
1/1	
	
12/12	
Met	

 L45	
Medication storage	
L	
11/11	

	
1/1	
	
12/12	
Met	

O	
 L46	
Med. Administration	
I	
11/11	
	
2/2	
	
3/3	
	
16/16	
Met	

 L47	
Self medication	
I	
10/10	
2/2	
2/2	
	
3/3	
	
17/17	
Met	

 L49	
Informed of human rights	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L50	
Respectful Comm.	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

 L51	
Possessions	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L52	
Phone calls	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L53	
Visitation	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L54	
Privacy	
L	
10/11	
1/1	
2/2	
	
1/1	
	
14/15	
Met
(93.33 %)	

 L55	
Informed consent	
I	
0/1	

	
0/2	
	
0/3	
Not Met
(0 %)	

 L56	
Restrictive practices	
I	
5/7	
	
1/1	

	
6/8	
Not Met
(75.00 %)	

 L57	
Written behavior plans	
I	
7/7	

	

7/7	
Met	

 L58	
Behavior plan component	
I	
5/7	

	

5/7	
Not Met
(71.43 %)	

 L59	
Behavior plan review	
I	
7/7	

	

7/7	
Met	

 L60	
Data maintenance	
I	
7/7	

	

7/7	
Met	

 L61	
Health protection in ISP	
I	
4/5	

	
3/3	
	
7/8	
Met
(87.50 %)	

 L62	
Health protection review	
I	
5/5	

	
3/3	
	
8/8	
Met	

 L63	
Med. treatment plan form	
I	
7/11	

	
1/2	
	
8/13	
Not Met
(61.54 %)	

 L64	
Med. treatment plan rev.	
I	
9/10	

	
1/2	
	
10/12	
Met
(83.33 %)	

 L67	
Money mgmt. plan	
I	
7/10	
2/2	
2/2	
	
1/1	
	
12/15	
Met
(80.0 %)	

 L68	
Funds expenditure	
I	
11/11	
	
2/2	
	
1/1	
	
14/14	
Met	

 L69	
Expenditure tracking	
I	
10/11	
	
1/2	
	
0/1	
	
11/14	
Not Met
(78.57 %)	

 L70	
Charges for care calc.	
I	
11/11	
2/2	
1/1	
	
2/2	
	
16/16	
Met	

 L71	
Charges for care appeal	
I	
11/11	
2/2	
1/1	
	
3/3	
	
17/17	
Met	

 L77	
Unique needs training	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L78	
Restrictive Int. Training	
L	
8/8	
	
1/1	

	
9/9	
Met	

 L79	
Restraint training	
L	
4/5	

	

4/5	
Met
(80.0 %)	

 L80	
Symptoms of illness	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

 L81	
Medical emergency	
L	
11/11	
1/1	
2/2	
	
1/1	
	
15/15	
Met	

O	
 L82	
Medication admin.	
L	
11/11	

	
1/1	
	
12/12	
Met	

 L84	
Health protect. Training	
I	
5/5	

	
3/3	
	
8/8	
Met	

 L85	
Supervision 	
L	
11/11	
1/1	
2/2	
	
0/1	
	
14/15	
Met
(93.33 %)	

 L86	
Required assessments	
I	
6/9	
1/2	
2/2	
	
1/1	
	
10/14	
Not Met
(71.43 %)	

 L87	
Support strategies	
I	
6/10	
1/2	
2/2	
	
1/1	
	
10/15	
Not Met
(66.67 %)	

 L88	
Strategies implemented	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L89	
Complaint and resolution process	
L	

	
	
1/1	
	
1/1	
Met	

 L90	
Personal space/ bedroom privacy	
I	
11/11	
2/2	
2/2	
	
3/3	
	
18/18	
Met	

 L91	
Incident management	
L	
2/10	
1/1	

0/1	
	
3/12	
Not Met
(25.00 %)	

#Std. Met/# 79 Indicator	

	

	

71/79	

	
Total Score	

	

	

80/89	

	

	

	

	
89.89%	

		
							
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	
5/5	
	
4/4	
9/9	
Met	

 L5	
Safety Plan	
L	
2/2	
	
2/2	
4/4	
Met	

O	
 L6	
Evacuation	
L	
2/2	
	
2/2	
4/4	
Met	

 L7	
Fire Drills	
L	
2/2	
	
2/2	
4/4	
Met	

 L8	
Emergency Fact Sheets	
I	
5/5	
	
3/4	
8/9	
Met
(88.89 %)	

 L9	
Safe use of equipment	
L	
3/3	
	
2/2	
5/5	
Met	

 L10	
Reduce risk interventions	
I	
2/2	
	
2/2	
4/4	
Met	

O	
 L11	
Required inspections	
L	
2/2	
	
2/2	
4/4	
Met	

O	
 L12	
Smoke detectors	
L	
2/2	
	
2/2	
4/4	
Met	

O	
 L13	
Clean location	
L	
2/2	
	
2/2	
4/4	
Met	

 L14	
Site in good repair	
L	
1/1	

1/1	
Met	

 L15	
Hot water	
L	
2/2	
	
2/2	
4/4	
Met	

 L16	
Accessibility	
L	
2/2	
	
2/2	
4/4	
Met	

 L17	
Egress at grade 	
L	
2/2	
	
2/2	
4/4	
Met	

 L20	
Exit doors	
L	
2/2	
	
2/2	
4/4	
Met	

 L21	
Safe electrical equipment	
L	
2/2	
	
2/2	
4/4	
Met	

 L22	
Well-maintained appliances	
L	
2/2	
	
2/2	
4/4	
Met	

 L25	
Dangerous substances	
L	
2/2	
	
2/2	
4/4	
Met	

 L26	
Walkway safety	
L	
2/2	
	
2/2	
4/4	
Met	

 L28	
Flammables	
L	
2/2	
	
2/2	
4/4	
Met	

 L29	
Rubbish/combustibles	
L	
2/2	
	
2/2	
4/4	
Met	

 L30	
Protective railings	
L	
1/1	

1/1	
Met	

 L31	
Communication method	
I	
5/5	
	
4/4	
9/9	
Met	

 L32	
Verbal & written	
I	
5/5	
	
4/4	
9/9	
Met	

 L37	
Prompt treatment	
I	
4/4	
	
2/2	
6/6	
Met	

O	
 L38	
Physician's orders	
I	

4/4	
4/4	
Met	

 L39	
Dietary requirements	
I	

2/2	
2/2	
Met	

 L44	
MAP registration	
L	

2/2	
2/2	
Met	

 L45	
Medication storage	
L	

2/2	
2/2	
Met	

O	
 L46	
Med. Administration	
I	

3/3	
3/3	
Met	

 L49	
Informed of human rights	
I	
5/5	
	
4/4	
9/9	
Met	

 L50	
Respectful Comm.	
L	
3/3	
	
2/2	
5/5	
Met	

 L51	
Possessions	
I	
5/5	
	
4/4	
9/9	
Met	

 L52	
Phone calls	
I	
5/5	
	
4/4	
9/9	
Met	

 L54	
Privacy	
L	
3/3	
	
2/2	
5/5	
Met	

 L55	
Informed consent	
I	
2/2	

2/2	
Met	

 L57	
Written behavior plans	
I	
1/1	
	
3/3	
4/4	
Met	

 L58	
Behavior plan component	
I	
1/1	
	
3/3	
4/4	
Met	

 L59	
Behavior plan review	
I	
1/1	
	
3/3	
4/4	
Met	

 L60	
Data maintenance	
I	
1/1	
	
3/3	
4/4	
Met	

 L63	
Med. treatment plan form	
I	

2/2	
2/2	
Met	

 L64	
Med. treatment plan rev.	
I	

2/2	
2/2	
Met	

 L73	
DOL certificate	
L	
3/3	
	
2/2	
5/5	
Met	

 L77	
Unique needs training	
I	
5/5	
	
4/4	
9/9	
Met	

 L78	
Restrictive Int. Training	
L	

1/1	
1/1	
Met	

 L79	
Restraint training	
L	
1/1	
	
2/2	
3/3	
Met	

 L80	
Symptoms of illness	
L	
3/3	
	
2/2	
5/5	
Met	

 L81	
Medical emergency	
L	
3/3	
	
2/2	
5/5	
Met	

O	
 L82	
Medication admin.	
L	

2/2	
2/2	
Met	

 L85	
Supervision 	
L	
3/3	
	
2/2	
5/5	
Met	

 L86	
Required assessments	
I	
3/5	
	
3/4	
6/9	
Not Met
(66.67 %)	

 L87	
Support strategies	
I	
3/5	
	
2/4	
5/9	
Not Met
(55.56 %)	

 L88	
Strategies implemented	
I	
4/5	
	
3/4	
7/9	
Not Met
(77.78 %)	

 L91	
Incident management	
L	
2/3	
	
0/2	
2/5	
Not Met
(40.0 %)	

#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	

	

	

							
ABI-MFP Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
3/3	
Met	

 C8	
Family/guardian communication	
3/3	
Met	

 C9	
Personal relationships	
3/3	
Met	

 C10	
Social skill development	
3/3	
Met	

 C11	
Get together w/family & friends	
3/3	
Met	

 C12	
Intimacy	
2/3	
Not Met (66.67 %)	

 C13	
Skills to maximize independence 	
3/3	
Met	

 C14	
Choices in routines & schedules	
3/3	
Met	

 C15	
Personalize living space	
1/1	
Met	

 C16	
Explore interests	
3/3	
Met	

 C17	
Community activities	
3/3	
Met	

 C18	
Purchase personal belongings	
3/3	
Met	

 C19	
Knowledgeable decisions	
3/3	
Met	

 C20	
Emergency back-up plans	
1/1	
Met	

 C46	
Use of generic resources	
3/3	
Met	

 C47	
Transportation to/ from community	
3/3	
Met	

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

 C49	
Physical setting is consistent 	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
3/3	
Met	

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

 C53	
Food/ dining choices	
3/3	
Met	

 C54	
Assistive technology	
2/3	
Not Met (66.67 %)	

Individual Home Supports	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
2/2	
Met	

 C8	
Family/guardian communication	
2/2	
Met	

 C9	
Personal relationships	
2/2	
Met	

 C10	
Social skill development	
1/1	
Met	

 C11	
Get together w/family & friends	
2/2	
Met	

 C12	
Intimacy	
0/2	
Not Met (0 %)	

 C13	
Skills to maximize independence 	
2/2	
Met	

 C14	
Choices in routines & schedules	
2/2	
Met	

 C15	
Personalize living space	
1/1	
Met	

 C16	
Explore interests	
2/2	
Met	

 C17	
Community activities	
2/2	
Met	

 C18	
Purchase personal belongings	
2/2	
Met	

 C19	
Knowledgeable decisions	
2/2	
Met	

 C20	
Emergency back-up plans	
1/1	
Met	

 C21	
Coordinate outreach	
2/2	
Met	

 C46	
Use of generic resources	
2/2	
Met	

 C47	
Transportation to/ from community	
2/2	
Met	

 C48	
Neighborhood connections	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

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

 C53	
Food/ dining choices	
2/2	
Met	

 C54	
Assistive technology	
1/2	
Not Met (50.0 %)	

Placement Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
2/2	
Met	

 C8	
Family/guardian communication	
2/2	
Met	

 C9	
Personal relationships	
2/2	
Met	

 C10	
Social skill development	
2/2	
Met	

 C11	
Get together w/family & friends	
2/2	
Met	

 C12	
Intimacy	
1/2	
Not Met (50.0 %)	

 C13	
Skills to maximize independence 	
2/2	
Met	

 C14	
Choices in routines & schedules	
2/2	
Met	

 C15	
Personalize living space	
2/2	
Met	

 C16	
Explore interests	
2/2	
Met	

 C17	
Community activities	
2/2	
Met	

 C18	
Purchase personal belongings	
1/1	
Met	

 C19	
Knowledgeable decisions	
2/2	
Met	

 C20	
Emergency back-up plans	
2/2	
Met	

 C46	
Use of generic resources	
1/2	
Not Met (50.0 %)	

 C47	
Transportation to/ from community	
2/2	
Met	

 C48	
Neighborhood connections	
2/2	
Met	

 C49	
Physical setting is consistent 	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
2/2	
Met	

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

 C53	
Food/ dining choices	
2/2	
Met	

 C54	
Assistive technology	
1/2	
Not Met (50.0 %)	

Residential Services	

Indicator #	
Indicator	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
11/11	
Met	

 C8	
Family/guardian communication	
11/11	
Met	

 C9	
Personal relationships	
10/11	
Met (90.91 %)	

 C10	
Social skill development	
11/11	
Met	

 C11	
Get together w/family & friends	
11/11	
Met	

 C12	
Intimacy	
6/11	
Not Met (54.55 %)	

 C13	
Skills to maximize independence 	
11/11	
Met	

 C14	
Choices in routines & schedules	
11/11	
Met	

 C15	
Personalize living space	
11/11	
Met	

 C16	
Explore interests	
9/11	
Met (81.82 %)	

 C17	
Community activities	
9/11	
Met (81.82 %)	

 C18	
Purchase personal belongings	
11/11	
Met	

 C19	
Knowledgeable decisions	
11/11	
Met	

 C20	
Emergency back-up plans	
11/11	
Met	

 C46	
Use of generic resources	
11/11	
Met	

 C47	
Transportation to/ from community	
11/11	
Met	

 C48	
Neighborhood connections	
9/11	
Met (81.82 %)	

 C49	
Physical setting is consistent 	
11/11	
Met	

 C51	
Ongoing satisfaction with services/ supports	
11/11	
Met	

 C52	
Leisure activities and free-time choices /control	
11/11	
Met	

 C53	
Food/ dining choices	
11/11	
Met	

 C54	
Assistive technology	
10/11	
Met (90.91 %)