PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
SOUTH SHORE SUPPORT SERVICES, INC.
317 Libbey Industrial Pkwy. B300
 Weymouth, MA 02189    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
November 2, 2017	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
SOUTH SHORE SUPPORT SERVICES, INC.	

	

	

	

	
Review Dates	

	
10/4/2017 - 10/11/2017	

	

	

	

	
Service Enhancement 
Meeting Date	

	
10/25/2017	

	

	

	

	

	

	
Survey Team	

	
Barbara Mazzella	

Scott Nolan	

Ed Sutka (TL)	

Margareth Larrieux	

	

	

	

	

	

	
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	
70 / 80 Defer Licensure   	
	
65 / 73 Certified    	

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

Full Review	
19 / 22	

Placement Services	
1 location(s) 1 audit (s) 	

Full Review	
22 / 22	

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

Full Review	
21 / 23	

Planning and Quality Management (For all service groupings)	

	
Full Review	
3 / 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) 8 audit (s) 	
Targeted Review	
DDS 18 / 18
Provider 29 / 34

47 / 52 2 Year License 10/25/2017-  10/25/2019	
	
DDS 24 / 27
Provider 14 / 15

38 / 42 Certified 10/25/2017 -  10/25/2019	

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

DDS Targeted Review	
14 / 14	

Employment Support Services	
1 location(s) 4 audit (s) 	

DDS Targeted Review	
21 / 22	

Planning and Quality Management (For all service groupings)	

	
Full Review	
3 / 6	

	

	

	

	

EXECUTIVE SUMMARY :	

	

	

South Shore Support Services is a non-profit human service agency that was founded in 1995 to provide supports for people with disabilities and their families throughout the south shore area.  The agency offers a number of service types, including family support, adult family care, residential supports and day supports.  The agency's day supports encompass approximately 22 individuals in the community based day supports model and 20 individuals in the employment supports model.  The agency's residential services include 22 people in 24/7 supports, 4 people in the shared living model, and 28 people who receive less than 24 hour supports.    

The licensure and certification review of residential supports was conducted by the Department of Developmental Services (DDS) survey team.  This included a sampling of both 24 hour and less than 24 hour supports, as well as one person who was supported through the shared living model.  The review of the agency's day supports included people who were supported through two models: employment supports and community based day supports (CBDS).   The agency undertook the self-assessment process for its day supports, and the DDS portion of this review was targeted to a limited number of indicators.  The complete licensure and certification review of the agency's day supports reflected a combination of the DDS targeted review and ratings from the agency's self-assessment.  

During the course of the review, the DDS survey team identified a number of strengths throughout the agency.  For instance, respect between people and their staff was reinforced in a number of ways. This was seen, for example, in the long-term relationships between people receiving support and their staff at all levels of the agency, from direct care staff to senior administrators.  Although the agency has grown somewhat larger over the years, it has continued to be successful in maintaining a personalized approach to delivering supports.      

The agency was found to have achieved areas of successes in a number of the indicators relating to licensing.  For instance, a review of staff training revealed that mandatory trainings as well as many supplementary trainings were in place.  Within the agency's residential supports, staff were familiar with people's varied communication styles and were responsive when people were in need of prompt attention to health concerns.

A number of strengths were identified within the certification indicators for residential supports.  For instance, people were supported throughout their daily routines and choose community activities based on their personal interests, such as attending movies, local events, or social gatherings.  People were also supported to assist with activities designed to build skills and increase independence, such as grocery shopping.  Staff were noted to make consciousness efforts to respond to people in ways that addressed their concerns.

Within the agency's day supports, the licensure indicators reviewed by the DDS survey team were found to be consistently in place.  Within the certification indicators, employment supports were provided to help people gain or maintain employment at a number of community businesses, such as Stop and Shop and Papa Gino's.  Group supported employment was also offered at locations such as a local farmer's market.  Within CBDS, people were enjoying a variety of opportunities to participate in community activities which were of interest to them.

While there were many positives noted throughout, there were a few provider monitoring and data analysis systems that could benefit from further attention.  For example, efforts by the agency to gather and collect data relevant to implementing essential safeguards were noted; however, these efforts were sometimes less than entirely successful, especially in relation to building a quality assurance system that was capable of preventing recurrences of problems.   The impact of this was particularly seen in relation to some of the residential indicators related to licensure.  For instance, at four residential locations situations were identified by the survey team that were in need of prompt attention.  These included either high hot water temperature, less than fully functioning interconnected smoke detectors, or problems related to medication administration.  Another example that was identified of where the agency's safeguard systems needed to be strengthened related to achieving consistency in the monitoring and implementation of physician ordered treatment protocols.  As a result of these critical items not being in place across several sites, the agency's license will be deferred pending follow-up.      

For some of the residential certification indicators, further efforts were needed to ensure outcomes that were fully successful.  For instance, while the agency had initiated efforts to provide staff training in the area of sexuality and intimacy, an increased focus on assessing individuals' needs in this area and providing appropriate guidance and education is recommended.  In another instance, while the agency recently initiated a Community Connector Plan to identify individuals' interests and to make plans to help them meet others in the community who have similar preferences for cultural, social or recreational activities, these plans will need further efforts to reach full fruition.  

Based on the findings of this report, South Shore Support Services has earned a Two Year License for its Employment and Day Supports group and a deferred license for its Residential and Individual Home Supports group.  Both of these service groupings have received a Two-Year Certification.  The residential license is deferred due to ratings of Not Met in two critical indicators.  The DDS survey team will return in approximately 60 to review these indicators, as well as any other licensing indicators that were rated Not Met, and a final level of licensure will be determined at that time.  The agency will conduct its own follow-up for its day supports for any licensing indicators rated Not Met and submit the results to the DDS Office of Quality Enhancement within 60 days.  A description of the provider's self-assessment process follows.	

	

	

	

	

	

Description of Self Assessment Process:	

	

	

On July 1, 2017, SSSS had 7 individuals in supported employment; 19 individuals in group supported employment; and 22 individuals in community based day support (CBDS). Individuals are split between Launch 1 in Cohasset (12) and Launch 2 in Hingham (10).  Using a target sample size of 25%, SSSS reviewed: 5 of the 19 in group supported, 6 of the 22 in CBDS, and 5 of the 7 in supported employment. The sample size for individual supported employment is inflated to allow for an 80% scoring indicator. The review sample was non-duplicated across service delivery models.  
Our assessment tool was the tool used in DDS licensing and certification. We measured our indicators using the information source and how measured in the current DDS tool.  The criteria for a standard being met or not mirrored the survey and certification tool. The methodology used to determine if an indicator was met for the agency was 80% or above for surveyed participants. 
The Self-Assessment Team Members work in other departments at SSSS. The team members have combined knowledge in ISP development and implementation, human rights, employee and participant training, mental health and adult family care services, community resources, and vocational service delivery models. 
With regard to personal safety indicators: abuse/neglect training (all trainings were up to date), evacuation (all individuals were able to safely exit the building within 2.5 minutes), fire drills (at least four are conducted yearly), safe use of equipment (each individual has a completed safety assessment located in their clinical book), and reducing risk interventions (PBS plans were present as needed). Although safety plans were present, this area was considered to be NOT MET as there were areas which needed to be updated. In regards to emergency fact sheets, this area was also considered to be NOT MET as inconstancies were found between the information on the physicals and that on the emergency fact sheets. 
Regarding environmental safety, all required inspections were up to date.  Launch 2 was having an issue with their hot water at the time of the survey, thus leading to getting a NOT MET in this category. Both locations have interconnected smoke alarms which are in working condition.  At Launch 2, there is some paint chipping on the back of the building and some siding missing from the side of the building near the roof.  The interior of the building was in good condition.   Door, walkways and stairs were clear of debris.  All cleaning chemicals and combustibles were stored in separately in a safe manner.
Program staff were observed to have an understanding of the individual's communication needs and effectively communicated as well as made concerted efforts to communicate with the individual by evidence and observation of the use of picture/vision boards as well as technological devices that enhanced communication between individuals served, program staff, outside employers and family members.  In regards to feedback on staff performance the program allows individuals served to provide feedback throughout the intake admission process and provides feedback during program support staff performance reviews/evaluations.  Communication between family/guardians is effective through mediums including but not limited to mailings, emails, telephone and community message boards located at the program location sites.
 It was reported that neither location administered medications. Launch 1 has a MAP certificate, but Launch 2 did not, despite the fact that the program holds an EpiPen for a consumer.  Launch 2 had an EpiPen protocol that was not individualized to the consumer nor was it signed by his physician. It was also determined that there was a client who could benefit from a seizure protocol. In regards to specialized diets, it was determined that this area was considered to be NOT MET, as one client should be following a "low in saturated fat" diet (per his physical); however, it does not appear as though this suggestion is being followed. 
All critical indicators were met for Human Rights (HR).  All consumers were trained in their rights annually and documentation is kept within their books at the program.  Human Rights are also discussed at morning and afternoon meetings.  Both staff and consumers were trained in DPPC training, as well.  The DPPC hotline number is posted at both locations.  One DPPC was filed by Launch staff in regards to an incident that was reported to them.  Staff  have been trained using the DDS DPPC Mandated Reporting training since December of 2016.  Both Launch programs are part of the SSSS Human Rights Committee.  The committee meets at least 4 times per year.  All incidents that have been submitted into HCSIS have or will be reviewed by the committee.  Recommendations from the committee are followed. There were no reported restraints.  All individuals had access to their belongings and times were available for cell phone use.  L55 was rated as a not met.  Photo releases were not filled out accurately with specific start dates/end dates listed on them.  
All individual surveyed submitted the required ISP paperwork within the allotted time frame except for one individual.  Notes were kept on every individual's progress. Goals were reflective of each consumer's unique needs and interests.  Goals were geared towards competitive employment and building the skills needed to maintain employment.  Other goals were in regards to assisting others to further their education through Quincy College and Well-Spring.  One consumer is working on his degree while the other consumer is trying to obtain her high school diploma.
Although all current providing program support staff are qualified and trained on an ongoing basis, surveyors found inconsistencies with the program's personnel system. The program could benefit from developing a more structured and consistent hiring/screening process to ensure they continue and employ qualified staff to support individuals served.  In regards to staff training, the program hold individuals served to similar training standards/requirements as staff training is critical to employee growth and development whether it be employment within the providing agency or outside employment.
There continues to be no documentation of a benefit analysis report for individuals who are currently working within or outside the providing agency of how future earnings will affect individual's entitlements, but the program has increased their explanation efforts to families/guardians through informational mailings as well as live training opportunities conducted by Metropolitan Public Affairs Specialist from the SSA.  This resulted in a NOT MET rating for C26.  In addition there appeared to be no concrete system in place that explained employee benefits to those individuals served who are working within the providing agency.  Some individuals who do have outside agency employment did have proof on record of benefits explained for their particular employer, but the providing agency did not. This resulted in a NOT MET rating for C33.
Both indicators (C44/C45) were met for meaningful and satisfying day activities. Each client has several assessments in their clinical books which help determine which volunteer/job sites may appeal to them. Both locations also have many community connections - Launch 2 has 30 job training sites, while Launch 1 has over 15 job training sites. Support staff report that individuals are encouraged to make decisions throughout the day and that individuals can sign up for each volunteer/job site either in advance or on a daily basis. It was also reported that individuals are encouraged to enter the community with staff for various social activities, including cardio walks, "find it out Fridays," and open mic days. 
         Both indicators (C51/C54) were met for choice, growth and control. Support staff report that clients are offered choices throughout each day, starting with the daily morning meeting, where clients are encouraged to express themselves and their opinions. Support staff also reports that clients are encouraged to sign up for the job/volunteer sites that interest them. Support staff reports that they also encourage each client to be as independent as possible while working/volunteering in the community. Each client has a satisfaction survey located in their clinical book.  Consumers and their families are also encouraged to fill out a satisfaction survey on a yearly basis (those surveys are located at the SSSS main office). Each client has a completed assistive technology assessment in their clinical book and are able to have access to various assistive technology devices throughout the day, including I-pads, computers and Bluetooth devices to assist individuals with travel training.
Both Launch programs have collaborated with several other agencies to enhance the services they provide.  They regularly check in at the Hingham Library, COA Cohasset and Hingham.  Volunteer examples include the COA, Meals on Wheels, Cooking at the COA, South Shore Hospital, Sunrise assisted living, Carriage House preschool, Scituate Public  Preschool, Village Greenery, St. Anthony's, Hull Animal Shelter and Harborview Assisted living, and Cohasset Housing authority.  Community opportunities are regularly offered such as swimming at Scituate Raquetball, Cohasset Town pool, South Shore Art Center, South Shore Conservatory and survival cooking at Elm St Cohasset community room. Gentle Yoga and Book club will begin in October. Find it out Fridays has proved to be an effective way to incorporate travel training on the bus and train. Volunteer/work/community opportunities were posted on the wall at Launch with a sign-up sheet for those interested. Both programs take part in community events and stay connected to the community by making Active donations to Lynus Fund, making blankets for military families, Donations at Christmas to Toys for Tots and Hurricane relief funds.
Career planning, development and employment is the programs central focus during the individual's served hiring/screening/assessment/orientation process and then ongoing after that.  Individuals served are given the opportunity to explore a wide range of employment opportunities while developing their skills individually as well as in a group setting.  Support staff are knowledgeable of individuals abilities and work closely with them to help overcome any external barriers that may inhibit employment/workforce development.  Individuals served interviewed during this survey period reported feeling supported by the program staff in their employment/career goals and felt they were closer to reaching their goals by attending this program.	

	

	

	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/8	
0/8	

Residential and Individual Home Supports	
62/72	
10/72	

    Residential Services
    Placement Services
    Individual Home Supports

	

Critical Indicators	
6/8	
2/8	

Total	
70/80	
10/80	
88%	

Defer Licensure	

	

# indicators for 60 Day Follow-up	
	
10	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
8/8	
0/8	

Employment and Day Supports	
39/44	
5/44	

    Community Based Day Services
    Employment Support Services

	

Critical Indicators	
6/6	
0/6	

Total	
47/52	
5/52	
90%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
5	

	

	

	

	

	

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

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L74	
The agency screens prospective employees per requirements.	
Proper record of screening is not on file (i.e. job descriptions are not on file and/or not signed by hired employee, resumes are not on file to match job descriptions, lack of proof of reference checks conducted).	
SSSS will identify additional staffing hours in human resources to improve on documentation collection and completion.  When employees do not have resumes we will use our job application form to collect information needed.	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L10	
The provider implements interventions to reduce risk for individuals whose behaviors may pose a risk to themselves or others.  	
Interventions to reduce risk were reviewed for three individuals. In one instance, staff was not implementing strategies as designed to reduce the potential for risk. The agency needs to ensure that strategies to reduce the potential for risk are implemented. 	

O	
 L12	
 Smoke detectors and carbon monoxide detectors, and other essential elements of the fire alarm system required for evacuation are located where required and are operational.  	
The fire alarm system was tested at four locations. In two instances, essential elements of the fire alarm system were not operational. In one home, all smoke detectors were not interconnected and in another home, the smoke alarm/carbon monoxide detector did not operate when tested. The agency needs to ensure that all essential elements of the fire alarm system are located where required and are operational. 	

 L15	
Hot water temperature tests between 110 and 130 degrees.	
The hot water temperature was tested at five locations. The hot water temperature at two of these homes exceeded allowable limits. The agency needs to ensure that hot water temperatures are within allowable limits of 110-120 degrees.

O	
 L38	
Physicians' orders and treatment protocols are followed (when agreement for treatment has been reached by the individual/guardian/team). 	
Physician's orders and treatment protocols were reviewed for nine individuals. In two instances, staff were not implementing physician ordered treatment protocols for significant medical concerns as written. The agency needs to ensure staff is knowledgeable, implement the procedure correctly and that the effectiveness of this protocol is periodically reviewed.	

 L43	
The health care record is maintained and updated as required.  	
Health Care Records (HCR's) were reviewed for ten individuals. In three instances, required information such as hospitalizations was not included.  The agency needs to ensure HCR's are accurate and updated as required.	

 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.	
A restrictive practice of utilizing auditory alarms on all egress doors was reviewed at one home. Provisions were not included to mitigate the effect of this restriction on three individuals residing in this home. The agency needs to ensure that restrictive practices include provisions so as to not unduly restrict the rights of others.	

 L67	
There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	
Money management plans were reviewed for nine individuals.  In three instances,
the agency had shared and delegated money management responsibility, in these instances agreement to the written agreement was not obtained by the guardian or the amount of monies that could be independently managed by individuals was not included in the plan. The agency needs to ensure money management plans include all required components.	

 L69	
Individual expenditures are documented and tracked.	
Financial transaction records were reviewed for eight individuals. The agency did not have an effective cash in/cash out process which occurred at the time of transactions for two individuals and in another instances there was a lack of documentation regarding  expenditures for several months. The agency needs to ensure that expenditures are documented and tracked when it has shared and delegated money management responsibilities. 	

 L86	
Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	
Assessments were reviewed for eight individuals. In two instances, assessments were not submitted within 15 days of the ISP. The agency needs to ensure that assessments are submitted within required timeframes. 	

 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 eight individuals. In two instances, support strategies were not submitted within 15 days of the ISP. The agency needs to ensure that strategies are submitted within required timeframes. 	

	

	

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

Indicator #	
Indicator	
Issue identified	
Action planned to address	

 L5	
There is an approved safety plan in home and work locations. 	
Relocation site's phone # needs to be revised to (781) 331-8420.  Launch (I) - Cohasset's capacity is still listed at (12) within the Safety-Plan. In regards to the egress plan, it should be updated to reflect that a new step was recently built (there are now two steps down, not one).	
The Safety Plans for both Launch sites were updated with corrections.  Area office sign off was received on 9/26/17.  Staff have reviewed changes.	

 L8	
Emergency fact sheets are current and accurate and available on site.	
Updated date needs to be listed at the top. Medical information (i.e. height, weight, diagnosis, allergies and medication should be updated and match most recent medical documentation that is filed in charts.	
The Emergency Fact sheets have been updated to reflect all of the information that we have in our files.  We are finding that we do not always get consistent medical information from families.  We are redesigning a tool to request updated medical information that better reflects the unique needs of those we serve.	

 L15	
Hot water temperature tests between 110 and 130 degrees.	
On the date of inspection surveyors found that the hot water was not working at the Launch (II) - Hingham location.	
The heating system has been adjusted and the hot water at Launch 2 has been repaired.  The water has been tested and is at 110 degrees.  Both Launch directors will check their hot water monthly and report the results to the Clinical Director during supervision.	

 L39	
Special dietary requirements are followed. 	
In client's physical, it is written that client should follow a diet "low in saturated fat;" however, it does not appear as though this recommendation is being followed.	
Individuals supported at Launch usually bring their lunches from home. There are, however, opportunities to make community purchases.  We will develop a guideline for the individual that has the low in saturated fat diet.	

 L44	
The location where MAP certified staff is administering medication is registered by DPH.	
At the time of this survey Launch (II) - Hingham did not have MAP registration for their site.	
SSSS applied for and received a MAP sight registration for Launch 2 on 9/1/17.  The MAP # is MAP07999.  The certificate # is 753791.	

	

	

	

	
CERTIFICATION FINDINGS	

	

	

	

	

Reviewed by	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS	
3/6	
3/6	

Individual Home Supports	
DDS	
21/23	
2/23	

Placement Services	
DDS	
22/22	
0/22	

Residential Services	
DDS	
19/22	
3/22	

Total	
	
65/73	
8/73	
89%	

Certified	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS	
3/6	
3/6	

Employment and Day Supports	
DDS 21/21
Provider 14/15	
35/36	
1/36	

Community Based Day Services	
DDS 11/11
Provider 3/3	
14/14	
0/14	

Employment Support Services	
DDS 10/10
Provider 11/12	
21/22	
1/22	

Total	
	
38/42	
4/42	
90%	

Certified	

	

	

	

	

	
	
Planning and Quality Management Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

 C1	
The provider collects data regarding program quality including but not limited to incidents, investigations, restraints, and medcation occurrences.	
Although the agency gathered information related to incidents, investigations, and medication occurrences, it did not have adequate mechanisms to collect comprehensive data related to program quality.  The agency needs to broaden the types of information gathered to include indicators of program quality.	

 C2	
The provider analyzes information gathered from all sources and identifies patterns and trends.	
The agency needs to develop a more effective system to analyze information from a variety of sources to identify any patterns and/or trends regarding service improvement needs  across all service types.	

 C5	
The provider has a process to measure progress towards achieving service improvement goals.	
The agency's process to set specific service improvement goals did not include an effective system of monitoring for targeting quality measures.  The agency needs to develop and implement an effective oversight process to measure service improvement targets.	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For one individual, there was no evidence that education has been provided to staff supporting individuals in the area of sexuality and intimacy. In addition, there were no  assessments made of an individual's need for intimacy and companionship in concert with his unique learning style. The agency needs to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship. 	

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
For one individual, exploration of interests regarding cultural, social, recreational and spiritual activities was not provided on a consistent and ongoing basis.  The agency needs to support individuals to explore, discover and connect with their interests on a regular basis. 	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
For four individuals, there was no evidence that education has been provided to staff supporting individuals in the area of sexuality and intimacy. In addition, there were no assessments made of an individual's need for intimacy and companionship in concert with individual's unique learning styles. The agency needs to assess individuals and provide training to staff to support individuals to explore, define and express their need for intimacy and companionship.  	

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Exploration of individual's interests regarding cultural, social, recreational and spiritual activities was not identified for two individuals on a consistent and ongoing basis. The agency needs to support individuals to explore, discover and encourage participation of integrated cultural, social, recreational and spiritual activities on a regular basis. 	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
The supports for six individuals were reviewed and in three instances assessments of assistive technology needs were completed. However, these did not include plans to maximize their independence in their home or community based on the assessment. The agency needs to develop recommendations and develop strategies which incorporate modifications and/or assistive technology that could maximize individual's independence. 	

	

	

	
Employment Support Services- Areas Needing Improvement on Standards not met From Provider review:	

Indicator #	
Indicator	
Issues identified	
Action planned to address	

 C33	
Employee benefits and rights are clearly explained to the individual.	
No information available outlining rights and benefits by employers outside the agency or within the agency (when provider is the employer).	
SSSS will address provider as employer by reviewing benefits and rights for Launch employees.	

	

	

	

	
	MASTER SCORE SHEET LICENSURE	

										
	Organizational: SOUTH SHORE SUPPORT SERVICES, INC.	

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

O	
 L2	
Abuse/neglect reporting	
8/8	
Met	

 L3	
Immediate Action	
2/2	
Met	

 L4	
Action taken	
2/2	
Met	

 L48	
HRC	
1/1	
Met	

 L74	
Screen employees	
4/4	
Met	

 L75	
Qualified staff	
2/2	
Met	

 L76	
Track trainings	
10/10	
Met	

 L83	
HR training	
10/10	
Met	

										
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
6/6	
3/4	
1/1	

	
10/11	
Met
(90.91 %)	

 L5	
Safety Plan	
L	
2/2	
2/2	
1/1	

	
5/5	
Met	

O	
 L6	
Evacuation	
L	
2/2	
2/2	
1/1	

	
5/5	
Met	

 L7	
Fire Drills	
L	
2/2	

	

2/2	
Met	

 L8	
Emergency Fact Sheets	
I	
6/6	
3/4	
1/1	

	
10/11	
Met
(90.91 %)	

 L9	
Safe use of equipment	
L	
2/2	
4/4	

	
	
6/6	
Met	

 L10	
Reduce risk interventions	
I	
0/1	
1/1	
1/1	

	
2/3	
Not Met
(66.67 %)	

O	
 L11	
Required inspections	
L	
2/2	
1/1	
1/1	

	
4/4	
Met	

O	
 L12	
Smoke detectors	
L	
1/2	
0/1	
1/1	

	
2/4	
Not Met
(50.0 %)	

O	
 L13	
Clean location	
L	
2/2	
1/1	
1/1	

	
4/4	
Met	

 L14	
Site in good repair	
L	
2/2	
1/1	
1/1	

	
4/4	
Met	

 L15	
Hot water	
L	
2/2	
1/2	
0/1	

	
3/5	
Not Met
(60.0 %)	

 L16	
Accessibility	
L	
2/2	
2/2	
1/1	

	
5/5	
Met	

 L17	
Egress at grade 	
L	
2/2	
2/2	
1/1	

	
5/5	
Met	

 L18	
Above grade egress	
L	
	
1/1	

	
	
1/1	
Met	

 L19	
Bedroom location	
L	
2/2	
1/1	

	
	
3/3	
Met	

 L20	
Exit doors	
L	
2/2	
2/2	

	
	
4/4	
Met	

 L21	
Safe electrical equipment	
L	
2/2	
1/1	
1/1	

	
4/4	
Met	

 L22	
Clean appliances	
L	
2/2	
1/1	
1/1	

	
4/4	
Met	

 L23	
Egress door locks	
L	
2/2	

	

2/2	
Met	

 L24	
Locked door access	
L	
2/2	

	

2/2	
Met	

 L25	
Dangerous substances	
L	
2/2	
1/1	

	
	
3/3	
Met	

 L26	
Walkway safety	
L	
2/2	
1/1	
1/1	

	
4/4	
Met	

 L28	
Flammables	
L	
2/2	
1/1	

	
	
3/3	
Met	

 L29	
Rubbish/combustibles	
L	
2/2	
1/1	
1/1	

	
4/4	
Met	

 L30	
Protective railings	
L	
2/2	
2/2	
1/1	

	
5/5	
Met	

 L31	
Communication method	
I	
6/6	
4/4	
1/1	

	
11/11	
Met	

 L32	
Verbal & written	
I	
6/6	
4/4	
1/1	

	
11/11	
Met	

 L33	
Physical exam	
I	
6/6	
2/2	
1/1	

	
9/9	
Met	

 L34	
Dental exam	
I	
6/6	
2/2	
1/1	

	
9/9	
Met	

 L35	
Preventive screenings	
I	
6/6	
2/2	
0/1	

	
8/9	
Met
(88.89 %)	

 L36	
Recommended tests	
I	
6/6	
2/2	
1/1	

	
9/9	
Met	

 L37	
Prompt treatment	
I	
6/6	
2/2	
1/1	

	
9/9	
Met	

O	
 L38	
Physician's orders	
I	
4/6	
3/3	

	
	
7/9	
Not Met
(77.78 %)	

 L39	
Dietary requirements	
I	
2/2	
2/2	

	
	
4/4	
Met	

 L40	
Nutritional food	
L	
2/2	
2/2	

	
	
4/4	
Met	

 L41	
Healthy diet	
L	
2/2	
3/3	
1/1	

	
6/6	
Met	

 L42	
Physical activity	
L	
2/2	
3/3	
1/1	

	
6/6	
Met	

 L43	
Health Care Record	
I	
4/6	
3/3	
0/1	

	
7/10	
Not Met
(70.0 %)	

 L44	
MAP registration	
L	
2/2	
1/1	

	
	
3/3	
Met	

 L45	
Medication storage	
L	
2/2	
1/1	

	
	
3/3	
Met	

O	
 L46	
Med. Administration	
I	
6/6	
1/2	

	
	
7/8	
Met
(87.50 %)	

 L47	
Self medication	
I	
6/6	
1/1	
1/1	

	
8/8	
Met	

 L49	
Informed of human rights	
I	
6/6	
3/4	
1/1	

	
10/11	
Met
(90.91 %)	

 L50	
Respectful Comm.	
L	
2/2	
4/4	
1/1	

	
7/7	
Met	

 L51	
Possessions	
I	
6/6	
4/4	
1/1	

	
11/11	
Met	

 L52	
Phone calls	
I	
6/6	
4/4	
1/1	

	
11/11	
Met	

 L53	
Visitation	
I	
6/6	
4/4	
1/1	

	
11/11	
Met	

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

	
6/6	
Met	

 L55	
Informed consent	
I	
1/1	
	
1/1	

	
2/2	
Met	

 L56	
Restrictive practices	
I	
0/3	

	

0/3	
Not Met
(0 %)	

 L61	
Health protection in ISP	
I	
2/3	
1/1	

	
	
3/4	
Met	

 L62	
Health protection review	
I	
3/3	
1/1	

	
	
4/4	
Met	

 L63	
Med. treatment plan form	
I	
5/6	
2/2	

	
	
7/8	
Met
(87.50 %)	

 L64	
Med. treatment plan rev.	
I	
5/6	
2/2	

	
	
7/8	
Met
(87.50 %)	

 L67	
Money mgmt. plan	
I	
3/6	
2/2	
1/1	

	
6/9	
Not Met
(66.67 %)	

 L68	
Funds expenditure	
I	
6/6	
2/2	
0/1	

	
8/9	
Met
(88.89 %)	

 L69	
Expenditure tracking	
I	
4/6	
1/1	
0/1	

	
5/8	
Not Met
(62.50 %)	

 L70	
Charges for care calc.	
I	
6/6	
1/1	
1/1	

	
8/8	
Met	

 L71	
Charges for care appeal	
I	
6/6	
1/1	
1/1	

	
8/8	
Met	

 L77	
Unique needs training	
I	
6/6	
4/4	
1/1	

	
11/11	
Met	

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

	
	
2/2	
Met	

 L79	
Restraint training	
L	
1/1	
1/1	

	
	
2/2	
Met	

 L80	
Symptoms of illness	
L	
2/2	
4/4	
1/1	

	
7/7	
Met	

 L81	
Medical emergency	
L	
2/2	
3/3	
1/1	

	
6/6	
Met	

O	
 L82	
Medication admin.	
L	
2/2	
1/2	

	
	
3/4	
Met	

 L84	
Health protect. Training	
I	
3/3	
1/1	

	
	
4/4	
Met	

 L85	
Supervision 	
L	
1/2	
4/4	
1/1	

	
6/7	
Met
(85.71 %)	

 L86	
Required assessments	
I	
4/5	
1/2	
1/1	

	
6/8	
Not Met
(75.00 %)	

 L87	
Support strategies	
I	
4/5	
1/2	
1/1	

	
6/8	
Not Met
(75.00 %)	

 L88	
Strategies implemented	
I	
6/6	
2/2	
1/1	

	
9/9	
Met	

 L90	
Personal space/ bedroom privacy	
I	
6/6	
2/2	
1/1	

	
9/9	
Met	

#Std. Met/# 72 Indicator	

	

	

62/72	

	
Total Score	

	

	

70/80	

	

	

	

	
87.50%	

				
										
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	

O	
 L2	
Abuse/neglect reporting	
L	
Provider	
	
-	
-	
-	
Met	

 L4	
Action taken	
L	
Provider	
	
-	
-	
-	
Met	

 L5	
Safety Plan	
L 	
Provider	
	
-	
-	
-	
Not Met

O	
 L6	
Evacuation	
L	
DDS	

1/1	
1/1	
Met	

 L7	
Fire Drills	
L 	
Provider	
	
-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
	
-	
-	
-	
Not 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 	
Provider	
	
-	
-	
-	
Met	

 L22	
Clean 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	
2/2	
	
4/4	
6/6	
Met	

 L39	
Dietary requirements	
I 	
Provider	
	
-	
-	
-	
Not Met

	
 L44	
MAP registration	
L 	
Provider	
	
-	
-	
-	
Not Met

	
 L45	
Medication storage	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I 	
Provider	
	
-	
-	
-	
Met	

 L49	
Informed of human rights	
I	
DDS	
4/4	
	
4/4	
8/8	
Met	

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

 L51	
Possessions	
I 	
Provider	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
4/4	
	
4/4	
8/8	
Met	

 L54	
Privacy	
L	
DDS	

1/1	
1/1	
Met	

 L55	
Informed consent	
I	
DDS	
4/4	
	
2/2	
6/6	
Met	

 L77	
Unique needs training	
I 	
Provider	
	
-	
-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	
	
-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
	
-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
	
-	
-	
-	
Met	

 L85	
Supervision 	
L 	
Provider	
	
-	
-	
-	
Met	

 L86	
Required assessments	
I	
Provider	
	
-	
-	
-	
Met	

 L87	
Support strategies	
I	
Provider	
	
-	
-	
-	
Met	

 L88	
Strategies implemented	
I 	
Provider	
	
-	
-	
-	
Met	

#Std. Met/# 39 Indicator	

	

	
39/44	

	
Total Score	

	

	
47/52	

	

	

	
	
90.38%	

			
										
	MASTER SCORE SHEET CERTIFICATION	

										
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
	
Met/Rated	
Rating	

 C1	
Provider data collection	
	
0/1	
Not Met (0 %)	

 C2	
Data analysis	
	
0/1	
Not Met (0 %)	

 C3	
Service satisfaction	
	
1/1	
Met	

 C4	
Utilizes input from stakeholders	
	
1/1	
Met	

 C5	
Measure progress	
	
0/1	
Not Met (0 %)	

 C6	
Future directions planning	
	
1/1	
Met	

	

	

	
										
Community Based Day Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
4/4	
Met	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C13	
Skills to maximize independence 	
DDS	
4/4	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C40	
Community involvement interest	
DDS	
4/4	
Met	

 C41	
Activities participation	
DDS	
4/4	
Met	

 C42	
Connection to others	
DDS	
4/4	
Met	

 C43	
Maintain & enhance relationship	
DDS	
4/4	
Met	

 C44	
Job exploration	
Provider	
-	
Met	

 C45	
Revisit decisions	
DDS	
4/4	
Met	

 C46	
Use of generic resources	
DDS	
4/4	
Met	

 C47	
Transportation to/ from community	
DDS	
4/4	
Met	

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

 C54	
Assistive technology	
DDS	
4/4	
Met	

Employment Support Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
DDS	
4/4	
Met	

 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	
DDS	
4/4	
Met	

 C27	
Job benefit education	
DDS	
4/4	
Met	

 C28	
Relationships w/businesses	
DDS	
1/1	
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	
-	
Not Met (0 %)	

 C34	
Support to promote success	
DDS	
4/4	
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	
4/4	
Met	

 C50	
Involvement/ part of the Workplace culture	
DDS	
4/4	
Met	

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

 C54	
Assistive technology	
DDS	
4/4	
Met	

Individual Home Supports	

Indicator #	
Indicator	
	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
	
3/3	
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	
	
2/3	
Not Met (66.67 %)	

 C13	
Skills to maximize independence 	
	
4/4	
Met	

 C14	
Choices in routines & schedules	
	
2/2	
Met	

 C15	
Personalize living space	
	
2/2	
Met	

 C16	
Explore interests	
	
2/3	
Not Met (66.67 %)	

 C17	
Community activities	
	
4/4	
Met	

 C18	
Purchase personal belongings	
	
3/3	
Met	

 C19	
Knowledgeable decisions	
	
3/3	
Met	

 C20	
Emergency back-up plans	
	
2/2	
Met	

 C21	
Coordinate outreach	
	
2/2	
Met	

 C46	
Use of generic resources	
	
4/4	
Met	

 C47	
Transportation to/ from community	
	
4/4	
Met	

 C48	
Neighborhood connections	
	
2/2	
Met	

 C49	
Physical setting is consistent 	
	
3/3	
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	
	
3/3	
Met	

 C54	
Assistive technology	
	
3/4	
Met	

Placement Services	

Indicator #	
Indicator	
	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
	
1/1	
Met	

 C8	
Family/guardian communication	
	
1/1	
Met	

 C9	
Personal relationships	
	
1/1	
Met	

 C10	
Social skill development	
	
1/1	
Met	

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

 C12	
Intimacy	
	
1/1	
Met	

 C13	
Skills to maximize independence 	
	
1/1	
Met	

 C14	
Choices in routines & schedules	
	
1/1	
Met	

 C15	
Personalize living space	
	
1/1	
Met	

 C16	
Explore interests	
	
1/1	
Met	

 C17	
Community activities	
	
1/1	
Met	

 C18	
Purchase personal belongings	
	
1/1	
Met	

 C19	
Knowledgeable decisions	
	
1/1	
Met	

 C20	
Emergency back-up plans	
	
1/1	
Met	

 C46	
Use of generic resources	
	
1/1	
Met	

 C47	
Transportation to/ from community	
	
1/1	
Met	

 C48	
Neighborhood connections	
	
1/1	
Met	

 C49	
Physical setting is consistent 	
	
1/1	
Met	

 C51	
Ongoing satisfaction with services/ supports	
	
1/1	
Met	

 C52	
Leisure activities and free-time choices /control	
	
1/1	
Met	

 C53	
Food/ dining choices	
	
1/1	
Met	

 C54	
Assistive technology	
	
1/1	
Met	

Residential Services	

Indicator #	
Indicator	
	
Met/Rated	
Rating	

 C7	
Feedback on staff performance	
	
6/6	
Met	

 C8	
Family/guardian communication	
	
6/6	
Met	

 C9	
Personal relationships	
	
6/6	
Met	

 C10	
Social skill development	
	
6/6	
Met	

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

 C12	
Intimacy	
	
2/6	
Not Met (33.33 %)	

 C13	
Skills to maximize independence 	
	
6/6	
Met	

 C14	
Choices in routines & schedules	
	
6/6	
Met	

 C15	
Personalize living space	
	
2/2	
Met	

 C16	
Explore interests	
	
4/6	
Not Met (66.67 %)	

 C17	
Community activities	
	
6/6	
Met	

 C18	
Purchase personal belongings	
	
6/6	
Met	

 C19	
Knowledgeable decisions	
	
6/6	
Met	

 C20	
Emergency back-up plans	
	
2/2	
Met	

 C46	
Use of generic resources	
	
6/6	
Met	

 C47	
Transportation to/ from community	
	
6/6	
Met	

 C48	
Neighborhood connections	
	
5/6	
Met (83.33 %)	

 C49	
Physical setting is consistent 	
	
2/2	
Met	

 C51	
Ongoing satisfaction with services/ supports	
	
6/6	
Met	

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

 C53	
Food/ dining choices	
	
6/6	
Met	

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