SUMMARY OF OVERALL FINDINGS

Provider:  Southeastern Residential Services
Review Dates:  April 25 – May 1, 2013
Service Enhancement Meeting Date:  May 10, 2013
Survey Team:  Barbara Mazzella (TL), Dawne Doyle, Laura K. O’Connor, Jennifer Petersen, and 
                          Edward Sutka
Citizen Volunteers:  Laura Beaudoin, Matthew Cosgrove, and Paul Henthorne

 
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 Locations 16 Audits 	Full Review	81 / 85 Two-Year License 05/10/2013 - 05/10/2015	 

 	 

 	
Residential Services	14 Locations 14 Audits 	 

 
 	DDS Targeted Review	0 / 0 Certified	
Respite Services	1 Location   2 Audits 	 

 	No Review	No Review	
 
Survey Scope and Findings for Planning and Quality Management:	
Service Group   Type	Sample  Size	Licensure 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

Southeastern Residential Services (SRS) is a state-operated agency committed to providing residential and medical respite services to approximately 270 individuals living in 57 homes throughout southeastern Massachusetts.  SRS takes pride in implementing its mission to 'empower and support people to make informed choices and decisions, take reasonable risks, exercise their rights and be challenged to realize their fullest potential.' 

SRS remains steadfast in supporting individuals to be valued and contributing members of their community and acknowledged that a hallmark of its services and supports is the longevity of staff and their commit-ment to ensuring the safety and overall well-being of the people they support.  The majority of individuals supported by the agency has complex medical needs and/or is experiencing issues associated with aging. Most agency homes provide twenty-four hour supports.  This full licensure review consisted of examining services provided at fourteen locations where people received twenty-four hour residential supports as well as reviewing services provided for adults at a new medical respite home. 

EXECUTIVE SUMMARY, CONT.
Since the past licensing and certification review, SRS has continued to focus on strengthening the supports provided to individuals with intricate medical needs.  Towards this end, SRS created a unique and specialized respite home specifically designed for adults with complex medical needs.  This home is a welcome addition for many families who have cared for their sons and daughters at home, often going for extended periods of time without any relief for lack of dependable and skilled respite alternatives.  The full complement of nursing and trained support staff available to individuals utilizing this home coupled with environmental modifications and adaptations supporting individualized unique needs allow individuals to have continuity and strong medical oversight. 

SRS has also directed its attention since the last survey on strengthening and redesigning orientation for LPN's as well as enhancing staff training and utilized a consultant to conduct a two-day team building session.  Additional nursing supports were added on several shifts to assist individuals in twenty-four hour homes to maintain good health and assisted in recognizing early onset of signs and symptoms of disease or illness.  SRS also recognized that many individuals present behavioral/medical challenges as they age and is in the process of reorganizing and redesigning several homes to accommodate these develop-ments.  

SRS also developed a second self-advocacy group, which advocated statewide for budgetary increases as well as providing input and insight into programmatic improvements for individuals residing in SRS homes. An outcome from these efforts has included the identification and modification in a service practice that better meets individuals' expectations for respectful interactions.  

While SRS has many systems in place to ensure the presence of essential safeguards as evidenced throughout the survey visits, there are a few areas that would benefit from additional oversight and monitoring.  These include establishing a system for ensuring that all assessments submitted as part of the Individual Service Plan (ISP) are submitted within required time frames, as well as ensuring that supports and strategies agreed upon in the ISP are consistently implemented.  The agency also needs to review how the impact of restrictive interventions designed for one person in a home does not unduly restrict the rights of other members residing in that home and ensure that members with required expertise more consistently attend all Human Rights Committee meetings. 

As evidenced by the scoring percentage obtained in this full licensing review (95%), the agency continues to maintain a high level of achievement in supporting people with significant challenges.  SRS is congratulated on achieving a Two-Year License.

	

  

LICENSURE FINDINGS
  
 	Met / Rated	Not Met/ Rated	% Met	
Organizational	9/10	1/10	 	
Residential and Individual Home Supports	72/75	3/75	 

    Residential Services
    Respite Services	 

 	
Critical Indicators	8/8	0/8	 	
Total	81/85	4/85	95%	
Two-Year License	 	 	 	
# Indicators for 60 Day Follow-up	 
 	4	 

 

Organizational Area Needing Improvement on Standard Not Met/Follow-up to Occur:	
 	Indicator #	Indicator	Area Needing Improvement	

 

 
 	 L48	The agency has an effective Human Rights Committee (HRC).	While the Human Rights Committees provided detailed minutes in which evidence was noted of comprehensive review of all areas within their purview, lack of consistent attendance by members with required expertise compromised the effectiveness of these committees.  The agency needs to ensure that Human Rights Committee members with required expertise attend committee meetings a minimum of 75%. 

 
 	Residential Commendation on Standard Met:	
 	Indicator #	Indicator	Commendation	

 

 

 	 L77	The agency assures that staff are familiar with and trained to support the unique needs of individuals.	Supporters providing respite services utilized a comprehensive person-centered approach to ensure they were fully aware of a person's unique needs. Strategies included visiting people at their homes at   a frequency needed to get a full picture of the supports provided by their family members and other community service providers.  Additionally, a thorough care plan is completed for each person and updated prior to each use of the respite services.  Supporters are commended for ensuring continuity of care in the provision of respite services.

 
	
Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur:	
 	Indicator #	Indicator	Area Needing Improvement	

 
 	 L56	Restrictive practices intended for one individual that affect all individuals served at a location need to have a written rationale that is reviewed as required and have provisions so as not to unduly restrict the rights of others.
	Kitchen knives were being locked up in one home.  The agency needs to ensure that when a restrictive practice is in place, provisions are in place as to not unduly restrict the rights of others and obtain all required reviews. 	

 

 
 	 L86	Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	Six out of thirteen individuals' assessments were not submitted within DDS required timeframes.  The agency needs to ensure that ISP's completed after February 2013 include assessments that were sub-mitted fifteen days prior to the ISP and ISP's com-pleted in January 2013 or earlier include assessments that were submitted within ten working days. 

 

 
 	 L88	Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	The agency needs to ensure that services and strategies identified and agreed upon in the ISP are implemented.  Four out of fourteen individuals' support strategies were not being implemented as agreed upon. 	

 

CERTIFICATION FINDINGS

  	
Met / Rated
	
Not Met / Rated	
Certification - Planning and Quality Management
	0/0	0/0	
Residential and Individual Home Supports

 	
    Residential Services
	0/0	0/0	

  

Planning and Quality Management:  N/A

MASTER SCORE SHEET LICENSURE

Organizational: 

	Indicator #	Indicator	Met/Rated	Rating
(Met, Not Met, Not Rated)	
O	 L2	Abuse/Neglect reporting	15/15	Met	
 	 L3	Immediate Action	15/15	Met	
 	 L4	Action taken	14/14	Met	
 	 L48	HRC	0/3	Not Met (0%)	
 	 L65	Restraint Report submit	10/11	Met (90.91%)	
 	 L66	HRC restraint review	5/5	Met	
 	 L74	Screen employees	20/20	Met	
 	 L75	Qualified staff	20/20	Met	
 	 L76	Track trainings	20/20	Met	
 	 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	14/14			2/2	16/16	Met	
 	 L5	Safety Plan	L	12/14			1/1	13/15	Met
(86.67%)	
O	 L6	Evacuation
	L	14/14	 	 	1/1	15/15	Met	
 	 L7	Fire Drills
	L	14/14	 	 	 	14/14	Met	
 	 L8	Emergency Fact Sheets	I	12/14			2/2	14/16	Met
(87.50%)	
  	 L9	Safe use of equipment	L	8/9				8/9	Met
(88.89%)	
  	 L10	Reduce risk interventions	I	2/2				2/2	Met	
O	 L11	Required inspections	L	14/14			1/1	15/15	Met	
O	 L12	Smoke detectors	L	14/14			1/1	15/15	Met	
O	 L13	Clean location	L	14/14			1/1
	15/15	Met	
  	 L14	Site in good repair	L	11/11			 	11/11	Met	
 	 L15	Hot water	L	14/14	 	 	1/1
	15/15	Met	
	 L16	Accessibility	L	14/14
			1/1	15/15	Met	
Residential and Individual Home Supports, cont.

Indicator #	
Indicator	Location or Individual Indicator	
Residential Supports	
Individual Home Support	
Placement Support	
Respite Support	
Total Met/Rated	
Rating	
	 L17	Egress at grade 	L	14/14			1/1	15/15	Met	
	 L18	Above grade egress	L	1/1			 	1/1	Met	
	 L19	Bedroom location	L	14/14			1/1	15/15	Met	
 	 L20	Exit doors	L	14/14
			1/1	15/15	Met	
 	 L21	Safe electrical equipment	L	14/14			1/1	15/15	Met	
	 L22	Clean appliances	L	14/14			1/1	15/15	Met	
 	 L23	Egress door locks	L	9/9			1/1	10/10	Met	
 	 L24	Locked door access	L	14/14			  	14/14	Met	
 	 L25	Dangerous substances	L	14/14			1/1	15/15	Met	
 	 L26	Walkway safety	L	14/14			1/1	15/15	Met	
  	 L28
	Flammables	L	14/14			1/1	15/15	Met	
  	 L29	Rubbish/Com-bustibles	L	14/14			1/1	15/15	Met	
  	 L30	Protective railings	L	9/10			1/1	10/11	Met
(90.91%)	
	 L31	Communica-tion method	I	14/14			2/2	16/16	Met	
	 L32	Verbal & written	I	14/14			2/2	16/16	Met	
	 L33	Physical exam
	I	14/14				14/14	Met	
	 L34	Dental exam
	I	14/14				14/14	Met	
	 L35	Preventive screenings	I	14/14				14/14	Met	
	 L36	Recommended tests	I	14/14				14/14	Met	
	 L37	Prompt treatment	I	14/14			2/2	16/16	Met	
O	 L38	Physician's orders	I	14/14			2/2	16/16	Met	
	 L39	Dietary requirements	I	11/12			2/2	13/14	Met
(92.86%)	
	 L40	Nutritional food
	L	14/14			1/1	15/15	Met	
	 L41	Healthy diet
	L	14/14			1/1	15/15	Met	
 	 L42	Physical activity	L	14/14			  	14/14	Met	
  	 L43	Health Care Record	I	14/14			 	14/14	Met	
  	 L44	MAP Registration	L	14/14			1/1	15/15	Met	
Residential and Individual Home Supports, cont.

Indicator #	
Indicator	Location or Individual Indicator	
Residential Supports	
Individual Home Support	
Placement Support	
Respite Support	
Total Met/Rated	
Rating	
  	 L45	Medication storage	L	14/14			1/1	15/15	Met	
O	 L46	Medication administration	I	13/14			2/2	15/16	Met
(93.75%)	
  	 L47	Self-medication	I	10/10			  	10/10	Met	
	 L49	Informed of human rights	I	14/14			2/2	16/16	Met	
  	 L50	Respectful communication	L	14/14			1/1	15/15	Met	
  	 L51	Possessions
	I	14/14			2/2	16/16	Met	
  	 L52	Phone calls
	I	14/14			2/2	16/16	Met	
 	 L53	Visitation
	I	14/14	 	 	2/2	16/16	Met	
 	 L54	Privacy
	L	14/14	 	 	1/1	15/15	Met	
  	 L55	Informed consent	I	10/12			2/2	12/14	Met
(85.71%)	
  	 L56	Restrictive practices	I	1/2				1/2	Not Met
(50%)	
 	 L57	Written Behavior Plans	I	12/12				12/12	Met	
 	 L58	Behavior Plan component	I	12/12				12/12	Met	
  	 L59	Behavior Plan review	I	12/12				12/12	Met	
  	 L60	Data maintenance	I	10/11				10/11	Met
(90.91%)	
  	 L61	Health protection in ISP	I	13/14			2/2	15/16	Met
(93.75%)	
	 L62	Health protection review	I	13/14			2/2	15/16	Met
(93.75%)	
 	 L63	Medication Treatment Plan form	I	12/14			 	12/14	Met
(85.71%)	
  
 	 L64	Medication Treatment Plan review	I	11/12				11/12	Met
(91.67%)	
  	 L67	Money Mgmt. Plan	I	13/14				13/14	Met
(92.86%)	
 	 L68	Funds expenditure	I	14/14			1/1	15/15	Met	
 	 L69	Expenditure tracking	I	14/14			1/1	15/15	Met	
	 L70	Charges for care calc.	I	13/13				13/13	Met	
 	 L71	Charges for care appeal	I	12/13				12/13	Met
(92.31%)	
 	 L77	Unique needs training	I	12/14			2/2	14/16	Met
(87.50%)	

Residential and Individual Home Supports, cont.

Indicator #	
Indicator	Location or Individual Indicator	
Residential Supports	
Individual Home Support	
Placement Support	
Respite Support	
Total Met/Rated	
Rating	
 	 L78	Restrictive Int. Training	L	9/10			 	9/10	Met
(90%)	
	 L79	Restraint training	L	5/5			  	5/5	Met	
	 L80	Symptoms of illness	L	14/14			1/1	15/15	Met	
	 L81	Medical emergency	L	14/14			1/1	15/15	Met	
O	 L82	Medication administration	L	14/14			1/1	15/15	Met	
	 L84	Health Protection Training	I	13/14			2/2	15/16	Met
(93.75%)	
	 L85	Supervision
 	L	14/14			1/1	15/15	Met	
	 L86	Required assessments	I	7/13				7/13	Not Met
(53.85%)	
  	 L87	Support Strategies	I	12/13				12/13	Met
(92.31%)	
  
 	 L88	Strategies implemented	I	10/14				10/14	Not Met
(71.43%)	
  
 	#Std. Met/ 75 Indica-tors							72/75		
  	Total Score							81/85		
  	  							95.29%