PROVIDER REPORT FOR	

	

	

	

	

	

	

	

	

	
	
The Judge Rotenberg Educational Center, Inc
240 Turnpike Street
 Canton, MA 02021    	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Version	

	

	

	

	

	

	

	

	
Provider Web Report
April 6, 2018	

	

	

	

	

	

	

	
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

	

	

	

	

	

	

			
	SUMMARY OF OVERALL FINDINGS	

			

	

	

Provider	

	
The Judge Rotenberg Educational Center, Inc	

	

	

	

	
Review Dates	

	
2/22/2018 - 2/28/2018	

	

	

	

	
Service Enhancement 
Meeting Date	

	
3/14/2018	

	

	

	

	

	

	
Survey Team	

	
Margareth Larrieux	

Barbara Mazzella (TL)	

Tina Napolitan	

	

	

	

	

	

	
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	
6 location(s) 6 audit (s) 	
Targeted Review	
DDS 16 / 20
Provider 67 / 67

83 / 87 2 Year License 03/14/2018-  03/14/2020	
	
DDS 9 / 20
Provider 8 / 8

17 / 28 Certified with Progress Report 03/14/2018 -  03/14/2020	

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

DDS Targeted Review	
11 / 22	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

Survey scope and findings for Employment and Day Supports	

Service Group Type	
Sample Size	
Licensure Scope	
Licensure Level	
Certification Scope	
Certification Level	

Employment and Day Supports	
2 location(s) 6 audit (s) 	
Targeted Review	
DDS 12 / 13
Provider 57 / 57

69 / 70 2 Year License 03/14/2018-  03/14/2020	
	
DDS 15 / 27
Provider 15 / 15

30 / 42 Certified with Progress Report 03/14/2018 -  03/14/2020	

Community Based Day Services	
1 location(s) 3 audit (s) 	

DDS Targeted Review	
6 / 14	

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

DDS Targeted Review	
18 / 22	

Planning and Quality Management (For all service groupings)	

	
DDS Targeted Review	
6 / 6	

	

	

	

EXECUTIVE SUMMARY :	

	

	

The Judge Rotenberg Educational Center, Inc. (JRC) is a private not-for-profit organization that provides day and residential supports to children and adults who come from Massachusetts as well as several other states.  At the time of this survey, the agency supported 135 adults, all of whom received 24 hour residential and day services within its network of services. 

The agency was eligible for and elected to conduct a self-assessment of all licensure and certification indicators for its day and residential services, with DDS conducting a targeted review. The current targeted review by the DDS Office of Quality Enhancement included critical and past not-met licensing indicators for its day and residential services and a review of all Certification indicators which were new or revised in August of 2016. The results of this licensing and certification review reflect a combination of the DDS targeted review and the ratings from the agency's self-assessment. The DDS targeted review reviewed the services of adults who received residential services, Community Based Day Supports (CBDS), and individuals who received employment supports.
 
During the course of the review, the survey team identified a number of positive practices that were seen throughout the agency.  For instance, all locations visited by the survey team were found to be safe and in good repair.  Required inspections were up to date and individuals were supported to safely evacuate within required time frames.  In the provision of health care supports, physician ordered treatment protocols were implemented as designed and monitored to ensure consistency among supporters. Staff who administered medications were in compliance with all training requirements and a current listing of all MAP certified personnel is readily available at residential locations where support is needed to administer medications to individuals at home. 

The agency has also strengthened its system regarding the timely completion of submissions of required assessments and support strategies in preparation for the Individual Service Plan (ISP). Documentation reviewed for all individuals receiving residential services indicated that both assessments and support strategies were completed on time for the ISP. 
 
It was also noted that written and verbal communications throughout the day/employment and residential settings was respectful. Individuals were encouraged to voice their concerns through a variety of mechanisms such as e-mail or speaking with their designated advocate. 

Within the certification indicators, significant efforts were in place to foster on-going contact with family members. Several individuals commented on the support they received to go home and share successes with family members on community outings or participate in family events. A heightened emphasis was also evident regarding securing employment at community businesses, such as Target. Two out of three people were supported to attain competitive jobs. Within CBDS, people were enjoying participating in volunteer activities which could potentially lead to employment situations.

While the agency has demonstrated positive findings in its delivery of services, the survey team identified a number of areas where additional work was needed to fully meet outcomes in the areas of human rights. Several individuals with behavior plans had restrictive practices that did not contain all required components. For example, audio/visual monitoring was in place for some people and there were not provisions regarding plans to fade or eliminate this practice over time.  Another area that needed further refinement concerned practices that impact human rights including a right to privacy. Additionally, strategies need to be in place to assist individuals who have hearing or speech impairments to utilize accessible communication technologies to connect with families and friends. The agency also needs to ensure that its Human Rights Committee is comprised of the requisite expertise among its membership and those members with required expertise i.e. legal, are present at meetings.

Among the certification areas reviewed across residential services, findings indicated that the agency needs to assist individuals to explore and pursue integrated community interests and activities that reflect personal preferences and interests. Community activities and options should be broadened so that individuals can make more personalized choices about leisure time and non-scheduled activities. The agency should offer guidance and assistance to individuals to connect with neighbors. 

As identified in JRC's self-assessment, the agency needs to review and follow through on strategies to assist individuals in the areas of human sexuality and intimacy, and increasing personal relationships. Additionally, although the agency had taken initial steps toward evaluating people's need for the use of assistive technology, it needs to  train staff regarding how to assess people's needs and explore technology that may enhance people's independence at home and at day/employment locations.  

Within the agency's day supports, further strategies need to be developed to create ongoing opportunities for individuals to explore volunteer options and activities that expose individuals to new areas of interest. Supporters also need to create additional opportunities for individuals to access generic resources as possible venues for vocational exploration. 

Based on the findings of this review, the agency has earned Two-Year Licenses for both Residential/IHS supports and Employment/Day supports with licensure scores of 95% for Residential/IHS supports service grouping and 99% for Employment/Day supports service grouping. The agency will be completing its own follow up in regard to any licensing indicators rated Not Met, and forward the agency's follow up report to the DDS Office of Quality Enhancement within 60 days. The agency is also Certified with progress reports for both Residential/IHS and Employment/Day services as they received ratings of Met in 11 out of 22 indicators for residential supports, 6 out of 14 indicators for CBDS, and 18 out of 22 indicators for employments supports.  

The following is the agency's self-assessment of Licensure and Certification indicators.	

	

	

	

Description of Self Assessment Process:	

	

	

Under the direction of JRC's Director, we used the DDS Licensure/Certification Indicator Guidelines to establish criteria that was used to measure each indicator to ensure consistency among reviewers.  Each audit was completed using the corresponding worksheets and rating sheet. JRC used 80% as a threshold, as well as other measurements, to determine if an indicator was Met or Not Met.

In determining sample sizes, JRC ensured that a representative sample of records and programs were visited and reviewed. JRC's Assistant to the Director/Special Projects was responsible for determining the sample size, randomly choosing the sample, and reporting the sample to the applicable staff conducting the audits. Staff members responsible for conducting the audits were notified of the sample on January 25, 2018; and audits were conducted from February 1, 2018 to February 7, 2018.

Six DDS licensed homes were reviewed and six clients each were reviewed from Clusters A and Cluster B. In addition, six clients were selected from JRC's Community Based Day Services Program, and three clients each from JRC's Employment Support Services Program. Designated staff completed the Residential and Individual Home, Employment, and Day Supports indicator audits through record reviews, staff interviews, and site visits.

Completed worksheets and supporting documentation were provided to the Director, who was responsible for analyzing the data and determining which indicators were Met or Not Met.  JRC's Compliance Officer reviewed numerous indicators at the organizational level:

Personal Safety (Indicators L2, L3, L4) - The JRC Policy on Reporting Abuse outlines staff responsibilities as mandated reporters, including what constitutes a reportable condition, their role as a mandated reporter, practices for filing with DPPC, and reporting to supervisory personnel. JRC staff are provided on-line abuse/neglect training every 6 months, quarterly policy reminders, and annual client rights training. JRC takes immediate action once it becomes aware of an allegation. JRC uses an incident review committee to identify possible programmatic, staff, and systematic issues for all investigations. JRC's Compliance Officer interviewed direct care and administrative staff to determine knowledge of the Policy; and interviewed the Director of Student Services, and requested copies of DPPC/DDS action plans and supporting documentation for the last 12 months, which were reviewed to ensure appropriate follow-up.

Human Rights (Indicators L48, L65, L66) - JRC maintains an effective HRC, providing essential safeguards for clients served. The 2017 minutes were audited for mandated composition, meeting frequency, and quorums and to assess whether specific behavior plans were reviewed. Interviews were also conducted with JRC's HR Coordinator, by-laws were reviewed, as well as training provided to HRC members.

Restraint information via HCSIS for 2017 was reviewed, ensuring that information was entered in a timely and accurate manner. JRC provides DDS with copies of each restraint on a monthly basis as agreed upon by JRC and DDS. Restraints are reviewed by JRC's HRC within 120 days, which was confirmed through a review of HCSIS and HRC minutes.

Competent Workforce (Indicators L74, L75, L76, L83) - JRC screens prospective staff per applicable requirements, and ensures staff have the required qualifications and certifications. JRC utilizes an electronic database to track all trainings and in-services for each staff, including, safety awareness, environmental modifications, fire safety, first aid, CPR, human rights, and abuse and neglect reporting. A random sample of 20 employee files were audited to ensure that staff had the necessary qualifications and certifications that are required and specific to their job.

To ensure that Residential and Individual Home, Employment. and Day Supports Programs are compliant with DDS regulations, JRC maintains a number of quality assurance systems to meet essential safeguards in areas relating to:

Personal Safety: Each client is annually trained on abuse and neglect reporting. Training is documented and maintained as part of the client's record. JRC also has a procedure to solicit information about any possible incident or concern a client may have and has two staff to serve as investigators, providing regular reports to management. Each client is also educated about all aspects of their Human Rights through JRC's Human Rights Curriculum which is presented to each client quarterly.

The Student Services Department updates residential safety plans as necessary, and ensures that the Plans are maintained in each residential and work location. They are also responsible for maintaining residential and workplace fire drill and evacuation documentation.  Fire drills are coordinated and conducted at the residences by the supervisor; and at the Day Program by the Student Services department.

JRC maintains systems for tracking, monitoring and responding to behavioral issues, and subsequently reducing risk for clients whose behavior may pose a risk to themselves and others, including 24-hour clinical and administrator on-call that permits direct care staff to seek advice from clinicians and administrators at any time; direct care, supervisory, and administrative end-of-shift reports; staff incident reporting system; 24-hour behavior frequency data collection system, clinical review of significant behavioral incidents via DVR systems; current status documentation that is updated with behavioral, medical, and other information; a behavior program that includes positive/replacement behavior targets, consideration of relevant antecedent concerns, and differential reinforcement components; ongoing functional behavioral assessments in order to develop the most individualized treatment program; and a dynamic behavioral intervention program (BIP) change system that enables changes to BIP components to respond to changing needs. Many clients participate in behavioral counseling. These sessions assist clients with self-management and interventions to promote their educational, vocational, social, and behavioral progress.  Within JRC's ABA-based approach, supports and services are provided in a manner that promotes the opportunity to undergo typical developmental experiences, even though such experiences may entail an element of risk; however the client's safety and well-being is always paramount.

Environmental Safety: JRC staff are required to complete reports after each shift, documenting any repairs and maintenance needs. JRC residential monitors, who perform a number of important daily site maintenance functions, including, but not limited to evaluating residences for cleanliness and reporting any problems to Housekeeping or Maintenance.

Highly experienced staff are assigned roving shifts at the residences, reporting any repairs or needs that are discovered. All staff members are required to report repair or maintenance needs.  Internal reports citing any residential repair issues or maintenance needs are generated through JRC's database and are automatically disseminated electronically to Maintenance. When a repair is completed, maintenance signs and dates the documentation and files it.  JRC schedules required maintenance and inspections as required.

Communication: The communication needs for each client is clearly indicated on the recording sheet, enabling staff to communicate with clients in their method of communication, to the greatest extent possible. During the ISP process, JRC develops a written plan to implement necessary modifications and support services to identify and serve clients with special communication needs.

Health: JRC's nursing services are available 24 hours per day, seven days per week.. Nursing works in conjunction with its Nutritionist and Director of Physical Education, ensuring that each client's dietary and physical education needs are met. JRC ensures that annual physical and dental exams, preventive screenings, and recommended tests are completed. JRC utilizes emergency services at nearby hospitals as needed.

Nursing provides all medical information to the treatment team and all necessary personnel and is responsible for updating each client's information packet.  Nursing maintains and updates medical binders that contain all relevant medical information. A binder is kept at the main building and in the client's residence. JRC also maintains a full electronic record for each client.

JRC ensures that all sites where Medication Administration Plan (MAP) certified staff members are administering medication is registered by DPH. Nursing maintains a MAP that outlines all of the medications that clients are taking. All medication is locked in a secure cabinet out of reach of clients. Medication is self-administered when appropriate, in accordance with JRC's Policy on Administration of Medication.

Human Rights: JRC implements its program in a manner that promotes humane care and treatment of its clients. No client at JRC shall be subject to any form of abuse, mistreatment or neglect by any act or omission by a staff member or other client. The Director of Student Services serves as JRC's Human Rights Coordinator; and the client's Case Manager acts as their Human Rights Officer. The Human Rights Officer annually trains clients in the exercise of their human rights, to the maximum of their capabilities and interests, and to assist them to exercise those rights, including informing them of the grievance procedures and the right to go to the HRC on any issue involving human rights.

Competent Workforce: Each staff member is required to complete a minimum of three weeks of intensive training and testing prior to providing support to clients and a minimum of 30 hours of in-service training each year. JRC tracks the training requirements of each of its staff in a data base maintained by the Human Resources Department. The Training department notifies each staff member on a monthly basis when s/he needs to update any aspect of their training. Attendance is documented by the use of in-service attendance sheets that are completed by the staff trainer, and provided to Human Resources for recordkeeping. All successfully completed trainings and required renewal dates are tracked via JRC's electronic database.

Goal Development and Implementation: Fifteen days prior to the ISP meeting, JRC will send the progress summaries of the goals for the previous year, the new provider support agreements (goals), and any assessments and documents required by DDS.  JRC will also provide DDS with copies of the client's program description, residential practices, the 3 month treatment summary, a list of current medications, a medication plan if the client has a Roger's treatment plan, and copies of the last physical and dental exam.  After the ISP meeting, the new goals are tracked to ensure that the client is working on and making progress towards his/her goals. If the client fails to make reasonable progress, changes are made to the client's program. Quarterly progress reports are completed by each client's treatment team, and include areas such as residential and vocational status, behavioral progress, topography changes, medical issues, replacement behaviors, discharge plans, a summary and goals.

JRC provides training to all staff members to support the needs and goals reflected in the clients' ISPs. All staff members initially learn and are trained on the ISP and the clients' goals during their initial three week training period.  This is also reviewed during Supervisor training which occurs when any staff receives a supervisory position and during regularly scheduled in-service trainings.	

	

	

	

LICENSURE FINDINGS	

	

	

	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
74/77	
3/77	

    Residential Services

	

Critical Indicators	
8/8	
0/8	

Total	
83/87	
4/87	
95%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
4	

	

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
60/60	
0/60	

    Employment Support Services
    Community Based Day Services

	

Critical Indicators	
8/8	
0/8	

Total	
69/70	
1/70	
99%	

2 Year License	

	

# indicators for 60 Day Follow-up	
	
1	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L48	
The agency has an effective Human Rights Committee.	
The agency needs to ensure that the HRC meets mandated composition, and that these members actively and consistently attend meetings. In addition, the HRC needs to file minutes with the Office of Human Rights promptly. 	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

 L54	
Individuals have privacy when taking care of personal needs and discussing personal matters. 	
Three out of six locations did not provide opportunities for individuals to have privacy when discussing personal matters. Video monitoring was present in the bedrooms of these individuals which prevented private discussions from occurring. The agency needs to ensure that individuals are afforded privacy when discussing personal matters. 	

 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 six individuals. Three individuals have behavior plans which identify restrictive practices such as door alarms, motion detectors, video/audio monitoring and locking of sharps and chemicals. In two instances, the agency did not include a plan to fade or reduce these restrictions.  For the other individual, information did not demonstrate that the restriction in place was the least restrictive option. The agency needs to ensure that all required components are in place with the use of restrictive practices.  These include: 
*Restrictive practices are outlined in writing, identifying the rationale, and outlined as the least restrictive alternative.  
*A plan for elimination or fading is included with the rationale as part of the document
*Agreement is needed from the legal decision maker for the individual is being imposed.  
*Inclusion in the ISP.
*HRC review of the plan.
For other individuals in the location for whom the restriction is not needed, the provider needs to develop provisions for these individuals so as to not unduly restrict them.

	
 L90	
Individuals are able to have privacy in their own personal space.	
Three out of six individuals did not have lockable bedroom doors. The agency needs to ensure that individuals have bedroom doors with locks unless their door leads to an egress, or unless the lock has been determined to be contra-indicated through the ISP process. 	

	

	
CERTIFICATION FINDINGS	

	

	

	

	

Reviewed by	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 1/1
Provider 5/5	
6/6	
0/6	

Residential and Individual Home Supports	
DDS 8/19
Provider 3/3	
11/22	
11/22	

Residential Services	
DDS 8/19
Provider 3/3	
11/22	
11/22	

Total	
	
17/28	
11/28	
61%	

Certified with Progress Report	

	

	

Reviewed By	
Met / Rated	
Not Met / Rated	
% Met	

Certification - Planning and Quality Management	
DDS 1/1
Provider 5/5	
6/6	
0/6	

Employment and Day Supports	
DDS 14/26
Provider 10/10	
24/36	
12/36	

Community Based Day Services	
DDS 4/12
Provider 2/2	
6/14	
8/14	

Employment Support Services	
DDS 10/14
Provider 8/8	
18/22	
4/22	

Total	
	
30/42	
12/42	
71%	

Certified with Progress Report	

	

	

	

	

	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
Although the agency affords individuals various venues such as e-mail or the ability to comment anonymously on the performance of staff, there are no provisions to provide feedback at the time of hire. Additionally, there are no provisions for individuals who are unable to use the agency's web site or provide verbal feedback on staff performance using mechanisms such as signs or pictorial aides.   	

	
 C9	
Staff (Home Providers) act as bridge builders and provide opportunities to develop, and/or increase personal relationships and social contacts.	
Three out of six individuals did not have opportunities to regularly meet new people as a mechanism to develop new relationships. Strategies need to be developed to assist people with building and sustaining relationships with others. Opportunities need to be created to facilitate social contacts with others in addition to individuals with whom they live. 	

	
 C12	
Individuals are supported to explore, define, and express their need for intimacy and companionship.	
The agency needs to develop a formal or informal evaluation process to ensure that individual's needs are assessed and provide support which enables individuals to receive education that is geared toward their learning style. 	

	
 C15	
Staff (Home Providers) support individuals to personalize and decorate their rooms/homes and personalize common areas according to their tastes and preferences.	
The agency needs to support individuals to participate in selecting and decorating their bedrooms and common areas in a manner that is reflective of their tastes and preferences. 	

	
 C16	
Staff (Home Providers) support individuals to explore, discover and connect with their interests for cultural, social, recreational and spiritual activities.	
Four out of six individuals were not fully supported to explore and discover community organizations and activities that connect them with their culture, social and spiritual interests. The agency needs to assist individuals to make these connections. 	

	
 C18	
Staff (Home Providers) assist individual to purchase personal belongings. 	
For two individuals, additional support is needed to assist them to purchase personal belongings. 	

	
 C46	
Staff (Home Providers) support individuals to learn about and use generic community resources.	
Individuals were not supported to learn about and use generic community resources.  The agency needs to ensure that supporters provide opportunities for individuals to learn about and access generic community resources on a consistent and sustained basis. 	

	
 C48	
Individuals are a part of the neighborhood.	
Five out of six individuals need to be supported to become active participants within their neighborhood. The agency needs to ensure that opportunities are provided which encourage and support neighborhood connections.

	
 C52	
Individuals have choice and control over their leisure and non-scheduled activities.	
Four individuals were not provided opportunities to have choice and control over their leisure and non-scheduled activities. Individual's activities are coordinated and scheduled for each home location through an activities department. The agency needs to ensure that individuals are provided opportunities to choose leisure and non-scheduled activities on an individualized basis. 	

	
 C53	
Individuals are supported to have choice and control over what, when, where and with whom they want to eat.	
In two locations, individuals were not supported to have choice and control over when, where and with whom they want to eat.  The agency needs to ensure that individuals are supported to have choice and control over where and with whom they eat meals. 	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Individualized assessments regarding assistive technology and/or modifications were not completed. The agency needs to ensure that assistive technology and/or modification needs are assessed and actualized for each individual. 	

	

	

	
Community Based Day Services- Areas Needing Improvement on Standards not met From DDS Review:	

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
Although the agency affords individuals the ability to comment anonymously on the performance of staff, there are no provisions to provide feedback at the time of hire. 	

	
 C40	
Individuals are supported to explore, discover and connect with their personal interest and options for community involvement, personal interest and hobbies.	
All three individuals spent the majority of their time within the CBDS program rather than in the community.  The agency needs to expand individuals' opportunities to identify and explore their personal interests within the community.  	

	
 C41	
Individuals participate in activities, including those in the community, that reflect their interests and preferences.	
Activities scheduled for individuals often did not reflect individualized interests.  The agency needs to support individuals to participate in a range of activities that are based upon their preferences.  	

	
 C42	
Individuals are involved in activities that connect them to other people in the community.	
Community trips were often conducted in large groups or not provided on a regular basis, and opportunities to interact with others in the community was limited.  The agency needs to develop  strategies to develop and foster integrated community connections.	

	
 C43	
Staff act as bridge builders to support individuals to develop, sustain, and enhance relationships with others. 	
One individual of three was not supported to develop, sustain or enhance relationships with others. The agency needs to develop strategies to support, develop, maintain and enhance relationships with people other than paid staff. 	

	
 C44	
Staff have effective methods to assist individuals to explore their job interests if appropriate.	
One out of three individuals was not assessed or supported to explore job interests. The agency needs to implement ways to assess job interests on a regular basis and provide supports to explore expressed interests.	

	
 C46	
Staff (Home Providers) support individuals to learn about and use generic community resources.	
Individuals were not supported to learn about and use generic community resources such as a community hair salon/barber, bank, library, on a consistent or sustained basis.  The agency needs to ensure that supporters provide opportunities for individuals to learn about and access generic community resources. 	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Individualized assessments regarding assistive technology and/or modifications were not completed. The agency needs to ensure that assistive technology and/or modification needs are assessed and actualized for each individual. 	

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

Indicator #	
Indicator	
Area Needing Improvement	

	
 C7	
Individuals have opportunities to provide feedback at the time of hire / time of the match and on an ongoing basis on the performance/actions of staff / care providers that support them.	
Although the agency affords individuals the ability to comment anonymously on the performance of staff, there are no provisions to provide feedback at the time of hire. 	

	
 C26	
Career planning includes an analysis of how an individual's entitlements can be managed in a way that allows them to work successfully in the community.	
One of three individuals had not been assisted to understand how their earnings could impact their entitlements.  The agency needs to ensure that all individuals who receive employment supports receive an analysis and information so to better understand how wages could potentially impact entitlements.  	

	
 C30	
Individuals are supported to work in integrated job settings.	
One individual did not work in an integrated job setting. The agency needs to ensure that individuals are supported to work in integrated settings. 	

	
 C54	
Individuals have the assistive technology and/or modifications to maximize independence. 	
Individualized assessments regarding assistive technology and/or modifications were not completed for one individual. The agency needs to ensure that assistive technology and/or modification needs are assessed and actualized for each individual. 	

	

	

	

	MASTER SCORE SHEET LICENSURE	

								
	Organizational: The Judge Rotenberg Educational Center, Inc	

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

O	
 L2	
Abuse/neglect reporting	
DDS	
8/8	
Met	

 L3	
Immediate Action	
Provider	
-	
Met	

 L4	
Action taken	
Provider	
-	
Met	

 L48	
HRC	
DDS	
0/1	
Not Met(0 % )	

 L65	
Restraint report submit	
Provider	
-	
Met	

 L66	
HRC restraint review	
Provider	
-	
Met	

 L74	
Screen employees	
Provider	
-	
Met	

 L75	
Qualified staff	
Provider	
-	
Met	

 L76	
Track trainings	
Provider	
-	
Met	

 L83	
HR training	
Provider	
-	
Met	

								
	Residential and Individual Home Supports:	

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

 L1	
Abuse/neglect training	
I	
Provider	
-	

	

-	
Met	

 L5	
Safety Plan	
L 	
Provider	
-	

	

-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
6/6	

	

6/6	
Met	

 L7	
Fire Drills	
L 	
Provider	
-	

	

-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
-	

	

-	
Met	

 L9	
Safe use of equipment	
L 	
Provider	
-	

	

-	
Met	

 L10	
Reduce risk interventions	
I 	
Provider	
-	

	

-	
Met	

O	
 L11	
Required inspections	
L	
DDS	
6/6	

	

6/6	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
6/6	

	

6/6	
Met	

O	
 L13	
Clean location	
L	
DDS	
6/6	

	

6/6	
Met	

 L14	
Site in good repair	
L 	
Provider	
-	

	

-	
Met	

 L15	
Hot water	
L	
DDS	
6/6	

	

6/6	
Met	

 L16	
Accessibility	
L 	
Provider	
-	

	

-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
-	

	

-	
Met	

 L18	
Above grade egress	
L 	
Provider	
-	

	

-	
Met	

 L19	
Bedroom location	
L 	
Provider	
-	

	

-	
Met	

 L20	
Exit doors	
L 	
Provider	
-	

	

-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
-	

	

-	
Met	

 L22	
Well-maintained appliances	
L 	
Provider	
-	

	

-	
Met	

 L23	
Egress door locks	
L 	
Provider	
-	

	

-	
Met	

 L24	
Locked door access	
L 	
Provider	
-	

	

-	
Met	

 L25	
Dangerous substances	
L 	
Provider	
-	

	

-	
Met	

 L26	
Walkway safety	
L 	
Provider	
-	

	

-	
Met	

 L27	
Pools, hot tubs, etc.	
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	

 L33	
Physical exam	
I	
Provider	
-	

	

-	
Met	

 L34	
Dental exam	
I	
Provider	
-	

	

-	
Met	

 L35	
Preventive screenings	
I	
Provider	
-	

	

-	
Met	

 L36	
Recommended tests	
I 	
Provider	
-	

	

-	
Met	

 L37	
Prompt treatment	
I 	
Provider	
-	

	

-	
Met	

O	
 L38	
Physician's orders	
I	
DDS	
4/4	

	

4/4	
Met	

 L39	
Dietary requirements	
I 	
Provider	
-	

	

-	
Met	

 L40	
Nutritional food	
L 	
Provider	
-	

	

-	
Met	

 L41	
Healthy diet	
L 	
Provider	
-	

	

-	
Met	

 L42	
Physical activity	
L 	
Provider	
-	

	

-	
Met	

 L43	
Health Care Record	
I	
Provider	
-	

	

-	
Met	

 L44	
MAP registration	
L 	
Provider	
-	

	

-	
Met	

 L45	
Medication storage	
L 	
Provider	
-	

	

-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
5/6	

	

5/6	
Met
(83.33 %)	

 L47	
Self medication	
I 	
Provider	
-	

	

-	
Met	

 L49	
Informed of human rights	
I	
DDS	
6/6	

	

6/6	
Met	

 L50	
Respectful Comm.	
L	
DDS	
6/6	

	

6/6	
Met	

 L51	
Possessions	
I 	
Provider	
-	

	

-	
Met	

 L52	
Phone calls	
I	
DDS	
5/6	

	

5/6	
Met
(83.33 %)	

 L53	
Visitation	
I 	
Provider	
-	

	

-	
Met	

 L54	
Privacy	
L	
DDS	
3/6	

	

3/6	
Not Met
(50.0 %)	

 L55	
Informed consent	
I	
DDS	
1/1	

	

1/1	
Met	

 L56	
Restrictive practices	
I	
DDS	
3/6	

	

3/6	
Not Met
(50.0 %)	

 L57	
Written behavior plans	
I 	
Provider	
-	

	

-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
-	

	

-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
-	

	

-	
Met	

 L60	
Data maintenance	
I 	
Provider	
-	

	

-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
-	

	

-	
Met	

 L62	
Health protection review	
I 	
Provider	
-	

	

-	
Met	

 L63	
Med. treatment plan form	
I	
DDS	
6/6	

	

6/6	
Met	

 L64	
Med. treatment plan rev.	
I 	
Provider	
-	

	

-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
-	

	

-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
-	

	

-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
-	

	

-	
Met	

 L70	
Charges for care calc.	
I	
Provider	
-	

	

-	
Met	

 L71	
Charges for care appeal	
I	
Provider	
-	

	

-	
Met	

 L77	
Unique needs training	
I 	
Provider	
-	

	

-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	
-	

	

-	
Met	

 L79	
Restraint training	
L 	
Provider	
-	

	

-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
-	

	

-	
Met	

 L81	
Medical emergency	
L 	
Provider	
-	

	

-	
Met	

O	
 L82	
Medication admin.	
L	
DDS	
6/6	

	

6/6	
Met	

 L84	
Health protect. Training	
I 	
Provider	
-	

	

-	
Met	

 L85	
Supervision 	
L	
Provider	
-	

	

-	
Met	

 L86	
Required assessments	
I	
DDS	
3/3	

	

3/3	
Met	

 L87	
Support strategies	
I	
DDS	
3/3	

	

3/3	
Met	

 L88	
Strategies implemented	
I	
Provider	
-	

	

-	
Met	

 L90	
Personal space/ bedroom privacy	
I	
DDS	
3/6	

	

3/6	
Not Met
(50.0 %)	

#Std. Met/# 77 Indicator	

	

	

	
74/77	

	
Total Score	

	

	

	
83/87	

	

	

	

	
	
95.40%	

			
								
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	

 L5	
Safety Plan	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L6	
Evacuation	
L	
DDS	
1/1	
	
1/1	
2/2	
Met	

 L7	
Fire Drills	
L 	
Provider	
	
-	
-	
-	
Met	

 L8	
Emergency Fact Sheets	
I 	
Provider	
	
-	
-	
-	
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	
2/2	
Met	

O	
 L12	
Smoke detectors	
L	
DDS	
1/1	
	
1/1	
2/2	
Met	

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

 L14	
Site in good repair	
L 	
Provider	
	
-	
-	
-	
Met	

 L15	
Hot water	
L 	
Provider	
	
-	
-	
-	
Met	

 L16	
Accessibility	
L 	
Provider	
	
-	
-	
-	
Met	

 L17	
Egress at grade 	
L 	
Provider	
	
-	
-	
-	
Met	

 L18	
Above grade egress	
L 	
Provider	
	
-	
-	
-	
Met	

 L20	
Exit doors	
L 	
Provider	
	
-	
-	
-	
Met	

 L21	
Safe electrical equipment	
L 	
Provider	
	
-	
-	
-	
Met	

 L22	
Well-maintained 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	

3/3	
3/3	
Met	

 L39	
Dietary requirements	
I 	
Provider	
	
-	
-	
-	
Met	

 L44	
MAP registration	
L 	
Provider	
	
-	
-	
-	
Met	

 L45	
Medication storage	
L 	
Provider	
	
-	
-	
-	
Met	

O	
 L46	
Med. Administration	
I	
DDS	
3/3	
	
3/3	
6/6	
Met	

 L49	
Informed of human rights	
I	
DDS	
3/3	
	
3/3	
6/6	
Met	

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

 L51	
Possessions	
I 	
Provider	
	
-	
-	
-	
Met	

 L52	
Phone calls	
I	
DDS	
3/3	
	
3/3	
6/6	
Met	

 L54	
Privacy	
L	
DDS	
1/1	
	
1/1	
2/2	
Met	

 L55	
Informed consent	
I 	
Provider	
	
-	
-	
-	
Met	

 L56	
Restrictive practices	
I 	
Provider	
	
-	
-	
-	
Met	

 L57	
Written behavior plans	
I 	
Provider	
	
-	
-	
-	
Met	

 L58	
Behavior plan component	
I 	
Provider	
	
-	
-	
-	
Met	

 L59	
Behavior plan review	
I 	
Provider	
	
-	
-	
-	
Met	

 L60	
Data maintenance	
I 	
Provider	
	
-	
-	
-	
Met	

 L61	
Health protection in ISP	
I 	
Provider	
	
-	
-	
-	
Met	

 L62	
Health protection review	
I 	
Provider	
	
-	
-	
-	
Met	

 L63	
Med. treatment plan form	
I 	
Provider	
	
-	
-	
-	
Met	

 L64	
Med. treatment plan rev.	
I 	
Provider	
	
-	
-	
-	
Met	

 L67	
Money mgmt. plan	
I 	
Provider	
	
-	
-	
-	
Met	

 L68	
Funds expenditure	
I 	
Provider	
	
-	
-	
-	
Met	

 L69	
Expenditure tracking	
I 	
Provider	
	
-	
-	
-	
Met	

 L73	
DOL certificate	
L 	
Provider	
	
-	
-	
-	
Met	

 L77	
Unique needs training	
I 	
Provider	
	
-	
-	
-	
Met	

 L78	
Restrictive Int. Training	
L 	
Provider	
	
-	
-	
-	
Met	

 L79	
Restraint training	
L 	
Provider	
	
-	
-	
-	
Met	

 L80	
Symptoms of illness	
L 	
Provider	
	
-	
-	
-	
Met	

 L81	
Medical emergency	
L 	
Provider	
	
-	
-	
-	
Met	

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

 L84	
Health protect. Training	
I 	
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/# 60 Indicator	

	

	
60/60	

	
Total Score	

	

	
69/70	

	

	

	
	
98.57%	

			

MASTER SCORE SHEET CERTIFICATION	

								
	
Certification - Planning and Quality Management	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C1	
Provider data collection	
Provider	
-	
Met	

 C2	
Data analysis	
Provider	
-	
Met	

 C3	
Service satisfaction	
Provider	
-	
Met	

 C4	
Utilizes input from stakeholders	
DDS	
1/1	
Met	

 C5	
Measure progress	
Provider	
-	
Met	

 C6	
Future directions planning	
Provider	
-	
Met	

	

	

	
								
Community Based Day Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
0/3	
Not Met (0 %)	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C13	
Skills to maximize independence 	
DDS	
3/3	
Met	

 C37	
Interpersonal skills for work	
Provider	
-	
Met	

 C40	
Community involvement interest	
DDS	
0/3	
Not Met (0 %)	

 C41	
Activities participation	
DDS	
0/3	
Not Met (0 %)	

 C42	
Connection to others	
DDS	
0/3	
Not Met (0 %)	

 C43	
Maintain & enhance relationship	
DDS	
2/3	
Not Met (66.67 %)	

 C44	
Job exploration	
DDS	
2/3	
Not Met (66.67 %)	

 C45	
Revisit decisions	
DDS	
3/3	
Met	

 C46	
Use of generic resources	
DDS	
0/3	
Not Met (0 %)	

 C47	
Transportation to/ from community	
DDS	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

 C54	
Assistive technology	
DDS	
0/3	
Not Met (0 %)	

Employment Support Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
0/3	
Not Met (0 %)	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C22	
Explore job interests	
DDS	
3/3	
Met	

 C23	
Assess skills & training needs	
DDS	
3/3	
Met	

 C24	
Job goals & support needs plan	
DDS	
3/3	
Met	

 C25	
Skill development	
Provider	
-	
Met	

 C26	
Benefits analysis	
DDS	
2/3	
Not Met (66.67 %)	

 C27	
Job benefit education	
DDS	
3/3	
Met	

 C28	
Relationships w/businesses	
DDS	
1/1	
Met	

 C29	
Support to obtain employment	
Provider	
-	
Met	

 C30	
Work in integrated settings	
DDS	
2/3	
Not Met (66.67 %)	

 C31	
Job accommodations	
Provider	
-	
Met	

 C32	
At least minimum wages earned	
Provider	
-	
Met	

 C33	
Employee benefits explained	
DDS	
3/3	
Met	

 C34	
Support to promote success	
DDS	
3/3	
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	
3/3	
Met	

 C50	
Involvement/ part of the Workplace culture	
DDS	
3/3	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
3/3	
Met	

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

Residential Services	

Indicator #	
Indicator	
Reviewed By	
Met/Rated	
Rating	

 C7	
Feedback on staff / care provider performance	
DDS	
0/6	
Not Met (0 %)	

 C8	
Family/guardian communication	
Provider	
-	
Met	

 C9	
Personal relationships	
DDS	
3/6	
Not Met (50.0 %)	

 C10	
Social skill development	
Provider	
-	
Met	

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

 C12	
Intimacy	
DDS	
1/6	
Not Met (16.67 %)	

 C13	
Skills to maximize independence 	
DDS	
6/6	
Met	

 C14	
Choices in routines & schedules	
DDS	
6/6	
Met	

 C15	
Personalize living space	
DDS	
1/6	
Not Met (16.67 %)	

 C16	
Explore interests	
DDS	
2/6	
Not Met (33.33 %)	

 C17	
Community activities	
DDS	
5/6	
Met (83.33 %)	

 C18	
Purchase personal belongings	
DDS	
2/4	
Not Met (50.0 %)	

 C19	
Knowledgeable decisions	
DDS	
6/6	
Met	

 C20	
Emergency back-up plans	
Provider	
-	
Met	

 C46	
Use of generic resources	
DDS	
2/6	
Not Met (33.33 %)	

 C47	
Transportation to/ from community	
DDS	
6/6	
Met	

 C48	
Neighborhood connections	
DDS	
1/6	
Not Met (16.67 %)	

 C49	
Physical setting is consistent 	
DDS	
6/6	
Met	

 C51	
Ongoing satisfaction with services/ supports	
DDS	
6/6	
Met	

 C52	
Leisure activities and free-time choices /control	
DDS	
2/6	
Not Met (33.33 %)	

 C53	
Food/ dining choices	
DDS	
4/6	
Not Met (66.67 %)	

 C54	
Assistive technology	
DDS	
1/6	
Not Met (16.67 %)