PROVIDER REPORT FOR
Waverley Redemption Center and Work Services
23 Summer Ave
 Waltham, MA 02452    

 
August 12, 2013
Version
Provider Web Report

 
Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT	

SUMMARY OF OVERALL FINDINGS
 
Provider	
Waverley Redemption Center and Work Services	

Review Dates	
7/10/2013 - 7/15/2013	

Service Enhancement 
Meeting Date	
7/26/2013	

Survey Team	
 
Mark Boghoian (TL)	

Claire Paradiso	

 	

Citizen Volunteers	
 
N/A	

	

	

Survey scope and findings for Employment and Day Supports	
Service Group Type	Sample Size	Licensure Scope	Licensure Level	Certification Scope	Certification Level	
Employment and Day Supports	1 location(s) 4 audit (s) 	Full Review	41 / 45 2 Year License 07/26/2013 - 07/26/2015	 

 	 

 	
Employment Support Services	1 location(s) 4 audit (s) 	 
 	 
 	Full Review	8 / 15 Certified	
 
Survey scope and findings for Planning and Quality Management	
Service Group Type	Sample Size	Scope	Licensure Level	Certification Scope	Certification Level	
Planning and Quality Management	N/A	N/A	N/A	Full Review	5/6 Certified	

EXECUTIVE SUMMARY :
The can redemption service originated on the grounds of the Fernald Developmental Center in Waltham, Massachusetts in 1987.  In January 2012, a new can redemption center named The Waverley Redemption Center and Work Services (WRC) was opened in the Waltham Community.  A number of individuals and staff currently working at this new center began their careers as workers at the Fernald location.  Funded through the provider Work, Community, Independence (WCI), the WRC currently serves approximately twenty-five individuals with intellectual or developmental disabilities who receive services through DDS.  The Waverley Redemption Center and Work Services is open to the public six days per week, serving residents of local communities. Also, it has partnered with local businesses and institutions to support the bottle and can recycling enterprise.  Within WRC's services, there are two groups of working individuals.  One group is responsible primarily for picking-up and sorting cans and bottles.  The other group performs a variety of sorting, assembling and packaging work and makes crafts for sale at the Waverley Redemption Center and Work Services location.  

Approximately six months prior to this evaluation, WRC underwent a DDS Initial Licensing Review that is required for all new services.  This current evaluation was comprised of a review of all applicable DDS licensing and certification indicators and serves as the agency's first full DDS Licensing and Certification Review. For the purpose of this evaluation, the Employment Supports provided to four (4) individuals were reviewed.  

As identified previously through the Initial Review, the agency has a number of longstanding strengths within the licensing indicators.  A significant strength is that staff at all levels of the organization have known and worked with a large majority of the individuals served over many years.   Therefore, they have an in-depth and historical knowledge of the people they support.  A considerable number of individuals working at WRC have complex behavioral needs that require that residential staff accompany them to work.  WRC ensured that behavior plans and/or guidelines have been retrieved from the residential providers and WRC staff have been trained to be aware of antecedent and other behaviors that may have an impact on work performance and/or the work environment.  Also, the agency maintains a clean working environment that received all required inspections.   Additionally, it maintained current federal and state Department of Labor Certificates.  Likewise, the agency ensured that it maintained a current DDS Emergency Evacuation Safety Plan and it conducted emergency evacuation drills as required.  The agency also ensured that it evaluated each individual relative to safety skills in the workplace and provided training for the use of specialized equipment.  Furthermore, the agency trained all individuals relative to their human and employee rights and responsibilities as well as the reporting of suspected abuse or mistreatment.  These rights and responsibilities were detailed in the WRC handbook.  

Moving forward, the agency needs to address some areas in order to fully ensure compliance with DDS licensing measures.  One area the agency needs to focus on is its affiliation with and participation in a fully constituted Human Rights Committee (HRC).  The agency needs to ensure that there is consistent representation at all HRC meetings.  The agency also needs to submit and track the submission of required ISP assessments and support strategies to DDS within the required timelines.  Additionally, the agency needs to ensure that it implements its provider support strategies and maintains documentation of people's progress toward accomplishing their identified goals.  This documentation needs to include those strategies employed by staff and the resultant outcomes.  Furthermore, the agency needs to remedy its current inability to access the HCSIS system in order to report incidents as required.    

The agency needs to focus on achieving greater compliance with DDS certification indicators.  It is recognized that WRC is an agency in the initial phase of transition towards compliance with community based employment service standards.  The agency recently developed a strategic plan with a mission of 	

empowering and supporting individuals to achieve meaningful work and/or explore work opportunities in the community.  Its business base is envisioned as a training ground for future employment activities that are consistent with people's needs, capabilities and interests.  The relocation of this service into the community is seen as a significant strength in itself in that it provides individuals with the ability to serve the needs of residents and businesses in the local area.  A number of meaningful goals were established within the strategic plan.  The agency needs to establish baseline data from which it can incrementally measure progress towards the achievement of these service improvement goals.  The agency had conducted interest inventories with individuals with content that was preliminary.  WRC recognizes that it needs to ensure that it supports staff to utilize more comprehensive methods of accessing individual skills and interests.  It also recognizes the need to document each individual's skills, career interests and goals for the purpose of developing career plans and providing people with the requisite training and support needed to pursue their identified job interests.  Written plans will need to be developed that define how staff can promote individuals to be successful employees, while minimizing their need for support to the fullest extent possible.  The agency did not have a way to formally document and review people's performance on a regular basis.  The agency needs to develop a process to ensure that individuals receive regularly scheduled written and verbal feedback relative to their performance as employees.  In addition, the agency needs to develop a process for obtaining and acting upon feedback from individuals regarding the performance of the staff who support them.  This information needs to be used by the agency in its evaluation and training of staff.  

In summary, WRC continues to successfully transition into a community based employment service.  The agency received a Two-Year License with a score of 91% of the licensing indicators having been Met and it is Certified with eight out of fifteen certification indicators having been Met.  Because the agency Met more than 90% of the licensing indicators, it will conduct its own follow-up on the four licensing indicators that were Not Met and report those findings to the DDS Office of Quality Enhancement within sixty days.  It is anticipated that over the course of the next two years, the agency will continue to implement its newly developed strategic plan and make strides towards enhancing community employment opportunities for those individuals served.	

LICENSURE FINDINGS

 	Met / Rated	Not Met / Rated	% Met	
Organizational	4/5	1/5	 	
Employment and Day Supports	37/40	3/40	 
 	
    Employment Support Services	 

 	
Critical Indicators	5/5	0/5	 	
Total	41/45	4/45	91%	
2 Year License	 	 	 	
# indicators for 60 Day Follow-up	 
 	4	 

 
 	 	 	 	
 	Organizational Areas Needing Improvement on Standards not met/Follow-up to occur:	
 	Indicator #	Indicator	Area Needing Improvement	

 

 

 
 	 L48	The agency has an effective Human Rights Committee.	The agency is affiliated with another provider's human rights committee.  A review of meeting minutes dating back to the beginning of this affiliation (2/22/12) revealed that the committee's legal representative was only present for 2 out of 6 meetings and that the Waverley Redemption Center representative was only present for 3 out of 6 meetings.  The agency needs to ensure that it is affiliated with a fully constituted human rights committee and it needs to ensure that a representative from the Waverley Redemption Center and Work Services attend committee meetings on a regular basis.  	

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

 

 	 L86	Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	The agency had not submitted required ISP assessments to the DDS area office within the required timeframe prior to the ISP.  The agency needs to ensure that it maintains documentation confirming that all required ISP assessments are completed and submitted to the DDS area office within the required timeframe.	

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

 

 	 L87	Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	The agency had not submitted required ISP support strategies to the DDS area office within the required timeframe.  The agency needs to ensure that it maintains documentation confirming that provider support strategies are completed and submitted to the DDS area office within the required timeframe.	

 

 	 L88	Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	The agency had not implemented support strategies identified and agreed upon in people's ISP's.  The agency needs to ensure that it implements the various identified strategies and it documents progress/status in the achievement of developed strategies.  	

 
 
CERTIFICATION FINDINGS

 
 	Met / Rated	Not Met / Rated	
Certification - Planning and Quality Management	5/6	1/6	
Employment and Day Supports	 	 	
    Employment Support Services	8/15	7/15	
 
 	Planning and Quality Management Areas Needing Improvement on Standards not met:	
 	Indicator #	Indicator	Area Needing Improvement	

 

 
 
 	 C5	The provider has a process to measure progress towards achieving service improvement goals.	The provider had not yet implemented a process to measure progress relative toward achieving identified service improvement goals that are enumerated in its recently established strategic plan.  The agency needs to establish baseline data in order to begin to incrementally measure progress towards the achievement of its service improvement goals.  	

 
 	Employment Support Services- Areas Needing Improvement on Standards not met:	
 	Indicator #	Indicator	Area Needing Improvement	

 

 
 
 	 C7	Individuals have opportunities to provide feedback on the performance of staff that supports them. 	The agency had not developed a process for obtaining individual feedback on staff performance.  The agency needs to ensure that it develops a process for obtaining feedback from individuals relative to the performance of staff that support them and ensure that feedback is incorporated into the evaluation and training of staff.  	

 

 
 	 C22	Staff have effective methods to assist individuals to explore their job interests.	The agency had not effectively supported individuals to explore their potential job interests beyond what is available and offered on-site.  The agency needs to ensure that it regularly assesses people's job skills and interests and explores those identified interests with the individual.  	

 	Employment Support Services- Areas Needing Improvement on Standards not met:	
 	Indicator #	Indicator	Area Needing Improvement	

 

 

 	 C23	Staff utilize a variety of methods to assess an individual's skills, interests, career goals and training and support needs in employment.	The agency had not utilized a variety of methods to assess people's skills, interests, career goals and support needs.  Rather, it had conducted preliminary interest inventories with individuals.  The agency needs to ensure that it uses a variety of methods to assess people's career interests and determine their skills and training relative to their identified job interests.  	

 

 

 	 C24	There is a plan developed to identify job goals and support needs.	The agency did not have plans developed that identified job goals and support needs for those individuals that had career related interests beyond the jobs available on-site.  The agency needs to ensure that it develops detailed written plans that identify people's current interests and strengths.  Additionally, these plans need to address people's individual goals and support needs.  	

 

 
 	 C25	Staff assist individuals to work on skill development for job attainment and success.	The agency had not yet identified areas requiring skill development for each individual that would be required for them to attain a desired job and be successful at it.  The agency needs to support individuals to work on skill development for job attainment and success. 	

 

 	 C34	The agency provides the optimal level of support to promote success with a specific plan for minimizing supports.	The agency did not develop written plans of support that contained a specific plan to minimize supports.  The agency needs to provide the optimal level of support to promote success and have a specific written plan for minimizing supports.	

 

 
 
 	 C35	Individuals are given feedback on job performance by their employer.	The agency had not developed and implemented a process for providing individuals with a documented evaluation from which to provide performance feedback on a regularly scheduled basis.  The agency needs to ensure that it provides people with documented feedback on their job performance on a regularly scheduled basis.  	

 

 
 
MASTER SCORE SHEET LICENSURE
Organizational: Waverley Redemption Center and Work Services
 
 	Indicator #	Indicator	Met/Rated	Rating (Met, Not Met, Not Rated)	
O	 L2	Abuse/neglect reporting	1/1	Met	
 	 L48	HRC	0/1	Not Met(0 % )	
 	 L74	Screen employees	1/1	Met	
 	 L76	Track trainings	1/1	Met	
 	 L83	HR training	6/6	Met	

Employment and Day Supports:

 
 	Indicator #	Indicator	Location or Individual indicator	Employment Support	Center Based Work	Community Based Day Support	Total Met / Rated	Rating	
 
 	 L1	Abuse/neglect training	I	4/4	 
 	 
 	4/4	Met	
 	 L5	Safety Plan	L	1/1	 	 	1/1	Met	
O	 L6	Evacuation	L	1/1	 	 	1/1	Met	
 	 L7	Fire Drills	L	1/1	 	 	1/1	Met	
 
 	 L8	Emergency Fact Sheets	I	3/4	 
 	 
 	3/4	Met	
 
 	 L9	Safe use of equipment	L	1/1	 
 	 
 	1/1	Met	
 
 	 L10	Reduce risk interventions	I	2/2	 
 	 
 	2/2	Met	
O	 L11	Required inspections	L	1/1	 
 	 
 	1/1	Met	
O	 L12	Smoke detectors	L	1/1	 
 	 
 	1/1	Met	
O	 L13	Clean location	L	1/1	 	 	1/1	Met	
 
 	 L14	Site in good repair	L	1/1	 
 	 
 	1/1	Met	
 	 L15	Hot water	L	1/1	 	 	1/1	Met	
 	 L16	Accessibility	L	1/1	 	 	1/1	Met	
 
 	 L17	Egress at grade 	L	1/1	 
 	 
 	1/1	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Employment Support	Center Based Work	Community Based Day Support	Total Met / Rated	Rating	
 
 	 L18	Above grade egress	L	1/1	 
 	 
 	1/1	Met	
 	 L20	Exit doors	L	1/1	 	 	1/1	Met	
 
 	 L21	Safe electrical equipment	L	1/1	 
 	 
 	1/1	Met	
 
 	 L22	Clean appliances	L	1/1	 
 	 
 	1/1	Met	
 
 	 L25	Dangerous substances	L	1/1	 
 	 
 	1/1	Met	
 
 	 L26	Walkway safety	L	1/1	 
 	 
 	1/1	Met	
 
 	 L29	Rubbish/combustibles	L	1/1	 
 	 
 	1/1	Met	
 
 	 L30	Protective railings	L	1/1	 
 	 
 	1/1	Met	
 
 	 L31	Communication method	I	4/4	 
 	 
 	4/4	Met	
 
 	 L32	Verbal & written	I	4/4	 
 	 
 	4/4	Met	
 
 	 L49	Informed of human rights	I	4/4	 
 	 
 	4/4	Met	
 
 	 L50	Respectful Comm.	L	1/1	 
 	 
 	1/1	Met	
 	 L51	Possessions	I	4/4	 	 	4/4	Met	
 	 L52	Phone calls	I	4/4	 	 	4/4	Met	
 	 L54	Privacy	L	1/1	 	 	1/1	Met	
 
 	 L55	Informed consent	I	3/3	 
 	 
 	3/3	Met	
 
 	 L72	DOL requirements	I	4/4	 
 	 
 	4/4	Met	
 	 L73	DOL certificate	L	1/1	 	 	1/1	Met	
 
 	 L77	Unique needs training	I	4/4	 
 	 
 	4/4	Met	
 
 	 L79	Restraint training	L	1/1	 
 	 
 	1/1	Met	
 
 	 L80	Symptoms of illness	L	1/1	 
 	 
 	1/1	Met	
 
 	 L81	Medical emergency	L	1/1	 
 	 
 	1/1	Met	
 	 L85	Supervision 	L	1/1	 	 	1/1	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Employment Support	Center Based Work	Community Based Day Support	Total Met / Rated	Rating	
 
 	 L86	Required assessments	I	2/3	 
 	 
 	2/3	Not Met
(66.67 %)	
 
 	 L87	Support strategies	I	2/3	 
 	 
 	2/3	Not Met
(66.67 %)	
 
 	 L88	Strategies implemented	I	1/4	 
 	 
 	1/4	Not Met
(25.00 %)	

 	#Std. Met/# 40 Indicator	 

 

 	 

 
 	37/40	 

 
 	Total Score	 

 	 
 	 
 	41/45	 
 	
 	 	 	 	 	 	 	91.11%	 	
 
MASTER SCORE SHEET CERTIFICATION
 	Certification - Planning and Quality Management	
 	Indicator #	Indicator	Met/Rated	Rating	
 	 C1	Provider data collection	1/1	Met	
 	 C2	Data analysis	1/1	Met	
 	 C3	Service satisfaction	1/1	Met	
 	 C4	Utilizes input from stakeholders	1/1	Met	
 	 C5	Measure progress	0/1	Not Met (0 %)	
 	 C6	Future directions planning	1/1	Met	

Employment Support Services Reviewed By -DDS	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	0/4	Not Met (0 %)	
 C8	Family/guardian communication	4/4	Met	
 C22	Explore job interests	0/4	Not Met (0 %)	
 C23	Assess skills & training needs	0/4	Not Met (0 %)	
 C24	Job goals & support needs plan	2/4	Not Met (50.0 %)	
 C25	Skill development	0/4	Not Met (0 %)	
 C27	Job benefit education	2/2	Met	
 C28	Relationships w/businesses	1/1	Met	

Employment Support Services Reviewed By -DDS	
Indicator #	Indicator	Met/Rated	Rating	
 C29	Support to obtain employment	3/4	Met	
 C30	Work in integrated settings	4/4	Met	
 C33	Employee benefits explained	4/4	Met	
 C34	Support to promote success	1/4	Not Met (25.00 %)	
 C35	Feedback on job performance	0/4	Not Met (0 %)	
 C36	Supports to enhance retention	4/4	Met	
 C37	Interpersonal skills for work	4/4	Met