Provider:   United Cerebral Palsy of Berkshire County                Provider Address:   208 West St., Pittsfield, MA 01201            
       
Survey Team:  Denise Barci                                                         Date(s) of Review:  March 22, 2011

Follow-up Scope and results:

Service Grouping	Licensure level and duration
 	 # Critical Indicators std. met/ std. rated at follow-up 	  # Indicators std. met/ std. rated at follow-up	Sanction status prior to Follow-up	Combined Results post- Follow-up; for Deferred, License level
	Sanction status post Follow-up	
Residential/Home Supports

# locations
        2
# Audits
        2
	27/29

Two Year

   1/21/2011 to
    1/21/2013	N/A 	2/2	 Eligible for new business
(Two Year License)

 Ineligible for new business
(Deferred status; Two Year with Mid-cycle review License)	N/A 	 Eligible for new business
(80% or more std. met; no critical indicators std. not met)

 Ineligible for new business
(Deferred status; Two Year with Mid-cycle review License)	

Summary of Ratings

Organizational Areas Needing Improvement on Standards not met:

Indicator #	Indicator	Area Needing Improvement	Status at follow-up 	# met/ # rated at follow-up	Rating	
L48
	The agency has an effective Human Rights Committee. 	While the Human Rights Committee was fully constituted as of 11-10 that was not the case for the two years prior.  Until 11-10 there had been no member with legal expertise who had attended meetings.  Also, the member with clinical expertise had missed four of the seven scheduled meetings.  There was no official meeting of the committee held during the fall quarter of 2010.  UCP needs to ensure that the committee includes the required expertise, that meetings are consistently attended and that the committee meets at least quarterly.  	The agency has held one Human Rights Committee meeting, which occurred on March 10, 2011.  This meeting met the quarterly requirement.  Attendance at the meeting included a conference call with the attorney and physical presence by the clinical member.  At this time, the committee has met the composition requirements.  	1/1	Met	

Residential/ Home Supports Areas Needing Improvement on Standards not met:

Indicator #	Indicator	Area Needing Improvement	Status at follow-up 	# met/ # rated at follow-up	Rating	
L8
	Emergency fact sheets are current and accurate and available on site. 	The emergency fact sheet needs to include a section which highlights an individual’s special medical problems.  	Two emergency fact sheets were reviewed, and both documented the special medical needs of the individuals.  	2/2	Met