PROVIDER REPORT FOR
SEVEN HILLS FOUNDATION
81 HOPE AVE
 WORCESTER, MA 01603    

 

Version
Provider Web Report

Prepared by the Department of Developmental Services
OFFICE OF QUALITY ENHANCEMENT

	

SUMMARY OF OVERALL FINDINGS
 
Provider	
SEVEN HILLS FOUNDATION	

Review Dates	
10/9/2013 - 10/15/2013	

Service Enhancement 
Meeting Date	
10/28/2013	

Survey Team	
 
Denise Barci	

Ken Jones	

Brenda Cole (TL)	

Jill Walulak	

Alejandra Guzman	

Patty McCarthy	

Michelle Stomboly-Lorenzo	

Scott Nolan	

Ed Sutka	

Jennifer Petersen	

Janina Millet	

Lisa MacPhail	

Melanie McNamara	

Citizen Volunteers	
 
 NA	

	

 

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	52 location(s) 53 audit (s) 	Targeted Review	DDS 10 / 10
Provider 75 / 77

85 / 87 2 Year License 10/28/2013 - 10/28/2015	 

 

 

 

 

Residential Services	24 location(s) 24 audit (s) 	 

 
 	Provider Targeted Review	0 / 0 Certified	
Placement Services	21 location(s) 21 audit (s) 	 

 
 	Provider Targeted Review	0 / 0 Certified	
Respite Services	1 location(s) 2 audit (s) 	 
 	 
 	No Review	No Review	
Individual Home Supports	6 location(s) 6 audit (s) 	 

 
 	Provider Targeted Review	0 / 0 Certified	
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) 11 audit (s) 	Targeted Review	DDS 9 / 9
Provider 42 / 47

51 / 56 2 Year License 10/28/2013 - 10/28/2015	 

 

 

 

 

Community Based Day Services	1 location(s) 4 audit (s) 	 
 	 
 	Deemed	 
 	
Employment Support Services	0 location(s) 4 audit (s) 	 
 	 
 	Deemed	 
 	
Center Based Employment	1 location(s) 3 audit (s) 	 
 	 
 	Deemed	 
 	
 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	Provider Targeted Review	0/0 Certified	

 
EXECUTIVE SUMMARY

The Seven Hills Foundation is a multi-dimensional human service organization, headquartered in Worcester, MA, which offers a wide range of residential, educational, employment, and consultative services to children and adults across the central and eastern regions of the Commonwealth. Services provided to individuals with intellectual disabilities through contracts with the Department of Developmental Services (DDS) are the subject of this licensing review. 

For the current licensing and certification cycle, Seven Hills conducted a self-assessment of the safeguard systems in place for its day and residential services. During the previous survey, in September 2011, Seven Hills received a Two-Year license for both its day and residential services. As a result, the agency became eligible to conduct a self-assessment of its quality assurance systems for the current licensing cycle. This occurred in conjunction with a Targeted Review of the organization's two distinct service groups conducted by the DDS Office of Quality Enhancement. 

Through its self-assessment process, the organization reviewed applicable licensing indicators for a representative sample of services from the following DDS service types: twenty-four hour residential, individual home supports, placement services, respite, employment supports, center-based employment, and community-based day services. The Targeted Review, conducted by DDS, focused on eight indicators, designated as critical indicators in its Licensure Guidelines, along with any indicators that were not met by Seven Hills during the previous survey cycle. These indicators were reviewed for a random sample of services from each service type. The survey results reflect a combination of ratings from the self-assessment process conducted by Seven Hills and the Targeted Review conducted by DDS, with ratings from DDS prevailing where indicators were rated by both processes. 

Findings from the current survey indicate that the agency's oversight systems were responsive and effective. The standards for all eight critical indicators were met for the Targeted Review, along with five indicators where standards were not met previously. The organization's self-assessment process yielded comparable results, with standards met at a high rate for each service type. 

The organization's focus on continuous quality improvement has shaped a quality management system that evaluates services at all levels of supervision and management. Some oversight processes such as Team Monitoring and Balanced Scorecard reviews provide a comprehensive review of services, while other safeguard systems focus on discrete aspects of service delivery. Within residential services, regular monitoring of environmental safety, medication administration, and financial supports was conducted by clinical staff, managers or immediate supervisors, with each review conducted at a different interval.  Placement services as well as employment and day supports were evaluated by methods uniquely tailored to these service types. Safeguards for individuals in placement services were monitored through monthly home visits, where individuals' medications, health status, finances, and other support needs were reviewed. Case record reviews were regularly conducted for individuals who receive day and employment supports to ensure consistency of service practice. 

In keeping with continuous quality improvement, Seven Hills initiated a number of service improvements since the last licensing and certification review. For example, the organization's clinical services have been strengthened, with addition of clinical and counseling services provided to discrete services such as shared living. Seven Hills is also nearing completion of a goal to convert all of its record keeping within day and residential services to online storage. When finalized, the Totally Integrated Electronic Record (TIER) system will streamline record keeping at separate service, while enabling supervisors and clinical staff to access information and real-time data from remote locations. In addition, the development of Nursing and Clinical Practice Teams has enabled the organization to provide recommendations on complex cases by utilizing expertise from within the organization. These initiatives, along with current quality management systems ensured that essential safeguards were in place across settings and service types. 

Through combined ratings from the organization's self-assessment and the DDS Targeted Review, Seven Hills received a Two-Year License for its residential services as well as its employment and day services. Standards were met for 98% of indictors that were applied to the Residential Service Group and 91% of the indicators applied to the Day Service Group. Follow-up will be conducted by the agency in the areas of human rights committee membership and review of supports and health-related protections. Follow-up will also focus on development of formal behavior plans for interventions that meet the definition of behavior modification. 

The following is a description of the self-assessment process that was conducted by the Seven Hills Foundation.	

Description of Self Assessment Process
The Director of Quality Assurance/Program Improvement, in conjunction with the leadership of each program, used the DDS Licensure Tool to establish the specific criteria that would be used to measure each indicator to ensure consistency among reviewers. These criteria were based on the DDS Licensure Standards as well as best practices of each program. Each audit was completed using the corresponding DDS worksheet which was edited to include only the licensure indicators. Seven Hills used 80% as the threshold to determine if an indicator was Met or Not Met.

In determining the sample sizes, Seven Hills ensured that a representative sample of records and programs were visited/reviewed.  The Director of QA/PI was responsible for determining the sample size, randomly choosing the sample, and reporting the sample to the staff conducting the audits. The staff conducting the audits were notified of the sample early in the process (for planning purposes), however, the programs being audited were generally given a 3-5 day notice. 
•	15% of the Seven Hills Community Services 24-hour residential programs were audited, one in each area. In total, fourteen programs were reviewed and fourteen individuals were reviewed for Cluster A and fourteen individuals were reviewed for Cluster B. The Director of QA/PI, the Director of Nursing, and a Clinician completed these audits through documentation reviews, interviews with the Residential Directors and Area Directors, and visits to the programs.
•	Twenty Placement Supports/Shared Living Arrangements were audited across four areas (North Andover, North Central, Worcester, and South Valley). There were two audit teams, one lead by the SHFS Assistant Vice-President for Family Supports and one lead by the Director of Adult Family Care. Their audit process involved a review of records at the office location and visits to the placements to include an assessment of the environment, review of documentation at the home, and interview of the provider.
•	Ten individuals supported through Individual/Home Supports were included in the audit. These audits were conducted by the Director of QA/PI and the SHFS Assistant Vice-President of Shared Living/AFC. These audits included review of documentation, interviews with staff, and visits to the individuals' homes, as appropriate.
•	The SHFS Assistant Vice-President of Shared Living/AFC audited one respite location with two individual audits. This audit included a review of documentation, visit to the respite house, and interview with the Residential Director.

The Director of QA/PI completed the Employment and Day Supports audit, which included a review of four individuals in Employment Supports, four individuals in Center-Based Work Supports, and five individuals in Community Based Day Supports, an assessment of the environment, and a documentation review.

Completed worksheets and supporting documentation (as needed) from each audit were given to the Director of QA/PI, who was responsible for analyzing the data and determining which Indicators were Met or Not Met. This information was then given to the program Vice-Presidents for verification.
Several Indicators were reviewed at the Organizational level by the Director of QA/PI.
•	L3 and L4: Action is taken when there are reports of abuse/neglect. The Director of QA/PI requested documentation from the Assistant Vice-Presidents to ensure that DPPC action plans were completed and implemented as directed.
•	L65 and L66: Restraint Reports are submitted within the timeframes and reviewed by the Human Rights Committee. This information was verified via HCSIS and a review of Human Rights Committee Meeting Minutes.
•	L48: The Agency has an effective Human Rights Committee. The Director of QA/PI audited minutes from the last two years to review the Committee membership and to ensure the committee held the required number of meetings with quorums.
•	L85: There is on-going staff supervision and development. The Director of QA/PI reviewed a sample of employee files to ensure that there was a current performance evaluation in place. This was also reviewed for Placement Services; in auditing provider files, it was noted whether or not there was a current Provider Self-Assessment and Assessment in place.
•	L74 and L75: The agency screens prospective employees per requirements and ensures that staff have the necessary qualifications and certifications. The Director of QA/PI audited a sample of employee files to ensure that the appropriate qualifications were in place and that the appropriate pre-employment checks were conducted.
•	L76, L79, L80, L81, and L83: The agency utilizes a system to track required trainings and staff are trained in restraint, recognizing signs and symptoms of illness, how to respond to an emergency, and Human Rights. Seven Hills Foundation utilizes Essential Learning for on-line trainings and to track training compliance. The Director of QA/PI reviewed training information in Essential Learning for all of the programs where there was an on-site audit; during the site reviews, these were reviewed and additional training information gathered as necessary. This was also reviewed for Placement Services; in auditing provider files, provider training in CPR, First Aid, Infection Control, Human Rights, and Mandated Abuse Reporting were reviewed for compliance.

Seven Hills Foundation, to ensure continuous quality improvement and compliance with DDS regulations, has a number of quality assurance systems in place.
•	Personal Safety: The Director of QA/PI monitors and tracks all reports of abuse/neglect and notifies the appropriate staff. All staff and providers receive training in Mandated Abuse Reporting and this information is made available to individuals through postings at program locations, house meetings, meetings within their program location, or in meetings with their case managers/other key staff. The Director of QA/PI prepares the Quality Council Report for Senior Leadership on a quarterly basis which includes a review of all incidents, reports to state agencies, and an analysis of trends. Staff and individuals participate in evacuation drills and staff, providers, and individuals (as appropriate) receive training on safety plans.
•	Environmental Safety:  To ensure programmatic safety, there are facilities staff on call 24 hours a day and there is an on-line portal to submit maintenance request (WORX HUB).  The Safety and Risk Management Committee and Senior Leadership analyze Worker's Compensation Reports for trends in staff injuries. 
•	In Residential services, the Team Monitoring Reviews (TMR), the Balanced Score Card, monthly water temperature monitoring, and quarterly room and van inspections are used to monitor environmental safety. Any deficiencies noted in a TMR or BSC is noted in an Action Plan with the required follow-up and the Action Plan and results are shared with the AD and AVP.
•	In Placement Services, Case Managers conduct annual home inspections and complete monthly visit reports
•	In Employment Services, quarterly room and van inspections, the Balanced Score Card, and monthly water temperature monitoring are used to ensure environmental safety. BSC results are shared with the AVP and VP for appropriate follow-up on any deficiencies noted.
•	Health: Seven Hills Foundation is in the process of implementing TIER (Totally Integrated Health Record) across all programs. TIER will give the multidisciplinary team greater access to medical and programmatic information for individuals. 

In Residential Services, there is access to the Health Director and other nurses as needed for consultation. Confidential files are reviewed at least annually by a nurse and are reviewed as part of the TMR. New Residential Directors receive health training and staff receive site-specific training based on the health care needs of the individuals. There is access to a Nutritionist in the Central and North East areas for consultation and recommendations. 

Medication safeguards include regional pharmacies to ensure continuity, staff orientation to a program's medication system, and medication audits at a minimum of two times per year by nurses and ADs. Variances noted in the medication audits are reported to the RD, AD, AVP, and VP. When there is a medication occurrence, staff have a supervision session with their supervisor. MOR information is shared with the VP and Director of Nursing to monitor trends. Trends noted in MORs and medication audits are identified to determine programmatic training needs.

In Placement Services, during the monthly home visits, information regarding medical appointments 
In Residential Services, there is access to the Health Director and other nurses as needed for consultation. Confidential files are reviewed at least annually by a nurse and are reviewed as part of the TMR. New Residential Directors receive health training and staff receive site-specific training based on the health care needs of the individuals. There is access to a Nutritionist in the Central and North East areas for consultation and recommendations. 

Medication safeguards include regional pharmacies to ensure continuity, staff orientation to a program's medication system, and medication audits at a minimum of two times per year by nurses and ADs. Variances noted in the medication audits are reported to the RD, AD, AVP, and VP. When there is a medication occurrence, staff have a supervision session with their supervisor. MOR information is shared with the VP and Director of Nursing to monitor trends. Trends noted in MORs and medication audits are identified to determine programmatic training needs.

In Placement Services, during the monthly home visits, information regarding medical appointments and changes in status are reviewed and the case manager monitors the medication worksheets, counts the controlled substances, and completes a medication audit. All providers receive medication overview training and there is regular screening of individuals who self-medicate. There are annual audits of individual records to ensure appropriate documentation and follow through on In Residential Services, there is access to the Health Director and other nurses as needed for consultation. Confidential files are reviewed at least annually by a nurse and are reviewed as part of the TMR. New Residential Directors receive health training and staff receive site-specific training based on the health care needs of the individuals. There is access to a Nutritionist in the Central and North East areas for consultation and recommendations. 

Medication safeguards include regional pharmacies to ensure continuity, staff orientation to a program's medication system, and medication audits at a minimum of two times per year by nurses and ADs. Variances noted in the medication audits are reported to the RD, AD, AVP, and VP. When there is a medication occurrence, staff have a supervision session with their supervisor. MOR information is shared with the VP and Director of Nursing to monitor trends. Trends noted in MORs and medication audits are identified to determine programmatic training needs.
•	In Placement Services, during the monthly home visits, information regarding medical appointments	In Residential Services finances are reviewed monthly by the RDs and ADs, with random audits through the Business Office.
•	In Placement Services finances are reviewed during monthly home visits.
•	In Residential Services, The Director of Clinical Services/AVP and the clinical team are responsible for ensuring compliance with behavior plans and medication treatment plans, including timely review by the individual's team and the HRC, as appropriate. 
•	In Residential and Placement Services, Supportive and Health Related Protections and Restrictive Practices are reviewed by the individual's team and reviewed by the HRC on an annual basis.
•	Competent Workforce: Classroom and on-line trainings are offered through the Seven Hills Corporate College.  Seven Hills uses Essential Learning for all on-line trainings and to track training compliance. Staff and supervisors (RD, ADs, AVPs, VPs) can track training statistics to ensure compliance with regulations. The Director of QA/PI includes training statistics in the Quality Report to Senior Leadership. In addition to classroom and on-line trainings, there are trainings and in-services during staff meetings. In Placement Services, there are annual reviews of provider files to ensure that trainings and other documentation is current and complete.

Goal Development and Implementation: In Residential Services, the ISP Coordinator assists with monitoring data collection and progress notes and assists with the development of support strategies. The ISP Coordinators and ADs maintain grids of all upcoming ISPs to ensure that assessments and strategies are submitted as required. Assessments and strategies are faxed to DDS and a copy of the fax transmittal is saved. In Placement and Employment Services, the Case Record Review committee reviews individual records from each service to ensure compliance with regulations. There is documented follow-up of all items not in compliance.

Organizational	Met/Rate 9/10 Met 90%
Residential and Individual Home Supports Met/Rated 75/76 Met 98.7%
Critical Indicators Met/Rated 8/8 Met 100%	
Total Met/Rated 84/86 Met 97.7%

Employment and Day Supports Met/Rated 41/45 Met 91.1%
Critical Indicators Met/Rated 8/8 Met 100%
Total Met/Rated 50/55 Met 90.1%	

LICENSURE FINDINGS

 	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
76/77	
1/77	

 	

    Residential Services
    Placement Services
    Respite Services
    Individual Home Supports	

 

 

 

 

 	

Critical Indicators	
8/8	
0/8	

Total	
85/87	
2/87	
98%	

2 Year License	

 	

# indicators for 60 Day Follow-up	

2	

	 

Met / Rated	
Not Met / Rated	
% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
42/46	
4/46	

    Community Based Day Services
    Employment Support Services
    Center Based Employment	

 

 	

 

 	

 

 	

Critical Indicators	
5/5	
0/5	

Total	
51/56	
5/56	
91%	

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	

 

 

 
 	 L48	The agency has an effective Human Rights Committee.	While each Committee has met at least four times a year over the past two years, some of the Committees do not have the required membership.	Seven Hills will continue to recruit professionals for membership on each Committee. Seven Hills will work with the Advancement Office in the development of mailings to families and local professional organizations. Seven Hills will explore partnering with other agencies to share clinical and nursing staff between agency committees.	
 
 	Residential Areas Needing Improvement on Standards not met/Follow-up to occur:
From Provider review:	
 
 	Indicator #	Indicator	Issue identified	Action planned to address	

 

 

 
 	 L62	Supports and health related protections are reviewed by the required groups.	The Human Rights Committee review was missing for some supports and health related protections.	In Residential Services, a Supportive and Protective Devices tracking form will be implemented which will include the dates of physician and HRC review. The chart will be reviewed at least quarterly by the Residential Director and forwarded to the Area Director. In Placement Services, the Area Director will be responsible for completing the tracking form.	

 	Residential Commendations on Standards Met:	
 
 	Indicator #	Indicator	Commendations	
O	 L38	Physicians' orders and treatment protocols are followed (when agreement for treatment has been reached by the individual/guardian/team). 	The organization had developed a form to capture procedures for staff to follow when individuals experienced seizures. The format allowed for individualization of procedures as they varied from person to person, and information was presented in a manner that was clear and easy to follow in the event of an emergency.  	
 
 	Employment/Day Areas Needing Improvement on Standards not met/Follow-up to occur:
From Provider review:	
 
 	Indicator #	Indicator	Issue identified	Action planned to address	

 

 

 

 	 L57	All behavior plans are in a written plan.	A Behavior Guideline contained elements that required a formal Behavior Plan and review process.	The Behavior Specialist for the Employment and Day Supports program will be trained within 60 days by the Director of Clinical Services/AVP of SHCS on the DDS Regulations regarding behavior plans. All behavior plans will be reviewed by the Assistant Vice-President of Employment prior to implementation to ensure that the plan contains the required elements and has received the required reviews.	

 

 

 

 	 L58	All behavior plans contain the required components.	A Behavior Guideline contained elements that required a formal Behavior Plan and review process.	The Behavior Specialist for the Employment and Day Supports program will be trained within 60 days by the Director of Clinical Services/AVP of SHCS on the DDS Regulations regarding behavior plans. All behavior plans will be reviewed by the Assistant Vice-President of Employment prior to implementation to ensure that the plan contains the required elements and has received the required reviews.	

 

 

 

 	 L59	Behavior plans have received all the required reviews.	A Behavior Guideline contained elements that required a formal Behavior Plan and review process.	The Behavior Specialist for the Employment and Day Supports program will be trained within 60 days by the Director of Clinical Services/AVP of SHCS on the DDS Regulations regarding behavior plans. All behavior plans will be reviewed by the Assistant Vice-President of Employment prior to implementation to ensure that the plan contains the required elements and has received the required reviews.	

 

 

 

 	 L60	Data are consistently maintained and used to determine the efficacy of behavioral interventions.	A Behavior Guideline contained elements that required a formal Behavior Plan and review process.	The Behavior Specialist for the Employment and Day Supports program will be trained within 60 days by the Director of Clinical Services/AVP of SHCS on the DDS Regulations regarding behavior plans. All behavior plans will be reviewed by the Assistant Vice-President of Employment prior to implementation to ensure that the plan contains the required elements and has received the required reviews.	

 

CERTIFICATION FINDINGS

 
 	
Reviewed by	
Met / Rated	
Not Met / Rated	

Certification - Planning and Quality Management	
Provider	
0/0	
0/0	

Residential and Individual Home Supports	

 	

 	

 	

    Placement Services	
Provider	
0/0	
0/0	

    Individual Home Supports	
Provider	
0/0	
0/0	

    Residential Services	
Provider	
0/0	
0/0	

 
 	
Reviewed By	
Met / Rated	
Not Met / Rated	

Certification - Planning and Quality Management	
Provider	
0/0	
0/0	

Employment and Day Supports	

 

 	

 

MASTER SCORE SHEET LICENSURE
Organizational: SEVEN HILLS FOUNDATION
 
 	Indicator #	Indicator	Reviewed by	Met/Rated	Rating(Met, Not Met,
 Not Rated)	
O	 L2	Abuse/neglect reporting	DDS	52/53	Met(98.11 % )	
 	 L3	Immediate Action	Provider	-	Met	
 	 L4	Action taken	Provider	-	Met	
 	 L48	HRC	Provider	-	Not Met	
 	 L65	Restraint report submit	DDS	31/37	Met(83.78 % )	
 	 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:

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/
Rated	Rating	

 	 L1	Abuse/neglect training	I	Provider	-	-	-	-	-	Met	
 
 	 L5	Safety Plan	L 	Provider	-	-	-	-	-	Met	
O	 L6	Evacuation	L	DDS	24/24	3/3	21/21	1/1	49/49	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/
Rated	Rating	
 	 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	18/18	1/1	19/21	1/1	39/41	Met
(95.12 %)	
O	 L12	Smoke detectors	L	DDS	17/18	1/1	16/21	1/1	35/41	Met
(85.37 %)	
O	 L13	Clean location	L	DDS	18/18	1/1	21/21	1/1	41/41	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	
 
 	 L19	Bedroom location	L 	Provider	-	-	-	-	-	Met	
 
 	 L20	Exit doors	L 	Provider	-	-	-	-	-	Met	

 
 	 L21	Safe electrical equipment	L 	Provider	-	-	-	-	-	Met	

 	 L22	Clean appliances	L 	Provider	-	-	-	-	-	Met	

 	 L23	Egress door locks	L 	Provider	-	-	-	-	-	Met	

 	 L24	Locked door access	L 	Provider	-	-	-	-	-	Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/
Rated	Rating	

 
 	 L25	Dangerous substances	L 	Provider	-	-	-	-	-	Met	
 
 	 L26	Walkway safety	L 	Provider	-	-	-	-	-	Met	

 	 L27	Pools, hot tubs, etc.	L	DDS	1/1	 
 
 	7/7	 
 
 	8/8	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	18/18	 
 	6/7	 
 	24/25	Met
(96.00 %)	

 	 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	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/
Rated	Rating	

 	 L44	MAP registration	L 	Provider	-	-	-	-	-	Met	
 
 	 L45	Medication storage	L 	Provider	-	-	-	-	-	Met	
O	 L46	Med. Administration	I	DDS	23/24	 
 
 	19/20	2/2	44/46	Met
(95.65 %)	

 	 L47	Self medication	I 	Provider	-	-	-	-	-	Met	

 	 L49	Informed of human rights	I	Provider	-	-	-	-	-	Met	
 
 	 L50	Respectful Comm.	L 	Provider	-	-	-	-	-	Met	
 
 	 L51	Possessions	I 	Provider	-	-	-	-	-	Met	
 
 	 L52	Phone calls	I 	Provider	-	-	-	-	-	Met	
 	 L53	Visitation	I 	Provider	-	-	-	-	-	Met	
 	 L54	Privacy	L 	Provider	-	-	-	-	-	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	-	-	-	-	-	Not Met	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/
Rated	Rating	

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

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

 	 L65	Restraint report submit	L	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	24/24	 
 	 
 	1/1	25/25	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	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Residential Supports	Individual Home Support	Placement Support	Respite Support	Total Met/
Rated	Rating	

 
 	 L88	Strategies implemented	I 	Provider	-	-	-	-	-	Met	

 	#Std. Met/# 76 Indicator	 

 

 	 

 

 	 
 
 	76/77	 

 
 	Total Score	 

 	 

 	 
 	85/87	 

 	 

 	 

 	 
 	 
 	97.70%	 

Employment and Day Supports:

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Employment Support	Center Based Work	Community Based Day Support	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	DDS	4/4	3/3	3/4	10/11	Met
(90.91 %)	
 
 	 L9	Safe use of equipment	L 	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	DDS	 	1/1	1/1	2/2	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	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Employment Support	Center Based Work	Community Based Day Support	Total Met / Rated	Rating	
 
 	 L25	Dangerous substances	L 	Provider	-	-	-	-	Met	
 
 	 L26	Walkway safety	L 	Provider	-	-	-	-	Met	
 	 L28	Flammables	L 	Provider	-	-	-	-	Met	
 
 	 L29	Rubbish/combustibles	L 	Provider	-	-	-	-	Met	
 
 	 L31	Communication method	I 	Provider	-	-	-	-	Met	
 
 	 L32	Verbal & written	I 	Provider	-	-	-	-	Met	
 
 	 L37	Prompt treatment	I 	Provider	-	-	-	-	Met	
 
 	 L39	Dietary requirements	I 	Provider	-	-	-	-	Met	
 
 	 L49	Informed of human rights	I	Provider	-	-	-	-	Met	
 
 	 L50	Respectful Comm.	L 	Provider	-	-	-	-	Met	
 	 L51	Possessions	I 	Provider	-	-	-	-	Met	
 	 L52	Phone calls	I 	Provider	-	-	-	-	Met	
 	 L54	Privacy	L 	Provider	-	-	-	-	Met	
 
 	 L55	Informed consent	I	DDS	1/1	 
 	1/1	2/2	Met	

 	 L57	Written behavior plans	I 	Provider	-	-	-	-	Not Met	

 	 L58	Behavior plan component	I 	Provider	-	-	-	-	Not Met	
 
 	 L59	Behavior plan review	I 	Provider	-	-	-	-	Not Met	
 
 	 L60	Data maintenance	I 	Provider	-	-	-	-	Not Met	
 
 	 L69	Expenditure tracking	I 	Provider	-	-	-	-	Met	
 
 	 L72	DOL requirements	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	

 
 
 	Indicator #	Indicator	Location or Individual indicator	Reviewed by	Employment Support	Center Based Work	Community Based Day Support	Total Met / Rated	Rating	
 
 	 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/# 42 Indicator	 

 

 	 

 

 	42/46	 

 
 	Total Score	 

 	 

 	51/56	 
 	
 	 	 	 	 	 	 	 	91.07%