Title: DraftProviderReport_Com
Author: jolandry

ARC of Cape Cod, Inc.  -  Provider Report  -  3/29/13

SUMMARY OF OVERALL FINDINGS

Provider:  ARC of Cape Cod, Inc.

Review Dates:  March 5 & 6, 2013

Service Enhancement Meeting Date:  March 18, 2013

Survey Team:  Jennifer Petersen

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

0 Locations    3 Audits

Targeted Review

DDS 2 / 3
Provider 39 / 39

41 / 42          Two-Year License 03/18/2013 - 03/18/2015

Individual Home Supports | 0 Locations  3 Audits | | | Provider Targeted Review | 0 / 0 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 | Provider Targeted Review | 0 / 0 Certified

EXECUTIVE SUMMARY

The ARC of Cape Cod is a non-profit association that was formed in 1954.  The organization serves people with developmental disabilities.  The ARC of Cape Cod is a local affiliate of a statewide and national advocacy organization.  The mission of the ARC is "dedicated to securing opportunities for Cape Cod's resident's with developmental disabilities to achieve their fullest potential as active members of their communities through advocacy, education, individual supports, and recreational services."

Supports offered by the ARC of Cape Cod include: Residential and Individual Home Supports, Continuing Education, Advocacy, Family Education, Specialized Services, Social Programs and various Support Groups, Case Management, Individual Supports, Representative Payee, Personal Care Attendant Surrogacy, Housing Assistance, and Emergency Services.  Supports are offered to people living in all areas of Cape Cod. 

EXECUTIVE SUMMARY, CONT.

As the agency received a Two-Year License for Residential Supports service grouping in the previous survey, it is eligible to receive a DDS Targeted Review and implement a Self-Assessment Process in lieu of a full review.  The agency completed a self assessment of its Individual Home Supports utilizing the DDS licensing indicators, for this service, as its measurement tool.  The DDS Targeted Review consisted of a review of the critical indicators and the not met indicators from the previous cycle.  All indicators reviewed by DDS during this cycle were rated 'Met.'  Overall, the agency met 41 of the 42 (98%) applicable indicators.

A continued strength of the agency is the provision of Individual Home Supports that are tailored to each person's unique preferences and needs.  These include; the provision of services in a manner that respected individuals' choices and lifestyles, offered flexibility and responded in a manner which met each person's unique needs.  People supported spoke highly of the staff and indicated that they were treated respectfully and their opinions and wishes were solicited and honored.  

An area the agency should continue to improve is the effectiveness of its Human Rights Committee (HRC).  Members with required expertise were included on the membership list however their attendance was less that consistent.  To promote the Committee's ability to be an essential safeguard for the organization and those it supports, additional efforts and/or strategies are required which will ensure those with required membership have a forum to provide input at each meeting.

The agency has earned a Two-Year License.  The next survey for this agency will be a full license and certification of the services being provided at that time.

Description of Self Assessment Process:

The Arc of Cape Cod, Inc. has developed an active and continuous quality assurance system that helps to identify issues, patterns, trends, and systemic issues with follow-up to correct issues, and ensure that individual and systemic corrections are made.  A re-assessment is conducted of reoccurring issues to assure that there are no further problems.  Monthly meetings with DDS service coordinators and supervisor, risk assessments, and Action Plans where appropriate, information from HCSIS reports, DDS performance based objectives quarterly reports and the annual program member satisfaction survey insure the individualization of services.

Residential and individual support services utilize an ongoing monitoring system.  Case Managers perform standardized monthly tasks with program members  Monthly tasks include Safety Assessments, Food Stamp review, Fuel Assistance, Storm Preparation, etc.

Case Managers meet monthly with administrative staff to provide a detailed overview of each program members' status to insure that key indicators are addressed and discuss service options.  Administrative staff meets monthly with DDS to share information and develop/coordinate appropriate Action Plans.
   
The areas reviewed and the manner of their review are the following:

Physical Environment
With the exception of The Arc's office location, all program members live in their own homes/apart-ments and receive services in their community.  The Arc works closely with all local housing authorities, their agents, and property owners to address tenant concerns.  Annual Safety Assessments are conducted with each program member and updated if the individual moves during the year. Where appropriate, Safety Plans are prepared once every two years (more frequently when required), approved by the Executive Director and the DDS Area Director and then forwarded to the DDS Program Monitor for review.  Fire extinguishers are serviced annually to insure proper working order.

Physical Environment, cont.

During the Annual Safety Assessments, any changes in the ability of the individual from the previous year are noted and reviewed for impact on the individuals' safety in their home.  Where appropriate, actions are taken to assure individual safety is maintained.  Recently, Case Managers have begun monitoring water temperatures and notifying the appropriate housing agencies if discrepancies from the safe range are discovered.

Health Care
The Arc employs a part time R.N. who reviews medications, monitors all medical appointments and follow-ups are met via individual checklists, a calendar and notifications to Case Managers of upcoming appointments.  The R.N. also acts as a medical liaison with physicians and case managers and program members.  The R.N. also provides program members with training relative to their medical conditions and nutrition.  A Self-Medication Assessment is done with each program member and updated if any change in their medical condition or cognitive ability occurs.  Most program members have chosen to receive their medications pre-packaged in morning/afternoon/evening blister packs.

Program Supports and Implementation
Timely submission of materials for each ISP (including the submitting of an annual assessment and the completion of Provider Support Strategies fifteen days prior to the ISP) Meeting is monitored and all materials are reviewed prior to submission to insure the quality of reports.  ISP dates are set annually with DDS service coordinators and entered on a spreadsheet.  Weekly staff meetings include reminders of upcoming due dates and ISP's.  Management staff review and distribute upcoming ISP dates at the weekly staff meeting.

Quarterly Performance Based Objectives Reports are submitted to DDS at the end of each quarter that detail progress toward statewide and contract specific objectives.  The DDS Risk Committee is updated on the status and action plans for at risk individuals per a schedule based on the severity of the risk presented. 

Program member profiles are updated twice a month to keep information as current as possible.  Updates of medications and diagnosis are noted by the Program RN and forwarded to the Office Manager for entry into the program members' profile.  Information on the potential side effects of medications are placed in the program member's confidential record book at the same time.   

Case Managers develop Individual ISP goals based on program members' interests and needs.  Program members are empowered to play the primary role in goal development and implementation.  Where specific needs exist, options are presented to the program member on an on-going basis so they can make informed decisions on their personal goals.  Case Managers record semi-annual progress notes on goals.  

To review the efficacy of the quality management process in meeting the licensing standards set by the Department of Developmental Services, The Arc of Cape Cod has comprised a survey team made up of two senior administrators and three supervisory staff each with expertise in specific aspects of the overall program.  This team, using all the DDS Licensing Standards, evaluates 100% of the program members subject to licensing standards. 

The evaluation will be conducted prior to the DDS targeted licensing review, then annually to maintain the standard in non-review years.  The Arc of Cape Cod survey team will summarize results of the findings and aggregate ratings for each indicator are established using 80% as the criteria for assigning a rating of standard met.  If, in any area, the license indicator is Not Met (less than 80%) the agency will outline the specific issues identified and identify the steps to correct the issues(s).  Timeframes for these actions will be developed with deadlines established to insure that issues are consistently met in our corrective action plan.  The Summary and ratings will be presented to the Arc's President & Executive Director.  The ratings from the final set of evaluations are recorded on the Provider Self-Assessment Form for licensing.

Human Rights

The Arc of Cape Cod's Human Rights Committee has a Human Rights Coordinator and is properly constituted and scheduled to meet quarterly.  The committee annually reviews Agency Policy and Practices that have impact on Human Rights review Human Rights Training for staff and clients, ensuring awareness of DPPC reporting requirements.  The Arc of Cape Cod distributes business cards with D.P.P.C. contact numbers and information to all program members in both a wallet card and a refrigerator magnet.  The committee reviews restrictive practices, significant incidents and all investigations.  The Arc of Cape Cod does not permit restraints of its program members by staff or have any behavior plans for existing program members.  Human Rights policies are reviewed annually with all program participants.  If a program participant has a legal guardian this information is forwarded to them for their acknowledgement.  A corrective action plan is attached.

Staff Training and Development

   The Arc of Cape Cod ensures all direct care staff are up to date with required DDS trainings.  The Training Coordinator, via a spreadsheet, assures that all personnel are up-to-date on all trainings.  Staff receive training in First Aid, CPR, Fire Safety, Human Rights, DPPC, ISP, Signs of Illness and Blood Borne Pathogens.  The Arc also encourages the attendance of its staff at the trainings sponsored by the Area Training Council and attendance at the Arc's in Massachusetts annual Innovations Conference, which provides multiple training opportunities.  Two staff members are currently enrolled in Leadership Development training with the Gestalt Institute.

LICENSURE FINDINGS
| Met / Rated | Not Met / Rated | % Met
Organizational | 5/6 | 1/6 |
Residential and Individual Home Supports | 36/36 | 0/36 |
Individual Home Supports | | |
Critical Indicators | 1/1 | 0/1 |
Total | 41/42 | 1/42 | 98%
Two-Year License | | |
# Indicators for 60 Day Follow-up | | 1 |
 
Organizational Area Needing Improvement on Standard 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 at least four (quarterly) meetings are held each year and that input from members with the required expertise is sought at each meeting.

CERTIFICATION FINDINGS
 
| Reviewed By | Met / Rated | Not Met / Rated
Certification - Planning and Quality Management | Provider | 0/0 | 0/0
Residential and Individual Home Supports | | |
Individual Home Supports | Provider | 0/0 | 0/0

MASTER SCORE SHEET LICENSURE
Organizational: 
| Indicator # | Indicator | Reviewed by | Met/Rated | Rating (Met, Not Met, Not Rated)
🏳 | L2 | Abuse/Neglect reporting | DDS | 3/3 | Met
| L48 | HRC | DDS | 0/1 | Not Met (0%)
| 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 | Residen-tial Supports | Individual Home Support | Place-ment Support | Respite Support | Total Met/ Rated | Rating
| L1 | Abuse/Neglect training | I | Provider | | - | | | - | Met
| L5 | Safety Plan | L | Provider | | - | | | - | Met
🏳 | L6 | Evacuation | 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
| L33 | Physical exam | I | Provider | | - | | | - | Met
| L34 | Dental exam | I | DDS | | 3/3 | | | 3/3 | Met
| L35 | Preventive screenings | I | Provider | | - | | | - | Met
Residential and Individual Home Supports:
| Indicator # | Indicator | Location or Individual Indicator | Reviewed By | Residen-tial Supports | Individual Home Support | Place-ment Support | Respite Support | Total Met/ Rated | Rating
| L36 | Recommended tests | I | Provider | | - | | | - | Met
| L37 | Prompt treatment | I | Provider | | - | | | - | Met
| L41 | Healthy diet | L | Provider | | - | | | - | Met
| L42 | Physical activity | L | Provider | | - | | | - | Met
| L43 | Health Care Record | I | Provider | | - | | | - | Met
| L47 | Self-medication | I | Provider | | - | | | - | Met
| L49 | Informed of human rights | I | Provider | | - | | | - | Met
| L50 | Respectful communica-tion. | 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
| L61 | Health protection in ISP | I | Provider | | - | | | - | Met
| L62 | Health protection review | 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
| L80 | Symptoms of illness | L | Provider | | - | | | - | Met
| L81 | Medical emergency | L | Provider | | - | | | - | Met
| L85 | Supervision | L | Provider | | - | | | - | Met
| L86 | Required assessments | I | Provider | | - | | | - | Met

Residential and Individual Home Supports, cont.
| Indicator # | Indicator | Location or Individual Indicator | Reviewed By | Residen-tial Supports | Individual Home Support | Place-ment Support | Respite Support | Total Met/ Rated | Rating
| L87 | Support strategies | I | Provider | | - | | | - | Met
| L88 | Strategies implemented | I | Provider | | - | | | - | Met
| #Std. Met/36 Indicator | | | | | | | | 36/36 |
| Total Score | | | | | | | | 41/42 |
| | | | | | | | | 97.62% |