SUMMARY OF OVERALL FINDINGS

Provider:  Yawkey House of Possibilities, Inc.
Review Dates:  June 20 – 26, 2012
Service Enhancement Meeting Date:  July 6, 2012
Survey Team:  Scott F. Nolan
 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 Locations 
 3 Audits 	 Full Review	50 / 54 
Two-Year License (7/6/2012 - 7/6/2014)	 

 	 

 	
 Community-Based   
    Day Services	 1 Location   
 2 Audits 	 

 
 	Full Review	8 / 8 Certified - with all indicators stds. met.	
 Employment 
    Support Services	 1 Location   
 1 Audit	 

 	 

 	Full Review	12 / 15 Certified - with partial indicators stds. met.	

EXECUTIVE SUMMARY

The Yawkey House of Possibilities (HOPe) is a non-profit corporation that began service in 2009.  The agency provides community based day supports to nine individuals and employment supports to one individual all over the age of twenty-two funded through the Department of Developmental Services (DDS).  The agency also provides day habilitation services and children's respite which is not funded through DDS.  The goal of HOPe is to bring encouragement and compassion to children and adults living with developmental disabilities in a variety of ways to enjoy life to the fullest.  

This current Licensure and Certification Review was comprised of three (3) audits.  The sample included; two (2) audits conducted in Community-Based Day Supports (CBDS) and one (1) audit conducted in Employment Supports. 

Since the last licensure and certification review (2010), a continued strength of the agency is its commitment to providing individuals with a rich learning environment where individuals are able to learn daily living, social, and community skills.  The program offered individuals a flexible schedule to choose from different activities such as group meetings, exercising at a local gym with a fitness trainer, walking on the indoor track at Stonehill College, or volunteering in the local community.  The agency also offered yoga, karate and other classes to broaden people's experiences.  Individuals were provided education and training opportunities to talk about relationships, community safety, and responding to potential incidents of abuse, neglect, or mistreatment.  Although individuals received training in how to report abuse/neglect (DPPC) it was not effective as individuals interviewed did not recognize what the indicators of abuse were (e.g., physical, emotional) or whom to report it (DPPC or to report it to staff).

EXECUTIVE SUMMARY, CONT.

The agency should provide additional training in assisting individuals to recognize and report abuse based on information gathered during the survey.

Another strength of the agency was the relationships that individuals developed with staff and their families at all levels of the organization.  It was evident that individuals routinely engaged staff in conversation and sought out guidance regarding issues that were important to them.  Regular meetings were held to discuss individual's progress with the Executive Director while the agency nurse took an active role in educating support staff about general health topics.  For example, individuals were assisted by staff to learn proper nutrition and exercise on a regular basis to maintain a healthy lifestyle. 

The agency had systems in place to safeguard individuals and collect information on program quality which was reviewed on a regular basis.  Through the review of the agency's data collection for incident reporting over the past two years, it was identified that the agency was filing written reports but was not entering these into the DDS data management system (HCSIS).  The agency responded in a timely manner to address this requirement.

Although the Human Rights Committee (HRC) met on a quarterly basis it did not meet composition requirements, a member was serving on the committee which posed a potential conflict of interest (nurse) and another member did not attend meetings on a consistent basis (psychologist).  A review of the HRC meeting minutes and discussion with management staff suggest that training from the regional Human Right Specialist may be helpful to provide additional information and guidance in their roles and responsibilities from a DDS perspective.  As identified in the previous Licensure and Certification Report (2010), the agency's consent to videotape during program hours was in conflict with DDS policy and practice.  Since the previous review, the agency stopped its video taping during program hours.  The agency updated its Video/Photo Release to a Photo Release to remove authorization to videotape; however, during this review, the previous Video/Photo Release form was present in the individual records and should be removed and replaced with the updated version when needed (i.e., a specific instance or event when an photograph is to be taken and used.).  .  

Based on the results of this review, the Yawkey House of Possibilities will receive a Two-Year License of its Employment and Day Services.  The agency is congratulated on its success.

	

LICENSURE FINDINGS

 	
Met / Rated	
Not Met / Rated	
% Met	
Organizational	4/5	1/5	 	
Employment and Day Supports	45/48	3/48	 
 	
  Community-Based Day 
      Services
  Employment Support 
      Services	 

 	 

 	 

 	
Critical Indicators	8/8	0/8	 	
Total	50/54	4/54	93%	
Two-Year License	 	 	 	
# Indicators for 60 Day Follow-up	 
 	4	 

 
Organizational Area Needing Improvement on Standard Not Met/Follow-up to Occur:	
Indicator #	Indicator	Area Needing Improvement	
 L48	The agency has an effective Human Rights Committee.	The agency needs to secure a nurse without an administrative/financial interest in the organization to serve in its Human Rights Committee.

The agency needs to ensure that members consis-tently attend meetings so that the committee may benefit from their active participation and expertise. 

  
Employment/Day Areas Needing Improvement on Standards Not Met/Follow-up to Occur:	
Indicator #	Indicator	Area Needing Improvement	
 L1	Individuals and guardians are trained in how to report alleged abuse/neglect.	The agency needs to ensure that individuals are trained in recognizing indicators of abuse and how to report alleged abuse/neglect.

 L29	No rubbish or other combustibles are accumulated within the location including near heating equipment and exits. 	The agency needs to ensure that no rubbish or other combustibles are accumulated within the location including near heating equipment (e.g., furnace rooms).
	
 L55	Informed consent is obtained from individuals or their guardians when required.  Individuals or their guardians know that they have the right to with-draw consent.
	When the agency is seeking consent for the use of an individual's photograph and/or write-up for use in an agency publication and/or website; the consent needs to be specific to date, event, and purpose.	

CERTIFICATION FINDINGS

 
 	
Met / Rated	
Not Met / Rated	
 Certification - Planning and  
     Quality Management	 6/6	 0/6	
 Employment and Day Supports 	 	 	
    Community-Based Day Services
    Employment Support Services
	 8/8 
 12/15 	 0/8 
 3/15 	

Community-Based Day Services Commendations on Standard Met:	
Indicator #	Indicator	Commendation	
 C8	There are opportunities for communica-tion between guardians, family members, and staff on a regular and timely basis. 	The agency is commended for it use of a variety of methods to foster communication between guardians, family members and staff.  These included regular contact via email and telephone conversations and an open door policy at the day support location.

Employment Support Services- Areas Needing Improvement on Standards Not Met:	
Indicator #	Indicator	Area Needing Improvement	
 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.

	The agency needs to provide the individual/legal guardian more information and guidance about the work options available while retaining entitlements to assist in career planning. 	
 C33	Employee benefits and rights are clearly explained to the individual.	The agency needs to ensure that individuals know their workplace rights and how to exercise them (e.g., American with Disabilities Act, reasonable accommodation, harassment).

 C37	There is support to develop appropriate work related inter-personal skills.	The agency needs to provide training and ongoing guidance to support individuals to develop appropriate work-related interpersonal skills.

	

MASTER SCORE SHEET LICENSURE
Organizational: 
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	
   L75	 Qualified staff	1/1	Met	
   L76	 Track trainings	5/5	Met	
   L83	 HR Training	5/5	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	0/1	  	0/2	0/3	Not Met
(0%)	
 	 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	1/1		2/2	3/3	Met	
 	 L9	Safe use of equipment	L	 
 		1/1	1/1	Met	

 	 L10	Reduce risk interventions	I	 
 	 
 	1/1	1/1	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	
 
 	 L18	Above grade egress	L	 
 	 
 	1/1	1/1	Met	
Employment and Day Supports:

	

Indicator #	

Indicator	Location or Individual Indicator	
Employment Support	
Center- Based Work	
Community- Based Day Support	

Total Met / Rated	

Rating	
 	 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	
	 L28	Flammables	L	 
	 	1/1	1/1	Met	
 
 	 L29	Rubbish/Com-bustibles	L	 
 	 
 	0/1	0/1	Not Met
(0%)	
 
 	 L30	Protective railings	L	 
 	 
 	1/1	1/1	Met	
 
 	 L31	Communication method	I	1/1	 
 	2/2	3/3	Met	
 
 	 L32	Verbal & 
written	I	1/1	 
 	2/2	3/3	Met	
 
 	 L37	Prompt 
treatment	I	1/1	 
 	2/2	3/3	Met	
O	 L38	Physician's orders	I	 
 	 
 	2/2	2/2	Met	

 	 L39	Dietary requirements	I	 
 	 
 	1/1	1/1	Met	

 	 L44	MAP 
Registration	L	 
 	 
 	1/1	1/1	Met	
 
 	 L45	Medication storage	L	 
 	 
 	1/1	1/1	Met	
O	 L46	Medication administration	I	 
 	 
 	2/2	2/2	Met	
 
 	 L49	Informed of human rights	I	1/1	 
 	2/2	3/3	Met	
 
 	 L50	Respectful communication	L	 
 	 
 	1/1	1/1	Met	
 	 L51	Possessions
	I	1/1	 	2/2	3/3	Met	
 	 L52	Phone calls
	I	1/1	 	2/2	3/3	Met	
 	 L54	Privacy
	L	 	 	1/1	1/1	Met	
 
 	 L55	Informed 
consent	I	0/1	 
 	0/2	0/3	Not Met
(0%)	
 	 L61	Health protection in ISP	I			1/1	1/1	Met	
Employment and Day Supports, cont.

	

Indicator #	

Indicator	Location or Individual Indicator	
Employment Support	
Center- Based Work	
Community- Based Day Support	

Total Met / Rated	

Rating	
	 L62	Health protection review	I			1/1	1/1	Met	
  	 L77	Unique needs training	I			2/2	2/2	Met	
  	 L80	Symptoms of illness	L			1/1	1/1	Met	
  	 L81	Medical emergency	L			1/1	1/1	Met	
O	 L82	Medication administration	L			1/1	1/1	Met	
 	 L84	Health protection training	I	  	  	1/1	1/1	Met	
	 L85	Supervision 
	L	 	 	1/1	1/1	Met	
 	 L86	Required assessments	I	1/1		2/2	3/3	Met	
 	 L87	Support Strategies	I	1/1		2/2	3/3	Met	
 	 L88	Strategies implemented	I	1/1		2/2	3/3	Met	

 	# Std. Met/48 Indicators						45/48	 
  	
  	Total Score	 

 	 
 	 
 	50/54	 
 	
 	 	 	 	 	 	 	92.59%	 

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	1/1	Met	
 C6	Future directions planning	1/1	Met	

Community-Based Day Services	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	2/2	Met	
 C8	Family/Guardian communication	2/2	Met	
 C13	Skills to maximize independence 	2/2	Met	
C40	Community involvement interest	2/2	Met	
C41	Activities participation	2/2	Met	
C42	Connection to others	2/2	Met	
 C43	Maintain & enhance relationship	2/2	Met	
 C45	Revisit decisions	2/2	Met	

Employment Support Services	
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	1/1	Met	
 C8	Family/Guardian communication	1/1	Met	
 C22	Explore job interests	1/1	Met	
 C23	Assess skills & training needs	1/1	Met	
 C24	Job goals & support needs plan	1/1	Met	
 C25	Skill development	1/1	Met	
 C26	Benefits analysis	0/1	Not Met (0%)	
 C27	Job benefit education	1/1	Met	
 C29	Support to obtain employment	1/1	Met	
 C30	Work in integrated settings	1/1	Met	
 C32	At least minimum wages earned	1/1	Met	
C33	Employee benefits explained	0/1	Not Met (0%)	
 C34	Support to promote success	1/1	Met	
 C35	Feedback on job performance	1/1	Met	
 C37	Interpersonal skills for work	0/1	Not Met (0%)