Title: DraftProviderReport_NEW
Author: sabreu
Last saved by: jolandry

Human Service Options, Inc.  -  Provider Report  -  2/1/13

SUMMARY OF OVERALL FINDINGS
Provider:  Human Service Options, Inc.

Review Dates:  January 10 – 16, 2013

Service Enhancement Meeting Date:  January 25, 2013

Survey Team:  Steve Abreu (TL), Barbara Mazzella, and Edward Sutka

Citizen Volunteer:  Corey Fencer

 
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

8 Locations  9 Audits

Full Review

78 / 82 
Two-Year License 01/25/2013 - 01/25/2015

Residential Services | 6 Locations  6 Audits | | | Full Review | 14 / 14 Certified - with all indicators std. met.
Individual Home Supports | 2 Locations  3 Audits | | | Full Review | 15 / 15 Certified - with all indicators std. met.
 
Survey Scope and Findings for Planning and Quality Management
Service Group Type | Sample Size | Licensure Scope | Licensure Level | Certification Scope | Certification Level
Planning and Quality Management | N/A | N/A | N/A | Full Review | 5/6 Certified

 

EXECUTIVE SUMMARY

Human Service Options, founded in 1980, is a for-profit organization serving adults with developmental disabilities throughout the Greater Boston and South Shore areas.  The agency offers two different residential options; twenty-four hour supervised home settings and individualized home supports providing less than twenty-four hours of support, based on individuals' unique needs.  The agency provides residential supports to approximately 140 individuals.  The findings of this Licensing and Certification review were based on a random selection of services; six audits were conducted in twenty-four hour residential homes and three audits were conducted in individualized home supports.

EXECUTIVE SUMMARY, CONT.

Since the last review (January 2011), a number of positive steps had been accomplished by the agency.  Human Service Options had revised its new staff orientation, developed additional tracking systems in the area of medication administration and Medication Treatment Plans, and continued to focus on reducing interventions with the potential to be restrictive.  The findings of this review indicated that these systems had been positively impacted through these efforts.

A continued strength of the agency is the relationships between the individuals and their long-term staff.  It was noted that staff in all levels, from direct care to senior administration, had many years of service within the organization and provided a rich history as well as friendship to those receiving support.  This demonstrated the agency's commitment to both its staff and the individuals supported.

While the agency's overall performance was strong, there were a few areas that would benefit from continued focus.  The agency's Human Rights Committee (HRC) met quarterly.  Meeting minutes showed that the HRC reviewed investigations, behavior plans, and supportive and health-related protective devices.  Some additional strategies should be evaluated to ensure members with the required expertise are consistently in attendance.  The agency should also expand on their internal systems to ensure ongoing review of medical protocols, location specific training such as physical restraint and health related protections. 

The agency met 79 out of 82 (96%) licensing indicators, and 34 out of 35 (97%) certification indicators.  As a result of the Licensure and Certification findings, Human Service Options has received a Two-Year License.  The agency is congratulated for its ongoing efforts in service improvement.

 

LICENSURE FINDINGS
| Met / Rated | Not Met / Rated | % Met
Organizational | 9/10 | 1/10 |
Residential and Individual Home Supports | 70/72 | 2/72 |

Residential Services
  Individual Home Supports

Critical Indicators | 8/8 | 0/8 |
Total | 79/82 | 3/82 | 96%
Two-Year License | | |
# Indicators for 60 Day Follow-up | | 3 |

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 (HRC). | The agency's Human Rights Committee met quarterly and maintained a quorum at its meetings.  However, one member with the required expertise (medical) did not regularly attend the meetings.  The agency needs to review current practices to ensure consistent attendance by Committee members, particularly those with the required expertise.

Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur:
Indicator # | Indicator | Area Needing Improvement
L59 | Behavior plans have received all the required reviews. | Within the survey sample, there was only one individual supported using restrictive practices.  The plan reviewed contained a contingency for restitution.  Although a plan considered to contain only Level 1 interventions does not require a review by the Human Rights Committee (HRC), the use of restitution does require HRC review.  Alternatively, if this contingency is no longer needed, it should be removed from the plan.
L84 | Staff are trained in the correct utilize-ion of health-related protections per regulation. | The agency needs to ensure that staff can demonstrate the ability to safely and effectively implement health-related protections.

 
CERTIFICATION FINDINGS
 
| Met / Rated | Not Met / Rated
Certification - Planning and Quality Management | 5/6 | 1/6
Residential and Individual Home Supports | |
Individual Home Supports | 15/15 | 0/15
Residential Services | 14/14 | 0/14

Planning and Quality Management Areas Needing Improvement on Standards Not Met:
Indicator # | Indicator | Area Needing Improvement
C1 | The provider collects data regarding program quality including but not limited to incidents, investigations, restraints, and medication occurrences. | The agency had developed some mechanisms to collect information on service quality, such as tracking of Medication Treatment Plans.  However, the agency should continue to expand its internal systems to include ongoing review of medical protocols, location specific training such as physical restraint and health-related protections, and tracking of ISP support strategies.

  
MASTER SCORE SHEET LICENSURE
Organizational: 
| Indicator # | Indicator | Met/Rated | Rating (Met, Not Met, Not Rated)
🏳 | L2 | Abuse/Neglect reporting | 9/9 | Met
| L3 | Immediate Action | 13/13 | Met
| L4 | Action taken | 7/7 | Met
| L48 | HRC | 0/1 | Not Met (0%)
| L65 | Restraint report submit | 3/3 | Met
| L66 | HRC restraint review | 3/3 | Met
| L74 | Screen employees | 2/2 | Met
| L75 | Qualified staff | 1/1 | Met
| L76 | Track trainings | 17/20 | Met (85%)
| L83 | HR training | 20/20 | Met

Residential and Individual Home Supports:
| Indicator # | Indicator | Location or Individual Indicator | Residential Supports | Individual Home Support | Placement Support | Respite Support | Total Met/Rated | Rating
| L1 | Abuse/Neglect training | I | 6/6 | 3/3 | | | 9/9 | Met
| L5 | Safety Plan | L | 5/6 | 2/2 | | | 7/8 | Met (87.50%)
🏳 | L6 | Evacuation | L | 6/6 | 2/2 | | | 8/8 | Met
| L7 | Fire Drills | L | 5/6 | | | | 5/6 | Met (83.33%)
| L8 | Emergency Fact Sheets | I | 6/6 | 3/3 | | | 9/9 | Met

Residential and Individual Home Supports, cont.
| Indicator # | Indicator | Location or Individual Indicator | Residential Supports | Individual Home Support | Placement Support | Respite Support | Total Met/Rated | Rating
| L9 | Safe use of equipment | L | 6/6 | 2/2 | | | 8/8 | Met
🏳 | L11 | Required inspections | L | 6/6 | 2/2 | | | 8/8 | Met
🏳 | L12 | Smoke detectors | L | 6/6 | 2/2 | | | 8/8 | Met
🏳 | L13 | Clean location | L | 6/6 | 2/2 | | | 8/8 | Met
| L14 | Site in good repair | L | 5/5 | 2/2 | | | 7/7 | Met
| L15 | Hot water | L | 6/6 | 2/2 | | | 8/8 | Met
| L16 | Accessibility | L | 6/6 | 2/2 | | | 8/8 | Met
| L17 | Egress at grade | L | 6/6 | 2/2 | | | 8/8 | Met
| L18 | Above grade egress | L | 4/4 | 2/2 | | | 6/6 | Met
| L19 | Bedroom location | L | 4/4 | | | | 4/4 | Met
| L20 | Exit doors | L | 6/6 | 2/2 | | | 8/8 | Met
| L21 | Safe electrical equipment | L | 6/6 | 2/2 | | | 8/8 | Met
| L22 | Clean appliances | L | 6/6 | 2/2 | | | 8/8 | Met
| L23 | Egress door locks | L | 2/2 | | | | 2/2 | Met
| L24 | Locked door access | L | 6/6 | | | | 6/6 | Met
| L25 | Dangerous substances | L | 6/6 | 2/2 | | | 8/8 | Met
| L26 | Walkway safety | L | 6/6 | 2/2 | | | 8/8 | Met
| L28 | Flammables | L | 6/6 | 2/2 | | | 8/8 | Met
| L29 | Rubbish/Com-bustibles | L | 5/5 | | | | 5/5 | Met
| L30 | Protective railings | L | 5/5 | 2/2 | | | 7/7 | Met
| L31 | Communica-tion method | I | 6/6 | 3/3 | | | 9/9 | Met
| L32 | Verbal & written | I | 6/6 | 3/3 | | | 9/9 | Met
| L33 | Physical exam | I | 6/6 | 3/3 | | | 9/9 | Met
| L34 | Dental exam | I | 6/6 | 3/3 | | | 9/9 | Met
| L35 | Preventive screenings | I | 6/6 | 3/3 | | | 9/9 | Met
| L36 | Recommended tests | I | 6/6 | 3/3 | | | 9/9 | Met
Residential and Individual Home Supports, cont.
| Indicator # | Indicator | Location or Individual Indicator | Residential Supports | Individual Home Support | Placement Support | Respite Support | Total Met/Rated | Rating
| L37 | Prompt treatment | I | 6/6 | 3/3 | | | 9/9 | Met
🏳 | L38 | Physician's orders | I | 3/4 | | | | 3/4 | Met
| L39 | Dietary requirements | I | 2/2 | | | | 2/2 | Met
| L40 | Nutritional food | L | 6/6 | 2/2 | | | 8/8 | Met
| L41 | Healthy diet | L | 6/6 | 2/2 | | | 8/8 | Met
| L42 | Physical activity | L | 6/6 | 2/2 | | | 8/8 | Met
| L43 | Health Care Record | I | 6/6 | 3/3 | | | 9/9 | Met
| L44 | MAP Registration | L | 6/6 | | | | 6/6 | Met
| L45 | Medication storage | L | 6/6 | 1/1 | | | 7/7 | Met
🏳 | L46 | Medication administration | I | 6/6 | | | | 6/6 | Met
| L47 | Self-medica- tion | I | 1/1 | 2/2 | | | 3/3 | Met
| L49 | Informed of human rights | I | 6/6 | 3/3 | | | 9/9 | Met
| L50 | Respectful communication | L | 6/6 | 2/2 | | | 8/8 | Met
| L51 | Possessions | I | 6/6 | 3/3 | | | 9/9 | Met
| L52 | Phone calls | I | 6/6 | 3/3 | | | 9/9 | Met
| L53 | Visitation | I | 6/6 | 3/3 | | | 9/9 | Met
| L54 | Privacy | L | 6/6 | 2/2 | | | 8/8 | Met
| L56 | Restrictive practices | I | 1/1 | | | | 1/1 | Met
| L57 | Written behavior plans | I | 1/1 | | | | 1/1 | Met
| L58 | Behavior plan component | I | 1/1 | | | | 1/1 | Met
| L59 | Behavior plan review | I | 0/1 | | | | 0/1 | Not Met (0%)
| L60 | Data maintenance | I | 1/1 | | | | 1/1 | Met
| L61 | Health protection in ISP | I | 2/2 | | | | 2/2 | Met
| L62 | Health protection review | I | 2/2 | | | | 2/2 | Met
| L63 | Medication Treatment Plan form | I | 6/6 | 1/1 | | | 7/7 | Met

Residential and Individual Home Supports, cont.
| Indicator # | Indicator | Location or Individual Indicator | Residential Supports | Individual Home Support | Placement Support | Respite Support | Total Met/Rated | Rating
| L64 | Medication Treatment Plan review | I | 6/6 | 1/1 | | | 7/7 | Met
| L67 | Money Mgmt. Plan | I | 5/6 | 2/2 | | | 7/8 | Met (87.50%)
| L68 | Funds expenditure | I | 6/6 | 2/2 | | | 8/8 | Met
| L69 | Expenditure tracking | I | 5/6 | | | | 5/6 | Met (83.33%)
| L70 | Charges for care calc. | I | 6/6 | 1/1 | | | 7/7 | Met
| L71 | Charges for care appeal | I | 6/6 | 1/1 | | | 7/7 | Met
| L77 | Unique needs training | I | 6/6 | 3/3 | | | 9/9 | Met
| L78 | Restrictive Int. Training | L | 2/2 | | | | 2/2 | Met
| L80 | Symptoms of illness | L | 6/6 | 2/2 | | | 8/8 | Met
| L81 | Medical emergency | L | 6/6 | 2/2 | | | 8/8 | Met
🏳 | L82 | Medication administration | L | 6/6 | | | | 6/6 | Met
| L84 | Health protec-tion Training | I | 1/2 | | | | 1/2 | Not Met (50%)
| L85 | Supervision | L | 6/6 | 2/2 | | | 8/8 | Met
| L86 | Required assessments | I | 5/5 | 3/3 | | | 8/8 | Met
| L87 | Support strategies | I | 6/6 | 1/2 | | | 7/8 | Met (87.50%)
| L88 | Strategies implemented | I | 5/6 | 2/2 | | | 7/8 | Met (87.50%)
| # Stds. Met / 72 Indicators | | | | | | | 70/72 |
| Total Score | | | | | | | 79/82 |
| | | | | | | | 96.34% |

MASTER SCORE SHEET CERTIFICATION

Certification - Planning and Quality Management
Indicator # | Indicator | Met/Rated | Rating
C1 | Provider data collection | 0/1 | Not Met (0%)
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
Individual Home Supports Reviewed By DDS:
Indicator # | Indicator | Met/Rated | Rating
C7 | Feedback on staff performance | 3/3 | Met
C8 | Family/Guardian communication | 3/3 | Met
C9 | Personal relationships | 3/3 | Met
C10 | Social skill development | 3/3 | Met
C11 | Get together w/family & friends | 3/3 | Met
C12 | Intimacy | 3/3 | Met
C13 | Skills to maximize independence | 3/3 | Met
C14 | Choices in routines & schedules | 3/3 | Met
C15 | Personalize living space | 2/2 | Met
C16 | Explore interests | 3/3 | Met
C17 | Community activities | 3/3 | Met
C18 | Purchase personal belongings | 3/3 | Met
C19 | Knowledgeable decisions | 3/3 | Met
C20 | Emergency back-up plans | 2/2 | Met
C21 | Coordinate outreach | 2/2 | Met
Residential Services Reviewed By DDS:
Indicator # | Indicator | Met/Rated | Rating
C7 | Feedback on staff performance | 6/6 | Met
C8 | Family/Guardian communication | 6/6 | Met
C9 | Personal relationships | 6/6 | Met
C10 | Social skill development | 6/6 | Met
C11 | Get together w/family & friends | 6/6 | Met

Residential Services Reviewed By DDS:
Indicator # | Indicator | Met/Rated | Rating
C13 | Skills to maximize independence | 6/6 | Met
C14 | Choices in routines & schedules | 6/6 | Met
C15 | Personalize living space | 6/6 | Met
C16 | Explore interests | 6/6 | Met
C17 | Community activities | 6/6 | Met
C18 | Purchase personal belongings | 6/6 | Met
C19 | Knowledgeable decisions | 6/6 | Met
C20 | Emergency back-up plans | 6/6 | Met