SUMMARY OF OVERALL FINDINGS

Provider:  LifeStream, Inc.

Review Dates:  June 5 – 10, 2014

Service Enhancement Meeting Date:  June 19, 2014

Survey Team:  Sally Hajjar (TL), Barbara Mazzella, Scott F. Nolan, and 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	12 Locations 12 Audits 	Targeted Review	DDS 8 / 8
Provider 77 / 77

85 / 85        Two-Year License 06/19/2014 - 06/19/2016			
Residential Services	6 Locations     6 Audits			Provider Targeted Review	0 / 0 Certified	
Placement Services	2 Locations     2 Audits 			Provider Targeted Review	0 / 0 Certified	
Individual Home Supports	4 Locations      4 Audits 			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	1 Location       6 Audits 	Targeted Review	DDS 8 / 8
Provider 52 / 52

60 / 60         Two-Year License 06/19/2014 - 06/19/2016
			
Community Based Day Services	1 Location       3 Audits 			Provider Targeted Review	0 / 0 Certified	
Employment Support Services	0 Locations      3 Audits 			Provider Targeted Review	1 / 1 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
LifeStream, Inc. (LifeStream) is a private, non-profit, human service agency which was founded in 1976 by concerned parents who were searching for superior care for their adult children with intellectual and physical disabilities.  LifeStream currently provides services to adults and children in the greater New Bedford and Fall River areas.  These services encompass a broad spectrum of populations including adults and children with intellectual disabilities, individuals with Acquired Brain Injury (ABI), and people who are on the autism spectrum.  LifeStream provides services to a variety of populations including:  individuals in approximately thirty 24-hour group homes, individuals who receive less than 24-hours of supports, as well as individuals in community-based day and employment programs.  This current review focused on adults who receive services from the Department of Developmental Services (DDS).  Guided by their mission statement, LifeStream, “provides community-based services throughout Southeastern Massachusetts that promote personal dignity, independence, and the removal of barriers through the provision of individualized support and education."  

As LifeStream had earned a Two-Year License for its day and residential supports during its previous review in June 2012 (earning 100% met in applicable Licensure indicators across all service types), the agency was eligible for and elected to exercise the option of conducting a self-assessment of all applicable indicators for its 2014 review.  In conjunction with the provider's Self-Assessment, DDS conducted a 'Targeted Review,' which consisted of examining only the eight indicators considered 'critical' across all service types.  The results of the current DDS review are based on the findings from eight residential audits, four individual home supports audits, two placement service audits, three community-based day support audits, and three employment audits.  

Since the last review LifeStream indicated it has continued expansion into the ABI arena and it has fully embraced the DSS's initiative for Positive Behavior Supports.  As such, they added a master's level clinician and a doctorate level neuropsychologist to their staff.  Additionally the agency is utilizing the DDS's Home and Community Services Information System (HCSIS) computer program to monitor, track, analyze, and identify any trends across the agency.  The agency is also developing a peer review process to analyze major events leading up to hospitalizations to determine if anything could have been done to prevent the hospitalization and or if additional trainings are necessary.

The review by the DDS survey team coupled with the agency's reported outcomes from its self-assessment exhibited a continued commitment to ensuring that services promote the optimal health and safety of people served.  Additionally, the homes visited during the survey reflected individuals' preferences and tastes, and staff demonstrated their commitment and knowledge of people's unique needs.  Additionally, the team observed that individuals were supported to embrace community activities and services.  These witnessed practices affirm the agency's belief in full community inclusion.  

The agency met 100% of the residential support indicators and 100% of the day support indicators that comprised this review.  The agency is congratulated for receiving a Two-Year License for both its day and residential supports.

The following section of this report contains LifeStream's description of its self-assessment process.

Description of Self-Assessment Process:
LifeStream, Inc. has developed a quality assurance program to ensure compliance with all regulations and the provision of quality supports across the agency.  The tool used to evaluate services across the organization is based on DDS licensure standards as well as best practices across the organization.  All programs are audited internally at least twice a year by program coordinators and/or program directors along with nursing coordinators.  The result of the audit along with action plans for any findings are reviewed by program directors.  Action plans include timeline for implementation and completion.  

LifeStream's Program Review Committee is comprised of members of the Board of Directors and senior management.  The committee's purpose is to develop a system that monitors the ongoing performance of all aspects of LifeStream's programs and services.  The committee looks at agency progress by yearly comparison of specifics benchmarks and against industry statistics.  The committee presents to the Board of Directors quarterly to review incident management, investigations, medication administration occurrences, human resources statistics along with employee and consumer satisfaction.  During each review the committee evaluates changes and trends in organizational performance and identifies areas that require further investigation.  

In addition to our standardized Quality Assurance Reviews LifeStream has several other quality assurance systems in place:  

*	Health and Safety:  Nursing staff review all medication administration documentation monthly at the program site.  This review occurs at the end of the month to ensure accuracy of current medication administration and carry over to the next month.  Nursing staff along with manage-ment also review all PRN medication and documentation during this review.  RN coordinators act as a liaison for all hospitalization admissions and discharges, write quarterly medical assess-ments and review all physician encounters to address any concerns or follow-up required.  Lab work is also tracked by our nursing department.  An RN coordinator is on call 24/7.
*	Property and Vehicle Safety:  LifeStream's Director of Operations oversees our Facility Department.  The Facilities Manager is on call 24/7.  Structural systems such as HVAC, fire alarms, sprinklers, generators and lift systems are inspected annually by licensed technicians in the respective areas.  Annual inspections are conducted and work orders generated based on inspection finding.  Work orders are submitted electronically as needed for routine corrective and preventive maintenance. Vehicles are inspected monthly by a third party vendor to ensure safety.
*	Staff Development:  LifeStream's Education and Training Division is certified by the Commonwealth as a private business school.  Our Training Department maintains a training database that tracks all required training.  This information is distributed to all managers on a monthly and/or as needed basis to ensure on-going training compliance.  All employees attend an extensive orientation program that includes:  Introduction to Developmental Services, Human Rights and Mandated Reporting, CPR, First Aid, Medication Administration, Vital Signs, Universal Precautions, Body Mechanics, NVMAB, Nutrition, Dysphasia and Meal Preparation, Positive Behavior Supports, and agency Policies and Procedures.  Site-specific and consumer-specific training occur at the program location.  LifeStream is an approved testing site for the Medication Administration Program.  Registered Nurses provide training in g-tube nutrition, flushes and medication administration.  LifeStream maintains a Staff Training and Development Course Catalog with over 100 training topics offered on an as needed basis.  LifeStream has trainers on staff in the following areas:  Medication Administration, Certified Nursing Aide, NVMAB, Positive Behavior Supports, CPR, First Aid, Human Rights, Abuse Prevention, Dysphagia, and Nutrition.  We have 5 Registered Nurses who are all trained MAP consultants.  LifeStream actively participates on the New Bedford and regional training committees. 

Description of Self-Assessment Process, cont.
*	Interdisciplinary Team:  LifeStream's interdisciplinary members include nursing, therapy services, psychology, management, direct care support and DDS personnel.  This internal team meets twice a month to review individuals at risk medically or behaviorally. LifeStream employs 3 master's level clinicians and 2 doctorate level consultants within our Psychology Department.  
*	Human Rights:  LifeStream's Human Rights Committee meets monthly and has a full complement of required membership.  The Human Rights Committee reviews incidents, restraints, restrictive procedures, behavior plans, investigations, human rights complaints and supportive and protective devices.  The committee also ensures that individual, staff and family members are aware of their rights. LifeStream mails a Human Rights newsletter to individuals and family members twice a year.  The Clinical Director meets with all human rights officers on a quarterly basis to provide on-going education.  Individuals meet with their human rights officer monthly to review information regarding their rights.  LifeStream also has a human rights complaint form that can be completed and submitted to the Human Rights Committee.  A telephone hot line is also in place to assist those who would like to submit a complaint privately.  Only the Clinical Director and Human Rights Chair have access to retrieve messages from the Human Rights hotline. 
*	Standards Committee:  LifeStream's Standards Committee includes representation across the agency with expertise in several disciplines.  The committee meets monthly to develop standardized forms, procedures and to ensure implementation of systems throughout the agency.  The Standards Committee keeps apprised of new initiatives and regulations and updates agency procedures as needed.  This committee also audits programs to ensure consistent use and implementation of standardized procedures, protocols and forms.
*	Safety Committee:  LifeStream's Safety Committee meets monthly to review all work-related injuries and safety concerns.  The committee has initiated several programs to ensure safe practices throughout the agency.  Protocols such as 'safe lifting' and 'transportation safety' have been developed and implemented by the Safety Committee.  The committee conducts audits to ensure compliance with safe practices such as unannounced van inspections and 1:1 observation of wheelchair securement procedures for transportation.  The committee attends house meetings to discuss program specific safety concerns and provide education as it relates to safety procedures. Safety concern forms are available at each location for individual and employee use.  All completed forms are forwarded to the Safety Committee for review and recommendation.

LifeStream received a Two-Year License during its last DDS Licensing and Certification Survey meeting 100% of all indicators.  LifeStream has chosen to conduct a self-assessment audit.

The Chief Operating Officer and Clinical Director, along with the leadership of each program, utilized the DDS Licensure Tool to develop the sample size and conduct each individual survey.  The Clinical Director, Nursing Coordinator and Program Directors worked in teams to conduct each individual survey.  This approach ensured expertise in psychology, nursing and program management for each survey conducted.  All program locations audited were given a 7 day notice.  However, individuals being surveyed were only identified on the day of the audit.

 LifeStream used 80% as the threshold to determine if an indicator was Met or Not Met. All audits included interviews with staff/care provider and individuals along with documentation reviews and visits to the home/work location:

*	25% of 24/7 residential programs were surveyed.  One home under each Program Coordinator was selected allowing for a sampling across several different management teams. This approach was taken to ensure agency systems are in place throughout.  In total 6 residential homes were audited including 6 individuals from Cluster A and 6 individuals from Cluster B.  

Description of Self-Assessment Process, cont.
*	6 Individual/Home Support service locations were audited.  Individuals chosen represented a sample across management in the New Bedford and Fall River areas.  

*	25% of Placement services or 2 individuals were selected.  The audit included interviews with the caregiver and the individual served along with documentation reviews and visits to the home location.

*	Three individuals from Supported Employment and three individuals from Community-Based Day Support were audited.  A combination of individuals from Cluster A and Cluster B were audited.  Each audit team was responsible for reviewing all data and determining what indicators were met or not met for each individual audited.  This information was given to the Chief Operating Officer for review and inclusion into the Provider Assessment Report.  

All indicators at the Organizational level were reviewed by the Chief Operating Officer along with the Clinical Director.  They include:

*	L2, L3 and L4:  Immediate action is taken to protect the health and safety of individuals and action is taken when an individual is subject to abuse and neglect.  All DPPC Action Plans were reviewed to ensure compliance with all requirements. 

*	L65 and L66: Restraint Reports are submitted within required timelines and are reviewed by the Human Rights Committee.  Review of HR Committee minutes and HCSIS reports were utilized when auditing these indicators.  

*	L48: The agency has an effective Human Rights Committee.  The Chief Operating Officer reviewed two years of minutes to ensure proper attendance and reviews, committee membership, roles and by-laws.

*	L74, L75 and L76: The agency screens prospective employees, ensures that staff has the necessary qualifications and certifications and has and utilizes a system to track required trainings.  When reviewing training compliance 20 personnel jackets were audited to ensure compliance with the printed tracking system.  The sample of employees reviewed included positions that required Certification and Licensure and employees within their first three months of employment.  Annual performance evaluations along with pre-employment screenings were also reviewed.  Documentation of compliance with the CORI audit conducted on June 11, 2013 was also reviewed.

*	L83: Support staff are trained in Human Rights.  The training data base was reviewed by location and supplemented by an audit of personnel files.

Based on the findings of all audits completed LifeStream has met all Licensing indicators at 100%.  

	

LICENSURE FINDINGS

 	

Met / Rated	
Not Met / Rated	

% Met	

Organizational	
10/10	
0/10	

Residential and Individual Home Supports	
75/75	
0/75	

	

  Residential 
    Services
  Placement Services
  Individual Home 
    Supports	

	

	

	

Critical Indicators	
8/8	
0/8	

Total	
85/85	
0/85	
100%	

Two-Year License	

	

# Indicators for 60 Day Follow-up	

0	

	 

Met / Rated	
Not Met / Rated	

% Met	

Organizational	
10/10	
0/10	

Employment and Day Supports
	
50/50	
0/50	

  Community-Based 
    Day Services
  Employment 
    Support Services

	

	

	

Critical Indicators	
8/8	
0/8	

Total	
60/60	
0/60	
100%	

Two-Year License	

	

# Indicators for 60 Day Follow-up	

0	

	

 

CERTIFICATION FINDINGS

 

Reviewed By	

Met / Rated	
Not Met / Rated	

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

Residential and Individual Home Supports	

	

	

	

Residential Services	
Provider	
0/0	
0/0	

Individual Home Supports	
Provider	
0/0	
0/0	

Placement 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

 	

	

Employment Support Services	
Provider	
1/1	
0/1	

Community Based Day Services

Provider	
0/0	
0/0	

			

MASTER SCORE SHEET LICENSURE
Organizational: 

Indicator #	
Indicator	
Reviewed By	
Met/Rated	Rating
(Met, Not Met,
Not Rated)	
O	 L2	Abuse/Neglect reporting	DDS	13/13	Met	
 	 L3	Immediate Action	Provider	-	Met	
 	 L4	Action taken	Provider	-	Met	
 	 L48	Human Rights Committee	Provider	-	Met	
 	 L65	Restraint Report submitting	Provider	-	Met	
 	 L66	HRC restraint review	Provider	-	Met	
 	 L74	Screen employees	Provider	-	Met	
 	 L75	Qualified staff	Provider	-	Met	
 	 L76	Track trainings	Provider	-	Met	
 	 L83	Human Rights training	Provider	-	Met	

Residential and Individual Home Supports:

Ind. #	
Ind.	Loc. or Indiv.	
Reviewed By	
Res. Supports	
Ind. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Sup.	
ABI-MFP Place.	Total Met/ Rated	
Rating	
 
 	 L1	Abuse/ Neglect training	I	Provider	-	-	-		-	-	-	Met	
  	 L5	Safety Plan	L 	Provider	-	-	-		-	-	-	Met	
O	 L6	Evacua-tion	L	DDS	6/6	4/4	2/2		 
 	 
 	12/12	Met	
  	 L7	Fire Drills	L 	Provider	-	-	-		-	-	-	Met	

 	 L8	Emer-gency Fact Sheets	I 	Provider	-	-	-		-	-	-	Met	
	 L9	Safe use of equip-ment	L 	Provider	-	-	-		-	-	-	Met	
	 L10	Reduce risk interven-tions	I 	Provider	-	-	-				-	Met	
O	 L11	Required inspec-tions	L	DDS	6/6	3/3	2/2				11/11	Met	
O	 L12	Smoke detec-tors	L	DDS	6/6	3/3	2/2				11/11	Met	
Residential and Individual Home Supports, cont.

Ind. #	
Ind.	Loc. or Indiv.	
Reviewed By	
Res. Supports	
Ind. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Sup.	
ABI-MFP Place.	Total Met/ Rated	
Rating	
O	 L13	Clean location	L	DDS	6/6	3/3	2/2				11/11	Met	
	 L14	Site in good repair	L 	Provider	-	-	-		-	-	-	Met	
	 L15	Hot water	L 	Provider	-	-	-		-	-	-	Met	
	 L16	Access-ibility	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 equip-ment	L 	Provider	-	-	-		-	-	-	Met	
	 L22	Clean appli-ances	L 	Provider	-	-	-		-	-	-	Met	
	 L23	Egress door locks	L 	Provider	-	-	-		-	-	-	Met	
	 L24	Locked door access	L 	Provider	-	-	-		-	-	-	Met	
	 L25	Danger-ous sub-stances	L 	Provider	-	-	-	 	-	-	-	Met	
	 L26	Walkway safety	L 	Provider	-	-	-		-	-	-	Met	
	 L28	Flam-mables	L 	Provider	-	-	-		-	-	-	Met	
	 L29	Rubbish/ Combus-tibles	L 	Provider	-	-	-		-	-	-	Met	
	 L30	Protec-tive railings	L 	Provider	-	-	-		-	-	-	Met	
	 L31	Com-munica-tion method	I 	Provider	-	-	-		-	-	-	Met	
	 L32	Verbal & written	I 	Provider	-	-	-		-	-	-	Met	
	 L33	Physical exam	I	Provider	-	-	-		-	-	-	Met	
	 L34	Dental exam
	I	Provider	-	-	-		-	-	-	Met	
Residential and Individual Home Supports, cont.

Ind. #	
Ind.	Loc. or Indiv.	
Reviewed By	
Res. Supports	
Ind. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Sup.	
ABI-MFP Place.	Total Met/ Rated	
Rating	
	 L35	Preven-tive screen-ings	I	Provider	-	-	-		-	-	-	Met	
	 L36	Recommended tests	I 	Provider	-	-	-		-	-	-	Met	
	 L37	Prompt treat-ment	I 	Provider	-	-	-		-	-	-	Met	
O	 L38	Physi-cians’ orders	I	DDS	6/6	  	1/1				7/7	Met	
  	 L39	Dietary require-ments	I 	Provider	-	-	-		-	-	-	Met	
	 L40	Nutri-tional food	L 	Provider	-	-	-		-	-	-	Met	
	 L41	Healthy diet	L 	Provider	-	-	-		-	-	-	Met	
	 L42	Physical activity	L 	Provider	-	-	-		-	-	-	Met	
	 L43	Health Care Record	I 	Provider	-	-	-		-	-	-	Met	
	 L44	MAP registra-tion	L 	Provider	-	-	-		-	-	-	Met	
	 L45	Medica-tion storage	L 	Provider	-	-	-		-	-	-	Met	
O	 L46	Med. admin-istration	I	DDS	6/6	1/1	1/1				8/8	Met	
	 L47	Self-medica-tion	I 	Provider	-	-	-	 	-	-	-	Met	
 
 	 L49	Informed of human rights
	I	Provider	-	-	-	  	-	-	-	Met	
	 L50	Respect-ful com-munica-tion	L 	Provider	-	-	-		-	-	-	Met	
	 L51	Posses-sions	I 	Provider	-	-	-		-	-	-	Met	
	 L52	Phone calls	I 	Provider	-	-	-		-	-	-	Met	
	 L53	Visitation	I 	Provider	-
	-	-		-	-	-	Met	
	 L54	Privacy	L 	Provider	-

	-	-		-	-	-	Met	
Residential and Individual Home Supports, cont.

Ind. #	
Ind.	Loc. or Indiv.	
Reviewed By	
Res. Supports	
Ind. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Sup.	
ABI-MFP Place.	Total Met/ Rated	
Rating	
	 L55	Informed consent	I 	Provider	-	-	-		-	-	-	Met	
	 L56	Restric-tive practices	I 	Provider	-	-	-		-	-	-	Met	
	 L57	Written Behavior Plans	I 	Provider	-	-	-		-	-	-	Met	
 	 L58	Behavior Plan com-ponent	I 	Provider	-	-	-		-	-	-	Met	
	 L59	Behavior plan review	I 	Provider	-	-	-		-	-	-	Met	
	 L60	Data main-tenance	I 	Provider	-	-	-		-	-	-	Met	
	 L61	Health protect-tion in ISP	I 	Provider	-	-	-		-	-	-	Met	
	 L62	Health protect-tion review	I 	Provider	-	-	-		-	-	-	Met	
	 L63	Med. Treat-ment Plan form	I 	Provider	-	-	-		-	-	-	Met	
	 L64	Med. Treat-ment Plan rev.	I 	Provider	-	-	-		-	-	-	Met	
  	 L67	Money Mgmt. Plan	I 	Provider	-	-	-	  	-	-	-	Met	
	 L68	Funds expen-diture	I 	Provider	-	-	-		-	-	-	Met	
	 L69	Expendi-ture 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	Restric-tive Int. Training
	L 	Provider	-	-	-		-	-	-	Met	
Residential and Individual Home Supports, cont.

Ind. #	
Ind.	Loc. or Indiv.	
Reviewed By	
Res. Supports	
Ind. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Sup.	
ABI-MFP Place.	Total Met/ Rated	
Rating	
	 L79	Restraint training	L 	Provider	-	-	-		-	-	-	Met	
	 L80	Sym-ptoms of illness	L 	Provider	-	-	-		-	-	-	Met	
	 L81	Medical emer-gency	L 	Provider	-	-	-		-	-	-	Met	
O	 L82	Medica-tion admin-stration	L	DDS	6/6	1/1					7/7	Met	
	 L84	Health Protec-tion Training	I 	Provider	-	-	-		-	-	-	Met	
	 L85	Super-vision 	L	Provider	-	-	-		-	-	-	Met	
	 L86	Required assess-ments	I	Provider	-	-	-		-	-	-	Met	
  
 	 L87	Support Strate-gies	I	Provider	-	-	-		-	-	-	Met	
  	 L88	Strate-gies imple-mented	I 	Provider	-	-	-		-	-	-	Met	

 
 	#Std. Met/75 Indi-cator										75/75	 

 
 	Total Score	 

 

 	 

 

 	 

 

 	85/85	 

											100%

 

Employment and Day Supports:

Ind. #	
Ind.	
Loc. or Indiv.	
Reviewed By	
Emp. Sup.	
Cent. Based Work	
Com. Based Day	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	Met	
 	 L7	Fire Drills	L 	Provider	 
	-	-	-	Met	
Employment and Day Supports, cont.

Ind. #	
Ind.	
Loc. or Indiv.	
Reviewed By	
Emp. Sup.	
Cent. Based Work	
Com. Based Day	Total Met / Rated	
Rating	
 
 	 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	 
 	 	1/1	1/1	Met	
O	 L12	Smoke detectors	L	DDS	 
 	  	1/1	1/1	Met	
O	 L13	Clean location	L	DDS	 
 	  	1/1	1/1	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	
 	 L20	Exit doors	L 	Provider	 
	-	-	-	Met	
  
 	 L21	Safe electrical equipment	L 	Provider	  
	-	-	-	Met	

 	 L22	Clean appliances	L 	Provider	 
	-	-	-	Met	
 
 	 L25	Dangerous substances	L 	Provider	 
	-	-	-	Met	
 
 	 L26	Walkway safety	L 	Provider	 
	-	-	-	Met	
 	 L28	Flammables	L 	Provider	 
	-	-	-	Met	
  	 L29	Rubbish/Com-bustibles	L 	Provider	  	-	-	-	Met	
  	 L31	Communica-tion method	I 	Provider	  	-	-	-	Met	
  	 L32	Verbal & written	I 	Provider	  	-	-	-	Met	
O	 L38	Physician's orders	I	DDS	2/2	  	3/3	5/5	Met	
  	 L39	Dietary requirements	I 	Provider	  	-	-	-	Met	
  	 L44	MAP registration	L 	Provider	  	-	-	-	Met	
  	 L45	Medication storage	L 	Provider	 
 	-	-	-	Met	
O	 L46	Medication administration	I	DDS	2/2	  	3/3	5/5	Met	
  	 L49	Informed of human rights	I 	Provider	  	-	-	-	Met	
 	 L50	Respectful comm.	L 	Provider	  	-	-	-	Met	
	 L51	Possessions	I 	Provider	 
	-	-	-	Met	
Employment and Day Supports, cont.

Ind. #	
Ind.	
Loc. or Indiv.	
Reviewed By	
Emp. Sup.	
Cent. Based Work	
Com. Based Day	Total Met / Rated	
Rating	
 	 L52	Phone calls	I 	Provider	 
	-	-	-	Met	
 	 L54	Privacy	L 	Provider	 
	-	-	-	Met	
  	 L55	Informed consent	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	
  	 L63	Medication Treatment Plan form	I 	Provider	  	-	-	-	Met	
  
 	 L64	Medication Treatment Plan review	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 administration	L	DDS	  	  	1/1	1/1	Met	
 	 L85	Supervision 	L 	Provider	 
	-	-	-	Met	
 	 L87	Support strategies	I	Provider	  	-	-	-	Met	
  	 L88	Strategies implemented	I 	Provider	  	-	-	-	Met	
  
 	#Std. Met/50 Indicator							50/50	  
 	
 	Total Score							60/60	  	
 	 	 	 	 	 	 	 	100%

MASTER SCORE SHEET CERTIFICATION
Employment Support Services Reviewed By -Provider	
Indicator #	Indicator	Met/Rated	Rating	
 C30	 Work in integrated settings.	-	Met