SUMMARY OF OVERALL FINDINGS
Provider:  The May Institute, Inc.

Review Dates:  February 19 – 25, 2014

Service Enhancement Meeting Date:  March 7, 2014

Survey Team:  Edward Sutka (TL), Steve Abreu, Mark Boghoian, Steve Goldberg, Joyce Herrmann,           Ken Jones, Barbara Mazzella, Janina Millet, Scott F. Nolan, and Laura K. O’Connor

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	22 Locations 22 Audits	Targeted Review	DDS 19 / 23
Provider 56 / 64

75 / 87 
Two-Year License 03/07/2014 - 03/07/2016			
Residential Services	19 Locations 19 Audits 			Deemed	 
  	
Individual Home Supports	3 Locations   3 Audits 	 
 	 
 	Deemed	 
 	
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  7 Audits 	Full Review	42 / 49 

Two-Year License 03/07/2014 - 03/07/2016	 

 	 

 	
Employment Support Services	1 Location    3 Audit (s) 	 
 	 
 	Full Review	2 / 2 Certified	
Center-Based Employment	1 Location    4 Audits 

 	Full Review	7 / 14 Certified	
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
The May Institute, which was founded in 1955, provides services for people with developmental disabilities in Massachusetts as well as in a number of other states, with the agency's Massachusetts services admin-istered from hubs in Mashpee, Revere, and Springfield.  In addition to its Department of Developmental Services (DDS) funded services, the agency offers supports, such as children's services and day habilitation, that are funded by other sources.  The agency's DDS supports encompass 319 people served residentially and 12 people who receive employment supports.  Since the previous DDS review (February 2012), the agency had closed its DDS funded day supports in Mashpee, Revere, and Raynham, with the only remaining day support site being in Walpole.  For the current review, nineteen residential locations were visited that provide twenty-four hours supports, and supports were surveyed for three people who receive fewer than twenty-four hours of support.  The day support sample consisted of eight people who performed work for sub-minimum wages at the Walpole site and three people who worked for minimum wage at an enclave.  The agency was eligible for, and elected to exercise the option of conducting a self-assessment for its residential supports.  Results of this self-assessment were combined with ratings by the DDS survey team for the eight indicators considered critical, the seven indicators that had been rated standard ‘Not Met’ in the previous review, and the nine others that are evaluated and rated on an organizational level.  The DDS survey team's review of the agency's day supports encompassed all licensing and certification indicators, as this component was not eligible for the self-assessment process.

While the agency continues to make behavioral treatment its major area of focus, other aspects of providing support have received expanded emphasis since the previous review.  Notably, the agency's Quality Improvement division has taken an increasingly active role, and this has led to improvements in a number of areas that had previously been problematic.  For instance, the current review resulted in ratings of standard ‘Met’ for all licensing indicators considered critical, including the one indicator that had been rated ‘Not Met’ in the previous DDS review, and improvements were noted as well in regard to medication administration, based upon concerns that had been self-identified by the agency during its self-assessment process.  Other recent initiatives by the agency have included increased efforts to create a culture of openness and transparency, a shift toward expanded implementation of positive behavioral supports as part of its treatment options, and additional efforts to identify and address concerns of importance to staff.  While the agency has made many positive organizational changes, a need for further strengthening was identified in relation to certain organizational outcomes that were part of the review, such as the agency's Human Rights Committees.   

The number of people supported at the agency's day support location in Walpole had declined significantly in recent years, and adjusting to this change has created challenges, especially in relation to how expectations in the field in regard to day supports have evolved.  Except for a small number of hours during which people were offered the opportunity to perform on-site janitorial work at the Walpole location, people were offered only two employment options: on-site sheltered work at sub-minimum wages and work at a community enclave site, where people earned minimum wage, but through a contractual arrangement were paid by the agency rather than directly by the employer.  None of the people selected for the survey sample worked at the enclave site more than three days a week, and most participated only in on-site work at the Walpole location for sub-minimum wages.  While day support staff worked conscientiously, the survey team identified a need for the agency to provide additional support to staff to aid them to become fully effective in regard to assisting people to explore their interests regarding employment, develop related job skills, and then develop employment options based upon this exploratory process.  This aspect of staff's role, which would be important in any circumstances, is becoming increasingly vital given the impending closure of the sheltered workshop model in Massachusetts as of July 1st, 2015.  While the agency has made recent efforts to develop plans to address these concerns, the implementation of most of these efforts was still in its early stages.  As plans solidify, the agency is encouraged to incorporate any best practices that might be helpful and to access the DDS Area Office for on-going technical support. 

The agency is congratulated on earning a Two-Year License for both its day and residential supports.  Follow-up by the DDS survey team will occur within approximately 60 days pertaining to any licensing out-comes that were rated ‘Not Met.’  The provider's description of its self-assessment process in contained in the following section of this report.

Description of Self-Assessment Process:

May Institute utilizes an ongoing quality improvement process that ensures that quality services are being delivered.  Some components of this process are: satisfaction surveys to all stakeholders; research; extensive training; quality monitoring audits of residential, day habilitation and employment services sites (these reviews are completed by the Quality Improvement (QI) Department and Program Supervisors using a tool created by the agency); external reviews by an independent environmental specialist; outcome reports measuring performance in effectiveness, efficiency, access, and satisfaction; and dashboard data systems to monitor program indicators.   

Our performance improvement program provides a planned systematic organization-wide approach to designing, measuring, and improving processes, systems and outcomes of the various programs of the May Institute.  The plan is comprehensive and interdisciplinary and covers critical functions; customer input, health and safety, individual-centered service planning, access to services, human rights, outcomes management, human resources development, information management, leadership, financial planning and management, and strategic planning. 

May Institute has multiple levels of oversight to insure the clinical integrity of our services.  Among the clinical resources is a Peer Review system as well as standing committees which include Clinical Steering, Clinical Standards, and High Risk Review.  These layers of support provide input from various levels of the organization to ensure clinical oversight, direction and management of systems in the areas of access to services, clinical integrity, and follow-up data.

May Institute has a comprehensive safety/risk program that manages the various components of safety through internal monitoring and tracking of data.  The QI Department reviews several components of the Safety and Risk Management status of each program on a monthly basis at Program Management Meetings.  Components of this system include: Infection Control; Medication Management; Life Safety; Incident Management; Allegations; Mortality Reviews; Environmental Safety; Individuals At Risk; Pharmacy Reviews; Privacy; and Security.  It is the policy of the May Institute to learn from significant incidents through systematic investigation of the circumstances and contributory factors, and where possible, to implement improvements to reduce the risk of recurrence.  This is accomplished the through incident reporting and quality improvement processes.  Data is analyzed and benchmarked against previous rates, trends are identified and addressed.

The QI Healthcare Manager conducts medical risk reviews of individuals throughout the agency, and facilitates communication and best practices amongst the healthcare professionals in the field.  The programs, in consultation with their QI department liaison, identify individuals for review.  This is based on concerns resulting from medical-related significant incidents, a new diagnosis and/or behavioral concerns that may be secondary to a medical condition.  In addition, the agency has a Healthcare Roundtable in which the healthcare representatives from all programs meet regularly to address areas of concern, initiatives, policies, new systems, and best practices. 

In order to share best practices and streamline operational practices, the QI Department initiated formal ‘Records Committees’ for each service delivery area.  The QI Department facilitates these committee meetings with key representatives from each service area in order to unify and standardize systems while utilizing best practices.  Several initiatives have been completed within these committee meetings, such as standardized table of contents for records, standardized consent packets and satisfaction surveys.

The Facilities Department regularly monitors smoke/fire and CO2 alarms as well as water temperatures at all sites.  They provide ongoing seasonal maintenance and repairs are addressed through a centralized reporting system called the Facility Wizard.  The Department also manages all annual site inspections, pest control contracts and agency vehicles.  The Fleet Manager chairs the Vehicle Accident Review Committee which reviews every vehicle accident and makes safety recommendations regarding policies, practices and training for the agency.

Description of Self-Assessment Process, cont.

The targeted review for self-assessment was conducted from January 8, 2014 through February 7, 2014 using the 24hr residential audit worksheet from the DDS Licensing and Certification Manual, fifth edition.  The Quality Improvement Department determined the sample size using an 80% confidence level, which resulted in 18 sites with 24hr supports and 2 sites with less than 24hr supports.  Sites were divided amongst the three service centers as follows: West Springfield - 4 sites (24hr) and 2 less than 24hr, Mashpee - 6 sites (24hr), Revere - 8 sites (24hr).  Specific sites within each service center were randomly selected via computer (using the random number function) from each service center.  Review teams consisted of 2 reviewers from the QI Department and 1-2 reviewers from the service center's leadership team.  Training for the reviews consisted of an orientation to the self-assessment process provided by Office of Quality Enhancement staff, conducting preparatory reviews using the tool in conjunction with QI Department staff, and review of indicator guidelines and interpretations. 

At each site, 2 individuals were selected randomly via computer (using the random number function) for review and the names of the individuals chosen were provided the day of the review.  Using the DDS tools the teams: reviewed documentation, individual records, and logs.  In addition team members conducted observations of the environment, conducted interviews; and used thermometers to test water temperatures at each site location.  Programs received immediate feedback at the end of each review on the rating for each indicator, upon which the programs began the process of rectifying any deficiencies noted.

The QI Department compiled the scores from all reviewers into a final report and ensured consistency in scoring for each indicator across all reviews.  The results of the audits determined that 73 out of 85 indicators were ‘Met.’  An indicator had to be met at 80% or better to be considered ‘Met’ across all sites. Overall the programs were at 86% compliance with all indicators rated.

LICENSURE FINDINGS
	
Met / Rated	
Not Met / Rated	
% Met	

Organizational	
6/10	
4/10	

Residential and Individual Home Supports	
69/77	
8/77	

	

    Residential Services
    Individual Home Supports	

	

	

	

Critical Indicators	
8/8	
0/8	

Total	
75/87	
12/87	
86%	

Two-Year License	

	

# Indicators for 60 Day Follow-up	

12	

		
Met / Rated	
Not Met / Rated	

% Met	

Organizational	
6/10	
4/10	

Employment and   Day Supports	
36/39	
3/39	

    Employment Support Services
    Center Based Employment	

	

	

	

Critical Indicators	
6/6	
0/6	

Total	
42/49	
7/49	
86%	

Two-Year License	

	

# Indicators for 60 Day Follow-up	

7	

	

Organizational Areas Needing Improvement on Standards Not Met/Follow-up to Occur:
From DDS Review:	
  	Indicator #	Indicator	Area Needing Improvement	

 

 
 
 	 L48	The agency has an effective Human Rights Committee.	One or more of the agency's three Human Rights Committees (HRC's) need to meet requirements in terms of frequency of meetings, conduct of regular site visits, dissemination of minutes to the DDS Human Rights Specialists, at least annual review of the agency's policies in regard to human rights, ensuring that all inter-ventions come before the full HRC for approval, and seeking a waiver for any HRC's that serve locations in multiple DDS regions.	

 	 L65	Restraint reports are submitted within required timelines.	All restraint reports need to be submitted within the required time frames.	

 	 L66	All restraints are reviewed by the Human Rights Committee.	All Restraints need to be reviewed by the agency's Human Rights Committees within required time lines.	

 	 L74	The agency screens prospective employees per requirements.	All employees need to undergo reference checks, as per agency policy.	

Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur:
From Provider Review:	
 
 	Indicator #	Indicator	Issue Identified	Action Planned To Address	

 

 

 

 	 L1	Individuals and guardians are trained in how to report alleged abuse/ neglect.	There has been drift in the materials distributed to guardians and reviewed with individuals supported.  Some of the packets no longer contained sufficient information about reporting abuse and neglect.	Once the issue was identified, programs added abuse and neglect reporting information to packets and distributed to guardians.  All materials will be reviewed and a standardized packet will be distributed to program managers to distribute to guardians and train individuals supported.  In addition the packet of information will be uploaded onto our email server as a standardized packet for access and ease of use.	

 

 	 L43	The health Care Record is maintained and up-dated as required.  	Some of the Health Care Records on HCSIS did not include information noted on the EFS, physician’s orders, and/or ISP.	Ongoing monitoring will occur to ensure the HCR is updated when the physician’s orders or status change occurs.  Point persons will be appointed at each program to maintain and update the HCR.	

Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur:
From Provider Review:	
 
 	Indicator #	Indicator	Issue Identified	Action Planned To Address	

 

 
 
 	 L61	Supports and health- related protections are included in ISP assess-ments and the continued need is outlined.	Some supports and health-related protections were not included in the ISP assessments or ISP.	Programs will provide re-training to program managers re: ensuring supports and health-related pro-tections are included in the ISP assessments.  Managers will also be reinforced to continue to follow up with Service Coordinators to ensure the appropriate information is included in the ISP.	

 

 

 
 	 L65	Restraint Reports are submitted within required timelines.	Some Restraint Reports were out of compliance with timelines for submission and others were out of compliance with timelines for restraint manager review.	The agency has worked to increase compliance rates sub-stantially over the past two years.  The QI Department will continue to conduct regular reviews of the restraint reporting and provide feedback on compliance.  Programs will identify additional back-up employees for both restraint report entry into HCSIS and Restraint Managers review   to ensure timelines are met.

 	 L79	Staff are trained in safe and correct administration of restraint.	Some sites did not have enough trained authorizers.	Moving forward, all staff will be trained as authorizers.  Attempts will be made to ensure all restraint trainers are also approved restraint authorizer trainers therefore the annual training can be complete in conjunction with initial restraint training and annual refresher training.

 
 	 L86	Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	For all individuals reviewed, the assessments were present.  Some files were missing documentation of when the assessments were submitted to DDS, so it could not be determined if they met the timelines for submission.
	Now that all ISP assessments are submitted on HCSIS, submission dates will be maintained in the system.	
 
 	 L87	Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	For all individuals reviewed, support strategies were present.  Some files were missing documentation of when the strategies were submitted to DDS, so it could not be determined if they met the timelines for submission.
	Now that all support strategies are submitted on HCSIS, submission dates will be maintained in the system.	

Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur:
From Provider Review:	
 
 	Indicator #	Indicator	Issue Identified	Action Planned To Address	
	 L88	Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.	Some goals were not implemented at the frequency identified in the ISP.	The agency will increase monitoring reviews of compliance with implementing goals at the frequency designated in the ISP.  Staff will receive additional training and feedback on imple-mentation techniques and alternate activities.

Employment/Day Areas Needing Improvement on Standards Not Met/Follow-up to Occur:
From DDS Review:	
 
 	Indicator #	Indicator	Area Needing Improvement	

 

 

 

 
 	 L85	The agency provides on-going supervision and staff development	In relation to both center-based work and the enclave setting, staff need additional support tailored to increasing their understanding of how to best assist people to reach their potentialities in relation to exploring a full range of day support options, particularly community employment, and to facilitate the transition away from the sheltered workshop model.  Although the agency had recently implemented a more structured process for providing supervision, documentation reviewed for the past year indicated a lack of consistent staff development and on-going supervision in relation to job exploration and job placement.  These lacks contributed to lessened opportunities for people to develop alternatives to sheltered work, including fewer opportunities for employment that matched people's skills and interests. 

 
  
 	 L87	Support strategies necessary to assist an individual to meet their goals and objec-tives are completed and submitted as part of the ISP.
	All support strategies need to be submitted within the required time frames.	

  
 	 L88	Services and support strategies identified and agreed upon in the ISP for which the provider has designated responsibility are being implemented.
	The agency needs to ensure that staff are knowledgeable about support strategies and these strategies are being implemented as designed. 	

 

CERTIFICATION FINDINGS

	
Reviewed By	
Met / Rated	
Not Met / Rated	

Certification - Planning and Quality Management	
DDS	
5/6	
1/6	

Residential and Individual Home Supports

	

	

	

	

	
Reviewed By	
Met / Rated	
Not Met / Rated	

Certification - Planning and Quality Management	
DDS	
5/6	
1/6	

Employment and Day Supports	

	

    Center Based Employment	
DDS	
7/14	
7/14	

    Employment Support Services	
DDS	
2/2	
0/2	

			
 
Planning and Quality Management Area Needing Improvement on Standard Not Met From DDS Review:	
Indicator #	Indicator	Area Needing Improvement	
 C6	The provider has mechanisms to   plan for future directions in service delivery and implements strategies   to actualize these plans.	While a planning process was in the development stage in regard to future directions for the agency's day supports, these plans were still in the early stages of implementation, and will need to be more fully actualized.	

Center-Based Employment - Areas Needing Improvement on Standards Not Met From DDS Review:	
Indicator #	Indicator	Area Needing Improvement	
 C22	Staff have effective methods to assist individuals to explore their job interests.	The agency recently assessed individuals' job interests; however, these interests were not fully identified or actualized as evident by recent assessments. 
	
 C23	Staff utilize a variety of methods to assess an individual's skills, interests, career goals and training and support needs in employment.	In 4/4 reviews, vocational annual assessments indicated that "no additional recommendations or service needs are needed at this time."  The agency needs to ensure that assessment results provide feedback to the individual to enable the development of job skills or proficiencies relative to their career goals. 
	
 C25	Staff assist individuals to work on skill development for job attainment and success.	The agency needs to ensure that goals and objectives are operationalized to evaluate the progress for individuals to be successful in job attainment. 
	
 C34	The agency provides the optimal level of support to promote success with a specific plan for minimizing supports.	The agency needs to ensure that planning includes strategies to match individual learning styles and periodic feedback on job performance in an effort to fade supports to promote successful future community employment. 

Center-Based Employment- Areas Needing Improvement on Standards Not Met From DDS Review, cont.:	
Indicator #	Indicator	Area Needing Improvement	
 C35	Individuals are given feedback on job performance by their employer.	The agency needs to ensure that feedback is provided in an ongoing and timely manner and offers guidance regarding future skill development in an effort to continually improve performance.  
	
 C38	Specific habilitative and behavioral goals necessary to prepare individuals for work are identified.	The agency needs to ensure that habilitative and behavioral goals are developed in accordance with individuals' unique needs including strategies to address any obstacles to employment. 
	
 C39	There is a plan developed to identify job goals and support needs that would lead to movement into supported employment.	The agency needs to ensure that a detailed plan     is in place which identifies the progression of individuals' skills, abilities or competencies necessary for supported employment. 

MASTER SCORE SHEET LICENSURE
Organizational: 

	Indicator #	Indicator	Met/Rated	Rating                           (Met, Not Met, Not Rated)	
O	 L2	Abuse/Neglect reporting	23/23	Met	
 	 L3	Immediate Action	15/15	Met	
 	 L4	Action taken	7/7	Met	
 	 L48	Human Rights Committee 	0/3	Not Met (0%)	
 	 L65	Restraint Report submit	77/118	Not Met (65.25%)	
 	 L66	HRC restraint review	76/106	Not Met (71.70%)	
 	 L74	Screen employees	8/13	Not Met (61.54%)	
 	 L75	Qualified staff	4/4	Met	
 	 L76	Track trainings	17/20	Met (85%)	
 	 L83	Human Rights training	23/23	Met	

Residential and Individual Home Supports:
	
Indicator #	
Indicator	Location or Individual Indicator	
Reviewed By	
Residential Supports	
Individual Home Support	
Place-ment Support	
Respite Support	
Total Met/ Rated	
Rating	
 
 	 L1	Abuse/Neglect training	I	Provider	-	-			-	Not Met	
 	 L4	Action taken
	L	Provider	-	-			-	Met	
 	 L5	Safety Plan
	L 	Provider	-	-			-	Met	
O	 L6	Evacuation
	L	DDS	19/19	2/2			21/21	Met	
 	 L7	Fire Drills
	L 	Provider	-	-			-	Met	
 	 L8	Emergency Fact Sheets	I	DDS	18/19	3/3			21/22	Met
(95.45%)	
 	 L9	Safe use of equipment	L 	Provider	-	-			-	Met	
	 L10	Reduce risk interventions	I 	Provider	-	-			-	Met	
O	 L11	Required inspections	L	DDS	17/19	 			17/19	Met
(89.47%)	
O	 L12	Smoke detectors	L	DDS	19/19				19/19	Met	
O	 L13	Clean location
	L	DDS	19/19				19/19	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	
	 L25	Dangerous substances	L 	Provider	-	-			-	Met	
	 L26	Walkway safety	L 	Provider	-	-			-	Met	
	 L28	Flammables	L 
	Provider	-	-			-	Met	
	 L29	Rubbish/Com-bustibles	L 	Provider	-	-			-	Met	
	 L30	Protective railings	L 	Provider	-	-			-	Met	
Residential and Individual Home Supports, cont.
	
Indicator #	
Indicator	Location or Individual Indicator	
Reviewed By	
Residential Supports	
Individual Home Support	
Place-ment Support	
Respite Support	
Total Met/ Rated	
Rating	
	 L31	Communica-tion 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	12/15	  			12/15	Met
(80%)	
	 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	-	-			-	Not Met	
	 L44	MAP Registration	L 	Provider	-	-			-	Met	
	 L45	Medication storage	L 	Provider	-	-			-	Met	
	 L46	Medication administration	I	DDS	17/19	  			17/19	Met
(89.47%)	
	 L47	Self- medication	I	DDS	12/12	2/2			14/14	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	DDS	7/7				7/7	Met	
	 L56	Restrictive practices	I	DDS	11/12				11/12	Met
(91.67%)	
	 L57	Written Behavior Plans	I 	Provider	-	-			-	Met	

Residential and Individual Home Supports, cont.
	
Indicator #	
Indicator	Location or Individual Indicator	
Reviewed By	
Residential Supports	
Individual Home Support	
Place-ment Support	
Respite Support	
Total Met/ Rated	
Rating	
 	 L58	Behavior Plan component	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	-	-			-	Not Met	
	 L62	Health protect-tion review	I 	Provider	-	-			-	Met	
	 L63	Medication Treatment Plan form	I	DDS	18/18	 			18/18	Met	
	 L64	Medication Treatment Plan review	I 	Provider	-	-			-	Met	
	 L65	Restraint Report submit	L 	Provider	-	-			-	Not Met	
	 L67	Money Management 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	-	-			-	Not Met	
	 L80	Symptoms of illness	L	DDS	19/19	3/3			22/22	Met	
	 L81	Medical emergency	L 	Provider	-	-			-	Met	
O	 L82	Medication admin.	L	DDS	19/19	 
 			19/19	Met	
	 L84	Health protect. Training	I 	Provider	-	-			-	Met	
	 L85	Supervision
 	L	Provider	-	-			-	Met	
	 L86	Required assessments	I	Provider	-	-			-	Not Met	
  	 L87	Support strategies	I	Provider	-	-			-	Not Met	
 	 L88	Strategies implemented	I 	Provider	-	-			-	Not Met	

Residential and Individual Home Supports, cont.
	
Indicator #	
Indicator	Location or Individual Indicator	
Reviewed By	
Residential Supports	
Individual Home Support	
Place-ment Support	
Respite Support	
Total Met/ Rated	
Rating	
  
 	#Std. Met/77 Indicators								69/77		
  	Total Score								75/87		

 								86.21%		

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	3/3	4/4	  	7/7	Met	
 	 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	  	3/4	  	3/4	Met	
 
	 L9	Safe use of equipment	L	1/1	1/1		2/2	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	
 	 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/Combustibles
	L	  	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	
	 L31	Communication method
	I	3/3	4/4		7/7	Met	
	 L32	Verbal & written
	I	3/3	4/4		7/7	Met	
	 L37	Prompt treatment
	I		4/4		4/4	Met	
O	 L38	Physician's orders
	I		1/1		1/1	Met	
	 L39	Dietary requirements
	I		1/1		1/1	Met	
	 L49	Informed of human rights
	I	3/3	4/4		7/7	Met	
	 L50	Respectful 
communication	L	1/1	1/1		2/2	Met	
 	 L51	Possessions
	I	 	4/4	 	4/4	Met	
 	 L52	Phone calls
	I	3/3	4/4	 	7/7	Met	
 	 L54	Privacy
	L	 	1/1	 	1/1	Met	

	 L72	DOL requirements	I		4/4		4/4	Met	

	 L73	DOL Certificate	L		1/1		1/1	Met	
  
	 L77	Unique needs training	I	   	3/3	 	3/3	Met	
 
 	 L80	Symptoms of illness	L	1/1	1/1		2/2	Met	
 
	 L81	Medical emergency	L	1/1	1/1		2/2	Met	
 
	 L85	Supervision 	L	0/1	0/1		0/2	Not Met
(0%)	
 
	 L86	Required assessments	I	  	3/4		3/4	Met	
 
	 L87	Support strategies	I	  	2/4		2/4	Not Met
(50%)	
 
 	 L88
	Strategies implemented	I	3/3	2/4		5/7	Not Met
(71.43%)	
  	#Std. Met/39 Indicators	 					36/39	 	

 	Total Score	 

 	 
 	 
 	42/49	

	 	85.71%	 	

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	0/1	Not Met	

Center-Based Employment Reviewed By DDS:
Indicator #	Indicator	Met/Rated	Rating	
 C7	Feedback on staff performance	4/4	Met	
 C8	Family/guardian communication	4/4	Met	
 C22	Explore job interests	0/4	Not Met (0%)	
 C23	Assess skills & training needs	0/4	Not Met (0%)	
 C24	Job goals & support needs plan	4/4	Met	
 C25	Skill development	0/4	Not Met (0%)	
 C27	Job benefit education	4/4	Met	
 C31	Job accommodations	4/4	Met	
 C33	Employee benefits explained	4/4	Met	
 C34	Support to promote success	0/4	Not Met (0%)	
 C35	Feedback on job performance	0/4	Not Met (0%)	
 C37	Interpersonal skills for work	4/4	Met	
 C38	Habilitative & behavioral goals	1/4	Not Met (25%)	
 C39	Support needs for employment	2/4	Not Met (50%)	

Employment Support Services Reviewed By DDS:
Indicator #	Indicator	Met/Rated	Rating	
 	 C7	Feedback on staff performance	3/3	Met	
 	 C8	Family/Guardian communication	3/3	Met