SUMMARY OF OVERALL FINDINGS

Provider:  The Arc of the South Shore, Inc.

Review Dates:  June 20 – 25, 2014

Service Enhancement Meeting Date:  July 2, 2014

Survey Team:  Scott F. Nolan (TL), Sally Hajjar, Michael Marchese, and Edward Sutka
 
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	4 Locations 9 Audits 	Full Review	78 / 82 
Two-Year License 07/02/2014 - 07/02/2016	 

 	 

 	
Residential Services	2 Locations 6 Audits	 
 	 
 	DDS Targeted Review	0 / 0 Certified	
Individual Home Supports	2 Locations 3 Audits	 
 	 
 	DDS 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	4 Locations 10 Audits	Full Review	60 / 61   Two-Year License 07/02/2014 - 07/02/2016	 

 	 

 	
Community-Based Day Services	1 Location   3 Audits 	 
 	 
 	DDS Targeted Review	0 / 0 Certified	
Employment Support Services	2 Locations 4 Audits 	 
 	 
 	DDS Targeted Review	0 / 0 Certified	
Center-Based Employment	1 Location  3 Audits 	 
 	 
 	DDS Targeted Review	0 / 0 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	DDS Targeted Review	0/0 Certified	

EXECUTIVE SUMMARY

The Arc of the South Shore, Inc. has provided advocacy, supports, and services to children and adults with developmental and intellectual disabilities throughout the South Shore area since 1951.  The agency's mission, 'to provide the highest quality services and advocacy for children and adults with cognitive, physical, and other intellectual and developmental disabilities' serves as its overriding foundation.

The agency earned a Two-Year License for its Residential and Employment/Day Services during its previous review by the Department of Developmental Services (DDS) in 2012.  For the current review the agency was eligible to conduct a self-assessment for all Licensure and Certification indicators as it met 100% of the indicators in all DDS contracted supports in 2012.  However, it chose to have a full Licensure review conducted by DDS.  The current review consisted of six audits conducted at two 24-hour residences, three audits at 2 locations that provided less than 24-hour supports, three audits within Community-Based Day Support, Center-Based Employment, and four audits within Employment Support Services.

Since the last Licensure and Certification Review, the agency has reorganized and restructured its medical oversight within its residential supports.  For example, the agency has assigned a house manager to each residential home, a registered nurse was hired to provide oversight for medically involved individuals and to provide support to residential staff, and the agency hired a part-time MAP consultant.  Additionally, since the last review, the agency has made major capital improvements to many of their residential homes and to their day site.  Several of these improvements included new roofs, windows, and replacing full kitchens.  

During the current survey several areas of strength were evident.  For example, the team observed that the agency consistently ensured the provision of extensive medical care, oversight, and monitoring.  Additionally, in both residential and day/employment services the mutually respectful relationships established over time with individuals was apparent.  While across the agency staff were knowledgeable of their mandated reporting responsibilities, at one residential location, staff were unable to clearly identify their mandated reporting responsibilities and could benefit from additional training in this area.

The agency continues to demonstrate its commitment to transition individuals from Center-Based Employment to broader based community models.  The agency has developed collaborative relationships with external stakeholders to assess and maximize individuals' skills in a number of areas such as personal development, community integration, and employment vocational training.  These efforts have resulted in greater involvement in the local community. 

The Arc of the South Shore is congratulated for receiving a Two-Year License for both its Day and Residential supports.  The agency met 95% of its residential indicators and 98% of its Employment and Day Services indicators.  The agency is eligible to conduct its own follow-up for those indicators that were rated, 'Not Met' within 60 days of the Service Enhancement Meeting.

	

LICENSURE FINDINGS

 	

Met / Rated	
Not Met / Rated	

% Met	

Organizational	
9/10	
1/10	

Residential and Individual Home Supports	
69/72	
3/72	

	

  Residential 
    Services
  Individual Home 
    Supports

	

	

	

Critical Indicators	
8/8	
0/8	

Total	
78/82	
4/82	
95%	

Two-Year License	

	

# Indicators for 60 Day Follow-up	

4	

	 

Met / Rated	
Not Met / Rated	

% Met	

Organizational	
9/10	
1/10	

Employment and Day Supports	
51/51	
0/51	

  Community-Based 
    Day Services
  Employment
    Support Services
  Center-Based  
    Employment	

	

	

	

Critical Indicators	
8/8	
0/8	

Total	
60/61	
1/61	
98%	

Two-Year License	

	

# Indicators for 60 Day Follow-up	

1	

	

Organizational Area Needing Improvement on Standard Not Met/Follow-up to Occur:	
 	Indicator #	Indicator	Area Needing Improvement	

 	 L65	Restraint Reports are submitted within required timelines.	The manager's review of the restraint needs to be submitted to the area office within 5 days of the occurrence.	

Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur:	
 
 	Indicator #	Indicator	Area Needing Improvement	

 

 	 L67	There is a written plan in place accompanied by a training plan when the agency has shared or delegated money management responsibility.	The agency needs to ensure that money management training plans contain all required components.  This includes a written strategy to support individuals to actively participate and develop skills in the management of money on both a daily and long-term basis to promote individual involvement and independence.

  
 
 	 L86	Required assessments concerning individual needs and abilities are completed in preparation for the ISP.	The agency needs to ensure that required assessments are submitted within DDS timelines.	

Residential Areas Needing Improvement on Standards Not Met/Follow-up to Occur, cont.	
 
 	Indicator #	Indicator	Area Needing Improvement	

 
 
 	 L87	Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP.	The agency needs to ensure that required assessments are submitted within DDS timelines.	

MASTER SCORE SHEET LICENSURE
 Organizational: 

Indicator #
	
Indicator	
Met/Rated	
Rating
(Met, Not Met, Not Rated)	
O	 L2	Abuse/Neglect reporting	6/7	Met (85.71% )	
 	 L3	Immediate Action	1/1	Met	
 	 L4	Action taken	1/1	Met	
 	 L48	Human Rights Committee	1/1	Met	
 	 L65	Restraint Report submit	0/1	Not Met (0% )	
 	 L66	HRC restraint review	1/1	Met	
 	 L74	Screen employees	2/2	Met	
 	 L75	Qualified staff	1/1	Met	
 	 L76	Track trainings	9/9	Met	
 	 L83	Human Rights training	9/9	Met	

Residential and Individual Home Supports:
	
Indic. #	
Indicator	
Location or Individual	
Res. Supports	
Indiv. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Supports	
ABI-MFP Place-ment	
Total Met/ Rated
	
Rating	

 	 L1	Abuse/Neglect training	I	6/6	3/3					9/9	Met	
O	 L2	Abuse/Neglect reporting	L	 
 
 	1/1					1/1	Met	
 
 	 L5	Safety Plan	L	2/2	1/1					3/3	Met	
O	 L6	Evacuation	L	2/2	2/2
					4/4	Met	
 
 	 L7	Fire Drills	L	2/2	 
 					2/2	Met	

Residential and Individual Home Supports, cont.
	
Indic. #	
Indicator	
Location or Individual	
Res. Supports	
Indiv. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Supports	
ABI-MFP Place-ment	
Total Met/ Rated
	
Rating	
 
 	 L8	Emergency Fact Sheets	I	5/6	3/3					8/9	Met
(88.89%)	
  
 	 L9	Safe use of equipment	L	2/2	2/2					4/4	Met	
  
 	 L10	Reduce risk interventions	I	 
  	1/1					1/1	Met	
O	 L11	Required inspections	L	2/2	1/1					3/3	Met	
O	 L12	Smoke detectors	L	2/2	1/1					3/3	Met	
O	 L13	Clean location	L	2/2	1/1
					3/3	Met	
  	 L14	Site in good repair	L	2/2	1/1					3/3	Met	

 	 L15	Hot water	L	2/2	1/1					3/3	Met	
 
 	 L16	Accessibility	L	2/2	1/1					3/3	Met	
 
 	 L17	Egress at grade 	L	2/2	1/1					3/3	Met	
  
 	 L18	Above grade egress	L	2/2	  
 					2/2	Met	
 
 	 L19	Bedroom location	L	2/2	1/1					3/3	Met	
 
 	 L20	Exit doors	L	2/2	1/1					3/3	Met	
  
 	 L21	Safe electrical equipment	L	2/2	1/1					3/3	Met	
	 L22	Clean appliances	L	2/2	1/1					3/3	Met	
	 L23	Egress door locks	L	2/2						2/2	Met	
	 L24	Locked door access	L	1/1						1/1	Met	
	 L25	Dangerous substances	L	2/2	1/1					3/3	Met	
	 L26	Walkway safety	L	2/2	1/1					3/3	Met	
	 L28	Flammables	L	2/2	1/1	
				3/3	Met	
	 L29	Rubbish/combustibles	L	2/2	1/1					3/3	Met	
	 L30	Protective railings	L	2/2	1/1					3/3	Met	
	 L31	Communication 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	
Residential and Individual Home Supports, cont.
	
Indic. #	
Indicator	
Location or Individual	
Res. Supports	
Indiv. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Supports	
ABI-MFP Place-ment	
Total Met/ Rated
	
Rating	
	 L34	Dental exam	I	6/6	3/3
					9/9	Met	
	 L35	Preventive screenings	I	6/6	2/2					8/8	Met	
	 L36	Recommended tests	I	6/6	2/2					8/8	Met	
	 L37	Prompt treatment	I	6/6	2/2					8/8	Met	
O	 L38	Physician's orders	I	1/1	1/1					2/2	Met	
  	 L39	Dietary requirements	I	4/4	1/1					5/5	Met	
 
 	 L40	Nutritional food	L	2/2	1/1					3/3	Met	

 	 L41	Healthy diet	L	2/2	2/2					4/4	Met	
 
 	 L42	Physical activity	L	2/2	2/2					4/4	Met	
 	 L43	Health Care Record	I	4/5	3/3					7/8	Met
(87.50%)	
  	 L44	MAP registration	L	2/2	  					2/2	Met	
  
 	 L45	Medication storage	L	2/2	  
 					2/2	Met	
O	 L46	Medication administration	I	6/6	  
 					6/6	Met	
	 L47	Self-medication	I	0/1	3/3					3/4	Met	
	 L49	Informed of human rights	I	6/6	3/3					9/9	Met	
	 L50	Respectful communication	L	2/2	2/2					4/4	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	2/2	1/1
					3/3	Met	
 
 	 L55	Informed consent	I	5/5	1/1					6/6	Met	
	 L56	Restrictive practices	I	2/2						2/2	Met	
	 L61	Health protection in ISP	I	5/5						5/5	Met	
	 L62	Health protection review	I	5/5						5/5	Met	

Residential and Individual Home Supports, cont.
	
Indic. #	
Indicator	
Location or Individual	
Res. Supports	
Indiv. Home Supports	
Place-ment	
Respite	
ABI-MFP Res. Supports	
ABI-MFP Place-ment	
Total Met/ Rated
	
Rating	
	 L63	Medication Treatment Plan form	I	4/4						4/4	Met	
	 L64	Medication Treatment Plan review	I	2/2						2/2	Met	
	 L65	Restraint Report submit	L	1/1						1/1	Met	
	 L67	Money Mgmt. Plan	I	4/6	2/2					6/8	Not Met
(75%)	
	 L68	Funds expenditure	I	6/6	2/2					8/8	Met	
  	 L69	Expenditure tracking	I	6/6	2/2					8/8	Met	
  	 L70	Charges for care calc.	I	6/6	2/2					8/8	Met	

 	 L71	Charges for care appeal	I	6/6	2/2					8/8	Met	
	 L77	Unique needs training	I	6/6	3/3					9/9	Met	
	 L78	Restrictive Int. Training	L	 
  	1/1					1/1	Met	
	 L80	Symptoms of illness	L	2/2	2/2					4/4	Met	
	 L81	Medical emergency	L	2/2	2/2					4/4	Met	
O	 L82	Medication administration	L	2/2						2/2	Met	

 	 L84	Health Protec-tion Training	I	5/5						5/5	Met	
	 L85	Supervision 	L	2/2	2/2
					4/4	Met	
	 L86	Required assessments	I	6/6	1/3					7/9	Not Met
(77.78%)	
	 L87	Support Strategies	I	5/6	1/3					6/9	Not Met
(66.67%)	
	 L88	Strategies implemented	I	6/6	3/3					9/9	Met	
# Std. Met/72 Indic.									69/72		
Total Score	
								78/82		

								95.12%		

Employment and Day Supports:
	
Indicator #	
Indicator	
Location     or 
Individual
	
Employment Supports	
Center- Based Work	
Community- Based Day	
Total Met / Rated	
Rating	
 
 	 L1	Abuse/Neglect training	I	4/4	3/3	3/3	10/10	Met	
 	 L5	Safety Plan	L	1/1	1/1
	 	2/2	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	3/3	3/3	9/10	Met
(90%)	

 	 L9	Safe use of equipment	L	2/2	1/1	 
 	3/3	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	
 	 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/Combus-tibles	L	 
 	1/1	 
 	1/1	Met	
 
 	 L31	Communication method	I	4/4	3/3	3/3	10/10	Met	
 
 	 L32	Verbal & written	I	4/4	3/3	3/3	10/10	Met	
 
 	 L37	Prompt treatment	I	3/3	 
 	3/3	6/6	Met	
O	 L38	Physician's 
orders	I	1/1	3/3	3/3	7/7	Met	
 
 	 L44	MAP 
registration	L	1/1	1/1	 
 	2/2	Met	
 
 	 L45	Medication
 storage	L	1/1	1/1	 
 	2/2	Met	
Employment and Day Supports, cont.
	
Indicator #	
Indicator	
Location     or 
Individual
	
Employment Supports	
Center- Based Work	
Community- Based Day	
Total Met / Rated	
Rating	
O	 L46	Medication administration	I	 
 	3/3	1/1	4/4	Met	
 
 	 L49	Informed of human rights	I	4/4	3/3	3/3	10/10	Met	

 	 L50	Respectful communication	L	2/2	1/1	1/1	4/4	Met	
 	 L51	Possessions
	I	4/4	3/3	3/3	10/10	Met	
 	 L52	Phone calls
	I	4/4	3/3	3/3	10/10	Met	
	 L54	Privacy
	L	2/2	1/1	1/1	4/4	Met	
 
 	 L55	Informed consent	I	2/2	3/3	  	5/5	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			1/1	1/1	Met	
 
 	 L64	Medication Treatment Plan review	I			1/1	1/1	Met	
 
 	 L67	Money Management Plan	I		3/3	3/3	6/6	Met	
 
 	 L68	Funds 
expenditure	I		3/3	3/3	6/6	Met	
 
 	 L69	Expenditure tracking	I		3/3	3/3	6/6	Met	
 
 	 L72	DOL 
requirements	I	3/3	3/3	 
 	6/6	Met	
 	 L73	DOL 
Certificate	L	 	1/1	 	1/1	Met	
 
 	 L77	Unique needs training	I	2/2	2/2	3/3	7/7	Met	
 
 	 L78	Restrictive Intervention Training	L	1/1	 
 	1/1	2/2	Met	
 
 	 L80	Symptoms of illness	L	2/2	1/1	1/1	4/4	Met	
 
 	 L81	Medical emergency	L	2/2	1/1	1/1	4/4	Met	
O	 L82	Medication administration	L	1/1	1/1	 
 	2/2	Met	
  	 L84	Health Protection Training	I	  	  	2/2	2/2	Met	
 	 L85	Supervision 
	L	2/2	1/1	1/1	4/4	Met	
 
 	 L86	Required assessments	I	4/4	3/3	3/3	10/10	Met	

Employment and Day Supports, cont.
	
Indicator #	
Indicator	
Location     or 
Individual
	
Employment Supports	
Center- Based Work	
Community- Based Day	
Total Met / Rated	
Rating	
 
 	 L87	Support   Strategies	I	4/4	3/3	3/3	10/10	Met	
 
 	 L88	Strategies implemented	I	4/4	3/3	3/3	10/10	Met	

 	#Std. Met/51 Indicators						51/51	  	
 
 	Total Score	 

 	 
 	 
 	60/61	 
 	
 	 	 	 	 	 	 	98.36%