SUMMARY OF OVERALL FINDINGS
Provider:  Southeastern Massachusetts Educational Collaborative
Review Dates:  January 31 – February 5, 2013
Service Enhancement Meeting Date:  February 15, 2013
Survey Team:  Edward Sutka (TL), and Laura K. O’Connor
Citizen Volunteer:  Joseph MacDonald
 
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	2 Locations 
6 Audits 	Targeted Review	DDS 8 / 9
Provider 62 / 62
              70 / 71 
Two-Year License 02/15/2013 - 02/15/2015	 

  

 	 

  

 	
Residential Services	1 Location     2 Audits 	 

 
 	Provider Targeted Review	0 / 0 Certified	
Individual Home Supports	1 Location      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      4 Audits	Targeted Review	DDS 8 / 9
Provider 43 / 43
              51 / 52 
Two-Year License 02/15/2013 - 02/15/2015	 

 

 	 

 

 	
Employment Support Services	1 Location      4 Audits	 

 
 	Provider Targeted Review	1 / 1 Certified - with all indicators std. met.	
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

Supporting Adults for inclusive Living (SAIL) is a component of the Southeastern Massachusetts Educational Collaborative (SMEC).  SAIL supports well over 100 individuals and accounts for approximately half of the individuals working in competitive employment who are funded by the Department of Developmental Services (DDS) New Bedford Area Office.  While the administrative offices for both SMEC and SAIL are located in New Bedford, competitive job placements supported by SAIL can be found both in the greater New Bedford area as well as in other parts of southeastern Massachusetts.  While employment supports constitute SAIL's largest component, SAIL also provides residential supports for people who receive either 24 hours or a lesser amount of support each day.

This review by DDS focused on the DDS funded day and residential services provided by the SAIL program.  A high percentage of people who had been supported by SMEC before becoming adults chose to continue to receive supports through SAIL once they entered the adult system.  While SAIL's day supports concentrate on offering people individualized employment options, the adult day health model, which did not fall within the scope of this review, is also offered within SMEC's continuum of services for those who chose not to pursue employment options.  Among SAIL components not encompassed by this review are an "Evening Program" and a "Community Day Program" which offer people recreational and skill building opportunities.    

Because the provider earned a Two-Year License during the previous DDS review (February 2011), the provider was eligible for and elected to conduct a self-assessment on all applicable licensure indicators and have a DDS targeted review in lieu of a full review for both service groupings (Residential/Individual Home Supports and Employment/Day Supports).  The DDS targeted review was one in which the DDS survey team rated the 8 licensing indicators considered critical, as well as the three other licensing indicators that had been rated not met in the previous review.  In addition to the DDS ratings for these eleven indicators, the agency completed a self-assessment for both day and residential services which evaluated all 88 indicators in the licensure tool, as well as the one certification outcome that had been rated not met in the previous review.  The eleven ratings given by the DDS survey team were combined with the ratings from the agency's self-assessment for the other indicators to produce an overall licensure rating of 99% "standards met" in residential services and 98% "standard met" in day services.  As a result of these combined ratings, the agency received Two-Year Licenses for Residential/Individual Home Supports and Employment/Day Supports.  Only one indicator, which pertained to the agency's Human Rights Committee that had been rated “Not Met” in the 2011 survey was still rated “Not Met” in the current review. 

Within the scope of the review by the DDS survey team, a consistent pattern of effective systems was found to be in place to ensure people's health and safety, and agency staff were found to be responsive to any suggestions or recommendations made by the surveyors during the course of the review.  The survey team also noted that that the agency's retention of key long-term staff who knew individuals well aided in the effectiveness of the agency's safeguard systems to protect individuals' well-being.  The agency is congratulated for its continued success in providing a high level of service quality for those whom it supports.  The provider self-assessment of its day and residential supports is described in the following section of this report.

Description of Self-Assessment Process

OVERVIEW:  Our self-assessment process starts with input from Direct Care Staff, is reviewed and supplemented with information from Team Leaders and Supervisors until the material is garnered accurately, and finalized by the Administrative Team. Our main means of collecting such data is through our Required Monthly Duties checklist.  This packet, which is handed to each department supervisor, informs them on paperwork due monthly to ensure compliance with QE indicators and DDS regulations.  Through this tool, supervisors are instructed on timelines to collect Progress Notes from staff, which ISP Quarterly and Semi-Annual Reports are due, and when staff's re-certifications are due.  These checklists serve as reminders for forms that are required periodically such as home inspections, Safety Plans, staff evaluation deadlines, fire drill schedules, self-medication dates, and proof of vehicle insurance, among other things.

In addition to our monthly checklists, SAIL Team Leaders and Supervisors visit each home and employment site we support to interact first hand with consumers, staff and employers. Supervisors submit department summaries and status reports that include findings within the home and workplace that provide pertinent information to the Administrative Team such as job performance, exercise routines, meal plans and eating habits, and medication compliance.

A new assessment mechanism that SAIL has implemented for this audit cycle are our Monthly and Quarterly QE Assessment Tool checklists that are used in our Community Program and for each home in which we provide supports. These new tools address specific indicators appropriate to living conditions and ensure that all eight critical indicators are consistently being reviewed. They incorporate a variety of factors ranging from environmental concerns, medication administration, health care appointments, and consumer rights; all to reiterate to supervisors and staff how significant these indicators are in providing our consumers with the best supports possible.

The team used random.org to find a sample of 32 consumers from the Employment &amp; Day Support from our population of 124 consumers. This segment, 25% of our total roster, was evaluated by basing the criteria for rating 'standard met' on finding substantial compliance at 80% or more of the locations and/or individuals reviewed. Our agency reviewed the licensing indicators by conducting a self-assessment based on the QE worksheet provided and 100% of the indicators were found in compliance.

For Residential Home Supports, the team surveyed 5 out of 5 of our 24/7 funded residential sites for a 100% sample of the contract roster. The criteria for 'standard met' was based on finding substantial compliance of 80% or above by conducting safeguard reviews at each residence in conjunction with completing the self assessment based on the QE worksheet provided. 100% of the indicators were found to be in compliance with licensure.

HEALTH:  To address health concerns, SAIL has access to the Collaborative's nursing staff. SAIL videotaped our nurse conducting gait belt trainings and has posted epi-pen, colostomy bag care, and seizure protocol trainings so that staff may view these instructional videos on the internet, making many of our trainings much more time effective and easily accessible. SAIL staff has ensured we have doctors' orders for all medically necessary interventions such as wheelchairs and gait belts in addition to all other required paperwork. Case Managers assist consumers in attending medical appointments and keep records of appropriate doctor's visits. Administration also conducts quarterly reviews of HCSIS reports for emerging patterns. Residential logs take into account the ordering and re-filling of medications for each residential individual.

Description of Self-Assessment Process, cont.

HUMAN RIGHTS:  For Human Rights compliance, we conduct Human Rights/DPPC trainings with all staff and consumers on a yearly basis. Human Rights Committee meetings continue to be conducted regularly and systems have been implemented to address the Not Met criteria from our last audit, as will be explained in detail later.
The Administrative Team developed Consumer Handbooks during this cycle to address such issues as bullying, dress codes, complaint procedures, and overall codes of conduct. We have worked with local law enforcement to speak with consumers regarding specific issues. A professional speaker conducted social media appropriateness training for our media savvy population, and we have actively sought out more professional therapists for consumers who have indicated they would like to seek out counseling. With our Supervisory and Administrative offices located here in the building, we are proud of the fact that we foster an environment of availability and have long held an open door policy for when consumers need to discuss a variety of personal matters.

ENVIORNMENTAL SAFETY:  SAIL employs consumers to perform light custodial duties in the building five days a week, and we employ an outside maintenance employee to address concerns four evenings a week. This staff uses a checklist of QE indicator driven criteria to ensure our workplace is in compliance. In addition, we also have the Olympia Tower maintenance crew at our disposal to address any major concerns.
The senior Administrative Team reviews all house and Team Leader logs, Supervisor summaries and QE audit checklists on an ongoing basis to reconcile issues and identify trends that appear over time. Administration meets bi-weekly with the Executive Director of the Collaborative to discuss the status of all departments, consumers, staff and other logistics.

STAKEHOLDERS:  The SAIL team encourages input from consumers, family, and staff in the form of consumer surveys, quarterly correspondence with families and guardians concern supports and goals, and bi-annual staff evaluations.  The Supervisory and Administrative team also promotes an open door policy and assists residentially supported consumers in filling out evaluations pertaining to their house staff. We look to promote from within and work with our staff to provide professional development at every opportunity.

PROGRAMATIC RESTRUCTURING:  During this last audit cycle, Administration has become members of ADDP, are members of Chamber of Commerce, improved staff communication by launching Collaborative email for everyone, and sent Administrators to H.R seminars to improve hiring and training processes.

We have also restructured to address organizational needs.  We now have a Billing Specialist to address accuracy with DDS contracts. We have redefined our Weekend Coordinator's role to include oversight of payroll.

NOT MET CRITERIA: To address the not met areas, our HRC Chairperson now sends out emails and phone calls to remind members of meetings. She specifically calls the member with lower attendance and has an alternate to take his place if given enough notice. The chairperson has also added an additional meeting onto the schedule to increase overall attendance.

Concerning the assessments and strategies that were deemed not met, the Program Manager keeps a list of ISP dates and sends out notice to supervisors for paperwork. Instead of requiring assessments 10 days before and strategies 15 days after an ISP meeting, our office submits paperwork 15 days prior to and 7 days after, to avoid missed deadlines.

Description of Self-Assessment Process/NOT MET CRITERIA, cont.

Our employment team addressed the lack of assessments in the form of obtaining new vocational profiles that serve as evaluations on each consumer, factoring in histories, skills, behaviors, trainings, and personal preferences to discover what positions they are best suited for.  Our Job Developer has attended a Supporting Meaningful Employment course at Rhode Island College to further her job knowledge.  The Job Developer has implemented Person Centered Planning Meetings with consumers and families to discuss career goals.

Our employment team addressed the lack of assessments in the form of obtaining new vocational profiles that serve as evaluations on each consumer, factoring in histories, skills, behaviors, trainings, and personal preferences to discover what positions they are best suited for.  Our Job Developer has attended a Supporting Meaningful Employment course at Rhode Island College to further her job knowledge.  The Job Developer has implemented Person Centered Planning Meetings with consumers and families to discuss career goals.

LICENSURE FINDINGS

 	

Met / Rated	
Not Met / Rated	

% Met	

Organizational	
7/8	
1/8	

Residential and Individual Home Supports	
63/63	
0/63	

 	

  Residential Services
  Individual Home        
     Supports	

 	

 	

 	

Critical Indicators	
6/6	
0/6	

Total	
70/71	
1/71	
99%	

Two-Year License	

 	

# Indicators for 60 Day Follow-up	

1	

	  

Met / Rated	
Not Met / Rated	

% Met	

Organizational	
7/8	
1/8	

Employment and Day Supports
	
41/41	
0/41	

  Employment 
     Support Services

 	

 

Critical Indicators	
8/8	
0/8	

Total	
51/52	
1/52	
98%	

Two-Year License	

 	

# Indicators for 60 Day Follow-up	

1	

	

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

 
 
 	 L48	The agency has an effective Human Rights Committee.	The agency needs to ensure that its Human Rights Committee (HRC) meets the requirements pertaining to attendance of all members, scope and frequency of policy review and site visits, and sharing of meeting minutes with the DDS Human Rights Specialist. 

CERTIFICATION FINDINGS

  
 	
Reviewed By	
Met / Rated	
Not Met / Rated	

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

Residential and Individual Home Supports	
67/67	
0/67	

	

  Residential Services

  Individual Home        
     Supports	
Provider

Provider	
0/0

0/0	
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	

    

 
MASTER SCORE SHEET LICENSURE

Organizational: 
 
 	Indicator
#	
Indicator	Reviewed By	
Met/Rated	Rating
(Met, Not Met, Not Rated)	
O	 L2	Abuse/Neglect reporting	DDS	6/6	Met	
 	 L3	Immediate Action	Provider	-	Met	
 	 L4	Action taken	Provider	-	Met	
 	 L48	HRC	DDS	0/1	Not Met (0%)	
	 L74	Screen employees	Provider	-	Met	
 	 L75	Qualified staff	Provider	-	Met	
 	 L76	Track trainings	Provider	-	Met	
 	 L83	HR training	Provider	-	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	-	-			-	Met	
 	 L5	Safety Plan	L 
	Provider	-	-			-	Met	
O	 L6	Evacuation
	L	DDS	1/1	1/1			2/2	Met	
 	 L7	Fire Drills	L 	Provider	-
	-			-	Met	
	 L8	Emergency Fact Sheets	I 	Provider	-	-			-	Met	
	 L9	Safe use of equipment	L 	Provider	-	-			-	Met	
O	 L11	Required inspections	L	DDS	1/1	1/1			2/2	Met	
O	 L12	Smoke detectors	L	DDS	1/1	1/1			2/2	Met	
O	 L13	Clean location	L	DDS	1/1	1/1			2/2	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/ Combust-ibles	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	2/2	  			2/2	Met	
	 L39	Dietary re-quirements	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	-	-			-	Met	
	 L44	MAP Registration	L 	Provider	-	-			-	Met	
 	 L45	Medication storage	L 	Provider	-	-			-	Met	
	 L47	Self-medica- tion	I 	Provider	-	-			-	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 	Provider	-	-			-	Met	
	 L61	Health pro-tection in ISP
	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	
	 L62	Health protection review	I 	Provider	-	-			-	Met	
	 L63	Medication Treatment Plan form	I 	Provider	-	-			-	Met	
	 L64	Medication Treatment Plan review	I 	Provider	-	-			-	Met	
	 L67	Money Mgmt. Plan	I 	Provider	-	-			-	Met	
	 L68	Funds expenditure	I 	Provider	-	-			-	Met	
 	 L69	Expenditure tracking	I 	Provider	-	-			-	Met	
 	 L77	Unique needs training	I 	Provider	-	-			-	Met	
 	 L80	Symptoms of illness	L 	Provider	-	-			-	Met	
 	 L81	Medical emergency
	L 	Provider	-	-			-	Met	
	 L84	Health protect. Training	I 	Provider	-	-			-	Met	
	 L85	Supervision 	L	Provider	-
	-			-	Met	
	 L86	Required assess-ments	I	DDS	2/2	4/4			6/6	Met	
	 L87	Support Strategies	I	DDS	2/2	4/4			6/6	Met	
	 L88	Strategies imple-mented	I 	Provider	-	-			-	Met	
  
 	# Stds. Met/63 Indicators								63/63	  	
  	Total Score								70/71	  	
 	  								98.59%

Employment and Day Supports:

	Indicator #	Indicator	Location or Individual Indicator	Reviewed by	Employ-ment Support	Center-Based Work	Community- Based Day Support	Total Met / Rated	Rating	
  	 L1	Abuse/Neglect training	I	Provider		-		-	Met	
O	 L2	Abuse/Neglect reporting	L	Provider		-		-	Met	

Employment and Day Supports, cont.

	Indicator #	Indicator	Location or Individual Indicator	Reviewed by	Employ-ment Support	Center-Based Work	Community- Based Day Support	Total Met / Rated	Rating	
 	 L5	Safety Plan	L 	Provider	 	-
	 	-	Met	
O	 L6	Evacuation	L	DDS	1/1
	 	 	1/1	Met	
 	 L7	Fire Drills	L 	Provider	 	-
	 	-	Met	
  	 L8	Emergency Fact Sheets	I 	Provider		-		-	Met	
  	 L9	Safe use of equipment	L 	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	
	 L29	Rubbish/Com-bustibles	L 	Provider		-		-	Met	
	 L28	Flammables	L
	Provider		-		-	Met	
 	 L30	Protective railings	L 	Provider		-		-	Met	
  	 L31	Communication method	I 	Provider		-		-	Met	
  	 L32	Verbal & written	I 	Provider		-
		-	Met	
  	 L37	Prompt treatment	I 	Provider		-		-	Met	
O	 L38	Physicians’ orders	I	DDS	2/2	  		2/2	Met	
  	 L39	Dietary requirements
	I 	Provider	  	-		-	Met	

Employment and Day Supports, cont.

	Indicator #	Indicator	Location or Individual Indicator	Reviewed by	Employ-ment Support	Center-Based Work	Community- Based Day Support	Total Met / Rated	Rating	
	 L44	MAP Registration	I	Provider		-		-	Met	
	 L45	Medication storage	I	Provider		-		-	Met	
O	 L46	Medication administration	I	DDS	1/1	  		1/1	Met	
  	 L49	Informed of human rights	I 	Provider	  	-		-	Met	
 	 L50	Respectful communication	L 	Provider	  	-	  	-	Met	
 	 L51	Possessions	I 	Provider	 	-
	 	-	Met	
 	 L52	Phone calls	I 	Provider	 	-
	 	-	Met	
 	 L54	Privacy	L 	Provider	 	-
	 	-	Met	
	 L55	Informed consent	I 	Provider		-		-	Met	
	 L77	Unique needs training	I 	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	
	 L86	Required assessments	I 	Provider		-		-	Met	
	 L87	Support Strategies	I 	Provider		-		-	Met	
	 L88	Strategies implemented	I 	Provider		-		-	Met	
  
 	# Stds. Met/44 Indicators							44/44	 	
  	Total Score							51/52	  	
 	 	 	 	 	 	 	 	98.08%

MASTER SCORE SHEET CERTIFICATION
 
Employment Support Services Reviewed By Provider:	
Indicator #	Indicator	Met/Rated	Rating	
 C23	Assess skills & training needs	-	Met