DEPARTMENT OF DEVELOPMENTAL SERVICES

LICENSURE AND CERTIFICATION

DDS FOLLOW-UP REPORT

Provider / NEXUS / Provider Address / 888 Main Street , Woburn
Survey Team / Hazelton, John; / Date(s) of Review / 06-FEB-15 to 06-FEB-15
Follow-up Scope and results :
Service Grouping / Licensure level and duration / # Critical Indicators std. met/ std. rated at follow-up / # Indicators std. met/ std. rated at follow-up / Sanction status prior to Follow-up / Combined Results post- Follow-up; for Deferred, License level / Sanction status post Follow-up
Residential and Individual Home Supports / 2 Year License / 6/8 / x / Eligible for new business
(Two Year License) / 2 Year License / x / Eligible for New Business
(80% or more std. met; no critical std. not met)
4 Locations
10 Audits / o / Ineligible for new business. (Deferred Status: Two year mid-cycle review License) / o / Ineligible for New Business
(<=80% std met and/or more critical std. not met)

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DEPARTMENT OF DEVELOPMENTAL SERVICES

LICENSURE AND CERTIFICATION

DDS FOLLOW-UP REPORT

Summary of Ratings

Residential and Individual Home Supports Areas Needing Improvement on Standard not met - Identified by DDS
Indicator # / L8
Indicator / Emergency Fact Sheets
Area Need Improvement / The agency needs to ensure that Emergency Fact Sheets (EFS) are updated as significant information about the individual changes, and that the EFS contains required information, such as the individual's current medical diagnoses. (Corrected)
Status at follow-up / This indicator was met at 75%; one EFS did not contain information pertaining to "likely response to search efforts". The individual had been lost in an airport previously and did not respond to male airline staff when approached by them, but did respond to female airline staff.
#met /# rated at followup / 3/4
Rating / Met
Indicator # / L26
Indicator / Walkway safety
Area Need Improvement / The agency needs to ensure that all walkways, driveways and ramps are in good repair and clear of ice and snow. In one home, the landing outside a second floor egress was flooded due to sump pump drainage to the area. This could create a slippery landing area, or compel residents to jump to avoid the area; in winter months, this area would freeze creating a slippery and hazardous egress from the home. The agency has created a temporary correction to the area, with a permanent solution planned for the spring.
Status at follow-up / This indicator was met in both of the two sites sampled.
#met /# rated at followup / 2/2
Rating / Met
Indicator # / L51
Indicator / Possessions

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DEPARTMENT OF DEVELOPMENTAL SERVICES

LICENSURE AND CERTIFICATION

DDS FOLLOW-UP REPORT

Area Need Improvement / Electric razors are being held in the staff office closet due to safety concerns. While the staff office door is not locked, nor is the door to the closet in which the razors are stored, there still remains a situation where the individuals can not keep their razors in their bedrooms, or access them without the knowledge of supporters; therefore, this is considered a restrictive practice. As such, there needs to be a written rationale for this practice, Human Rights Committee review of this practice, and a teaching plan in place to reduce or eliminate the need for this practice. (Corrected)
Status at follow-up / This indicator was met in all six audits.
#met /# rated at followup / 6/6
Rating / Met
Indicator # / L56
Indicator / Restrictive practices
Area Need Improvement / One of the 24 hour residences is equiped with a home security system; as doors to the home are opened, a gentle chime sounds. The individuals in the home do not appear to notice the chime, or view it as having any restrictive or uncomfortable effect; therefore this is not considered a restrictive practice. The same home also has one door on the second floor with a separate alarm device that sounds loudly when the door is opened. This device is considered a restriction as it provides a deterent effect to opening the door, and clearly alerts staff when the door is opened. (Corrected)
Status at follow-up / This indicator was met in both of the two sites sampled.
#met /# rated at followup / 2/2
Rating / Met
Indicator # / L67
Indicator / Money mgmt. plan
Area Need Improvement / When the agency has shared or delegated money management responsiblities, it needs to ensure that there is a training plan in place to decrease or eliminate the need for the agency to provide money management assistance to the individual. The individual also needs to give consent for the agency to hold and manage his or her funds. (Corrected)
Status at follow-up / This indicator was met in all four audits.
#met /# rated at followup / 4/4

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DEPARTMENT OF DEVELOPMENTAL SERVICES

LICENSURE AND CERTIFICATION

DDS FOLLOW-UP REPORT

Rating / Met
Indicator # / L86
Indicator / Required assessments
Area Need Improvement / The agency needs to ensure that ISP Assessments are submitted to the DDS Area Office at least 15 days prior to the occurance of ISP meetings.
Status at follow-up / This indicator was not met in two of the four individuals surveyed as ISP assessments were not submitted to the Area Office service coordinator within 15 days of the ISP meeting. The angency needs to ensure that ISP assessments are submitted to the service coordinator within 15 days of the ISP meeting.
#met /# rated at followup / 2/4
Rating / Not Met
Indicator # / L87
Indicator / Support strategies
Area Need Improvement / The agency needs to ensure that ISP Support Strategies are submitted to the DDS Area Office at least 15 days prior to the occurance of ISP meetings.
Status at follow-up / This indicator was not met in two of the four individuals surveyed as ISP support strategies were not submitted to the Area Office service coordinator within 15 days of the ISP meeting. The angency needs to ensure that ISP support strategies are submitted to the service coordinator within 15 days of the ISP meeting.
#met /# rated at followup / 2/4
Rating / Not Met
Administrative Areas Needing Improvement on Standard not met - Identified by DDS
Indicator # / L48
Indicator / HRC
Area Need Improvement / The agency needs to ensure that the required composition is present for, or gives input to, Human Rights Committee meetings.

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DEPARTMENT OF DEVELOPMENTAL SERVICES

LICENSURE AND CERTIFICATION

DDS FOLLOW-UP REPORT

Status at follow-up / This indicator was met. The agency Human Rights Committee had one meeting since the survey; all required members were present at the meeting.
#met /# rated at followup / 1/1
Rating / Met

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