Office of quality enhancement summary of overall findings



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PROVIDER REPORT FOR

BEST BUDDIES INTERNATIONAL

45 Bromfield St., 7th Fl.

Boston, MA 02108

December 03, 2013

Version

Provider Web Report

Prepared by the Department of Developmental Services

OFFICE OF QUALITY ENHANCEMENT



SUMMARY OF OVERALL FINDINGS



Provider

BEST BUDDIES INTERNATIONAL




Review Dates

11/5/2013 - 11/7/2013




Service Enhancement

Meeting Date

11/15/2013




Survey Team



Bruce LaFlamme (TL)




















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(s) 4 audit (s)

Targeted Review

DDS 5 / 5

Provider 18 / 19

23 / 24 2 Year License 11/15/2013 - 11/15/2015






Employment Support Services

1 location(s) 4 audit (s)





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

2/2 Certified



EXECUTIVE SUMMARY:

Best Buddies Jobs is one of eight formal components of Best Buddies International, a non-profit organization dedicated to creating opportunities for one to one friendships, integrated employment, and leadership development for individuals with intellectual and developmental disabilities. Best Buddies Jobs provides Employment Support Services to thirty three individuals in Eastern Massachusetts funded by the Department of Developmental Services.

In 2011, the agency achieved a Two-Year License for its Employment and Day Support Service group. As a result the agency was afforded the opportunity and chose the option to conduct its own self- assessment and to receive a DDS targeted licensing review. The DDS targeted review was comprised of an evaluation of two applicable critical indicators and three additional licensing indicators that were found to have been not met in the DDS survey of November 2011. For the purpose of this DDS targeted review four audits in Employment Supports were conducted. The provider self-assessment consisted of all licensure indicators in the Employment and Day Support Service group and three Certification indicators previously not met.
All five Licensing indicators previously not met were found to be met as a result of this review. The agency had made successful improvements to ensure that emergency fact sheets were in compliance with DDS requirements, that informed consent practices were revised to protect individuals' rights to privacy, and the Human Rights Committee of which it was a member successfully carried out its mandated roles and responsibilities. The agency had also successfully implemented SET-Works a secure, comprehensive information management database that captures all critical participant, employer, Employment Consultant activity, and job development information. The agency had begun to integrate this application into data collection activities around participant progress as well as satisfaction with staff supports provided, and tracking of overall program activities. These were all areas identified as requiring further attention in the previous survey.

In conclusion, as a result of combined ratings of the self-assessment performed by Best Buddies Jobs and the targeted review performed by DDS, the agency received a Two-Year License for its Employment Supports with 96% of licensing indicators being met. The agency determined through its self-assessment a need for compliance with tighter timelines for the completion and submission of ISP assessments to the department. Since the agency received a score above 90% for the Employment and Day Supports Service Grouping, it will conduct its own follow-up and report its finding to DDS within sixty days of the Service Enhancement Meeting. Best Buddies Jobs has presented the following self-assessment report describing the agency's ongoing quality assurance systems and the agency's current evaluation of compliance with all DDS licensing standards in Employment Supports.







Description of Self Assessment Process:

Best Buddies Jobs (BBJ) is highly committed to ongoing quality enhancement and has taken steps nationally and locally during the past two years to ensure that this dedication continues. Among the national actions that greatly benefit BBJ locally, two new senior management positions were created: BBJ National Director and Deputy Director. These positions were developed following the establishment of the Best Buddies 2020 Initiative (2011) which includes the goal of developing 1,000 jobs worldwide for people with intellectual and developmental disabilities by the year 2020. The National Director's and Deputy Director's job duties focus primarily on ongoing program quality enhancement from the ground up, consistent staff/program support nationally, and oversight of all expansion efforts to ensure that all procedures, best practices, and principles are effective and are unified nationally.


Among the significant actions that have been initiated by the National Director and facilitated by the Deputy Director is the enrollment of all BBJ Program staff into membership with the Association of People Supporting Employment First (APSE) which has opened the door to a wealth of information and professionals within the field of integrated employment. Since enrollment, four BBJ staff have passed the exam to obtain APSE's nationally recognized Certified Employment Support Professional certificate. This certification adds legitimacy to BBJ staff members' skill sets in the eyes of participants, funding sources, employers, professional peers, and themselves by confirming that they have developed a strong skill set for providing outstanding person-centered service in the field of supported employment. Another significant action that has been initiated is the implementation of SET-Works. SET-Works is a secure, comprehensive information management database that captures all critical participant, employer, EC, and job development information. SET-Works also contains reporting features that facilitate quantitative supervision/review/analysis. BBJ initiated the daily use of SET-Works in January 2013. SET-Works now plays a pivotal role in BBJ supervision and management at every level: national, state, caseload, and individual participant.
The BBJ Supervisor oversees the day-to-day operations of the program in Massachusetts (MA) and supervises the program's five EC's. The Supervisor reports directly to the State Director, and also communicates consistently with the National Director, the Deputy Director, and all supervisors of BBJ programs nationally. When hired, each EC is trained to be an expert on each individual that they serve, to manage all aspects of their caseload, and to use SET-Works daily to ensure strong, accurate records. EC duties include such annual meetings as the human rights orientation, abuse reporting discussion, social security discussion, safety review, Individualized Written Program Plan (IWPP) creation, Individualized Support Plan (ISP) meetings/corresponding paperwork when applicable, etc. Based on an 11% sample (8 of 76 BBJ participants), all required case file documents and activity records are 100% current within 10 days of most recent services delivered. The supervisor uses SET-Works reporting tools weekly and monthly to ensure that EC activity records are current within 10 days of service delivery, and to monitor what services (activity record narratives in SET-Works) and what number of service hours (SET-Works reports) are being provided to each participant in relation to their established goals and funding allocation. SET-Works allows the program supervisor to view all of this info for all EC's and participants in one comprehensive system. The supervisor reviews this material with each EC in individual monthly meetings, meeting more frequently and establishing action plans when needs are identified through this supervision.
The Program Supervisor also leads each Employment Consultant through the Best Buddies performance evaluation process. The supervisor and EC meet for a 90-day probationary review, conduct quarterly reviews of goal progress, and meet annually for a full performance review. Based on a 33% sample (two of the six BBJ staff in Massachusetts), 100% timely completion has been achieved with all performance evaluation processes. Although the rule of thumb for maximum number of participants per caseload is 15, the supervisor can determine case load size more accurately via SET-Works reports by viewing the number of service hours delivered by each EC each month. The supervisor uses this data in conjunction with monthly individual meetings to determine which EC's can benefit from further case load management training and which EC caseloads can be decreased or increased to optimally support a high quality of service delivery and effective program growth, respectively.
The supervisor also reviews each case file at least once annually, leads bi-weekly Jobs team meetings to monitor progress on team-wide initiatives, participates in monthly national supervisors' calls, and participates in monthly all Jobs staff calls. Based on a 33% sample (two of the six BBJ staff in Massachusetts), all required personnel training certificates (Basic Human Rights, Human Rights Systems, Fire Safety, CPR, First Aid) are 100% current. Supervisors' and program-wide calls are led by the National and Deputy Directors and are used to bring challenges from any/all BBJ program locations to the table so that national best practices can be identified and discussed. These calls are also an opportunity for all Jobs staff to hear updates on progress in other BBJ program locations, and to maintain a strong understanding of BBJ's principles, national initiatives, new employer partners in other Jobs program locations, and important updates such as new SET-Works reporting features.
Best Buddies is highly dedicated to individual safety and well-being. DPPC reports are sent in a timely manner (within 48 hours of incident), along with communication of concerns to service coordinators, residential staff, and families, as appropriate. Complaints are handled immediately by the Program Supervisor and plans of action are put into place to resolve any issues. The Supervisor seeks further counsel from the State Director, Deputy Director, and National Director as needed, and works with EC's to review issues and develop plans to ensure the safety and well-being of individuals are protected. All Jobs staff attend basic human rights training and annually participate in trainings on how to identify abuse and correctly report incidents to DPPC. Additionally, the BBJ supervisor recently enrolled in the HCSIS system following recommendation from DDS Quality Enhancement. Best Buddies has an active Human Rights Committee (HRC) that it shares with two other community employment providers. Membership is comprised of all of the required professionals and individuals. The committee meets quarterly and meeting minutes and attendance are documented and filed each quarter. The Human Rights Committee Coordinator is responsible for scheduling the meetings and working with the partner agencies to ensure that membership is meeting the DDS guidelines. The HRC Coordinator reports committee activities to the Program Director on a quarterly basis to ensure that the Human Rights Committee continues to operate according to DDS regulations and performs the functions effectively. Individuals and guardians annually receive one-on-one human rights, and neglect & abuse training. In addition individuals and guardians are informed of how to file a grievance or complaint on an annual basis.
Best Buddies MA, in accordance with Best Buddies International regulations, has a vigorous hiring process that ensures that candidates are qualified for the positions they are applying for. All new program staff completes several online trainings teaching Best Buddies' history, mission, procedures, and software. Staff also completes BBJ policies and procedures training, as well as training for specific program participants via direct hands-on training with their supervisor. Staff are trained on how to communicate effectively and provide unique supports to the individuals with whom they will be working. This training utilizes all acquired vocational and psychological evaluations, and the Best Buddies Participant Profile which is a comprehensive assessment of the individual's strengths, challenges, habits, work history, interests, hard and soft skills in varying scenarios, and other pertinent information.
Best Buddies conducts satisfaction surveys with participants, funding source contacts, employers, and supervisors to identify areas for growth and improvement. Participant surveys are comprehensive, reviewing satisfaction with program services and outcomes, as well as with the individual's current EC. Survey outreach begins in January of each year to capture data that reflects performance during the entirety of the previous calendar year. Data is analyzed and action plans are developed and monitored to ensure that any areas in need of improvement are effectively addressed. Based on a 10% minimum sample size in each stakeholder group (10% Employer, 14% Supervisor, 13% Funding Source, and 11% Participant), all stakeholder groups surpass the 80% benchmark satisfaction rate.

LICENSURE FINDINGS



Met / Rated

Not Met / Rated

% Met

Organizational

6/6

0/6



Employment and Day Supports

17/18

1/18



Employment Support Services







Critical Indicators

1/1

0/1



Total

23/24

1/24

96%

2 Year License







# indicators for 60 Day Follow-up



1















Employment/Day Areas Needing Improvement on Standards not met/Follow-up to occur:

From Provider review:


Indicator #

Indicator

Issue identified

Action planned to address



L86

Required assessments concerning individual needs and abilities are completed in preparation for the ISP.

Best Buddies staff have not been meeting at least 80% success in sending required ISP paperwork to Service Coordinators at least 15 days prior to the ISP meeting. This occurred as a result of BBJ mistakenly operating under the belief that the materials must be sent a minimum of 10 days prior to the ISP meeting as opposed to 15.

This discrepancy was clarified with most Massachusetts BBJ staff members and the Deputy Director in Best Buddies pre-survey meeting. The Program Supervisor clarified the discrepancy with all Massachusetts BBJ staff members following the pre-survey meeting.

Moving forward, ECs will complete one of the following three actions upon receipt of ISP notice from the Service Coordinator to ensure completion and submission at least 15 days prior to the ISP:

- Immediately complete all required ISP materials.

- Immediately schedule meetings to complete all required ISP items.



- Immediately build appropriate time into their calendar to complete all required ISP items at least 15 days prior to ISP.
To safeguard against delayed receipt of ISP notice from the Service Coordinator, the EC will also enter a Service Coordinator ISP check-in reminder into their calendar on a date that occurs six weeks prior to the ISP anniversary date. If no correspondence is received by this time, the EC will reach out to the Service Coordinator.
In order to ensure that all ISP materials are being completed and submitted at least 15 days prior to each participants ISP meeting, the Program Supervisor will view this material in periodic case file reviews.



CERTIFICATION FINDINGS





Reviewed By

Met / Rated

Not Met / Rated

Certification - Planning and Quality Management

Provider

2/2

0/2

Employment and Day Supports







Employment Support Services

Provider

1/1

0/1


MASTER SCORE SHEET LICENSURE

Organizational: BEST BUDDIES INTERNATIONAL



Indicator #

Indicator

Reviewed by

Met/Rated

Rating (Met, Not Met, Not Rated)



L2

Abuse/neglect reporting

DDS

1/1

Met



L48

HRC

DDS

1/1

Met



L74

Screen employees

Provider

-

Met



L75

Qualified staff

Provider

-

Met



L76

Track trainings

Provider

-

Met



L83

HR training

Provider

-

Met

Employment and Day Supports:



Indicator #

Indicator

Location or Individual indicator

Reviewed by

Employment Support

Center Based Work

Community Based Day Support

Total Met / Rated

Rating



L1

Abuse/neglect training

I

Provider



-



-

Met



L2

Abuse/neglect reporting

L

DDS

1/1





1/1

Met



L8

Emergency Fact Sheets

I

DDS

4/4





4/4

Met



L31

Communication method

I

Provider



-



-

Met



L32

Verbal & written

I

Provider



-



-

Met



L49

Informed of human rights

I

Provider



-



-

Met



L50

Respectful Comm.

L

Provider



-



-

Met



L51

Possessions

I

Provider



-



-

Met



L52

Phone calls

I

Provider



-



-

Met



L54

Privacy

L

Provider



-



-

Met



L55

Informed consent

I

DDS

4/4





4/4

Met



Indicator #

Indicator

Location or Individual indicator

Reviewed by

Employment Support

Center Based Work

Community Based Day Support

Total Met / Rated

Rating



L77

Unique needs training

I

Provider



-



-

Met



L80

Symptoms of illness

L

Provider



-



-

Met



L81

Medical emergency

L

Provider



-



-

Met



L85

Supervision

L

Provider



-



-

Met



L86

Required assessments

I

Provider



-



-

Not Met



L87

Support strategies

I

Provider



-



-

Met



L88

Strategies implemented

I

Provider



-



-

Met



#Std. Met/# 17 Indicator













17/18





Total Score













23/24



















95.83%





MASTER SCORE SHEET CERTIFICATION



Certification - Planning and Quality Management



Indicator #

Indicator

Met/Rated

Rating



C3

Service satisfaction

-





C5

Measure progress

-















Employment Support Services Reviewed By -Provider

Indicator #

Indicator

Met/Rated

Rating

C7

Feedback on staff performance

-

Met














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