Community Health Link by jey14242

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									                               Department of Mental Retardation
                 Office of Quality Management, Office of Quality Enhancement
                                   Licensure and Certification

                                                                           Report Date: April 30, 2007
Agency: Community Health Link
Review Dates: 3/5/2007 to 3/13/2007
Licensure: 3/23/2007 to 3/23/2009
Licensure Level: Two-Year License
Follow-Up Required: No
Certification Performed By: The Department of Mental Retardation for Work/Day Supports
Certification Completed On: 4/5/2007
Certification Outcome: Certified with 6 out of 6 Quality of Life Areas Achieved
Survey Team: Mike Pavlis (Team Leader)
Citizen Volunteer(s): None
Number of Individual Reviews Completed: [ 3 ]

                                                    [ 0 ] Residential Reviews
                                                    [ 3 ] Work/Community Reviews
                                                    [ 0 ] Respite Reviews (Not Rated)
                                                    [ 0 ] Safeguard System Reviews (Not Rated)

                                       EXECUTIVE SUMMARY
Community Health Link (CHL) is a multi-service, private, nonprofit organization, located in central
Massachusetts, which serves over sixteen thousand individuals each year through eighty-three different
programs. The organization’s mission, which applies to all of its programs, is to promote, maintain, and restore
the dignity, well-being, and mental health of individuals and families. Among the various services offered
through CHL’s Outpatient Rehabilitation Division is Gateway, a day program located in Worcester, MA, which
focuses on services to individuals with mental health needs or those who are dually diagnosed. Gateway
currently serves fifty individuals, eight of whom receive community-based day supports funded by DMR. For
the purpose of this licensing and certification survey, the services to three individuals were randomly selected
for review. One individual had a long-term association with Gateway, while two others had participated for less
than a year. All three individuals were attending on a part-time basis.

Over the past two years, the senior management team of Community Health Link has monitored the success of
its three-year strategic plan. The plan was designed to make CHL the provider of choice in the region, as well as
promote a therapeutic model of recovery and wellness within all of its programs. The impact of this plan on
Gateway’s services has been demonstrated in a number of ways. In March 2006, a vision document, outlining
potential future directions, was created by Gateway staff and those served. One of the action steps that resulted
from this document was the development of a leadership training course, which introduced the concept of
leadership and mentoring to program participants. The need for and benefits of staff and client satisfaction
surveys were also identified within the vision document and instituted on an annual basis. There was evidence
that the organization was already taking actions based on some of this feedback. Based on feedback from
employees, for example, decisions were made to provide more training to staff on the rehabilitation and
recovery model. The agency also decided to hold additional focus groups with individuals as a means to better
capture “the voice of those served.” It was clear that the agency had improved its services based on its strategic
planning process’.

Since its last survey in March 2005, Community Health Link has successfully strengthened many of its
safeguard systems. In particular, new systems were put in place to protect the safety of those served, to educate
individuals about their human rights, and to insure participant health and well-being. All individuals surveyed
had received annual safety assessments, and the results were taken into consideration when supporting
individuals, both while at the Gateway program and within the community. Despite the advanced age of the
building, Gateway had, for the most part, effective systems in place to address repair and maintenance issues in
a timely manner. All individuals and staff had received annual human rights training, and information was sent
to families and guardians in an effort to educate them to resources available to promote and protect human
rights. Mandated trainings were up-to-date for the majority of staff members, and noticeable effort was made to
obtain current medical information, including medication lists for all program participants. The recent addition
of a healthy breakfast option, along with a hot meal offered at noon, was mentioned as beneficial by a number of
members. As a result of attention to effective safeguard systems and focus on wellness and recovery, the agency
provides a safe and supportive environment for individuals who experience a variety of challenges on a daily
basis.

A continuing strength of Gateway was the flexibility of its program design, which promotes individual choice
and control. All three individuals in the survey sample attended on a part-time basis, three to four days a week,
which provided them the time they needed to tend to their medical or personal needs during the week. While the
program supported individual involvement in housekeeping, food preparation, or business skills training during
the morning hours, individualized programs were also developed according to interest. Individual input was
solicited through Gateway’s twice weekly community meetings and monthly meetings of its social club.
Planning for internal groups and activities was the primary purpose of the Monday and Friday community
meetings. Planning for weekly and Saturday afternoon community trips was the responsibility of the social club
directed by the Gateway members themselves. Individuals spoke highly of the activities provided by the social
club, which included trips to places such as Wachusett Mountain, local malls, cinemas and restaurants.

As in previous surveys, Gateway provided effective supports to individuals in the area of maintaining and
enhancing relationships with their family, friends and other members of the program. Many of the therapeutic
groups offered by the program focused on building interpersonal confidence and enhancing positive
relationships with others. For example, there was clear data that a recent anger management group had directly
led to fewer incidents between participants over the last year. One individual, who had left the program
temporarily, gave as a major reason for her return that she missed the relationships she had with both staff and
other members. Another individual, who had health problems over the last few months, stated she appreciated
the many calls from Gateway staff and members inquiring about her recovery.

The findings of the current licensing and certification review also identified some areas that are in need of
agency focus and attention. While the safeguard systems were generally found to be effective, the agency’s
human rights committee was lacking both a psychologist and a physician or nurse. For many of those served,
further exploration of individualized membership opportunities could potentially lead to more meaningful social
and community connections. Lastly, personal growth could be enhanced through development of data collection
and other monitoring systems that more clearly measure individual success on their chosen goals.

Community Health Link continues to provide unique supports to those individuals in the greater Worcester area
who are dually diagnosed. The program’s new director is an experienced manager and leader who has already
proven to be an asset to the organization. As a result of this current review, the agency will receive a Two-Year
License and is certified with achieved ratings in six out of six Quality of Life Areas measured by the DMR
Quality Enhancement Survey Tool.


                                                                                                                2
                                      Provider Scoring Summary

Licensure Review
                                                 Work/
  Quality of Life         Residential          Community                 Respite           Overall Provider
      Area                 Supports             Supports                Supports               Rating

Rights & Dignity                            Achieved                                          Achieved
Personal Well-
Being                                       Achieved                                          Achieved
Organizational Outcomes: The organization has systems in place to safeguard people.
                                                                                              Achieved


Certification Review
                                                 Work/
  Quality of Life         Residential          Community                 Respite           Overall Provider
      Area                 Supports             Supports                Supports               Rating

Individual Control                            Achieved                                        Achieved
Community and
Social Connections                            Achieved                                        Achieved
Personal Growth &
Accomplishments                               Achieved                                        Achieved
Organizational Outcomes: Staff have the skills and knowledge to support the quality
                                                                                              Achieved
                          of life of people.
Organizational Outcome: The organization supports growth and change to continually
                                                                                              Achieved
                         improve its quality of supports

Organizational Combined Rating:
(Based on both the licensure organizational outcome and the two certification quality of      Achieved
life outcomes)




                                                                                                          3
                                            QUALITY OF LIFE AREA
                                             RIGHTS AND DIGNITY
                                                Rating: Achieved
Principles: Support and affirmation of individual rights are safeguards for all people as citizens of the United States.
These rights are framed in the Constitution, Bill of Rights, and Federal and State statutes. They include such freedoms as
the rights to privacy, free speech and due process. The actualization of individual rights is especially important to people
with disabilities because they have not always been afforded these most basic of guarantees and may need support to
exercise their rights. In order to have their rights affirmed, individuals first must be respected, valued and treated with
positive regard.

                                    QUALITY OF LIFE SCORING SUMMARY

                                                                        Work &                               % of Indicators
                  Outcomes                          Residential                              Respite
                                                                       Community
                and Indicators                       Reviews                                 Reviews         (Excluding Respite)
                                                                        Reviews
             People are valued:
                                                   Yes       No        Yes       No        Yes       No       Yes         No
                 Achieved
A. Interactions are respectful of people.
                                                                        3         0                          100%          -
B. People are supported to identify themselves
                                                                        3         0                          100%          -
   as adults.
C. People are supported to take pride in
                                                                        3         0                          100%          -
   themselves and their surroundings.
D. People live and work in settings that are
                                                                        3         0                          100%          -
   typical of other members of the community.
        People’s rights are affirmed:
                                                   Yes       No        Yes       No        Yes       No       Yes         No
                  Achieved
A. People and/or those supporting them
                                                                        3         0                          100%          -
   understand individual rights.
B. People’s rights are exercised in their
                                                                        3         0                          100%          -
   everyday lives.
C. People receive the same treatment as other
                                                                       N/A       N/A                          N/A        N/A
   employees.
D. People receive comparable wages and
                                                                       N/A       N/A                          N/A        N/A
   benefits as other employees.
       People’s rights are protected.
                                                   Yes       No        Yes       No        Yes       No       Yes         No
                 Achieved
A. All interventions are the least intrusive and
                                                                        3         0                          100%          -
   are based upon people’s unique needs.
B. All interventions are included in a written
                                                                     (3 N/A)     N/A                          N/A        N/A
   plan.
C. People, or their guardians, knowingly and
   voluntarily give consent and have the
                                                                     (3 N/A)     N/A                          N/A        N/A
   opportunity to refuse or withdraw
   approval.
D. Safeguards ensure a thorough review and
                                                                     (3 N/A)     N/A                          N/A        N/A
   approval process when needed.
E. All interventions are safely, accurately and
                                                                     (3 N/A)     N/A                          N/A        N/A
   consistently implemented.




                                                                                                                            4
                                           QUALITY OF LIFE AREA
                                           PERSONAL WELL-BEING
                                               Rating: Achieved
Principles: Being safe, secure and healthy provides a foundation that enables people to have a truly fulfilling life and do
the things that are important to them. As with rights, certain universal things contribute to the well-being of everyone in
society, regardless of who they are and their personal circumstance. These universals include having routine physical
examinations, wearing seat belt, or installing smoke detectors. Beyond the universal safeguards, personal well-being is
supported by a recognition of people’s skills and needs as balanced against their lifestyle choices. Services are designed
to assist people to be secure, achieve and/or maintain good health, to make decisions that keep them out of harm’s way,
and to ensure a prompt response when people’s safety, security or health are compromised.

                                    QUALITY OF LIFE SCORING SUMMARY

                                                                        Work &                              % of Indicators
                 Outcomes                          Residential                              Respite
                                                                       Community
               and Indicators                       Reviews                                 Reviews         (Excluding Respite)
                                                                        Reviews
    People are safe at home and work:
                                                   Yes       No       Yes       No        Yes       No       Yes         No
                 Achieved
A. People’s home and work place are safe,
                                                                       3         0                          100%          -
   secure, and in good repair.
B. People and their supporters know what to
                                                                       3         0                          100%          -
   do in an emergency.
C. People can safely evacuate from their home
                                                                       3         0                          100%          -
   or work place in an emergency.
D. There are adequate supports for people to
                                                                       3         0                          100%          -
   be safe in their home and work.
E. People use materials and equipment safely.                          3         0                          100%          -
        People are free from harm:
                                                   Yes       No       Yes       No        Yes       No       Yes         No
                 Achieved
A. Supports are in place if people make
                                                                      N/A       N/A                          N/A        N/A
   decisions that put them at risk.
B. Immediate actions are taken to ensure
                                                                      N/A       N/A                          N/A        N/A
   people’s safety.
C. Actions are taken to correct the situation
                                                                      N/A       N/A                          N/A        N/A
   when people have been mistreated.
D. Steps are taken to prevent the situation
                                                                      N/A       N/A                          N/A        N/A
   from occurring again.
E. People know how or have support to report
   a situation where they feel they are being or                       3         0                          100%          -
   have been mistreated or harmed.




                                                                                                                           5
                                PERSONAL WELL BEING: - Continued

                                                                       Work &                               % of Indicators
                 Outcomes                          Residential                              Respite
                                                                      Community
               and Indicators                       Reviews                                 Reviews         (Excluding Respite)
                                                                       Reviews
       People maintain good health:
                                                  Yes        No       Yes       No        Yes       No        Yes          No
                Achieved
A. People are supported to have a health
                                                                       3         0                            100%         -
   lifestyle.
B. People are supported to be active
                                                                      N/A       N/A                           N/A       N/A
   participants in their health care.
C. People have needed routine and specialized
                                                                      N/A       N/A                           N/A       N/A
   health care services.
D. Supporters are knowledgeable about
                                                                       3         0                            100%         -
   people’s health care needs.
E. People’s medications are given properly
                                                                      N/A       N/A                           N/A       N/A
   and as prescribed by the practitioner.
      People’s funds are safeguarded:
                                                  Yes        No       Yes       No        Yes       No        Yes          No
                 Not Rated
A. People receive the support and/or
   education they need in managing their                              N/A       N/A                           N/A       N/A
   financial resources.
B. People’s funds are managed properly and
                                                                      N/A       N/A                           N/A       N/A
   with their consent.




                           OUTCOMES FOR THE ORGANIZATION

Principles: Positive outcomes for individuals are the result of many factors, not the least of which is a strong, coherent
organizational structure. For positive outcomes for individuals to be sustained over time, across all settings and by all
staff, agencies need to create an infrastructure and culture that supports quality and safeguards individuals.

                                                SCORING SUMMARY

                                    Outcome and Indicators                                                  Agency
                                                                                                            Totals
                                                                                                                  % of
              The organization has systems in place to safeguard individuals:
                                                                                                    Finding     Indicators
                                        Achieved                                                                 Present
A. The organization has strategies that proactively ensure that essential safeguards are in place
   across settings and over time.
                                                                                                      Yes
B. The organization has systems in place to affirm and protect the rights and dignity of
   individuals.
                                                                                                      No             67%
C. The agency implements procedures that minimize unnecessary risk to individuals.
                                                                                                      Yes




                                                                                                                            6
                                          QUALITY OF LIFE AREA
                                          INDIVIDUAL CONTROL
                                             Rating: Achieved
Principles: Being able to direct the course of one’s life is something for which all people strive. Self-determination is
expressed in all aspects of people’s lives, both in little, everyday things such as deciding when to get up as well as in
major life decisions that may have a deep, long lasting effect such as deciding on a certain career or moving to a new
community. The type and amount of support people need to take charge of their lives varies greatly. For some, even
making everyday choices is a new experience and they need much guidance in learning how to make both everyday and
major choices. For others, periodic check-ins and discussions are needed to keep them on course and to make sure they
have an understanding of their options and of the consequences of their decisions. What is important is that people have
all the information they need to make decisions, that they are empowered and supported to take action, and that they
understand how their decisions affect their lives.

                                   QUALITY OF LIFE SCORING SUMMARY

                                                                      Work &                              % of Indicators
                 Outcomes                         Residential                              Respite
                                                                     Community
               and Indicators                      Reviews                                 Reviews        (Excluding Respite)
                                                                      Reviews
          People are understood:
                                                  Yes       No       Yes       No       Yes       No        Yes        No
                 Achieved
A. Supporters understand what people are
                                                                      3         0                          100%         -
   expressing.
B. Supporters use people’s primary means of
                                                                      3         0                          100%         -
   communication.
C. Supporters assist people to communicate
                                                                      3         0                          100%         -
   with and be understood by others.
           People make choices in
            their everyday lives:                 Yes       No       Yes       No       Yes       No        Yes        No
                  Achieved
A. People make choices about their routines
                                                                      3         0                          100%         -
   and schedules.
B. People make choices about the work and
   household tasks for which they are                                 3         0                          100%         -
   responsible.
C. People spend their leisure time in
                                                                     N/A       N/A                          N/A       N/A
   personally satisfying ways.
     People are the primary decision-
          makers in their lives:                  Yes       No       Yes       No       Yes       No        Yes        No
                 Achieved
A. People develop their personal goals.
                                                                      2         1                          67%        33%
B. People influence who provides their
   supports.
                                                                      1         2                          33%        67%
C. People control important decisions about
                                                                     N/A       N/A                          N/A       N/A
   their home and home life.
D. People choose where they work or, if they
   choose not to work, people have options                            3         0                          100%         -
   that are meaningful to them.




                                                                                                                         7
                                 QUALITY OF LIFE AREA
                            COMMUNITY AND SOCIAL CONNECTIONS
                                     Rating: Achieved
Principles: Membership in community life supports people’s sense of belonging and provides opportunities for
citizenship, friendship and valued roles in society. Everyone has unique, identifiable ways that he or she is connected to
the community and to other people who are important to them. Being a part of community life means that people are
using all the resources and amenities that others use. Being connected also means that people have other people in their
lives who are important to them, who are there for them when needed and with whom they can share their thoughts and
concerns. It also includes having a place in society, a place that other people recognize and value. It may mean helping
out neighbors and friends when needed or having talents and gifts that are recognized and shared with other people.

                                  QUALITY OF LIFE SCORING SUMMARY

                                                                       Work &                              % of Indicators
                 Outcomes                          Residential                             Respite
                                                                      Community
               and Indicators                       Reviews                                Reviews         (Excluding Respite)
                                                                       Reviews
         People are integrated into
            their community:                      Yes       No        Yes       No       Yes       No        Yes        No
                 Achieved
A. People live and work in communities with
                                                                       3         0                         100%          -
   the resources they want and need.
B. People use the same community resources
                                                                       3         0                         100%          -
   as others on a frequent and ongoing basis.
         People are connected with
             their community:                     Yes       No        Yes       No       Yes       No        Yes        No
            Partially Achieved
A. People are supported to explore their
   personal interests and options for                                  0         3                            -       100%
   community involvement.
B. People are involved in activities that
   connect them to other people in the                                 0         3                            -       100%
   community.
         People have relationships:
                                                  Yes       No        Yes       No       Yes       No        Yes        No
                 Achieved
A. People are supported to maintain and
   enhance relationships with family, friends                          2         1                          67%        33%
   and co-workers.
B. People are supported to develop new
   friendships.
                                                                       2         1                          67%        33%
C. People are supported to explore, define,
                                                                      N/A      N/A                           N/A       N/A
   and express their need for intimacy.




                                                                                                                          8
                                 QUALITY OF LIFE AREA
                         PERSONAL GROWTH AND ACCOMPLISHMENT
                                     Rating: Achieved
Principles: While developing one’s own goals is a critical first step in making decisions about one’s life, achieving
personal goals and developing the skills to be as independent as possible give individuals a sense of purpose, direction
and self-fulfillment in their lives. The strategies and support used in assisting people to reach their goals takes on many
forms and should be tailored to people’s unique skills, needs, preferences and style of learning. It includes helping
people to learn from both planned as well as unanticipated events in their lives. While there is much to be proud of in
acquiring the skills to do things independently, it does not mean that people are independent in everything they do. There
is the joy that people feel in accomplishing things together and the feeling of self-worth that comes with completing
something as independently as possible.

                                   QUALITY OF LIFE SCORING SUMMARY

                                                                        Work &                              % of Indicators
                 Outcomes                          Residential                              Respite
                                                                       Community
               and Indicators                       Reviews                                 Reviews         (Excluding Respite)
                                                                        Reviews
       People accomplish their goals:
                                                  Yes        No       Yes       No        Yes       No       Yes         No
            Partially Achieved
A. People’s goals are the basis of actions and
   supports.
                                                                        1        2                           33%        66%
B. There is a match between what people are
   doing now and what they want to do in the                            3        0                          100%          -
   future.
C. People have access to needed resources in
                                                                        3        0                          100%          -
   order to accomplish their goals.
D. There are supports to get a job that people
                                                                      N/A       N/A                          N/A        N/A
   like.
E. There are supports to succeed at the job.                          N/A       N/A                          N/A        N/A
F. People are supported to advance in their
                                                                      N/A       N/A                          N/A        N/A
   job.
          People have autonomy:
                                                  Yes        No       Yes       No        Yes       No       Yes         No
                 Achieved
A. People complete day-to-day activities, tasks
                                                                        3        0                          100%          -
   and chores as independently as possible.
B. People have access within their home and
                                                                        3        0                          100%          -
   workplace.
         People grow through their
             life experiences:                    Yes        No       Yes       No        Yes       No       Yes         No
                 Achieved
A. Supporters are sensitive and attuned to
   both small and large events in people’s                              3        0                          100%          -
   lives.
B. People are encouraged to understand
                                                                        3        0                          100%          -
   experiences in their lives.
C. People are supported to grow from events
                                                                        3        0                          100%          -
   in their lives that affect them.




                                                                                                                           9
                            OUTCOME FOR THE ORGANIZATION
Principles: Positive outcomes for individuals are the result of many factors, not the least of which is a strong, coherent
organizational structure. For positive outcomes for individuals to be sustained over time, across all settings and by all
staff, agencies need to create an infrastructure and culture that supports quality and safeguards individuals.

                                                SCORING SUMMARY

                        Staff have the skills and knowledge to support                                           % of
                               the quality of life of individuals:                                 Finding     Indicators
                                            Achieved                                                            Present
A. The agency recruits and maintains a competent work force.
                                                                                                     Yes
                                                                                                                 100%
B. The agency has ways to support staff knowledge, effectiveness and creativity.
                                                                                                     Yes

             The organization supports growth and change to continually                                          % of
                          improve its supports to individuals:                                     Finding     Indicators
                                       Achieved                                                                 Present
A. The organization has processes to evaluate the quality of its supports.
                                                                                                     Yes
                                                                                                                 100%
B. The organization improves services as a result of these analyses.
                                                                                                     Yes




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