Licensure and Certification Survey

The Department shall conduct a licensure and certification survey of a provider in accordance with the timelines applicable to the provider's licensure and certification status as determined under 115 CMR 8.04 through 8.06. The Department may survey a provider more frequently if it is determined necessary to ensure compliance with 115 CMR. Only providers maintaining a full two year license are eligible to have the department accept a national accreditation process in lieu of the Department's certification survey. Surveys shall be conducted according to the following procedures: (1) Sample. The Department shall select for survey a sample of the sites where services and supports are provided by the provider and a sample of individuals who are receiving the services and supports from or through the provider. (a) The Department shall determine the number or percentage of sites and individuals to be reviewed and shall exclude individuals whose circumstances, such as extended vacation or hospitalization, would preclude their participation in the survey. (b) The sample shall be random and representative of the provider's services and supports subject to licensure and certification. (c) The Department may expand the selected sample during the survey if, the survey team identifies serious issues in areas such as, but not limited to, medication, money management, health care, safety, human rights, or restrictive interventions, and further information is considered necessary for thorough review. (2) Notification and Scheduling. (a) The survey team shall notify the provider, regional and area offices at least 30 days prior to the first day of the survey. (b) Notification of the specific sites and individuals in the survey sample shall be given to the provider, regional and area offices on the first day of the survey. (c) Surveys shall ordinarily be made with prior notice to the provider and at reasonable times, giving due regard to the privacy of the individuals served and the interruption that the survey may cause. However, the Department may review any service or support subject to licensure and certification at any time and without prior notice. (d) Refusal by a provider to permit a survey, with or without prior notice, shall be grounds for termination of contracts or agreements with the Department and may result in the recommendation to terminate or deny licensure and certification. The provider shall make all relevant documents, as determined by the Department, available to the survey team upon request. (e) Surveys shall be scheduled to facilitate the participation of citizen volunteers. (3) Survey Team. The Department shall determine the size and composition of the survey team. The size of the survey team shall vary depending on the size of the provider. (a) The Department shall designate such Department employee(s) as it considers necessary to accomplish the purpose of the survey. The Department may use citizen volunteers and professionals in the field of human services on the survey team. (b) In assembling the survey team the Department shall consider the language or method of communication of individuals included in the survey sample. (c) Team members shall have no conflict of interest with the provider being surveyed and shall adhere to the requirements in the conflict of interest statement established by the Department. A challenge by a provider to the composition of the team based on conflict of interest must be submitted in writing to the Department ten days prior to the first day scheduled for the survey. (d) Information about individuals gathered during the survey process shall be considered confidential and shall not be disclosed except in accordance with state and federal law. Team members shall execute such documents as the Department determines are necessary to protect against unauthorized disclosure of confidential and private information under state and federal law. (4) Conduct of the Survey. The Department shall conduct the following activities as part of the licensure and certification survey. (a) Observation. Team members shall visit and observe the individual at the location where services or supports are provided. Team members will not visit an individual at a competitive employment site unless the individual, provider, and employer agree. Any individuals selected as part of the sample who lives in a home that they own, rent, or lease may refuse a home visit. In addition, personal belongings, clothing, and storage spaces (closets, dressers, trunks, etc.) of any individual served shall not be subject to inspection by the Department without permission from the individual. (b) Discussion. Team members shall speak with individuals, staff, family members and guardians, and other significant people about the services and supports being surveyed. The team member shall interview the service coordinator of each individual in the sample. The team member shall speak with other people such as human rights committee members or clinicians when additional information is needed to complete the survey tool and assess compliance with 115 CMR. Individuals who refuse to be interviewed personally shall not receive a personal interview but shall remain in the sample and the quality of their services and supports shall be evaluated. (c) Review of Documentation. Prior to and during the survey, team members shall review documents that provide information about the impact of services and supports on the quality of life of individuals served and about the organization and operation of the provider. 1. Team members shall review documentation in an individual's record, including but not limited to the individual's support plans (ISP, progress notes, medication and health information, bank books, financial transaction sheets, behavior plans, incident reports, and informed consents. 2. Team members may review provider policies and procedures that include, but are not limited to, the following safeguards: emergencies (e.g. search and safety plans); restraint; money management; restrictive interventions; human rights; medication administration; legal competency and guardianship; fire drill logs. 3. Team members may review other documentation, including, but not limited to staff training, job descriptions, other policies and procedures, membership and minutes of the human rights committee and peer review committee, education and teaching curriculum, mission statement, results of internal evaluations and strategic planning, staff evaluations, and other monitoring reports. 4. Team members shall review the Department logs of complaints, and the decisions, action plans and resolution letters of investigations and administrative reviews for the previous year. (5) Feedback. The team shall present the findings and results of the survey to the provider and to area and regional staff at a service enhancement meeting. The presentation shall include review of the initial provider report with the findings and decision on the provider's license and certification levels. (6) Immediate Jeopardy. Immediate jeopardy is defined as any circumstance in which the life, health, or safety of an individual is severely threatened if the situation is not immediately corrected. A team member who observes a situation that places an individual in immediate jeopardy shall immediately notify the provider, the regional director and area director of the circumstances and the need to correct the situation within 48 hours. The provider shall take any and all action necessary to correct the situation. The team member shall confirm that the situation has been corrected. (7) Action Required. A team member who identifies a situation that is not immediate jeopardy but requires action in a timely manner shall immediately notify the provider, the regional and area director of the circumstances and the need to correct the situation within 30 days. The team member shall confirm that the situation has been corrected. (8) In all cases where a condition reportable under 115 CMR 9.00: Investigations and Reporting Responsibilities, M.G.L. c. 19C, or other applicable law or regulation is observed, each team member is a mandated reporter and shall follow regulatory and statutory reporting procedures. (9) Reports. (a) The initial provider report shall be developed upon completion of the survey and sent to the provider, regional and area directors at least two days in advance of the service enhancement meeting. (b) Following the service enhancement meeting, the final report shall be issued to the provider and a copy sent to the regional office and area office. (c) The final provider report is available to the public, provided that any portion of the report containing confidential information concerning an individual is not a public record. (10) Follow-up. The Department shall follow-up with providers on all issues of immediate jeopardy, action required, and any indicator in a licensure or certification standard that was not met.