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Our questions about the DDS provider licensure system

How effective is the Department of Developmental Services’ licensing and certification system for operators of community-based group homes in Massachusetts? 

We reviewed 30 online licensure and certification reports and DDS’s revamped licensure and certification manual.   We also reviewed a 2008 licensure survey report by the state Department of Public Health of the state-run Fernald Developmental Center.

Our review found that the federal-state certification process for state developmental centers appears to be significantly more rigorous and comprehensive than the DDS licensing and certification process for state and privately run group homes.   This difference would appear to have implications for the relative safety and wellbeing of clients in the widely dispersed, community-based group home system.

DDS licenses and certifies providers that operate more than 2,700 24-hour residential programs in the state, according to figures provided by the department. 

State-run developmental centers, which must meet strict federal standards of care, are surveyed by state DPH staff, which follows requirements established by the federal Centers for Medicare and Medicaid Services.  The community-based group homes are surveyed by staff of the DDS’s Office of Quality Enhancement, supplemented by volunteer surveyors. 

Here are some of our findings.  (Additional information about our review can be found in the October 2011 issue of The COFAR Voice): 

  • Under the DDS’s licensure and certification process for group home providers, only 25 percent of those group home sites are inspected or surveyed by licensing staff during each two-year licensing period.  This means that a provider can receive a two-year license to operate even though 75 percent of its homes were not inspected.
  • While two of the licensure survey reports we sampled contained detailed findings of deficiencies in care and procedures in the providers’ group homes, the majority of the reports appeared to focus on whether the providers were working to achieve broad and often vaguely worded goals such as  “maximizing independence” and “supporting people to live healthy and active lives.”   One of the most frequently cited problems in the licensure reports was the makeup of the providers’ human rights committees, whether they had bylaws, and how frequently they met.   

In contrast, the 2008 survey report on the Fernald Center contained 56 pages of detailed findings about treatment and care, based on direct observation by surveyors as well as on resident records.  Observed injuries were noted in the CMS-DPH report, as well as direct observations that certain residents were not receiving adequate treatment.

While the Fernald Center had some 180 residents in 2008, many of the group home providers whose reports we reviewed provided services to that many or more individuals in their individual networks of group homes.

  • Few of the DDS provider reports, most of which were only a few pages in length, appeared to mention the results of direct observations about the care provided to individuals in the residences.  None of the reports contained findings of observed signs of injuries to residents or of abuse or neglect. Yet, the state’s Disabled Persons Protection Commission receives some 1,500 complaints of abuse and neglect each year in the community system, more than one third of which are substantiated, according to agency figures.
  • In many cases, the DDS licensure surveyors appeared eager to say positive things about the providers, but even those statements usually did not refer directly to observed care issues. 

For instance, the DDS licensure report for Fidelity House, Inc., stated that a “remarkable” example of  “the way people were valued in their homes” was that “confidential records had one page profiles which carefully described each individual in the first person.”  In a number of cases, the survey reports contained the vague statements that the particular provider being reviewed “takes great pride” in its programs or facilities or, in one case, that the provider’s services were “founded upon a values-based mission.”

  • All of the DDS provider reports reviewed indicated that the providers were granted licenses to operate, even in the relatively rare cases in which potentially serious problems were cited.  In one case, a provider, Behavioral Associates of Massachusetts, was given a one-year conditional license to continue operating even though the license survey found that only two out of six required “quality of life areas” had been achieved.  Among the problems noted by the surveyors were that residents’ confidential records were altered and that the provider’s day program was inappropriately operating in the basement of one of the residences. 

In another case, the Center for Human Development received a two-year license to operate even though there had been three instances in the previous two-year licensing period in which reportable incidents of abuse or neglect in its residences had not been reported to the Disabled Persons Protection Commission as required.

In October 2010, the Kennedy Donovan Center received a recommendation for a “deferred license” for its residential services after failing to meet the standard on 20 indicators of care and services.   The surveyors found that residents in six different group homes had gone more than a year without a physical exam, with two residents having gone 18 months and two having gone 17 months without an exam.  One resident who didn’t have a dental exam for more than two years was later was found to need several fillings and extractions, the report stated.  Another resident, who had had pneumonia was not provided with a follow-up review by a physician.

A deferred license means the agency can continue operating, but has 60 days to correct the problems.  There was no information online to indicate whether those corrections were made. 

  • Of the 30 online reports surveyed, fully one third were out of date on the DDS website, some by as much as two years.  It wasn’t clear whether the DDS has simply been slow in posting licensure reports on its website or whether the licenses may have expired for some of the providers reviewed.   
  • The DDS licensure and certification procedure was revamped in July 2010, based on input from the providers themselves. In 2009, the Association of Developmental Disabilities Providers stated that it was working with DDS to revamp the licensure system and that it was seeking to reduce the number of group home sites surveyed and the time spent surveying in each location.

Among the changes made by DDS in 2010 were a reduction in the licensure survey time spent in group homes from one to two weeks down to 5 working days, according to the online licensure manual.

  • Both the old and revamped reports did not always specify the total number of clients served by each provider or even the total number of group homes run by the provider.  Some reports listed all relevant indicators while others didn’t.  

We plan to bring our findings to the attention of state legislators who deal with DDS issues, many of whom may be unaware that there is any difference in the state’s oversight of developmental centers and community-based care settings.  The claim that the community system provides equal or better care than the developmental centers doesn’t mean much if the oversight of the two systems is not equal.

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  1. Anonymous
    October 25, 2011 at 12:41 am

    Those who have worked in both settings have DDS say that the rules are the same and so is the inspection process. DSS reviews itself, can you expect anything else. The house need independent review. The evidence is there from misspent money to questionable care. In Facility, you are inspected annually, no exceptions, with on site follow up for any outstanding issues.This on the major reasons constituent mebers are frightened for their relatives and friends. Also what happens to vendor that flunks, where do the individuals go…..
    There is minimal interaction between the home and vendor which minimizes integrated teaching. It works better, when the vendor has both the Day Program and the house because team members can cross between.
    As the centers close why can’t some of the DPH resources that inspected facilities be used for quality control in the community???
    Beth Gray-Nix

  2. mzanger
    October 25, 2011 at 5:23 am

    As a COFAR professional member (not a family member), I have great respect for the majority of private non-profit providers, and the community based system they have built over the last 40 years. However a transition to a contracted-out service model requires DDS to develop more and better regulatory powers, as well as the ability to foster services in all regions of the state. When privatization produces the problems of the banking system — providers “too big to fail,” bailouts, insider inurement, nepotism, sweetheart real-estate deals, elected officials on the payroll, and the other stuff of state auditor reports — the providers, already evolved several generations beyond their roots as family organizations, begin dictating the terms of the contracts, rather than bidding competitively, It is apparent from COFAR’s survey that DDS is suffering from what the Department of Education would have to call grade inflation and social promotion. We are in Lake Woebegon, where all the providers are above average. Yet somehow the number of DPPC cases rises yearly and hardly anyone can find a good day program,

  3. Anonymous
    October 26, 2011 at 2:05 am

    COFAR is right on! I can attest to years of negligence and secretivenss in my son’s care in one of a network of group homes; that there is gross lack of accountability — both by such agencies themselves and DDS which is supposed to oversee them.

  4. October 27, 2011 at 12:37 am

    As always the issue with the State is providing effective and efficient services, because they are unable to do so running the programs themselves they contract out to these for profit business.
    The state tax payers only get burn again when the old issue rises, because it’s about a lack of accountability among the system of management in charge of departments.

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