29-455 (5) NOV-02-2001 05 :53 PM LESLIE EDUCATIONAL 413 737 6321 P. 04
olo
egt
GROUP INTERACTIONS:
Since the four women living together will be compatible in terms of age,
capability and interests, there are no circumstances or conditions that would
prevent them from exiting their home with staff, within the required 2.5
minutes.
ENVIRONMENTAL STANDARDS:
The residence is a two-story, single family home with four bedrooms, two full
baths, a living room, kitchen/dining area and small office/den. Two bedrooms
and one bath are on the second floor. There are three means of egress from the
first story. An additional means of egress from a second story bedroom is to be
added, prior to the move of the women into the home.
This home is equipped with interconnected smoke and heat detectors. There
will be carbon monoxide detectors located on each story, and in the basement,
prior to the move of the women. There will also be fire extinguishers located on
each story of the home, and in the basement.
64 Crestview Drive has gas hot air, central heating, on the first floor. The
second story, which was added ten years after the home was originally built,
has electric heat, with separate thermostats. There is a large gas hot water
heater in the basement.
Barbara and Alison will have bedrooms on the second story of the home. Nicole
and the fourth woman to be referred will have bedrooms on the first floor.
There is a small office/den next to the first floor bedrooms. Overnight staff will
remain on the first story during the night, in order to assist Nicole in the event
of emergency. There will be no locks on any bedroom door. Smoking is not
permitted within any Leslie home.
ADAPTIVE TECHNOLOGY:
Neither Barbara nor Alison use any form of adaptive technology in order to exit
the home in the required 2.5 minutes. Once Nicole and the fourth woman have
moved into the home, each will be assessed for possible adaptive technology
needs. Each of the four women will be ambulatory.
STAFFING:
Staffing during the hours that the four women are awake will be at a ratio of
2:4. During overnight asleep hours, awake staffing will be 1:4. At no time will
one or more of the women be at home or out in the community without staff
accompanying them.
Confidential Page 7 11/02/01
•
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NOV-02-2001 05 :52 PM LESLIE EDUCATIONAL 413 737 6321 P. 03
Alison. Niki will begin planning overnight visits after the move to
Crestview Drive, Florence has occurred. Her transition to becoming a
resident of the home is expected to last until June 30, 2002, giving Niki
and her parents the necessary time to adjust to living apart. Niki has
participated in fire drills at Riverside Industries, and understands that
fire is a danger which means she must evacuate the building. She is
able to identify the sound of the alarm at Riverside, but has not yet been
tested at a residential setting, since she has not stayed overnight. It is
fully expected that with verbal reassurance, routine practice, and some
physical guidance, Niki will learn to evacuate her home in the required
2.5 minutes. She is cooperative with staff directions, and is able to
communicate some of her needs in 1-2 word phrases. Once her visits to
the new home become more lengthy, she will begin routine practice drills
with her house mates and staff. Niki has no health, mobility or
behavioral issues which would hinder her safe evacuation from the home
in 2.5 minutes. She will be under the supervision of trained residential
staff at all times, whether at home or out in the community. Due to the
fact that Niki is legally blind, she will be offered physical assistance from
staff, in moving toward the appropriate exit, and getting out of the home.
Niki's bedroom is located on the first floor, to ensure safe and timely
evacuation during overnight fire drills.
3. Alison
Alison is a 29 year old woman with mild mental retardation, who lived at
home with her parents and siblings in Haydenville until this year, when
she moved to a Leslie-operated residence in Amherst. Alison works at
Riverside Industries in Easthampton, and is familiar with safety rules
and regular fire drills at work and at home. She is able to recognize
danger and understand that fire is dangerous. Alison has good
communication skills, and is cooperative with safety and hazard
awareness. She is able to notify her staff of a dangerous situation in the
home, and evacuate independently within the required 2.5 minutes.
Alison is able to call 911, and understands to do so if her staff become
injured and unable to help or lead. Alison is under the supervision of
trained residential staff at all times, whether at home or out in the
community. She has no health, mobility, sensory or behavioral issues
which would hamper her evacuation from the residence in the event of
fire. She is capable of understanding and following directions, and is
able to verbally communicate her needs. Alison has practiced safe
evacuation during routine drills at her Amherst home, and is easily able
to meet the necessary requirements and timelines independently.
4. Vacancy:
The last resident to move to this home will be female, and within the
same age range as Barbara, Nicole and Alison. It is expected that the
woman will be ambulatory, and capable of exiting the home during an
emergency in the required 2.5 minutes, under the supervision of staff.
Confidential Page 6 11/02/01
NOV-02-2001 05 :52 PM LESLIE EDUCATIONAL 413 737 6321 P. 02
LESLIE EDUCATIONAL ALTERNATIVES, INC.
RESIDENTIAL SAFETY PLAN
RESIDENT NAMES: 1. , Barbara
2. , Nicole
3. , Alison
4. __-jvacancy]__
ADDRESS: 64 Crestview Drive
Florence, MA 01062
PHONE: (413) 584-7324
INDIVIDUAL SAFETY ASSESSMENTS:
1. Barbara :
Barbara is a 35 year old woman with mild mental retardation, who lived
at home with her parents and siblings until one year ago, when she
moved into a Leslie-operated residence in Amherst. Barbara works at
Riverside Industries in Easthampton, and is familiar with safety rules
and regular fire drills. She is able to recognize danger (such as fire) and
identify the sound of the alarm. Barbara is cooperative with safety and
hazard awareness, and will notify her staff and evacuate her residence in
Amherst independently, within the required 2.5 minutes. She is able to
call 911, and would do so if her staff were injured and unable to help
her. Barbara is under the supervision of trained residential staff at all
times, when at home or out in the community. Barbara has no health,
mobility, sensory or behavioral issues which would hamper her
evacuation from the residence in the event of fire. She is able to
understand and follow directions, and is able to verbally communicate
her needs. She has practiced safe evacuation during routine drills, and
is easily able to meet the necessary requirements and timelines.
2. Nicole •
Niki is a 30 year old woman with Down Syndrome, who has been
declared "legally blind" due to her visual deficits. She has lived at home
with her parents all of her life, and is shy and hesitant about making the
move to a residence with housemates her age. Her parents are close to
and protective of her, although she has been allowed to work at Riverside
Industries in Easthampton. Niki currently visits the home in Amherst on
a weekly basis, sharing dinner and a social activity with Barbara and
Confidential Page 5 11/02/01
S •
• �i
e •
NUV-02-2001 05 =b3 PM LESLIE EDUCATIONAL 413 737 6321 P. 05
EVACUATION:
Leslie will ensure that one staff member is able to successfully supervise the
evacuation of all four women from the home in 2.5 minutes, during overnight
asleep hours. During day or awake evening hours, two staff members will be on
duty to assist with the evacuation. As staff are leaving the home with the last of
the women, one employee is to take the red "SUPPORT MANUAL", which
contains all pertinent information needed in the event of resettlement. The red
"SUPPORT MANUAL is kept in the office/den, on the first story, next to the
telephone. All Leslie employees, including those working at 64 Crestview Drive,
are oriented to the specific Site Safety Plan, during initial orientation to the
home and individuals served.
EVACUATION DURING ASLEEP HOURS:
As soon as the alarm sounds, staff(awake on the first story) will proceed to the
stairs and call to Barbara and Alison, ensuring that they have awoken and
begun to descend the stairs to a first story exit. Should there be fire on the first
story or in the basement, staff will verbally direct Barbara and Alison to use the
fire escape exit from the second floor, and meet everyone on the way to, or at,
the designated meeting place (cul-de-sac or "circle" at end of Crestview Drive).
Once assured that Barbara and Alison are out of bed and leaving the building,
staff will proceed to the first floor bedroom area, and verbally direct and/or
escort Niki and the other resident out the safest first floor exit. Staff will lead
the two women around to the back of the home, where the fire escape is
located. Staff member with Niki and the other resident will meet Barbara and
Alison at the bottom of the fire escape (or on way to designated meeting area),
and continue (with all four residents) to the cul-de-sac or"circle", at the end of
Crestview Drive.
Once at the designated meeting area, staff will continue to monitor the activity
of the women, providing verbal reassurance and direction, as needed. Staff will
a
not stop evacuating the building, or remain behind to make calls from the
inside of 64 Crestview Drive.''
EVACUATION DURING WADING HOURS:
As soon as the alarm sounds, one staff member will locate Barbara and Alison.
The second staff member will locate Niki and the fourth woman. Each staff
member will remain with their assigned two women throughout the drill or
emergency evacuation. With verbal direction and reassurance, each staff
member will support or guide their two assigned women to the nearest
uninvolved exit. Once all four residents have evacuated the home with their
staff, all will proceed to the designated meeting area, which is the cul-de-sac or
"circle", at the end of Crestview Drive.
Once at the designated meeting area, staff will continue to monitor the activity
of the women, providing verbal reassurance and direction, as needed. Phone
calls to 911 or other emergency notification will be made from an outside
Confidential Page 8 11/02101
NOV-02-2001 05 :53 PM LESLIE EDUCATIONAL 413 737 6321 P. 06
• •
mobile phone, or the home phone of a neighbor. Staff will not stop evacuating,
or remain behind to make calls from the inside of 64 Crestview Drive.
FIRE DRILLS:
Routine fire drills are conducted at least quarterly, including two night drills
which occur during asleep hours. Should the alarm sound at any other time,
the women and their support staff will follow the above evacuation procedure,
regardless of the reason.
All Leslie employees are trained in implementation of the Site Safety Plan
at the time they are oriented to the site and residents living there. Each
employee must sign off on their Orientation Checklist, once they have
completely familiarized themselves with the Site Safety Plan. Staff sign-
off is considered an acknowledgement that staff fully understand and are
able to implement the Site Safety Plan.
METHOD OF NOTIFYING EMERGENCY PERSONNEL:
When responding to a real fire, all calls will be made from a safe location, one
other than 64 Crestview Drive. Upon arriving at the designated meeting place
(cul-de-sac, or "circle", at the end of Crestview Drive), one staff member will use
a cell phone, or proceed to the home of a neighbor, to use the telephone.
Order of Calls in Event of Emergency:
1. 911 [Police, Fire Department, andjor Ambulance]
2. 24-hour Leslie Beeper: 1-413-261-
[On-call supervisor will call back]
3. AFTER-HOURS ADMINISTRATIVE BACK UP:
Caren Feinberg, Prog. Director: 329-
Maddy Martinez, Prog. Director: 626-
Rev People for Notification After Emergency is Over:
Caren Feinberg, Prog. Director: 329-
Maddy Martinez, Prog. Director 626-
Barbara's Mother: (978) 724-
Alison's Mother: (413) 268-
Niki'a Mother/Father: (413) 774-
[4th Woman's Guardian]:
The on-call Manager will notify the Program Director, who will notify the DMR
Emergency Beeper as follows:
Confidential Page 9 11/02/01
S •
NuV-UZ°2001 05 :54 PM LESLIE EDUCATIONAL 413 737 6321 P. 07
S
1-800-752- PIN: 242_
Back-up PIN: 242_
Give Operator the PIN #, your name, and a brief message about what
happened. The on-call person from DMR will return your call. If no
response in 10 minutes time. ocall again, and give the Back-up PIN #.
TRANSPORTATION AND RESETTLEMENT:
In the event the four women must be temporarily relocated, because their home
is uninhabitable, staff person on duty will transport them to Pomeroy
Street, Easthampton. Phone: (413) 629
Directions: Take I-91 South to Exit 175. Right off
the ramp (Rt. 141). One mile up the road, take
CONTINUITY OF SERVICES:
If relocation is necessary, existing staffing and other supports will continue as
close to previously as possible. Riverside Industries and other day programs)
will be notified by the on-call manager, to pick up the four women at
Pomeroy Street, Easthampton. If this cannot be arranged, Leslie staff will
transport the women to and from day program(s) until more permanent
arrangements can be made.
If toiletries, clothing and other needed personal property of the residents cannot
be retrieved from the home, Leslie staff will purchase any needed items at the
expense of the agency.
If the women must relocate, a meeting will occur on the next working day after
the relocation, to determine how long the women will need to be out of their
home, and what temporary arrangements can be made for their care, if
warranted. Each of the women will be present at this meeting, as well as the
DMR Service Coordinator for each.
Each woman will continue working on the goals previously identified in her
Individual Support Plan.
A new Site Safety Plan will be submitted to the Department of Mental
Retardation, if one or more of the following occur:
1. The current Plan is no long effective because of changes in individuals'
capabilities, or numbers of people at the location;
2. A new home is opened; (Must be submitted and approved prior to opening);
Confidential Page 10 1 1/02/01
rvuv n�-Lnn1 n� :� a rI9 LtsL1t tUULHI1UNRL 413 737 6321 P_08
3, Relocation of existing home;
4. Changes in staffing ratios, fire drill protocols or environmental standards;
5. Provider of existing home changes;
Confidential Page I I 11/02/01
ivuvgr3t the1 Un :nn I1 LtSL1t hLUL- I 1UN -L 413 737 6321 P. 09
• o-�
C P
The Co onwealth o assachusetts
-� Executive Offic ut Health Human Services
e "'' Department of Mental Retardation
Li
Franklin/Hampshire Area Office
• "`+ One Roundhouse Plaza
Argeo Paul Cellucci Northampton, MA 01060
8 Gerald J. Morrissey, Jr.
Governor (413) 586-4948 Commissioner
TTY: (413) 584-9762
Jane Swift FAX (413) 584-0611 Teresa L. O'Hare
Lieutenant Governor Regional Director
William D. O'Leary William Zimmer
Secretary Area Director
MEMORANDUM
TO: Caren Feinberg
Program Director
FROM: Bill Benson /(
Program Monitor
DATE: 10/29/01
RE: SAFETY PLAN - Montague Rd
The Safety Plan for 2 individual(s) located at, Montague Rd has been approved. Enclosed is
the approved Provider Assurance Form for this site.
If you have any questions,please contact me.
BB:Ig
Enclosure
NUV-ac- cba1 a� _�� rrt
LESLIE ELUCHI1UNHL
•LIE EDUCATIONAL ALTERNITAVES; 413 737 6321 ; 413
321 ; 41 3 737 6321
l
OCT-24-01 2:40PM; POE 2 a
- r.rwir
PROVIDER ASSURANCE FORM
hereby certify under the pains and penalties of perjury that the home or work/day support
located at � syt �" . with a capacity of,p_individuals, and laddreu)
•
operated by meets or exceeds. or with respect to a new
(name of provider)
support, agree to Moat or exceed the requirements for assurances of safety ea listed below and in
accordance with the regulations of the Department of Mental Retardation (115 CMR 7.06)-
1. The written safety plan includes all the applicable components required in 115 CMR
7.0513); or the current disaster and evacustion plan will remain in effect,
2. The safety plan is designed for the safety of individuals requiring evacuatiorrin sr+
emergency. is Implemented. and is periodically tveluated for effectiveness.
3. All required fire safety equipment as referenced in the safety plan is functional (i.e., smoke
detectors, 'lerma, adaptive equipment, sprinklers, or emergency back-up aysterns, if
applicable).
4. The following documentation, as applicable. Is available for reviles:
a. Fire Drill log;
b. Bafety Plan;
a. Documentation that each staff parson/home provider has bean trained in implementation
of the Safety Plan. •l� 1
•
.i• a•.. i - :"." « ' J raw•
Signed Sig i {.� 1� ear x:.Date [ • — •
Print ..'. h; ' ,7*• r "
EMIR Arse D T 1 bane reviewed iind sppro4d lhe,lUety Plan as tubrnitted.
Signed , ►; :i // J • •-• • 'Date. • V ^ 26 re
or
hint Nettle 11 Title
- " Ar•TT OO/!;/10
I . •
NOV-02-2001 05 :56 PM LESLIE EIIUCATIONAL
0 413 737 6321 P. 11
'OLIE EDUCATIONAL ALTEANITAUES; 413 737 8321; OCT-2d•01 2:46P�1; PAGE 3
Form G
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to: urana stone Northampton High Sc from: MarkettlAPS 11-05-01 7:34am p. 1 of 1
V;fri, To: Diana Stone From: Toni Burkholder
Company: Northampton High School Phone: (570) 724-7355
Fax: 4135871272 Fax: (570) 724-7394 j
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NOV-02-2001 05 :51 PM LESLIE EDUCATIONAL 413 737 6321 P. 01
.79*- #3/(55
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Iw h Pc EDUCATIONAL ALTERNATIVES
„D 604 COTTAGE STREET
D
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SPRINGFIELD, MA 01104
FAX COVER SHEET
Date: November 2, 2001 Time: 6 PM
TO: Mr. Anthony Patillo, CBO Phone: (413) 587-1240
Northampton Building Dept. Fax: (413) 587-1272
From: Joy C. Hibsher, President Phone: (413) 737-5376
Fax: (413) 736.0127
RE: 84 Crestview. Florence: Standard 427.1.1.1- DMR Group Homes
Site Safety Plan Requirement
No. Pages (Incl. cover): 12
MESSAGE: Tony:
I have carefully read over the 3 pages of Building Code
Regulations& Standards. I think we fall under 427.1.1.1
"Department of Mental Retardation(DMR) Group Homes.
See Second Paragraph,Second Column,Pane 2 (the first page you
faxed to me). For this reason, I am faxing you a copy(with names
and numbers taken out)of our Site Safety
Plan, required by DMR. I am also faxing you three pages which were
attached to the Site Safety Plan for the location where two of the
women are currently living,in Amherst. Someone from DMR should
be calling you about this code. 1
Thanks for your assistance with this project.
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