COMMUNITY STRATEGIES: Comprehensive Program Review Angelo Maroun Abington, Bellingham, Carver, Franklin, Kingston, Leominster Wachusett Street, Medway, Middleboro, and Wrentham January 20th, 2012 Comprehensive Program Review

CLUSTER HIGHLIGHTS Delighting our Customers Community Care Services thanked CRJ through a letter for the homemade pies we baked and donated Parent sent a thank you letter to CRJ for the work being done with her son who while a resident of his previous vendor was a victim of abuse that has left him with PTSD Staff saved a residents life from choking by successfully using the Heimlich maneuver Education, Employment and Volunteer Activities 57% of residents are either employed or in educational programs Employment agencies include but not limited to: Fed Ex, Wal-Mart, Taco Bell, Father and Son Janitorial Services and various Newspaper Courier positions High Level of Volunteer activities including but not limited to: Catholic Charities, Habitat for Humanity, Parks Clean-up through Brockton Mayor’s Office, Local Animal Shelters, Milford Hospital, Medway Library, Teen Challenge for Recovering Addicts, and Meals on Wheels

CLUSTER HIGHLIGHTS CONT. Awards Resident in Bellingham won the Human Rights award for Self Advocate of the Year Franklin Manager Kellyanne Lynch won CRJ Gold Star Award Bellingham won Program of the Quarter Training Managers Shannon Newcomb and Tammy Manning became certified Treatment Culture trainers Mandy Adao became a certified PAC trainer Kellyanne Lynch and Mandy Adao completed Emerging Leaders Program

AREAS FOR IMPROVEMENT Eliminating the overtime by filling the vacant Residential Counselor positions Recognizing fiscal shortcomings quickly enough to avoid it altogether; i.e. process for reimbursement for absent clients, staggered vacations, and utilizing additional PT staff to fill in gaps. Continued improvement of the Meaningful Day activities in the programs (expansion on the jewelry making and other activities) Decreasing the number of Med Occurrences Increased development of the Nutritional and Healthy Living education and practices including increased exercising programs

Data obtained from the HR Measures & HR Personnel Summary STAFFING Current CPR Cluster average is 25.4% versus CS in MA overall = 27.8%. Previous CPR Cluster average was 16.3% versus CS in MA overall = 25.7%. Data obtained from the HR Measures & HR Personnel Summary

Overdue Performance Evaluations STAFFING Overdue Performance Evaluations June 2011 – November 2011 FT PT Abington 3 FT 2 PT Bellingham 0 FT 0 PT Carver 2 FT 1 PT Franklin Kingston 1 FT Leo. Wachusett St 5 FT Medway Middleboro 4 FT Wrentham Total of 18 FTE’s and 8 PTE’s with overdue performance evaluations between June 2011 – November 2011. Last CPR had a total of 60 FTE’s and 17 PTE’s with overdue performance evaluations from September 2010 -March 2011 Data obtained from the HR Measures & HR Personnel Summary

Medication Incidents & Occurrences (Per Client Per Month) June 2011 – November 2011 Previous CPR Total: 34 incidents and occurrences combined Med Occurrences by Program: Wrentham 5, Wachusett Street 1 Med Incidents by Program: Carver 10, Franklin 1, Wachusett Street 1 Data obtained from MMRs

CLINICAL HOURS Total Clinical Hours Per Client Per Month June 2011 – November 2011 Cluster Average is 2.6 Clinical Hours per Client Previous CPR Cluster Average (minus Wachusett St) was 2.3 Clinical Hours per Client Data obtained from MMRs

Activities per Client per Month COMMUNITY INCLUSION June 2011 – November 2011 Activities per Client per Month Average of 4.4 Inclusion Activities Participated in per Client per Month (71% participation rate) Average of 16.3 Mainstream Activities Participated in per Client per Month (79% participation rate) Data obtained from MMRs

De-escalation to Restraint Ratio June 2011 – November 2011 Elopements June 2011 – November 2011 Ratio Abington 121:0 Bellingham 21.5:1 Carver 24.3:1 Franklin 46:1 Kingston 181:1 Leo. Wachusett St 12.6:1 Medway 12.7:1 Middleboro 93:0 Wrentham 75.6:1 Cluster Average 83.9:1 Number Abington Bellingham Carver 2 Franklin 1 Kingston Leo. Wachusett St Medway Middleboro Wrentham Cluster Total 4 Previous CPR Cluster Average = 73.6:1 Data obtained from MMR’s

Key MMR Results Timely Mandatory ISP Documents – 87% (total) Timely Assessments – 89% Timely Provider Support Strategies – 100% Timely Progress Summaries – 72% Employment/Education 36% of residents are competitively employed 7% of residents are enrolled in education programs 14% of residents have paid employment through a day program Combined total of 57% of the cluster are either employed or in educational program Other 3 Contraband (Trigger) items found in the programs over this time period Data obtained from the MMR’s

Results of Monitoring Audits Cluster Areas to Improve Upon Cluster Positives Quarterly Fire Drills 100% Staff Training forms – 86% Safety, Search, & Disaster 78% Informal Fire Safety 89% Carbon Monoxide 89% Informal Human Rights 89% Mandatory Med. Appointments - 96% Annual Physical 100% Annual Dental 94% Bi-Annual Vision 94% Audits for the Cluster showed 82% full credit earned Cluster Areas to Improve Upon Mandatory Signatures Behavior Plans Psychotropic Treatment Plans Consent Forms Dated Documentation to DDS Individual Budgeting Sessions LOM and Restraint forms matching the monthly data numbers HRC signatures on LOM and Consent Forms Data Obtained from QA Audits

Staff Training Hours Cluster Monthly Totals June 2011 – November 2011 Total Hours: 2,942 Monthly Average Per Program is 54.5 Hours Data obtained from Shirley Training Records