Comprehensive Program Review Community Strategies: Mandy Adao’s Cluster Carver, Kingston, Middleboro and Paxton Comprehensive Program Review June 27, 2014

CLUSTER HIGHLIGHTS Highlights: Seven Promotions: 1 Program Coordinator, 2 Managers, 2 Assistant Managers, and 2 Meaningful Day Coordinators CM from Carver has been awarded her 3rd recognition from the House of Representatives. We have been able to accomplish more community inclusion activities for each client.   Best Practice: 100% of all residents are participating in Healthy Living with weight loss being shown. The residents have lost a total of 76 lbs which is a great start.

CHALLENGES Hiring open positions (because of all the internal promotions)   Using less overtime

STAFFING Staff Turnover Rates Staff Retention Rates Overdue Performance Evaluations Staff Training Hours

STAFF TURNOVER RATES The current CS Cluster average is 28.6% compared to the CSMA average of 26.5% Last CPR, Cluster average was 25.6% compared to the CSMA average of 25.7% Data obtained from HR Staff Retention & Turnover Report

STAFF RETENTION RATES 6/30/13 Retention Data for CSMA and Overall-CRJ = N/A (data not available) Data obtained from HR Staff Retention & Turnover Report

STAFF OVERDUE PERFORMANCE EVALUATIONS November 2013 – April 2014 Overdue Evaluations As April 30, 2014   FT PT Carver 1 Kingston Middleboro Paxton Cluster - Totals 2 January 2013 – June 2013 Overdue Evaluations As June 30, 2013   FT PT Carver 2 Kingston Middleboro Paxton Cluster - Totals Total of 2 FT and 0 PT overdue performance evaluations Last CPR, a total of 2 FT and 0 PT overdue performance evaluations Data obtained from HR Report

STAFF TRAINING HOURS November 2013 – April 2014 Total of 954.25 training hours were completed (22.8% increase from previous CPR) Average of 29.9 training hours per staff/over six months November 2013 – April 2014 E Training Hours MMR Training Hours Total Carver 70.75 376 446.75 Kingston 24.75 231.5 256.25 Middleboro 29.25 56 85.25 Paxton 110 166 Cluster 234.75 719.5 954.25 Last CPR: (June 2013) Total of 777 training hours were completed Average of 21.4 training hours per staff/over six months Data obtained from MMRs and HR Reports

CLIENT RELATED Clinical Hours Elopements Medication De-escalation and Restraints Mainstream/Community Inclusion Activities

CLINICAL HOURS November 2013 – April 2014 A total of 213.3 clinical hours; the Cluster average = 12 clinical hours per client/over six- months or 2 hours per client per month. Last CPR, a total of 204.5 clinical hours; the Cluster average was 11.4 clinical hours per client/over six-months or 1.9 hours per client per month. Data obtained from MMRs

CLIENT ELOPEMENTS November 2013 – April 2014 January 2013 – June 2013 Carver Kingston Middleboro Paxton 1 Cluster - Totals Data obtained from MMRs

MEDICATION INCIDENTS & OCCURRENCES November 2013 – April 2014 Total of 3 medication incidents and occurrences. For both time periods, all medication incidents and occurrences were client refusals. Last CPR, a total of 3 medication incidents and occurrences. Data obtained from MMRs

DE-ESCALATIONS : RESTRAINTS November 2013 – April 2014 January 2013 – June 2013 Carver 76:1 42:1 Kingston 169:0 139:0 Middleboro 213:0 412:0 Paxton 15:1 9:0 Cluster Average 87:1 135:1 Totals 785 De-escalations: 9 Restraints 814 De-escalations: 6 Restraints This is a 36% decrease in de-escalation and a 50% increase in restraints compared to previous CPR. Data obtained from MMRs

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (November 2013 – April 2014) Average of 34.4 community inclusion activities per client/over six months. This is a 39.8% increase from the last CPR  Last CPR: Average of 24.6 community inclusion activities participated in per client/over six months A total of 449 community inclusion activities offered; a total of 443 community inclusion activities participated in Data obtained from MMRs

MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered (November 2013 – April 2014) Average of 90.6 mainstream activities per client/over six months. This is a 19% decrease from the last CPR Last CPR: Average of 112 mainstream activities participated in per client/over six months A total of 2,103 mainstream activities offered; a total of 2,018 mainstream activities participated in Data obtained from MMRs

QUALITY ASSURANCE KEY MMR RESULTS SQA AUDITS

KEY MMR RESULTS Employment/Education: (As of April 30, 2014) 1 out of 18 (6%) clients competitively employed 2 out of 18 (11%) clients are in school 6 out of 18 (33%) clients are attending a sheltered workshop 9 out of 18 (50%) clients are in day programs Other: 18 out of 18 (100%) clients chose to participate in the healthy living options within their program; last CPR = 80% “0” contraband reported; last CPR = 0 contraband reported Staff Certifications: 100% certified in PAC/CPI and First Aid/CPR: 74.4% of staff are MAP Certified; this is a 3% decrease from the last CPR, (77% of staff were MAP certified) Current CPR: Carver 73%; Kingston = 80%; Middleboro = 57% ; Paxton = 88% Last CPR: Carver 86%; Kingston = 83%; Middleboro = 83% ; Paxton = 56%

RESULTS OF SQA MONITORING AUDITS November 2013 – April 2014 Positives Average Scores Confidential Files = 95% Financial Records = 99%  Program Forms = 95% Walk-throughs – All passed **Strengths of the Cluster ISP Paperwork (Assessment and Provider Support Strategies) Fire Drills Mandatory Medical Appointments Areas In Need of Improvement Required Roger’s Monitor documentation Required trainings for Skills Development Management Plans

This is the first CPR for Mandy’s Cluster CPR ACTION PLAN NOT APPLICABLE This is the first CPR for Mandy’s Cluster