Comprehensive Program Review January 18, 2012 Community Strategies: Janet Kachadoorian’s Cluster Fitchburgh, Leominster-Betanray, Leominster -Merriam, Templeton, Wendell and West Boylston WE want to be more than a boss to our staff. WE want the best possible results every time. WE want to lead OUR team to greatness. Notice how there is no “I” in our team!!! Comprehensive Program Review January 18, 2012

CLUSTER HIGHLIGHTS Cluster Highlight Volunteering with Habitat for Humanity and Adopt-A-Platoon (other houses participated but initiated in our cluster)    Program Highlights Diabetic individual is now successfully off all diabetes medication. Individual who has a long history of poor bedroom maintenance now requires no prompting to complete her bedroom maintenance. Two individuals have successfully taken leisure trips in the community without CRJ staff. Two individuals had deaths in their families and successfully used their skills to cope with their loss without engaging in any behaviors. All 4 individuals are volunteering twice weekly in the community. Individuals are learning about Healthy Living and following it.  One of our older gentleman has become more active; sleeps less during the day due to meaningful day activities. Our individuals have been going into the community to see where they can volunteer. One individual has been hospitalized at Hogan for numerous months and he recently has been medically cleared to have a knee replacement.

AREAS IN NEED OF IMPROVEMENT Car pooling to save on mileage Before using OT, we call cluster programs to see if staff can be pulled Re-training staff on neatness of time and mileage sheets. Re-training staff on the reasons to page a supervisor  

STAFFING Staff Turnover Rates Performance Evaluations Staff Training

STAFF TURNOVER RATES (12/1/11 – 11/31/12) The current CS Cluster average is 27.0% compared to the CSMA average of 22.0% Last CPR, Cluster average was 25.4% versus CSMA overall of 26.7% (March 1, 2011 – February 29, 2012) CS Cluster configuration has changed since the last CPR Data obtained from HR Turnover Reports

STAFF OVERDUE PERFORMANCE EVALUATIONS June 2012 - November 2012   Overdue Evaluations 2 > or more months FT PT Fitchburgh Leominster Betanray Leominster Merriam Templeton Wendell West Boylston Cluster - Totals June July Aug. Sept. Oct. Nov.   FT PT Fitchburgh Leominster Betanray 1 Leominster Merriam 2 Templeton Wendell West Boylston Cluster - Totals Total of 3 FT and 0 PT overdue performance evaluations Last CPR, a total of (27FT and 22 PT) overdue performance evaluations from September 2011- February 2012. CS Cluster configuration has changed since the last CPR Data obtained from HR Department & HR Personnel Summary

STAFF TRAINING HOURS June 2012 – November 2012 Total 1587.5 training hours were completed Average of 5.62 hours per staff per month Average of 33.8 hours per staff/over six months per cluster E Training Hours MMR Training Hours Total Fitchburgh Apt. Leominster Betanray 43.75 181 224.75 Leominster Merriam 43.25 540 583.25 Templeton 43 139 182 Wendell 104.5 207 311.5 West Boylston 52 209 261 Cluster 286.5 1301 1587.5 Last CPR, average per staff per month = 4 hours CS Cluster configuration has changed since last CPR Data obtained from MMRs and HR Reports

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

CLINICAL HOURS June 2012 – November 2012 Cluster Average of 8 clinical hours per client/six-months or 1.3 hours/per client per month Total Clinical Hours = 185 (Fitchburgh data for June and July 2012 only) Last CPR, the cluster average of clinical hours per client/month was 1.8 (September 2011 – February 2012); CS Cluster configuration has changed since last CPR. Data obtained from FMRs

CLIENT WALK-AWAYS June 2012 – November 2012 September 2011 – February 2012 Fitchburgh Apt. (June/July data only) Leominster Betanray 2 Leominster Merriam 1 Templeton Wendell West Boylston Cluster - Total 3 4 Data obtained from MMRs

MEDICATION INCIDENTS & OCCURRENCES June 2012 - November 2012 Total of 11 medication incidents and occurrences Last CPR, a total of 34 medication incidents and occurrences. CS Cluster configuration has changed since last CPR. Data obtained from MMRs

DE-ESCALATIONS : RESTRAINTS June 2012 – November 2012 September 2011 – February 2012 Fitchburgh Apt. (June and July data only) 0:0 Leominster Betanray 5:1 0.9:1 Leominster Merriam 38.6:1 77:1 Templeton 99:0 200:1 Wendell 15.5:1 11:1 West Boylston 2:1 Cluster Average 450 De-escalations: 14 Restraints or 32.1:1 7.7:1 CS Cluster configuration has changed since last CPR. Data obtained from MMRs

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (June 2012 – November 2012) Average of 4.08 community inclusion activities per client/six months (Fitchburgh data – June and July 2012 only; average = for two month period) Last CPR, average of 5.7 community inclusion activities participated in per client/six months CS Cluster configuration has changed since last CPR Data obtained from MMRs

MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered (June 2012 – November 2012) Average of 13.4 Mainstream Activities Participated in per client/six months (Fitchburgh data – June and July 2012 only; average = for two month period) Last CPR, average of 7 mainstream activities participated in per client/six months CS Cluster configuration has changed since last CPR Data obtained from MMRs

KEY MMR RESULTS Employment/Education: ( As of November 30, 2012) 7 out 23 clients are employed or in a pre-vocational training program 3 out of 23 clients are in school 13 out of 23 clients are in a day program Other: 19 out of 23 clients chose to participate in the healthy living options within their program “0” contraband reported 11 site visits conducted by outside funders Staff Certifications: 100% certified in PAC/CPI, First AID/CPR, Human Rights 83.4% of staff are MAP Certified Fitchburg Apt. – June and July 2012 data (0%); Leominster Betanray = 66.6%; Leominster Merriam = 100%; Templeton = 83%; West Boylston = 80%; Wendell = 87.5%

CPR ACTION PLAN See Handout