Comprehensive Program Review May 31, 2013 COMMUNITY STRATEGIES: Angelo Maroun Abington, Carver, Kingston, Leominster Pleasant Street, Leominster Wachusetts Street, and Middleboro Comprehensive Program Review May 31, 2013

CLUSTER HIGHLIGHTS Employment: phasing out the job coach and promoting independence Volunteerism: Salvation Army, Habitat for Humanity, Hope House, Fuller Craft Museum, Beautify Brockton, and Knights of Columbus Meaningful Day – Jewelry: success at the CRJ Spring Fundraiser event MAP certification up 11% QUEST in Carver One Lions Club members (client) attends activities independently Mandy Adao completed DDS Regional Director leadership Training Lucas Paine and Janna McPherson enrolled in CRJ supervision training

AREAS IN NEED OF IMPROVEMENT Challenges: Medication Occurrences Healthy Living Performance Appraisals Retention

STAFFING Staff Turnover Rates Performance Evaluations Staff Training

STAFF TURNOVER RATES 4/01/2012 - 3/31/2013 The current Cluster Average is 27.3% compared to the CSMA average of 24% Last CPR, Cluster Average (which included Alger) was 20.9% versus CSMA overall of 21.1% Data obtained from HR Reports

OVERDUE PERFORMANCE EVALUATIONS STAFFING OVERDUE PERFORMANCE EVALUATIONS October 2012 - March 2013 Overdue Evaluations As of March 31, 2013   FT PT Abington Carver 1 Kingston Middleboro 2 Pleasant 4 Wachusetts Cluster - Totals 7 3  March 2012 - August 2012 Overdue Evaluations As of August 31, 2012   FT PT Abington 1 Carver Kingston Middleboro Pleasant 2 Wachusetts 5 Cluster - Totals 7 Total of 7 FTE’s and 3 PTE’s with overdue performance evaluations between October 2012 – March 2013. Last CPR, a total of 7 FTE’s and 7 PTE’s with overdue performance evaluations from March 2012 – August 2012. Data obtained from HR Department & HR Personnel Summary

STAFF TRAINING HOURS Total of 1185.25 training hours were completed October 2012 – March 2013; Average of 19.9 hours per staff/cluster/over six months; Average training hours per staff/month = 3.3 hours. This is a 31% decrease from last CPR. Last CPR, total of 2340.25 training hours were completed March 2012 – August 2012; Average of 29 hours per staff/cluster/over six months; Average training hours per staff/month = 4.8 hours Data obtained from MMRs and HR Reports

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

CLINICAL HOURS Total Clinical Hours = 259.75 (October 2012 – March 2013); Cluster Average of 1.6 clinical hours per client/month Last CPR, Total Clinical Hours = 271 (March 2012 – August 2012); Cluster Average of 1.6 clinical hours per client/month Data obtained from MMRs

Client Walk-Aways October 2012 - March 2013 March 2012 - August 2012 Abington 1 Carver Kingston Pleasant Middleboro Wachusetts Cluster - Total 2 Client Walk-aways decreased by 50% compared to last CPR Data obtained from MMRs

MEDICATION INCIDENTS & OCCURRENCES Average: 0.13 medication incidents and occurrences per client/month; total of 22 medication incidents and occurrences (October 2012- March 2013.) This is a 64% decrease from the previous CPR. Last CPR: Average: 0.36 medication incidents and occurrences per client/month; total of 61 medication incidents and occurrences (March 2012 – August 2012). Data obtained from MMRs

De-Escalations : Restraints October 2012 – March 2013 March 2012 – August 2012 Abington 216:1 132:0 Carver 311:1 44:1 Kingston 445:0 372:0 Pleasant 8:1 3:1 Middleboro 124:0 177:0 Wachusetts 40:1 98:1 Cluster Average 286:1 275:1 This is a 4% increase in de-escalations from last CPR Data obtained from MMRs

COMMUNITY INCLUSION Average Community Inclusion Activities Participated In and Offered Per Client/ Month (October 2012 – March 2013) Average of 4.6 inclusion activities participated in by client/month (October 2012 – March 2013). The overall participation rate is 87%; This is a 8% increase from last CPR. Last CPR, the Cluster average of inclusion activities per client/month was 3.9; the overall participation rate = 79% Data obtained from MMRs

MAINSTREAM ACTIVITIES Average Mainstream Activities Participated In and Offered Per Client/ Month (October 2012 – March 2013) Average of 22.3 Mainstream Activities Participated in Per Client/Month (94% participation rate ). This is an 11% increase over last CPR. Last CPR, average of 16.8 Mainstream Activities Participated in Per Client/Month (84% participation rate). Data obtained from MMRs

QUALITY ASSURANCE Key MMR Results

KEY MMR RESULTS Employment/Education: (As of March 31, 2013) 8/27 (30%) of the residents are competitively employed or enrolled in pre-vocational training programs 6/27 (22%) of the residents are in a sheltered workshop 13/27 (48%) of the clients are in an alternative day program Other: 17/27 (63%) of the residents chose healthy living opportunities in programs 0 Contraband (Trigger) item found in the programs over this time period; last CPR = 1 Contraband (Trigger) item found Staff Certifications: 100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED 78% of the staff are MAP certified; this is a 11% increase from last CPR Last CPR: Abington 50%; Carver 59%; Kingston 71%; Pleasant 67%; Middleboro 67%; and Wachusetts 75% Current CPR: Abington 75%; Carver 71%; Kingston 83%; Pleasant 73%; Middleboro 86%; and Wachusetts 78%

CPR ACTION PLAN