Comprehensive Program Review October 17, 2014 Community Strategies: Oyeyemi Payne’s Cluster Franklin, Medway, Milford, Northborough, and Wrentham Comprehensive Program Review October 17, 2014

CLUSTER HIGHLIGHTS One of our individuals is celebrating his 14th year with Meals on Wheels. He started as a volunteer and is now a paid employee. An individual who has never showed any interest in obtaining employment participated in a seasonal employment opportunity this year for the first time with Liberty Tax. He did not miss any days and enjoyed the experience. An individual participated and acted in the Wendy Saba Stepping Stone theater group last July 2014. An individual was diagnosed with a type 2 Diabetes in March 2014 and he turned it around with weight loss (30 lbs.) and healthy diet. He is no longer diabetic.

PROMISING PRACTICE CHALLENGES We continuously strive to promote a healthy life style, a safe environment, and improve the overall quality of life of our individuals. CHALLENGES Reaching 100% compliance using Care Tracker. Struggling to be fully staffed in some of our programs.

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

STAFF TURNOVER RATES (8/1/2013 - 7/31/2014) Cluster average is 20.1% compared to CSMA average of 26.7% Last CPR, Cluster average was 17.1% compared to the CSMA average of 26.8% Data obtained from HR Reports

STAFF RETENTION RATES (8/1/2013 - 7/31/2014) Cluster average is 81.8% compared to CSMA average of 71.8% Last CPR, Cluster average was 82.7% compared to the CSMA average of 73.6% Data obtained from HR Reports

OVERDUE PERFORMANCE EVALUATIONS STAFFING OVERDUE PERFORMANCE EVALUATIONS Current CPR: as of 7/31/14 Last CPR: as of 11/30/13 FT PT Franklin 1 Medway Milford Northborough Wrentham Cluster - Totals Data obtained from HR Department & HR Personnel Summary

STAFF TRAINING HOURS February 2014 – July 2014 Total of 1,161.75 training hours; average of 23.4 hours per staff/over six months (6% decrease from last CPR) Last CPR, a total of 1,238.5 training hours (June 2013 - November 2013); Average of 24.9 hours per staff/over six months Data obtained from MMRs and HR Reports

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

CLINICAL HOURS (February 2014 – July 2014) A total of 218 clinical hours; this is a 11% decrease from previous CPR Cluster average of 8.8 clinical hours per client/over six months or 1.5 hours per client per month Last CPR, the Cluster Average of 10.2 clinical hours per client/over six-months or 1.7 hours/per client per month Total Clinical Hours = 251.25 (June 2013 – November 2013) Data obtained from MMRS

Client Elopements/Walk-Aways February 2014 – July 2014 June 2013 – November 2013 Franklin 1 Medway Milford Northborough Wrentham Cluster - Total 2 Decrease of 50% in elopements from last CPR Last CPR, a total of 2 client elopements Data obtained from MMRs

MEDICATION INCIDENTS & OCCURRENCES February 2014 - July 2014 A total of 4 medication incidents & occurrences – all 4 were clients refusing medications Last CPR, a total of 1 medication occurrence and incident; the medication incident & occurrence was a client refusing medication Data obtained from MMRs

De-Escalations : Restraints February 2014 – July 2014 June 2013 – November 2013 Franklin 136:0 43:1 Medway 171:1 80:1 Milford 14:1 69:1 Northborough 815:0 495:0 Wrentham 82:1 164:1 Cluster Average 1,759 De-escalations: 11 Restraints or 160:1 2,028 De-escalations: 16 Restraints or 127:1 Data obtained from MMRs

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (February 2014 – July 2014) Average of 7.6 community inclusion activities per client/six months; this is a 15% increase from previous CPR Last CPR, average of 6.6 community inclusion activities per client/six months (June 2013 – November 2013) Data obtained from MMRs

MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered (February 2014 – July 2014) Cluster average of 18.7 Mainstream Activities Participated In Per Client/Over Six Months; this is a 15% increase from previous CPR Last CPR, average of 16.3 Mainstream Activities Participated In Per Client/Over Six Months (June 2013 – November 2013) Data obtained from MMRs

QUALITY ASSURANCE KEY MMR RESULTS SQA AUDITS ACTION PLAN

KEY MMR RESULTS Employment/Education: (As of July 31, 2014) 1/25 or 4% of the residents are in school; last CPR, no residents in school 3/25 or 12% of the residents are in a sheltered workshop/prevocational training; last CPR = 16% 4/25 or 16% of the residents are competitively employed; last CPR = 20% 17/25 or 68% of the residents are enrolled in day activity programs ; last CPR = 64% Other: 17/25 or 68% of the residents chose healthy living opportunities in programs; last CPR, 15/25 or 60% chose healthy living opportunities 0 Contraband (Trigger) items found in the programs over this time period; last CPR = 0 Staff Certifications: 100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED 90% of the staff are MAP certified; last CPR = 80% Current CPR: Franklin 100%; Medway 80%; Milford 100%; Northborough 88%; and Wrentham 80% Last CPR: Franklin 83%; Medway 70%; Milford 90%; Northborough 86%; and Wrentham 70%

RESULTS OF SQA MONITORING AUDITS Oyeyemi Payne’s Cluster: Positives Average Scores Confidential Files = 98.23% Financial Records = 99.8%  Program Forms = 95.75% Walk-Throughs = passing **Strengths of the Cluster Financials Walk-Throughs Areas In Need of Improvement Consents missing signatures Skill Plans missing signatures

CPR ACTION PLAN ISSUE: Increase the clinical hours per client/per month COMMENTS: Review the reporting and documentation of clinical hours – ensure the clinical hours are correctly reported on MMR. Last CPR, the average clinical hours/per client per month = 1.7 IMPROVEMENTS MADE: No, decrease occurred in clinical hours. The current average of clinical hours per month = 1.5 ISSUE: Increase the community inclusion hours COMMENTS: Last CPR, the community inclusion hours per client/over six months was 6.6 IMPROVEMENTS MADE: The current average of community inclusion hours per client/over six months = 7.6 ISSUE: Increase the mainstream activities per client/per month COMMENTS: Last CPR, the mainstream activities hours per client/over six months was 16.3 IMPROVEMENTS MADE: The current average of mainstream activities per client/over six months = 18.7 UPDATES TO BE PROVIDED: Status of Facility Repairs in Milford