Comprehensive Program Review February 27, 2015 COMMUNITY STRATEGIES: Angelo Maroun Abington, Bellingham, Leominster-Elm, Leominster-Wachusetts, Marlborough, Winchendon-Alger and Winchendon-Teel Comprehensive Program Review February 27, 2015

CLUSTER HIGHLIGHTS Caring Force participation/enrollment numbers SQA Audit Scores New cluster configuration as of 11/2014, team gelled and performs together

CHALLENGES Behavioral issues: costly facilities requests/workers comp/injuries Overtime Employment procurement

STAFFING Staff Turnover Rates Staff Retention Rates Staff Training Hours

STAFF TURNOVER RATES Cluster average is 26.7% compared to the CSMA average of 27.5% Last CPR, Cluster average was 28.4% compared to the CSMA average of 26.7% Data obtained from HR Reports

STAFF RETENTION RATES Cluster average is 73.5% compared to the CSMA average of 70.6% Last CPR, Cluster average was 69% compared to the CSMA average of 73.4% Data obtained from HR Reports

STAFF TRAINING HOURS Total of 1,797.8 training hours; (25% increase from previous CPR). Average of 25.3 hours per staff over six months. Last CPR, a total of 1,438.3 training hours were completed; Average of 19.9 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 Total Clinical Hours = 375.75 (July 2014 – December 2014); Cluster Average of 1.9 clinical hours per client/month (This is a 58% increase from previous CPR) Last CPR, Total Clinical Hours = 238.75 (August 2013 – January 2014)); Cluster Average of 1.2 clinical hours per client/month Data obtained from MMRs

Client Elopements July 2014- December 2014 August 2013 – January 2014 Abington Bellingham Leo - Elm 2 (both in /July) Leo- Wachusetts Marlborough (both in September) Winchendon - Alger Winchendon - Teel Cluster Totals 4 Total of 4 walk-aways/elopements reported for this reporting period. Data obtained from MMRs

MEDICATION INCIDENTS & OCCURRENCES A total of 13 medication incidents and 5 medication occurrences (This is a 20% increase from last CPR) This is .08 medication incidents & occurrences per client per month Last CPR, a total of 10 medication incidents and 5 medication occurrences This is .07 medication incidents & occurrences per client per month Data obtained from MMRs

De-Escalations : Restraints August 2013 – January 2014 July 2014 – December 2014 De-escalations: Restraints Ratio Abington 173:1 175:0 Bellingham 172:4 4:1 25:0 Leo - Elm 364:73 5:1 447:65 7:1 Leo - Wachusetts 282:19 15:1 62:11 6:1 Marlborough 334:13 26:1 604:15 40:1 Win - Alger 570:17 34:1 277:34 8:1 Win - Teel 651:18 36:1 166:2 Cluster Totals 2,546:145 18:1 1,225:118 11:1 A total of 118 restraints; this is a 23% decrease from last CPR, with 145 restraints reported; The ratios have been rounded off Data obtained from MMRs

Community Inclusion Participated In and Offered Per Client/ Month (July 2014 – December 2014) A total of 1,051 community inclusion activities participated in across the cluster by all clients over six months. (This is a 6% increase from previous CPR) Average of 5.3 community inclusion activities participated in by client/month (July 2014 – December 2014). This is a 8% increase from the previous CPR. The overall participation rate is 81% Last CPR, a total of 988 community inclusion activities participated in; an average of 4.9 community inclusion activities participated in by client/month (August 2013 - January 2014). The overall participation rate = 79%. Data obtained from MMRs

MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered Per Client/ Month (July 2014 – December 2014) A total of 2,991 mainstream activities participated in across the cluster by all clients over six months. (This is a 7% increase from previous CPR) Average of 14.8 mainstream activities participated in by client/month (July 2014 – December 2014). This is a 6% increase from the previous CPR. The overall participation rate is 89% Last CPR, a total of 2,795 mainstream activities participated in; an average of 13.9 mainstream activities participated in by client/month (August 2013 - January 2014). The overall participation rate = 86%. Data obtained from MMRs

QUALITY ASSURANCE Key MMR Results SQA Audit Results

KEY MMR RESULTS Employment/Education: (As of December 31, 2014) 15/34 (44%) of the residents are competitively employed; last CPR = 9/32 (28%) 12/34 (35%) of the clients are in an alternative day program; last CPR = 19/32 (59%) 4/34 (12%) of the clients are in a pre-vocational program; last CPR = 1/32 (3%) 3/34 (8%) of the residents are in a sheltered workshop; last CPR = 3/32 or (9%) Other: 94% of the residents chose healthy living opportunities in programs; last CPR = 93%. 0 Contraband (Trigger) item found in the programs over this time period; last CPR = 0 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; last CPR = 76% Current CPR: Abington 78%; Bellingham 82%; Leo-Elm 67%; Leo-Wachusetts 57%; Marlborough 75%; Win – Alger 85%; Win-Teel 100% Last CPR: Abington 88%; Bellingham 73%; Leo-Elm 50%; Leo-Wachusetts 89%; Marlborough 64%; Win – Alger 80%; Win-Teel 100%

RESULTS OF SQA MONITORING AUDITS July 2014-December 2014 Positives Average Scores Confidential Files = 95.63% Financial Records = 99.21%  Program Forms = 92.41% **Strengths of the Cluster Financials ISP Paperwork (Assessment and Provider Support Strategies) Completion of Walk-Through Action Plans Areas In Need of Improvement Required Program Training Sign-offs Obtaining co-guardian signatures on Skills Plans and Consents

CPR ACTION PLAN ISSUE: Increase Community Inclusion COMMENTS: Last CPR, average of 4.9 community inclusion activities per client/month IMPROVEMENTS MADE: Currently, average of 6.4 community inclusion activities per client/month ISSUE: Decrease medication incidents & occurrences COMMENTS: Last CPR, the total medication incidents & occurrences = 15 IMPROVEMENTS MADE: Currently, a total of 18 medication incidents & occurrences Monitor: Talk to Paul Swindlehurst about getting more donated tickets for increasing mainstream activities Improve recruitment period (fill vacancies sooner) so as to eliminate overtime.