Comprehensive Program Review January 31, 2014 Community Strategies: Oyeyemi Payne’s Cluster Bellingham, Franklin, Marlborough, Medway, Milford, Northborough, and Wrentham Comprehensive Program Review January 31, 2014

CLUSTER HIGHLIGHTS An individual from Marlborough moved into Shared Living in August. Six of our individuals in the cluster are on progressive independence. Wrentham hosted a cookout for all our programs in the cluster. One of the individual's mother came and two South Valley Service Coordinators attended along with four of our neighbors. An individual from Wrentham did an overnight trip to New York City. Four individuals at Wrentham lost a total of 135 lbs to date; one individual taken off insulin.

CHALLENGES Milford residence is in need of renovation. Facility started some of the repairs 8 months ago but is yet to be completed. Struggling to maintain staff at the Marlborough program.

STAFFING Staff Turnover & Retention Rates Performance Evaluations Staff Training

STAFF TURNOVER RATES (10/1/2012 – 11/30/2013) Cluster average is 21.9% compared to CSMA average of 26.8% Last CPR, Cluster average was 15.6% compared to the CSMA average of 21.4% (September 2011 – October 2012) Data obtained from HR Reports

STAFF RETENTION RATES (10/1/2012 – 11/30/2013) Data obtained from HR Reports

OVERDUE PERFORMANCE EVALUATIONS STAFFING OVERDUE PERFORMANCE EVALUATIONS June 2013 - November 2013   Overdue Evaluations As of 11/30/2013 FT PT Bellingham 1 Franklin Marlborough Medway Milford Northborough Wrentham Cluster - Totals 2 As of November 30, 2013, a total of 2 FT and 1 PT overdue performance evaluations Last CPR, a total of 1FT and 0 PT overdue performance evaluations at the end of October 2012. Data obtained from HR Department & HR Personnel Summary

STAFF TRAINING HOURS June 2013 – November 2013 Total of 1,745.3 training hours (June 2013 - November 2013); Average of 25.2 hours per staff/over six months Last CPR: (May 2012 - October 2012) Total 2582.5 training hours were completed; Average of 34.8 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 June 2013 – November 2013 A total of 356.25 clinical hours; this is a 31% increase from previous CPR Cluster average of 10.8 clinical hours per client/over six months or 1.8 hours per client per month Last CPR, the Cluster Average of 7.8 clinical hours per client/over six-months or 1.3 hours/per client per month Total Clinical Hours = 271.5 (May 2012 – October 2012) Data obtained from MMRS

Client Elopements/Walk-Aways June 2013 – November 2013 May 2012 – October 2012 Bellingham Franklin 1 Marlborough Medway 3 Milford Northborough Wrentham Cluster - Total 4 Last CPR, a total of 4 client elopements/walk-aways Data obtained from MMRs

MEDICATION INCIDENTS & OCCURRENCES June 2013 - November 2013 A total of 2 medication occurrences and 0 incidents; this is a 75% decrease from previous CPR The 2 medication occurrences were client refusal of medications Last CPR, a total of 8 medication incidents and occurrences (May 2012 – October 2012) 62.5% or 5 out of 8 medication incidents/occurrences were client refusal of medications Data obtained from MMRs

De-Escalations : Restraints June 2013 – November 2013 May 2012 – October 2012 Bellingham 76:1 31:1 Franklin 43:1 35:1 Marlborough 46:1 188:0 Medway 80:1 110:1 Milford 69:1 104:1 Northborough 495:0 605:0 Wrentham 164:1 88:1 Cluster Average 2,810 De-escalations: 31 Restraints or 91:1 2,392 De-escalations: 28 Restraints or 85:1 Data obtained from MMRs

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (June 2013 – November 2013) Average of 7.8 community inclusion activities per client/six months; this is a 59% increase from the previous CPR Last CPR, average of 4.9 community inclusion activities per client/six months (May 2012 - October 2012) Data obtained from MMRs

MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered (June 2013 – November 2013) Cluster average of 14.8 Mainstream Activities Participated In Per Client/Over Six Months; this is a 15% increase from previous CPR Last CPR, average of 12.9 Mainstream Activities Participated In Per Client/Over Six Months (May 2012 – October 2012) Data obtained from MMRs

QUALITY ASSURANCE Key MMR Results Action Plan

KEY MMR RESULTS Employment/Education: (As of November 30, 2013) 17/33 or 52% of the residents are competitively employed; last CPR = 8/35 or 23% 4/33 or 12% of the residents are in a sheltered workshop/prevocational training; last CPR = 3/35 or 8% 12/33 or 36% of the clients are enrolled in day activity programs; last CPR = 23/35 or 66% Other: 22/33 or 67% of the residents chose healthy living opportunities in programs; last CPR = 28/35 or 80% 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 84% of the staff are MAP certified; last CPR = 81% Bellingham 70%; Franklin 83%; Marlborough 70%; Medway 70%; Milford 90%; Northborough 86%; and Wrentham 70%

CPR ACTION PLAN Client Employment Rates: Mainstream Activities: ISSUE: Need to increase overall employment rates for clients. COMMENTS: Difficult to place some of the more challenging individuals. IMPROVEMENTS MADE: Currently 17 out of 33 or 52% of the residents are competitively employed; last CPR = 8 out of 35 or 23% were employed Mainstream Activities: ISSUE: Need to work on documentation – not staying on top of this. COMMENTS: Some documentation is inaccurate – staff misunderstand which activities are considered “mainstream.” Should help to educate staff with this. IMPROVEMENTS MADE: Current cluster average is 14.8 Mainstream Activities Participated in Per Client/Over Six Months ; this is a 15% increase from previous CPR