Comprehensive Program Review March 27, 2015 Community Strategies: Janet Kachadoorian’s Cluster Fitchburg, Wendell, Orange, Leominster-Crimson, Leominster-Union, Templeton and West Boylston Comprehensive Program Review March 27, 2015

Fitchburg, Wendell, Orange, Leominster-Crimson, Leominster-Union, Templeton and West Boylston

CLUSTER HIGHLIGHTS (1) Successful integration of Positive Behavioral Supports (PBS) as a pilot cluster Organized a team to work on a project to raise enough money and gifts for 96 homeless people Promoted 2 managers to Program Coordinators

CLUSTER HIGHLIGHTS (2)

CLUSTER HIGHLIGHTS (3) One individual at Union Street has lost almost 30 pounds by with the implementation of the EO-509 dietary guidelines We had our first cluster meeting with all the managers, assistants and meaningful day coordinators.  We enjoyed some team building exercises and we used the time to train lead staff across programs. Our next meeting on April 1, 2015 will focus on ways we can improve with medications

CHALLENGES for CONSULTATION Losing new hires or entry level DSPs for a higher starting salary Improved oversight for medication audits needed to improve services Uniform file systems are needed for internal trainings/tracking/filing and maintaining when new staff are hired

STAFFING Staff Turnover Rates Staff Retention Rates Staff Training Hours

STAFF TURNOVER RATES The current CS Cluster average is 23.2% compared to the CSMA average of 27.9% Orange: N/A = opened on 1/6/15 Last CPR, Cluster average was 29.2% compared to the CSMA average of 27.5% Data obtained from HR Turnover & Retention Reports

STAFF RETENTION RATES The current CS Cluster retention rate average is 69.8% compared to the CSMA average of 72.4% Orange: N/A = opened on 1/6/15 Leo-Crimson = N/A ( reopened for less than one year, formerly Leo-Merriam) Data obtained from HR Turnover & Retention Reports

STAFF TRAINING HOURS August 2014 – January 2015 Current CPR: Total of 2,035.75 training hours were completed (This is a 5% decrease from last CPR) Average of 29.8 hours per staff/over six months per cluster Aug. 2014 - Jan. 2015 E Training Hours MMR Training Hours Total Fitchburg 84.25 310 394.25 Leominster Crimson 86.75 166 252.75 Leominster Union 62 217 279 Templeton 64.75 129.5 194.25 Wendell 6.25 194 200.25 West Boylston 85.5 454 539.5 Orange 54.75 121 175.75 Cluster 444.25 1591.5 2,035.75 Last CPR: Total of 2,153.8 training hours were completed Average of 34.2 hours per staff/over six months per cluster Data obtained from MMRs and HR Reports

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

CLINICAL HOURS August 2014 – January 2015 A total of 196.9 clinical hours (46% decrease from previous CPR); the Cluster Average = 6.56 clinical hours per client/six-months or 1.09 hours per client per month. Last CPR, a total of 366.25 clinical hours; the Cluster Average = 15 clinical hours per client/six-months or 2.5 hours per client per month. Data obtained from MMR

CLIENT ELOPEMENTS August 2014 – January 2015 September 2013 – February 2014 Fitchburg Leominster Crimson 1 Leominster Union Templeton Wendell West Boylston Orange N/A Cluster - Totals Data obtained from MMR

MEDICATION INCIDENTS & OCCURRENCES August 2014 – January 2015 Total of 6 medication incidents and occurrences. This is a 33% decrease from last CPR. 50% or (3 out of 6) medication incidents/occurrences were client medication refusals. Last CPR, a total of 9 medication incidents and occurrences. 44% or (4 out of 9) medication incidents/occurrences were client medication refusals. Data obtained from MMR

DE-ESCALATIONS : RESTRAINTS August 2014 – January 2015 September 2013 – February 2014 Fitchburg 1.4:1 2:1 Leominster Crimson 36:1 51:1 Leominster Union 23:0 5:0 Templeton 112:1 443:0 Wendell 12:1 West Boylston 68:1 7:1 Orange 4:0 N/A Cluster Average 383 De-escalations: 17 Restraints or 22:1 741 De-escalations: 51 Restraints or 15:1 This is a 48% decrease in de-escalation and 67% decrease in restraints compared to previous CPR Data obtained from MMR

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (August 2014 – January 2015) Data obtained from MMR

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (August 2014 – January 2015) A total of 965 community inclusion activities participated in; this is a 45% increase from the last CPR. Average of 32 community inclusion activities per client/six months; overall participation rate = 80% Last CPR: Average of 20.2 community inclusion activities participated in per client/six month A total of 665 community inclusion activities offered; a total of 499 community inclusion activities participated in; overall participation rate = 75% Data obtained from MMR

MAINSTREAM ACTIVITIES Community Inclusion Activities Participated In and Offered (August 2014 – January 2015) Data obtained from MMR

MAINSTREAM ACTIVITIES Community Inclusion Activities Participated In and Offered (August 2014 – January 2015) A total of 2,541 mainstream activities participated in during this period; this is a 5.6% increase from the last CPR. [Orange data is for one month only] Average of 84 mainstream activities participated in per client/six months; overall participation rate = 91% Last CPR: Average of 81 mainstream activities participated in per client/six months A total of 2,406 mainstream activities offered; a total of 1,993 mainstream activities participated in; overall participation rate = 83% Data obtained from MMR

QUALITY ASSURANCE Key MMR Results SQA Audits Results

KEY MMR RESULTS Employment/Education: (As of January 31, 2015) 7 out of 30 or 23% individuals are employed or in a pre- vocational training program; last CPR = 3 out of 26 (12%) 5 out of 30 clients or 17% are attending a sheltered workshop; last CPR = 6 out of 26 (23%) 18 out of 30 clients or 60% are in meaningful day programs; last CPR =15 out of 26 (58%) 0 clients are in school; last CPR = 2 out of 26 (7%) Other: 30 out of 30 (100%) clients chose to participate in the healthy living options within their program; last CPR = 100% “0” contraband reported; last CPR = 0 contraband reported

KEY MMR RESULTS Staff Certifications: 100% certified in PAC/CPI: (last CPR = 90%) Last CPR: Fitchburg = 100%; Leominster Crimson = 100%; Leominster Union = 50%; Wendell = 90%; West Boylston = 100%; Templeton = 100%; Orange = N/A 100% certified in First Aid/CPR : (last CPR = 98.3%) Last CPR: Fitchburg = 100%; Leominster Merriam = 100%; Leominster Union = 100%; Wendell = 90%; West Boylston = 100%; Templeton = 100% ; Orange = N/A 89% of staff are MAP Certified (data does not include Orange); Overall with Orange = 83%; last CPR = (85.2% of staff were MAP certified) Current CPR: Fitchburg = 83%; Leominster Crimson = 80%; Leominster Union = 90%; Wendell = 91%; West Boylston = 90%; Templeton = 100%; Orange = 38% Last CPR: Fitchburg 80%; Leominster Crimson = 100%; Leominster Union = 70%; Wendell = 80%; West Boylston = 90%; Templeton = 91%; Orange = N/A

RESULTS OF SQA MONITORING AUDITS August 2014 – January 2015 Positives Average Scores Confidential Files = 95.74% Financial Records = 98.97%  Program Forms = 90.5% **Strengths of the Cluster ISP Paperwork (Assessment and Provider Support Strategies) Legal Paperwork Monthly Financial Audits Areas In Need of Improvement Updating of Search and Disaster Plans Updating of Consents

CPR ACTION PLAN (Past 6 months) ISSUE: Increase Community Inclusion COMMENTS: Last CPR, average of 20.2 community inclusion activities per client/over six months IMPROVEMENTS: Currently, average of 32 community inclusion activities per client/over six months  The overall participation rate in community inclusion activities increased by 5 percentage points. From 75% last CPR, to the current rate of 80%.

CPR ACTION PLAN (Next 6 months) Proposed Objective Proposed Metric 1. Review and update the Search and Disaster Plans July 2015 2. Updating of Consent forms as needed May 2015 3. Consult with Human Resources to review starting salaries of competing organizations. Determine the budget impact on adjusting starting salaries

CPR ACTION PLAN (Next 6 months) Proposed Objective Proposed Metric 4. Discuss processes that would ensure medication audits are conducted more frequently and thoroughly, possibly by QA or assigning one staff to visit all programs to audit. June 2015 5. Create an inventory of all program books and documents.  Then streamline the process so all cluster programs are uniform, including updated forms, color of binders, order of documents within binders, etc. June 2015 implement in Janet’s cluster 6. Share practice of uniform program books and documents with all clusters. Sept 2015 implement in all clusters