Community Strategies: Angelo Maroun Abington, Carver, Kingston, Leominster Pleasant Street, Leominster Wachusett Street, Middleboro, and Winchendon Alger Street Comprehensive Program Review October 19, 2012

 Meaningful day across the cluster making jewelry  Strong retention numbers versus CS average  Promotion from within, training and offering career advancement to our employees  Strong volunteer opportunities (Habitat for Humanity, Fuller Museum, Brockton Mayors Council)  Alger Street/Carver - significant decrease in restraints and hospitalizations  Delighting our customers - a very pleased family at Wachusett Street

Lowlights/Challenges:  Overtime across the cluster is high  Performance evaluation numbers not as favorable compared to last CPR  Financial Audits missed, stealing in Leominster  Loss of managers and seasoned staff  Medication occurrences, an increase since last CPR  Distance, new cluster is much more spread apart

STAFFING Staff Turnover Rates Performance Evaluations Staff Training

STAFF TURNOVER RATES 9/1/2011-8/31/2012  The current Cluster Average is 20.9% compared to the CSMA average of 21.1%  Last CPR, Cluster Average was 25.4% versus CSMA overall of 27.8%  Please note that the CS Cluster configuration has changed since the last CPR Data obtained from HR Reports Action Plan Item

OVERDUE PERFORMANCE EVALUATIONS March August 2012  Total of 66 FTE’s and 34 PTE’s with overdue performance evaluations between March 2012 – August Most overdue evaluations were completed within one month of due date.  Last CPR had a total of 18 FTE’s and 17 PTE’s with overdue performance evaluations from June November Please note: CS Cluster included Abington, Bellingham, Carver, Franklin, Kingston, Medway, Middleboro, Wachusett and Wrentham  Abington, Carver, Kingston, Wachusett and Middleboro: (March - August 2012) = 47 FTE’s and 20 PTE’s overdue compared to last CPR: (June – November 2011): 15 FTE’s and 5PTE’s overdue. Data obtained from HR Department & HR Personnel Summary MarchAprilMayJuneJulyAugust FTPTFTPTFTPTFTPTFTPTFTPT Abington Carver Kingston Middleboro Pleasant Wachusett Alger Cluster - Totals Overdue Evaluations 2 > or more months FTPT Abington11 Carver21 Kingston00 Middleboro00 Pleasant12 Wachusett52 Alger01 Cluster - Totals97 Action Plan Item

 Total 2,659 training hours were completed March – August 2012; average of 37.9 hours per staff/cluster/over six months  Average training hours per staff/month = 6.3 hours  Last CPR, total training hours = 2,942 (CS Cluster included Abington, Bellingham, Carver, Franklin, Kingston, Medway, Middleboro, Wachusett and Wrentham) Data obtained from MMRs and HR Reports Action Plan Item

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

 Cluster Average of 1.6 clinical hours per client/month  Total Clinical Hours = 319 (March – August 2012)  Last CPR, the cluster average of clinical hours per client/month was 2.6 (June – November 2011); please note that the CS Cluster configuration has changed. Data obtained from MMRs

Client Walk-Aways March – August 2012June – November 2011 Abington10 Carver02 Kingston00 Pleasant1N/A Middleboro00 Wachusett00 Alger0N/A Cluster - Total22  Please note: CS Cluster configuration has changed from last CPR Data obtained from MMRs

 Average: 0.33 medication incidents and occurrences per client/month  Total of 72 medication incidents and occurrences (March – August 2012)  The majority of the medication incidents/occurrences (90.3% or 65/72) were client refusal of medications  Last CPR, a total of 34 medications incidents and occurrences. CS Cluster configuration has changed since last CPR. Data obtained from MMRs Action Plan Item

De-Escalations : Restraints March – August 2012June – November 2011 Abington 132:0121:0 Carver 44:1 24.3:1 Kingston 372:0 181:1 Pleasant 3.1:1N/A Middleboro 177:0 93:0 Wachusett 98:1 12.6:1 Alger 34:1N/A Cluster Average4,102 De-escalations: 239 Restraints or 17.2:1 83.9:1  Please note: CS Cluster configuration has changed since last CPR Data obtained from MMRs

Average Community Inclusion Activities Participated In and Offered Per Client/ Month (March – August 2012)  Average of 11 Inclusion Activities Per Client/Month (86% participation rate)  Last CPR, average of 4.4 inclusion activities participated in per client/ month (71% participation rate). Please note that Cluster configuration has changed since last CPR. Data obtained from MMRs

Average Mainstream Activities Participated In and Offered Per Client/ Month (March – August 2012)  Average of 16.6 Mainstream Activities Participated in Per Client/Month (87.4% participation rate)  Last CPR, average of 16.3 mainstream activities participated in per client/ month (79% participation rate). Please note that CS Cluster configuration has changed since last CPR. Data obtained from MMRs

Quality Assurance Key MMR Results Monitoring Results

Employment/Education: ( As of August 31, 2012)  7/33 or 21% of the residents are competitively employed  18/33 or 55% of the residents are in meaningful day  8/33 or 24% of the residents are in a sheltered workshop  6/33 or 18% of the clients are enrolled in pre-vocational training programs Other:  28/33 or 85% of the residents chose healthy living opportunities in programs  1 Contraband (Trigger) item found in the programs over this time period; last CPR = 3 Contraband items found Staff Certifications:  100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED; Human Rights; Fire Safety  67% of the staff are MAP certified o Abington 50%; Carver 59%; Kingston 71%; Pleasant 67%; Middleboro 67%; Wachusett 75%; and Alger 86%

Positives Average Scores – Confidential Files = 82% – Financial Records = 91 % (Pleasant Street is not included in this number) – Program Forms = 88% Strengths of the Cluster – ISP Paperwork (Assessment and Provider Support Strategies) – Fire Drills and Safety Plans – Mandatory Medical Appointments Areas In Need of Improvement – Data tracking of the Restraints and LOM (Limitation of Movement) forms – Required signatures for Skills Management Plans, Consent forms and LOM forms – ISP Paperwork (Progress Summaries) Action Plan Item

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