1. COMMUNITY STRATEGIES: MAY 18 TH 2012 COMPREHENSIVE PROGRAM REVIEW

2.  Two individuals participate in therapeutic horseback riding on a weekly basis.  Two individuals have successfully taken leisure trips without CRJ staff.  An individual’s guardian recently joined the Human Rights Committee.  Healthy Living: ◦ Two programs have incorporated a Wii Active Exercise into meaningful day and individuals have been exercising 2-4 hours per week. ◦ Individuals at three programs are smoke-free - 2 of those 3 programs also have staff that are smoke-free! ◦ A diabetic individual is successfully off all medication. ◦ Nineteen individuals are currently involved in Special Olympics.  Volunteering, Employment and Education: ◦ Individuals have been participating in various volunteer activities including Knights of Columbus in Leominster, Calloway Stables in Lancaster and Habitat for Humanity. ◦ Two individuals are currently employed at Meals on Wheels. ◦ An individual enrolled in MCAS classes at Mt. Wachusett Community College and is waiting for test results. ◦ Two individuals are enrolled in a GED program.  Staffing: ◦ Jackie Bailey has been a great addition to Westminster as Assistant Program Manager (formerly Assistant Program Manager at Templeton). ◦ Promotions: Nicholas Jones was promoted from resident counselor in Westminster to Assistant Program Manager at Teel Road. Amanda Noone was promoted from resident counselor to Assistant Program Manager at West Boylston. A former Program Coordinator, Yemi Payne was recently promoted to Assistant Director. ◦ Karyn Cargill was awarded Human Rights Officer of the year and also participated in the Emerging Leaders Program along with Janet Szlyk and Larissa Young. ◦ One program had 3 staff become formal fire safety and Human Rights Officer trained. Data obtained from Janet Szlyk’s Cluster

3.  Need to find quality, low cost activities – both mainstream and community inclusion.  Provide better role modeling for individuals.  Work better as a team, utilize resources outside of the cluster, communicate with other Assistant Directors.  Increase staff morale.  Submit documents (performance reviews, fire drills, certifications) in a timely fashion.  Utilize all strengths across the board to cultivate and cross train staff.  Decrease use of overtime in programs (cluster is understaffed).  Improve Meaningful Day implementation and participation.  Improve results of program audits by ensuring all required signatures are provided on documents.  Be held accountable regarding program audits.  Increase supervisory feedback (managers  staff) and 1:1 training sessions with program staff.  Built stronger ties and increase involvement in the community in order to obtain more volunteer positions.  Leominster Merriam and Wendell are currently undergoing an investigation regarding theft. Data obtained from Janet Szlyk’s Cluster

4. Staff Turnover Rate MARCH 1 ST 2011-FEBRUARY 29 TH 2012 Overdue Performance Evaluations September 2011-February 2012 Total of 27 FT & 22 PT Overdue Performance Evaluations over 6 months. Last CPR: Programs had total of 12 Overdue Performance Evaluations over 6 months. * Betanray data is from 1/12 and 2/12 only CSMA: 26.7%CRJ: 26.9% Average of 25.4% Turnover for past year. Last CPR: Average of 38.5% turnover for year. * Betanray & Fitchburg not included in this measure. Data obtained from HR’s Personnel Summary Leo. Merriam10 FT12 PT Leo. Betanray0 FT0 PT Templeton1 FT0 PT Wendell5 FT0 PT W. Boylston1 FT0 PT Westminster7 FT4 PT Winch. Teel1 FT6 PT Fitchburg1 FT0 PT

5. MEDICATION ADMINISTRATION Medication Incidents and Occurrences: Average per Client (6 months) September 2011-February 2012 (Betanray from Nov 2011 –Feb 2012) Data obtained from MMRs Total of 37 medication incidents or occurrences over 6 months. Last CPR: Total of 4 medication incidents or occurrences over 6 months. Total Incidents & Occurrences by Program Leo. Merriam: 2W. Boylston: 3 Leo. Betanray: 27Westminster: 1 Templeton: 1Winch. Teel: 2 Wendell: 1Fitchburg: 0

6. CLINICAL HOURS Average Per Client (6 months) September 2011-February 2012 (Betanray from Nov 2011 –Feb 2012) Average of 1.8 clinical hours per client (6 months) Total of 380 Clinical Hours over 6 months Last CPR: Total of 362 of clinical hours over 6 months. Data obtained from MMRs

7. COMMUNITY INCLUSION & MAINSTREAM COMMUNITY ACTIVITIES September 2011-February 2012 (Betanray from Nov 2011-Feb 2012) Data obtained from MMRs Average of 5.7 community inclusion activities per client (6 months) Average of 7 mainstream community activities per client (6 months) Last CPR: Average of 12.7 community inclusion activities per client & Average of 23.3 mainstream community activities per client (6 months) Community Inclusion Activities Mainstream Community Activities Total Community Inclusion Activities (whole cluster over 6 months): 936 Total Mainstream Community Activities (whole cluster over 6 months): 1261 Average Per Client (6 months)

8. DE- ESCALATIONS:RESTRAINTS September 2011-February 2012 LEO. MERRIAM 77:1 LEO. BETANRAY CT. 0.9:1 TEMPLETON 200:1 WENDELL 11:1 W. BOYLSTON 2:1 WESTMINSTER 1.8:1 WINCHENDON TEEL 2.8:1 FITCHBURG APTS. 0:0 7.7:1 For 6 months Last CPR: 23.2:1 LEO MERRIAN AVE. 1 LEO. BETANRAY CT. 2 TEMPLETON 1 WENDELL 0 W. BOYLSTON 0 WESTMINSTER 0 WINCHENDON TEEL 0 FITCHBURG APTS. 0 Total Elopements: 4 Last CPR: Total of 8 ELOPEMENTS September 2011-February 2012 Data obtained from MMRs *Betanray data from Nov 2011-Feb 2012

9. RESULTS OF SQA AUDITS Data obtained from SQA Quality Assurance Coordinator for CS CLUSTER POSITIVES MANDATORY MEDICAL APPOINTMENTS Annual Physicals: 86% complete Dental Exams: 93% complete Vision Exam: 100% complete MANDATORY ISP DOCUMENTS Assessments: 93% complete Provider Support Strategies: 98% complete Progress Summaries: 86% complete MANDATORY SIGNATURES Psychotropic Treatment Plans: 98% complete Non-Restrictive Consent Forms: 92% complete CLUSTER AREAS TO IMPROVE UPON MANDATORY SIGNATURES Behavior Plans: 59% complete Restrictive Consent Forms: 64% complete BUDGETING SESSIONS 62% complete DDS DATED DOCUMENTATION 61% complete MONTHLY IN-HOUSE FINANCIAL AUDITS

10. STAFF TRAINING HOURS Average hours per employee per month (entire cluster) Data obtained from CSMA Average of 4 training hours per employee per month. Yearly average of 48 hours per staff member *staff members should have 40 hours (min.) of training hours each year.