1. COMMUNITY STRATEGIES: OYEYEMI PAYNE LEOMINSTER PLEASANT – MILFORD – NORTHBORO – WINCHENDON ALGER ST. MARCH 16, 2012 COMPREHENSIVE PROGRAM REVIEW

2.  2 individuals in Northboro started volunteering at a church in Woonsocket, RI with Milford guys, 2 individuals in Northboro joined a bowling league and individuals at Winchendon Alger volunteer weekly at Monadnock Human Society and Church.  An individual in Milford was taken off probation and lifetime parole.  Individual in Milford recently obtained employment at Waverly Redemption Center and an individual in Leominster Pleasant has been employed at McDonalds for two years and continues to get good reviews.  Residents in Leominster Pleasant visited the Boston aquarium in January.  Winchendon Alger won program of the quarter in January!  Winchendon Alger was one of the programs identified to have the best meaningful day activities in CS.  Verbal commendation from service coordinator regarding ISP assessments and timely submission.  Awards & Training: Godwin Adansi recently won a CRJ Star Award! Additionally, staff attended the Emerging Leaders Program and are (Formal) Fire Safety Certified.  Need to involve individuals in their communities and provide more volunteer opportunities for the individuals served.  Completely eliminate overtime by hiring more staff.  Increase development of the nutritional and healthy living education and practices, including more exercising programs. Data obtained from CSMA

3. Staff Turnover Rate March 1, 2011 – February 29, 2012 Overdue Performance Evaluations August 2011-January 2012 Leominster Pl: 11 FT 13 PT Milford: 2 FT 0 PT Northboro: 1 FT 4 PT Wnchdn Alger: 3 FT 4 PT Total of 38 (17 FT & 21 PT) Overdue Performance Evaluations over 6 months. Last CPR: Programs had total of 12 Overdue Performance Evaluations over 6 months. CSMA: 25.5% CRJ: 26% Average of 16.7% Turnover for past year. Last CPR: Average of 18.7% turnover for year. Data obtained from HR’s Personnel Summary

4. MEDICATION ADMINISTRATION Medication Incidents and Occurrences: Average per Client (6 months) August 2011 – January 2012 Data obtained from MMRs Total of 3 medication incidents or occurrences over 6 months. Last CPR: Total of 33 medication incidents or occurrences over 6 months.

5. CLINICAL HOURS Average Per Client August 2011 – January 2012 Average of 1.4 clinical hours per client (6 months) Total of 165 Clinical Hours over 6 months Last CPR: Average of 12.3 clinical hours per client each month. Data obtained from MMRs

6. COMMUNITY INCLUSION & MAINSTREAM COMMUNITY ACTIVITIES AUGUST 2011 – JANUARY 2012 Average Per Client (6 months) Data obtained from MMRs Average of 2.9 community inclusion activities per client (6 months) Average of 14.2 mainstream community activities per client (6 months) Last CPR: Average of 4.4 community inclusion activities per client (6 months) Average of 38.2 mainstream community activities per client (6 months) Community Inclusion Activities Mainstream Community Activities

7. DE- ESCALATIONS:RESTRAINTS August 2011 – January 2012 LEOMINSTER PLEASANT 3.4:1 MILFORD 70.5:1 NORTHBORO 467:0 WINCHENDON ALGER 27.9:1 13.2:1 For 6 months Last CPR: 10.4:1 LEOMINSTER PLEASANT 0 MILFORD 2 NORTHBORO 0 WINCHENDON ALGER 0 Total Elopements: 2 Last CPR: Total of 18 ELOPEMENTS August 2011 – January 2012 Data obtained from MMRs

8. RESULTS OF MONITORING AUDITS Data obtained from SQA Quality Assurance Coordinator for CS CLUSTER POSITIVES Mandatory Medical Appointments: 100% of annual physicals completed. 90% of dental exams completed. 90% of vision exams completed. Mandatory ISP Documents: 91% of Assessments completed. 94% of Provider Support Strategies completed. 84% of Progress Summaries completed. All four programs scored over the 90% ranking in their previous financial audits! CLUSTER AREAS TO IMPROVE UPON Mandatory Signatures 50% of behavioral plans were signed. 67% of Psychotropic Treatment Plans (PTP) were signed 71% of consent forms were signed. 45% of Limitation of Movement (LOM) forms were signed. 50% of clients received budgeting sessions. 44% of DDS dated documentation has been completed.

9.  Ratio of de-escalations:restraints has improved since last CPR (13.2:1 vs. 10.4:1).  There were no incidents involving contraband August-January (all programs).  Leominster Pleasant, Milford and Northboro all had no medication incidents or occurrences (August-January). Also, the total number of medication incidents/occurrences for the cluster has decreased by 91% (since last CPR)!  There were no elopements in Northboro, Winchendon Alger or Leominster Pleasant. Furthermore, Leominster Pleasant went from having 18 elopements last CPR to having 0 August-January!  Winchendon Alger had a total of 57 clinical hours over 6 months (the highest number in the cluster).  Leominster Pleasant offered a total of 744 mainstream activities (the highest of cluster) and Milford offered a total of 30 mainstream activities (the lowest of cluster).  August-January: 20% of Leominster Pleasant clients, 37% of Milford clients, 22% of Northboro clients and 0% of Winchendon Alger clients were competitively employed.  Northboro offered a total of 127 community inclusion activities August-Jan (the highest number in cluster) and Winchendon Alger offered a total of 22 community inclusion activities (the lowest of the cluster).  There has been an 89% decrease in the average number of clinical hours each client receives per month (12.3  1.4). KEY MMR RESULTS Data obtained from MMRs

10. STAFF TRAINING HOURS Cluster Monthly Totals August 2011-January 2012 Monthly Average Per Program: 139 Total Hours: 832 Data obtained from CSMA