2. Comprehensive Program Review April 24, 2015 1

3. Highlights: New FBOP- SOW went into effect on October 1, 2014 – HH now a Major Use Facility Walt Davies hired as Assistant Program Director New positions- Social Services Coordinator and Community Verification Specialist (part time) Zero deficiencies and 2 strengths on 1 st full monitoring December 2014 Best Practice/Promising Practice: Continued positive relationship with USPO Increase relationships with prospective employers for residents in area Staff development with the current change over and new staff – adapting to Hampshire House systems 2

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5.  Developing ongoing Accreditation documentation record keeping process  Finding competent applicants – CRJ Recruiters doing a good job and very helpful 4

6. STAFFING Staff Turnover Rates Staff Retention Rates Staff Training Hours 5

7.  Current Hampshire turnover rate = 26.7% compared to 32.1% for SJS  Last CPR (Oct. 2013 – March 2014), the turnover rate was 9.1% compared to 38% for SJS 6 Data obtained from HR Retention & Turnover Report

8.  Hampshire's retention rate = 66.7% compared to 65.5% for SJS  Last CPR (Oct. 2013 – March 2014), the retention rate was 88.2% compared to 59% for SJS 7 Data obtained from HR Retention & Turnover Report

9. 8 Data obtained from MMRs and HR Training Reports Last CPR: (October 2013 – March 2014)  Total of 391 training hours  Average of 65 training hours per month  Average of 3.6 hours per staff member per month or 21.48 hours over six months Current CPR: (September 2014 – February 2015)  Total of 657.3 training hours  Average of 109.5 training hours per month  Average of 5.8 hours per staff member per month or 34.8 over six months; 62% increase from last CPR

10. PROGRAMMING  Utilization  Program Completions with:  Employment  Permanent Housing 9

11. 10  The current utilization rate is 87.4% ; Hampshire House had an average of 39.3 clients.  Last CPR: Utilization rate was 95.1%; an average of 30.4 clients (Capacity was 32 residents) Data obtained from MMRs & Utilization Report

12. 11  Average of 80.3% of clients successfully completed the program. Last CPR: 75%  Average 55.1% of clients completed with employment. Last CPR: 53.6%  Average of 87.47% of clients completed with permanent housing. Last CPR: 100%  Average of 18.8% of clients were terminated before completing the program. Last CPR: 25% Data obtained from MMRs

13. CLIENT RELATED  Clinical Hours  Walk-Aways  Medication 12

14. 13  Average Total Hours per client/month: 9.26 Last CPR = 8.5  Average Life Skills Hours per client/month: 1.23: Last CPR = 1.5 hours.  Average Cognitive-Behavioral Hours per client/month: 8.02: Last CPR = 7 hours.  Total Hours = 2,233: Last CPR = 1,644 (This is a 36% increase)  Total Life Skills Hours= 298: Last CPR = 289.5  Total Cognitive-Behavioral Hours1,935 Last CPR = 1,354.5 Data obtained from MMRs

15. MonthNumber of Walk-Aways September 3 October 1 November 0 December 0 January 0 February 0 TOTAL 4 14 Data obtained from MMRs  Last CPR (October 2013 – March 2014), 2 walk-aways

16.  Total of 0 medication incidents and occurrences  Last CPR, 0 medication incidents 15 Data obtained from MMRs

17. QUALITY ASSURANCE KEY MMR RESULTS SQA AUDIT RESULTS SATISFACTION SURVEYS 16

18. 17  Three written commendations resulting from outside regulators/funders  Zero written deficiencies from outside funders  18 out of 21 staff certified in FA/CPR/AED – 2 new and 1 position vacant  87.5% of clients successfully completing the program had permanent housing; last CPR = 100%  87.5% of clients successfully completed the program with a full discharge plan; last CPR = 100%  90% of discharge plans developed with family involvement; last CPR = 100%  Average of 97% negative drug tests; last CPR = 97.9%

19. SQA AUDITS POSITIVES Case Files – well-organized; Treatment Plans and CRJ Intakes conducted within first 72 hours; using the new PREA and Medical Screening forms Walk-Throughs: facility is well-maintained and Hampshire submits Facility Requests in a timely manner AREAS IN NEED OF IMPROVEMENT The Medication Incidents reported on MMRs differ from the SQA medication audits 18

20. CLIENT SATISFACTION SURVEY February 2015 19

21. CLIENT SATISFACTION SURVEY February 2015 20

22. CLIENT SATISFACTION SURVEY February 2015 21

23. CLIENT SATISFACTION SURVEY February 2015 22

24. Discuss Transitional Housing at Think Tank meeting – what is the feasibility of utilizing the apartment building’ next to Hampshire House as a possible transitional housing program; Ernie Goodno met with USPO on this subject matter. USPO wants the availability, but no reliable funding is available. Revisit the existing SJS Client Satisfaction Survey Ensuring that a minimum of 60% of clients take the survey (August 2014 – only 33% had responded) (Feb. 2015 survey = 23/40 or 58% responded) Keep an Eye On: Wellness - Hampshire currently working with HCH on diabetes and smoking cessation classes for clients Classes and other opportunities are continuing Renovations/Expansion of Hampshire House Impact on programming – yes, staff has adjusted well to increase workload and new positions are very helpful with this process. Utilization – concern about keeping HH full after expansion is completed - the capacity is 45 clients; the average client per month from July 1, 2014 through March 31, 2015 = 39.3 23

25. Proposed ObjectiveProposed Timeline Work with QC and CQI pilot project to implement new hire training database through Relias Learning By the next CPR to have this in full operation Develop a network with temporary agencies or employers willing to hire residents for short term employment so out of state residents have a source of income prior to release By the next CPR in 6 months Logistical challenges of geographic locations for out of state residents i.e.: residents releasing to Vermont Continuing process 24