1. Comprehensive Program Review May 30, 2014
SARGENT HOUSE
Comprehensive Program Review
May 30, 2014

2. PROGRAM HIGHLIGHTS Highlights:
Utilization Average = 113% from October 2013 – March 2014
One client continues at Roxbury Community College while seeking employment. One client attends Ostiguy High School in Boston and is currently seeking volunteer opportunities. The remaining clients volunteer at Community Servings in Jamaica Plain while searching for employment.
Harvard Tutors now working twice a week with SH Residents
Increase of Life Skills groups – an increase of 38%
Created an ongoing partnership with Project Place, an employment and housing agency, for employment readiness and job placement services
Developed a partnership with More Than Words for employment opportunities
Best Practice/Promising Practices:
Established a new partnership with Whittier Health Center to begin a Men’s Group once a week at the Health Center for SH residents

3. CHALLENGES Hiring a new Director Overdue performance evaluations
A corrective action for the medication errors
Caring Together, the joint residential procurement through DMH and DCF, in final stages of negotiation
Getting all staff trained in MAP as required by the Caring Together contract

4. STAFFING Staff Turnover Rates Staff Retention Rates
Overdue Performance Evaluations
Staff Training Hours

5. OVERDUE PERFORMANCE EVALUATIONS
STAFFING
STAFF TURNOVER RATE
(4/1/2013 – 3/1/2014)
OVERDUE PERFORMANCE EVALUATIONS
As of March 30, 2014: 7 FTE performance evaluations overdue.
Last CPR: (December 2012 – May 2013)
4 FTE performance evaluations overdue.
Last CPR: Turnover rate was 26.7% compared to SJS rate of 31.3%
Since last CPR, SH turnover decreased by 12%; SJS increased by 21%; and CRJ Overall increased by 8%
Data obtained from HR Department & HR Personnel Summary

6. STAFF RETENTION RATE
6/30/13 data for SJS and Overall CRJ Retention Rates = Not Available (N/A)
Data obtained from HR Retention & Turnover Report

7. STAFF TRAINING HOURS Total of 213.5 training hours;
Average training hours per staff over six months = 16.2; This is a 31% decrease from the last CPR
Last CPR:
The total training hours = 376.5; the average training hours per staff/over six months = 23.64
Data obtained from MMRs and HR Training Reports

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

9. UTILIZATION October 2013 – March 2014
Total Capacity = Six Residents; the average utilization rate = 113%;
This is a 23.8% increase from the last CPR
Last CPR: Average Utilization Rate: 91.3% (December 2012 – May 2013)
As of 5/8/14, Sargent House has 7 residents .
Data obtained from MMRs and OMs

10. CLINICAL HOURS
A total of 401 clinical hours; this is a 38% increase from the last CPR.
Average of 9.8 clinical hours per client each month.
Last CPR, a total of 290 clinical hours total (December 2012 – May 2013)
Last CPR, average of 8.8 clinical hours per client per month
Data obtained from MMRs and OMs

11. A total of 11 medication incidents & occurrences.
2 out of 11 are client refusals of medications; 1 out of 11 = missed dose; 5 out of 11 are wrong medication -- client(s) self-administered a.m. medications in p.m. or vice versa
Last CPR: A total of 0 medication incidents or occurrences (December 2012 – May 2013)
WALK-AWAYS:
(October 2013 – March 2014)
Total of 3 Walk-Aways (December and February – same client AWOL)
Last CPR, a total of 1 Walk-Away in February 2013.
Data obtained from MMRs and OMs

12. DE-ESCALATIONS & RESTRAINTS
(October 2013 – March 2014)
OCTOBER 7:0
NOVEMBER 4:1
DECEMBER 4:0
JANUARY 21:1
FEBRUARY 9:1
MARCH 14:1
TOTAL: 76:6
Average = 13:1 For 6 Months
Last CPR:
DE-ESCALATIONS: RESTRAINTS
(December 2012 – May 2013)
DECEMBER 112:1
JANUARY 108:0
FEBRUARY 132:6
MARCH 102:0
APRIL 103:0
MAY 109:0
Average = 95:1 For 6 Months
Total of 6 restraints % decrease from last CPR.
Last CPR, total of 7 restraints (December – May 2013.)
Data obtained from MMRs and OMs

13. MAINSTREAM COMMUNITY ACTIVITIES
Average of 22 mainstream community activities per client over a six month period -- 19% increase from last CPR.
Last CPR, an average of mainstream community activities were participated in per client over a six month period (December 2012 – May 2013).
Data obtained from MMRs

14. Quality Assurance
Key MMR Results Satisfaction Surveys

15. KEY MMR RESULTS Education: (as of March 31, 2014)
1 client enrolled in high school
1 client attending Roxbury Community College, while seeking employment
Remaining clients volunteer at Community Servings while searching for employment
Community Service Hours
A total of 246 community service hours were completed in collaboration with the Community Servings
Site Visits by Outside Funders
A total of 7 site visits occurred from DCF/DMH/Mass Rehab

16. YOUTH SATISFACTION SURVEYS March 2014

17. YOUTH SATISFACTION SURVEYS
March 2014

18. YOUTH SATISFACTION SURVEYS
March 2014

19. CPR ACTION PLAN
Managing Overdue Performance Evaluations – with the new Performance Management system in place; how is SH managing to keep up with performance evaluations
Last CPR, 4 FT Evaluations were overdue; as of 3/30/14, 7 FT evaluations were overdue
Get all evaluations completed for 100% compliance within timeframes
Overtime needs to be reduced
Keep an Eye On:
Recording of Life Skills and Cognitive Behavioral Hours - last CPR, 290 hours.
Current CPR = 401 Hours: (38% increase) 246 Life skills and 155 Cognitive Behavioral hours 