1. COMMUNITY STRATEGIES: Comprehensive Program Review
Angelo Maroun
Abington, Bellingham, Carver, Franklin, Kingston, Leominster Wachusett Street, Medway, Middleboro, and Wrentham
January 20th, 2012
Comprehensive Program Review

2. CLUSTER HIGHLIGHTS Delighting our Customers
Community Care Services thanked CRJ through a letter for the homemade pies we baked and donated
Parent sent a thank you letter to CRJ for the work being done with her son who while a resident of his previous vendor was a victim of abuse that has left him with PTSD
Staff saved a residents life from choking by successfully using the Heimlich maneuver
Education, Employment and Volunteer Activities
57% of residents are either employed or in educational programs
Employment agencies include but not limited to: Fed Ex, Wal-Mart, Taco Bell, Father and Son Janitorial Services and various Newspaper Courier positions
High Level of Volunteer activities including but not limited to: Catholic Charities, Habitat for Humanity, Parks Clean-up through Brockton Mayor’s Office, Local Animal Shelters, Milford Hospital, Medway Library, Teen Challenge for Recovering Addicts, and Meals on Wheels

3. CLUSTER HIGHLIGHTS CONT.
Awards
Resident in Bellingham won the Human Rights award for Self Advocate of the Year
Franklin Manager Kellyanne Lynch won CRJ Gold Star Award
Bellingham won Program of the Quarter
Training
Managers Shannon Newcomb and Tammy Manning became certified Treatment Culture trainers
Mandy Adao became a certified PAC trainer
Kellyanne Lynch and Mandy Adao completed Emerging Leaders Program

4. AREAS FOR IMPROVEMENT
Eliminating the overtime by filling the vacant Residential Counselor positions
Recognizing fiscal shortcomings quickly enough to avoid it altogether; i.e. process for reimbursement for absent clients, staggered vacations, and utilizing additional PT staff to fill in gaps.
Continued improvement of the Meaningful Day activities in the programs (expansion on the jewelry making and other activities)
Decreasing the number of Med Occurrences
Increased development of the Nutritional and Healthy Living education and practices including increased exercising programs

5. Data obtained from the HR Measures & HR Personnel Summary
STAFFING
Current CPR Cluster average is 25.4% versus CS in MA overall = 27.8%.
Previous CPR Cluster average was 16.3% versus CS in MA overall = 25.7%.
Data obtained from the HR Measures & HR Personnel Summary

6. Overdue Performance Evaluations
STAFFING
Overdue Performance Evaluations
June 2011 – November 2011 FT PT
Abington
3 FT
2 PT
Bellingham
0 FT
0 PT
Carver
2 FT
1 PT
Franklin
Kingston
1 FT
Leo. Wachusett St
5 FT
Medway
Middleboro
4 FT
Wrentham
Total of 18 FTE’s and 8 PTE’s with overdue performance evaluations between June 2011 – November 2011.
Last CPR had a total of 60 FTE’s and 17 PTE’s with overdue performance evaluations from September March 2011
Data obtained from the HR Measures & HR Personnel Summary

7. Medication Incidents & Occurrences
(Per Client Per Month)
June 2011 – November 2011
Previous CPR Total:
34 incidents and occurrences combined
Med Occurrences by Program: Wrentham 5, Wachusett Street 1
Med Incidents by Program: Carver 10, Franklin 1, Wachusett Street 1
Data obtained from MMRs

8. CLINICAL HOURS Total Clinical Hours Per Client Per Month June 2011 – November 2011
Cluster Average is 2.6 Clinical Hours per Client
Previous CPR Cluster Average (minus Wachusett St) was 2.3 Clinical Hours per Client
Data obtained from MMRs

9. Activities per Client per Month
COMMUNITY INCLUSION
June 2011 – November 2011
Activities per Client per Month
Average of 4.4 Inclusion Activities Participated in per Client per Month (71% participation rate)
Average of 16.3 Mainstream Activities Participated in per Client per Month (79% participation rate)
Data obtained from MMRs

10. De-escalation to Restraint Ratio
June 2011 – November 2011
Elopements
June 2011 – November 2011
Ratio
Abington
121:0
Bellingham
21.5:1
Carver
24.3:1
Franklin
46:1
Kingston
181:1
Leo. Wachusett St
12.6:1
Medway
12.7:1
Middleboro
93:0
Wrentham
75.6:1
Cluster Average
83.9:1
Number
Abington
Bellingham
Carver 2
Franklin 1
Kingston
Leo. Wachusett St
Medway
Middleboro
Wrentham
Cluster Total 4
Previous CPR Cluster Average = 73.6:1
Data obtained from MMR’s

11. Key MMR Results Timely Mandatory ISP Documents – 87% (total)
Timely Assessments – 89%
Timely Provider Support Strategies – 100%
Timely Progress Summaries – 72%
Employment/Education
36% of residents are competitively employed
7% of residents are enrolled in education programs
14% of residents have paid employment through a day program
Combined total of 57% of the cluster are either employed or in educational program
Other
3 Contraband (Trigger) items found in the programs over this time period
Data obtained from the MMR’s

12. Results of Monitoring Audits Cluster Areas to Improve Upon
Cluster Positives
Quarterly Fire Drills 100%
Staff Training forms – 86%
Safety, Search, & Disaster 78%
Informal Fire Safety 89%
Carbon Monoxide 89%
Informal Human Rights 89%
Mandatory Med. Appointments - 96%
Annual Physical 100%
Annual Dental 94%
Bi-Annual Vision 94%
Audits for the Cluster showed 82% full credit earned
Cluster Areas to Improve Upon
Mandatory Signatures
Behavior Plans
Psychotropic Treatment Plans
Consent Forms
Dated Documentation to DDS
Individual Budgeting Sessions
LOM and Restraint forms matching the monthly data numbers
HRC signatures on LOM and Consent Forms
Data Obtained from QA Audits

13. Staff Training Hours Cluster Monthly Totals
June 2011 – November 2011
Total Hours: 2,942
Monthly Average Per Program is 54.5 Hours
Data obtained from Shirley Training Records