1. Comprehensive Program Review April 24, 2015
SARGENT HOUSE
Comprehensive Program Review
April 24, 2015

2. PROGRAM HIGHLIGHTS HIGHLIGHTS:
A total of 7 residents as of 4/1/15: 6 continuing residents and 1 resident who is on Follow Along status
Four residents in school: one attending Bunker Hill community college; three in high school
Harvard Tutors enhancing their services – will start taking residents out to visit school and/or educational activities within the community
Bowling League
The DCF “readiness” audit – February 19, 2015
BEST PRACTICE/PROMISING PRACTICE:
Fostering relationships with existing and new businesses – maintain weekly contact with “More Than Words” and established new relationships with Game Stop and Guitar Center (based on passions of residents)
Explanation of Follow Along Status

3. CHALLENGES Hiring a new Clinician
Hiring an Occupational Therapist (10 hours per week) and Nurse - (5 hours per week)
Getting all staff trained in MAP as required by the Caring Together contract
Medication Incidents

4. STAFFING Staff Turnover Rates Staff Retention Rates
Staff Training Hours

5. STAFFING TURNOVER RATE
Sargent’s turnover rate = 33.3%, compared to 32.1% for SJS
Last CPR: Turnover rate was 23.5% compared to SJS rate of 38%
Data obtained from HR Department & HR Personnel Summary

6. STAFFING RETENTION RATE
Sargent’s retention rate = 57.1% compared to 65.5% for SJS
Last CPR: Retention rate was 85.7% compared to SJS rate of 59%
Data obtained from HR Department & HR Personnel Summary

7. STAFF TRAINING HOURS Total of 466.8 training hours;
Average training hours per staff over six months = 34.8; This is a 114% increase from the last CPR
Last CPR:
The total training hours = 213.5; the average training hours per staff/over six months = 16.2
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 = Eight Residents. The average utilization rate = %
Last CPR: Average Utilization Rate: 113% (October 2013 – March 2014)
As of 4/1/15, Sargent House has 6 continuing residents and 1 resident who is on Follow Along status .
Data obtained from MMRs and OMs

10. CLINICAL HOURS
A total of 586 clinical hours; this is a 46% increase from the last CPR.
Average of 15 clinical hours per client each month.
Last CPR, a total of 401 clinical hours total; average of 9.8 clinical hours per client per month
Data obtained from MMRs and OMs

11. WALK-AWAYS: Total of 2 Walk-Aways
A total of 16 medication incidents and occurrences.
4 out of 16 are client refusals of medications.
Last CPR: A total of 11 medication incidents & occurrences.
WALK-AWAYS:
(October 2013 – March 2014)
Total of 2 Walk-Aways
Last CPR, a total of 3 Walk-Aways
Data obtained from MMRs and OMs

12. DE-ESCALATIONS & RESTRAINTS
(September 2014 – February 2015)
SEPTEMBER 13:0
OCTOBER 27:0
NOVEMBER 19:1
DECEMBER 19:1
JANUARY 12:1
FEBRUARY 22:1
TOTAL: :4
Average = 28:1 For 6 Months
Last CPR
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
Total of 4 restraints % decrease from last CPR.
Last CPR, total of 6 restraints
Data obtained from MMRs and OMs

13. MAINSTREAM COMMUNITY ACTIVITIES
Average of 27.6 mainstream community activities per client over a six month period -- 25% increase from last CPR.
Last CPR, an average of 22 mainstream community activities were participated in per client over a six month period.
Data obtained from MMRs

14. Quality Assurance
KEY MMR RESULTS SQA AUDIT RESULTS SATISFACTION SURVEYS

15. KEY MMR RESULTS Education: (as of February 28, 2015)
1 client enrolled in high school
1 client attending College, while seeking employment
2 clients working at More Than Words
Remaining clients volunteer at Community Servings while searching for employment
4/15/15 Update: 3 students in high school; 1 in college and 3 clients working: Game Stop (Worcester), More Than Words and Guitar Center
Community Service Hours
A total of 162 community service hours were completed in collaboration with the Community Servings
Site Visits by Outside Funders
A total of 3 site visits occurred from DCF/DMH

16. SQA AUDIT RESULTS POSITIVES:
Medication Administration Record and Client Daily Medication Count forms were 100% complete - information including errors/med refusal match information submitted on MMR
Treatment Plans were 100% completed
The new Client Daily Data (CDD) sheets call for goals/objectives to be checked off by either the first or second shift. The forms were 100% complete; in fact, 93% of both the first and second shift checked off this information.
AREAS IN NEED OF IMPROVEMENT:
Ensuring that CANS (Child and Adolescent Needs and Strengths) assessment are 3 months – given the departure of the clinician (effective 3/20/15)
Submission of SIRs in timely manner to SQA

17. YOUTH SATISFACTION SURVEYS February 2015

18. YOUTH SATISFACTION SURVEYS
February 2015

19. YOUTH SATISFACTION SURVEYS
February 2015

20. YOUTH SATISFACTION SURVEYS
February 2015

21. CPR ACTION PLAN (last CPR)
Overtime needs to be reduced
Keep an Eye On:
Recording of Life Skills and Cognitive Behavioral Hours - last CPR, 401 hours.
Current CPR = 586 Hours: (46% increase) 193 Life Skills and 393 Cognitive Behavioral hours 

22. CPR ACTION PLAN (Next 6 months)
Proposed Objective
Proposed Timeline
Recruitment of new Sargent House residents
SH conducts outreach via weekly outreach to area DCF offices and Quarterly Networking Meetings
Assistance from Development Office to develop marketing tools to bring to networking meetings
Next 6 months - ongoing
Refining the Sargent House Milieu
Need to hire a new clinician – to perform staff training to enhance understanding of clinical services
As part of Operation Integrate, refine job descriptions to clarify role/duties of staff and enhance awareness of working with young adults living with developmental disabilities
On-going