1. Comprehensive Program Review
Community Strategies: Mandy Adao’s Cluster Carver, Kingston, Middleboro and Paxton
Comprehensive Program Review
June 27, 2014

2. CLUSTER HIGHLIGHTS Highlights:
Seven Promotions: 1 Program Coordinator, 2 Managers, 2 Assistant Managers, and 2 Meaningful Day Coordinators
CM from Carver has been awarded her 3rd recognition from the House of Representatives.
We have been able to accomplish more community inclusion activities for each client.
Best Practice:
100% of all residents are participating in Healthy Living with weight loss being shown. The residents have lost a total of 76 lbs which is a great start.

3. CHALLENGES
Hiring open positions (because of all the internal promotions)
Using less overtime

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

5. STAFF TURNOVER RATES
The current CS Cluster average is 28.6% compared to the CSMA average of 26.5%
Last CPR, Cluster average was 25.6% compared to the CSMA average of 25.7%
Data obtained from HR Staff Retention & Turnover Report

6. STAFF RETENTION RATES
6/30/13 Retention Data for CSMA and Overall-CRJ = N/A (data not available)
Data obtained from HR Staff Retention & Turnover Report

7. STAFF OVERDUE PERFORMANCE EVALUATIONS
November 2013 –
April 2014
Overdue Evaluations
As April 30, 2014 FT PT
Carver 1
Kingston
Middleboro
Paxton
Cluster - Totals 2
January 2013 –
June 2013
Overdue Evaluations
As June 30, 2013 FT PT
Carver 2
Kingston
Middleboro
Paxton
Cluster - Totals
Total of 2 FT and 0 PT overdue performance evaluations
Last CPR, a total of 2 FT and 0 PT overdue performance evaluations
Data obtained from HR Report

8. STAFF TRAINING HOURS November 2013 – April 2014
Total of training hours were completed (22.8% increase from previous CPR)
Average of 29.9 training hours per staff/over six months
November 2013 –
April 2014
E Training Hours
MMR Training Hours
Total
Carver
70.75
376
446.75
Kingston
24.75
231.5
256.25
Middleboro
29.25 56
85.25
Paxton
110
166
Cluster
234.75
719.5
954.25
Last CPR: (June 2013)
Total of 777 training hours were completed
Average of 21.4 training hours per staff/over six months
Data obtained from MMRs and HR Reports

9. CLIENT RELATED Clinical Hours Elopements Medication
De-escalation and Restraints
Mainstream/Community
Inclusion Activities

10. CLINICAL HOURS November 2013 – April 2014
A total of clinical hours; the Cluster average = 12 clinical hours per client/over six- months or 2 hours per client per month.
Last CPR, a total of clinical hours; the Cluster average was 11.4 clinical hours per client/over six-months or 1.9 hours per client per month.
Data obtained from MMRs

11. CLIENT ELOPEMENTS November 2013 – April 2014 January 2013 – June 2013
Carver
Kingston
Middleboro
Paxton 1
Cluster - Totals
Data obtained from MMRs

12. MEDICATION INCIDENTS & OCCURRENCES November 2013 – April 2014
Total of 3 medication incidents and occurrences.
For both time periods, all medication incidents and occurrences were client refusals.
Last CPR, a total of 3 medication incidents and occurrences.
Data obtained from MMRs

13. DE-ESCALATIONS : RESTRAINTS
November 2013 –
April 2014
January –
June 2013
Carver
76:1
42:1
Kingston
169:0
139:0
Middleboro
213:0
412:0
Paxton
15:1
9:0
Cluster Average
87:1
135:1
Totals
785 De-escalations: Restraints
814 De-escalations: Restraints
This is a 36% decrease in de-escalation and a 50% increase in restraints compared to previous CPR.
Data obtained from MMRs

14. COMMUNITY INCLUSION
Community Inclusion Activities Participated In and Offered (November 2013 – April 2014)
Average of 34.4 community inclusion activities per client/over six months.
This is a 39.8% increase from the last CPR 
Last CPR:
Average of 24.6 community inclusion activities participated in per client/over six months
A total of 449 community inclusion activities offered; a total of 443 community inclusion activities participated in
Data obtained from MMRs

15. MAINSTREAM ACTIVITIES
Mainstream Activities Participated In and Offered (November 2013 – April 2014)
Average of 90.6 mainstream activities per client/over six months.
This is a 19% decrease from the last CPR
Last CPR:
Average of 112 mainstream activities participated in per client/over six months
A total of 2,103 mainstream activities offered; a total of 2,018 mainstream activities participated in
Data obtained from MMRs

16. QUALITY ASSURANCE
KEY MMR RESULTS
SQA AUDITS

17. KEY MMR RESULTS Employment/Education: (As of April 30, 2014)
1 out of 18 (6%) clients competitively employed
2 out of 18 (11%) clients are in school
6 out of 18 (33%) clients are attending a sheltered workshop
9 out of 18 (50%) clients are in day programs
Other:
18 out of 18 (100%) clients chose to participate in the healthy living options within their program; last CPR = 80%
“0” contraband reported; last CPR = 0 contraband reported
Staff Certifications:
100% certified in PAC/CPI and First Aid/CPR:
74.4% of staff are MAP Certified; this is a 3% decrease from the last CPR, (77% of staff were MAP certified)
Current CPR: Carver 73%; Kingston = 80%; Middleboro = 57% ; Paxton = 88%
Last CPR: Carver 86%; Kingston = 83%; Middleboro = 83% ; Paxton = 56%

18. RESULTS OF SQA MONITORING AUDITS
November 2013 – April 2014
Positives
Average Scores
Confidential Files = 95%
Financial Records = 99% 
Program Forms = 95%
Walk-throughs – All passed
**Strengths of the Cluster
ISP Paperwork (Assessment and Provider Support Strategies)
Fire Drills
Mandatory Medical Appointments
Areas In Need of Improvement
Required Roger’s Monitor documentation
Required trainings for Skills Development Management Plans

19. This is the first CPR for Mandy’s Cluster
CPR ACTION PLAN
NOT APPLICABLE
This is the first CPR for Mandy’s Cluster