1. Comprehensive Program Review January 18, 2012
Community Strategies: Janet Kachadoorian’s Cluster Fitchburgh, Leominster-Betanray, Leominster -Merriam, Templeton, Wendell and West Boylston
WE want to be more than a boss to our staff. WE want the best possible results every time. WE want to lead OUR team to greatness. Notice how there is no “I” in our team!!!
Comprehensive Program Review January 18, 2012

2. CLUSTER HIGHLIGHTS Cluster Highlight
Volunteering with Habitat for Humanity and Adopt-A-Platoon (other houses
participated but initiated in our cluster)   
Program Highlights
Diabetic individual is now successfully off all diabetes medication.
Individual who has a long history of poor bedroom maintenance now requires no prompting to complete her bedroom maintenance.
Two individuals have successfully taken leisure trips in the community without CRJ staff.
Two individuals had deaths in their families and successfully used their skills to cope with their loss without engaging in any behaviors.
All 4 individuals are volunteering twice weekly in the community.
Individuals are learning about Healthy Living and following it. 
One of our older gentleman has become more active; sleeps less during the day due to meaningful day activities.
Our individuals have been going into the community to see where they can volunteer.
One individual has been hospitalized at Hogan for numerous months and he recently has been medically cleared to have a knee replacement.

3. AREAS IN NEED OF IMPROVEMENT
Car pooling to save on mileage
Before using OT, we call cluster programs to see if staff can be pulled
Re-training staff on neatness of time and mileage sheets.
Re-training staff on the reasons to page a supervisor

4. STAFFING
Staff Turnover Rates
Performance Evaluations
Staff Training

5. STAFF TURNOVER RATES (12/1/11 – 11/31/12)
The current CS Cluster average is 27.0% compared to the CSMA average of 22.0%
Last CPR, Cluster average was 25.4% versus CSMA overall of 26.7% (March 1, 2011 – February 29, 2012)
CS Cluster configuration has changed since the last CPR
Data obtained from HR Turnover Reports

6. STAFF OVERDUE PERFORMANCE EVALUATIONS
June November 2012
Overdue Evaluations
2 > or more months FT PT
Fitchburgh
Leominster Betanray
Leominster Merriam
Templeton
Wendell
West Boylston
Cluster - Totals
June
July
Aug.
Sept.
Oct.
Nov. FT PT
Fitchburgh
Leominster Betanray 1
Leominster Merriam 2
Templeton
Wendell
West Boylston
Cluster - Totals
Total of 3 FT and 0 PT overdue performance evaluations
Last CPR, a total of (27FT and 22 PT) overdue performance evaluations from September February 2012.
CS Cluster configuration has changed since the last CPR
Data obtained from HR Department & HR Personnel Summary

7. STAFF TRAINING HOURS June 2012 – November 2012
Total training hours were completed
Average of 5.62 hours per staff per month
Average of 33.8 hours per staff/over six months per cluster
E Training Hours
MMR Training Hours
Total
Fitchburgh Apt.
Leominster Betanray
43.75
181
224.75
Leominster Merriam
43.25
540
583.25
Templeton 43
139
182
Wendell
104.5
207
311.5
West Boylston 52
209
261
Cluster
286.5
1301
1587.5
Last CPR, average per staff per month = 4 hours
CS Cluster configuration has changed since last CPR
Data obtained from MMRs and HR Reports

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

9. CLINICAL HOURS June 2012 – November 2012
Cluster Average of 8 clinical hours per client/six-months or 1.3 hours/per client per month
Total Clinical Hours = 185 (Fitchburgh data for June and July 2012 only)
Last CPR, the cluster average of clinical hours per client/month was (September 2011 – February 2012); CS Cluster configuration has changed since last CPR.
Data obtained from FMRs

10. CLIENT WALK-AWAYS June 2012 – November 2012 September 2011 –
February 2012
Fitchburgh Apt. (June/July data only)
Leominster Betanray 2
Leominster Merriam 1
Templeton
Wendell
West Boylston
Cluster - Total 3 4
Data obtained from MMRs

11. MEDICATION INCIDENTS & OCCURRENCES June 2012 - November 2012
Total of 11 medication incidents and occurrences
Last CPR, a total of 34 medication incidents and occurrences. CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

12. DE-ESCALATIONS : RESTRAINTS
June 2012 – November 2012
September 2011 –
February 2012
Fitchburgh Apt (June and July data only)
0:0
Leominster Betanray
5:1
0.9:1
Leominster Merriam
38.6:1
77:1
Templeton
99:0
200:1
Wendell
15.5:1
11:1
West Boylston
2:1
Cluster Average
450 De-escalations:
14 Restraints
or 32.1:1
7.7:1
CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

13. COMMUNITY INCLUSION
Community Inclusion Activities Participated In and Offered (June 2012 – November 2012)
Average of 4.08 community inclusion activities per client/six months
(Fitchburgh data – June and July 2012 only; average = for two month period)
Last CPR, average of 5.7 community inclusion activities participated in per client/six months
CS Cluster configuration has changed since last CPR
Data obtained from MMRs

14. MAINSTREAM ACTIVITIES
Mainstream Activities Participated In and Offered (June 2012 – November 2012)
Average of 13.4 Mainstream Activities Participated in per client/six months
(Fitchburgh data – June and July 2012 only; average = for two month period)
Last CPR, average of 7 mainstream activities participated in per client/six months
CS Cluster configuration has changed since last CPR
Data obtained from MMRs

15. KEY MMR RESULTS Employment/Education: ( As of November 30, 2012)
7 out 23 clients are employed or in a pre-vocational training program
3 out of 23 clients are in school
13 out of 23 clients are in a day program
Other:
19 out of 23 clients chose to participate in the healthy living options within their program
“0” contraband reported
11 site visits conducted by outside funders
Staff Certifications:
100% certified in PAC/CPI, First AID/CPR, Human Rights
83.4% of staff are MAP Certified
Fitchburg Apt. – June and July 2012 data (0%); Leominster Betanray = 66.6%; Leominster Merriam = 100%; Templeton = 83%; West Boylston = 80%; Wendell = 87.5%

16. CPR ACTION PLAN
See Handout