1. Comprehensive Program Review May 31, 2013
COMMUNITY STRATEGIES: Angelo Maroun Abington, Carver, Kingston, Leominster Pleasant Street, Leominster Wachusetts Street, and Middleboro
Comprehensive Program Review May 31, 2013

2. CLUSTER HIGHLIGHTS
Employment: phasing out the job coach and promoting independence
Volunteerism: Salvation Army, Habitat for Humanity, Hope House, Fuller Craft Museum, Beautify Brockton, and Knights of Columbus
Meaningful Day – Jewelry: success at the CRJ Spring Fundraiser event
MAP certification up 11%
QUEST in Carver
One Lions Club members (client) attends activities independently
Mandy Adao completed DDS Regional Director leadership Training
Lucas Paine and Janna McPherson enrolled in CRJ supervision training

3. AREAS IN NEED OF IMPROVEMENT
Challenges:
Medication Occurrences
Healthy Living
Performance Appraisals
Retention

4. STAFFING
Staff Turnover Rates
Performance Evaluations
Staff Training

5. STAFF TURNOVER RATES 4/01/2012 - 3/31/2013
The current Cluster Average is 27.3% compared to the CSMA average of 24%
Last CPR, Cluster Average (which included Alger) was 20.9% versus CSMA overall of 21.1%
Data obtained from HR Reports

6. OVERDUE PERFORMANCE EVALUATIONS
STAFFING
OVERDUE PERFORMANCE EVALUATIONS
October March 2013
Overdue Evaluations
As of March 31, 2013 FT PT
Abington
Carver 1
Kingston
Middleboro 2
Pleasant 4
Wachusetts
Cluster - Totals 7 3
 March
August 2012
Overdue Evaluations
As of August 31, 2012 FT PT
Abington 1
Carver
Kingston
Middleboro
Pleasant 2
Wachusetts 5
Cluster - Totals 7
Total of 7 FTE’s and 3 PTE’s with overdue performance evaluations between October 2012 – March 2013.
Last CPR, a total of 7 FTE’s and 7 PTE’s with overdue performance evaluations from March 2012 – August 2012.
Data obtained from HR Department & HR Personnel Summary

7. STAFF TRAINING HOURS
Total of training hours were completed October 2012 – March 2013; Average of 19.9 hours per staff/cluster/over six months; Average training hours per staff/month = 3.3 hours. This is a 31% decrease from last CPR.
Last CPR, total of training hours were completed March 2012 – August 2012; Average of 29 hours per staff/cluster/over six months; Average training hours per staff/month = 4.8 hours
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
Total Clinical Hours = (October 2012 – March 2013); Cluster Average of 1.6 clinical hours per client/month
Last CPR, Total Clinical Hours = 271 (March 2012 – August 2012); Cluster Average of 1.6 clinical hours per client/month
Data obtained from MMRs

10. Client Walk-Aways October 2012 - March 2013 March 2012 - August 2012
Abington 1
Carver
Kingston
Pleasant
Middleboro
Wachusetts
Cluster - Total 2
Client Walk-aways decreased by 50% compared to last CPR
Data obtained from MMRs

11. MEDICATION INCIDENTS & OCCURRENCES
Average: 0.13 medication incidents and occurrences per client/month; total of 22 medication incidents and occurrences (October March 2013.) This is a 64% decrease from the previous CPR.
Last CPR: Average: 0.36 medication incidents and occurrences per client/month; total of 61 medication incidents and occurrences (March 2012 – August 2012).
Data obtained from MMRs

12. De-Escalations : Restraints
October 2012 –
March 2013
March 2012 –
August 2012
Abington
216:1
132:0
Carver
311:1
44:1
Kingston
445:0
372:0
Pleasant
8:1
3:1
Middleboro
124:0
177:0
Wachusetts
40:1
98:1
Cluster Average
286:1
275:1
This is a 4% increase in de-escalations from last CPR
Data obtained from MMRs

13. COMMUNITY INCLUSION
Average Community Inclusion Activities Participated In and Offered Per Client/ Month (October 2012 – March 2013)
Average of 4.6 inclusion activities participated in by client/month (October 2012 – March 2013). The overall participation rate is 87%; This is a 8% increase from last CPR.
Last CPR, the Cluster average of inclusion activities per client/month was 3.9; the overall participation rate = 79%
Data obtained from MMRs

14. MAINSTREAM ACTIVITIES
Average Mainstream Activities Participated In and Offered Per Client/ Month (October 2012 – March 2013)
Average of 22.3 Mainstream Activities Participated in Per Client/Month (94% participation rate ). This is an 11% increase over last CPR.
Last CPR, average of 16.8 Mainstream Activities Participated in Per Client/Month (84% participation rate).
Data obtained from MMRs

15. QUALITY ASSURANCE
Key MMR Results

16. KEY MMR RESULTS Employment/Education: (As of March 31, 2013)
8/27 (30%) of the residents are competitively employed or enrolled in pre-vocational training programs
6/27 (22%) of the residents are in a sheltered workshop
13/27 (48%) of the clients are in an alternative day program
Other:
17/27 (63%) of the residents chose healthy living opportunities in programs
0 Contraband (Trigger) item found in the programs over this time period; last CPR = 1 Contraband (Trigger) item found
Staff Certifications:
100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED
78% of the staff are MAP certified; this is a 11% increase from last CPR
Last CPR: Abington 50%; Carver 59%; Kingston 71%; Pleasant 67%; Middleboro 67%; and Wachusetts 75%
Current CPR: Abington 75%; Carver 71%; Kingston 83%; Pleasant 73%; Middleboro 86%; and Wachusetts 78%

17. CPR ACTION PLAN