1. Comprehensive Program Review October 17, 2014
Community Strategies: Oyeyemi Payne’s Cluster Franklin, Medway, Milford, Northborough, and Wrentham
Comprehensive Program Review October 17, 2014

2. CLUSTER HIGHLIGHTS
One of our individuals is celebrating his 14th year with Meals on Wheels. He started as a volunteer and is now a paid employee.
An individual who has never showed any interest in obtaining employment participated in a seasonal employment opportunity this year for the first time with Liberty Tax. He did not miss any days and enjoyed the experience.
An individual participated and acted in the Wendy Saba Stepping Stone theater group last July 2014.
An individual was diagnosed with a type 2 Diabetes in March 2014 and he turned it around with weight loss (30 lbs.) and healthy diet. He is no longer diabetic.

3. PROMISING PRACTICE CHALLENGES
We continuously strive to promote a healthy life style, a safe environment, and improve the overall quality of life of our individuals.
CHALLENGES
Reaching 100% compliance using Care Tracker.
Struggling to be fully staffed in some of our programs.

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

5. STAFF TURNOVER RATES (8/1/2013 - 7/31/2014)
Cluster average is 20.1% compared to CSMA average of 26.7%
Last CPR, Cluster average was 17.1% compared to the CSMA average of 26.8%
Data obtained from HR Reports

6. STAFF RETENTION RATES (8/1/2013 - 7/31/2014)
Cluster average is 81.8% compared to CSMA average of 71.8%
Last CPR, Cluster average was 82.7% compared to the CSMA average of 73.6%
Data obtained from HR Reports

7. OVERDUE PERFORMANCE EVALUATIONS
STAFFING
OVERDUE PERFORMANCE EVALUATIONS
Current CPR:
as of 7/31/14
Last CPR:
as of 11/30/13 FT PT
Franklin 1
Medway
Milford
Northborough
Wrentham
Cluster - Totals
Data obtained from HR Department & HR Personnel Summary

8. STAFF TRAINING HOURS February 2014 – July 2014
Total of 1, training hours; average of 23.4 hours per staff/over six months (6% decrease from
last CPR)
Last CPR, a total of 1,238.5 training hours (June November 2013); Average of 24.9 hours per
staff/over six months
Data obtained from MMRs and HR Reports

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

10. CLINICAL HOURS (February 2014 – July 2014)
A total of 218 clinical hours; this is a 11% decrease from previous CPR
Cluster average of 8.8 clinical hours per client/over six months or 1.5 hours per client per month
Last CPR, the Cluster Average of 10.2 clinical hours per client/over six-months or 1.7 hours/per client per month
Total Clinical Hours = (June 2013 – November 2013)
Data obtained from MMRS

11. Client Elopements/Walk-Aways
February 2014 – July 2014
June 2013 – November 2013
Franklin 1
Medway
Milford
Northborough
Wrentham
Cluster - Total 2
Decrease of 50% in elopements from last CPR
Last CPR, a total of 2 client elopements
Data obtained from MMRs

12. MEDICATION INCIDENTS & OCCURRENCES February 2014 - July 2014
A total of 4 medication incidents & occurrences – all 4 were clients refusing medications
Last CPR, a total of 1 medication occurrence and incident; the medication incident & occurrence was a client refusing medication
Data obtained from MMRs

13. De-Escalations : Restraints
February 2014 –
July 2014
June 2013 – November 2013
Franklin
136:0
43:1
Medway
171:1
80:1
Milford
14:1
69:1
Northborough
815:0
495:0
Wrentham
82:1
164:1
Cluster Average
1,759
De-escalations:
11 Restraints
or 160:1
2,028
De-escalations: Restraints
or 127:1
Data obtained from MMRs

14. COMMUNITY INCLUSION
Community Inclusion Activities Participated In and Offered (February 2014 – July 2014)
Average of 7.6 community inclusion activities per client/six months; this is a 15% increase from previous CPR
Last CPR, average of 6.6 community inclusion activities per client/six months (June 2013 – November 2013)
Data obtained from MMRs

15. MAINSTREAM ACTIVITIES
Mainstream Activities Participated In and Offered (February 2014 – July 2014)
Cluster average of 18.7 Mainstream Activities Participated In Per Client/Over Six Months; this is a 15%
increase from previous CPR
Last CPR, average of 16.3 Mainstream Activities Participated In Per Client/Over Six Months (June 2013 –
November 2013)
Data obtained from MMRs

16. QUALITY ASSURANCE
KEY MMR RESULTS
SQA AUDITS
ACTION PLAN

17. KEY MMR RESULTS Employment/Education: (As of July 31, 2014)
1/25 or 4% of the residents are in school; last CPR, no residents in school
3/25 or 12% of the residents are in a sheltered workshop/prevocational training; last CPR = 16%
4/25 or 16% of the residents are competitively employed; last CPR = 20%
17/25 or 68% of the residents are enrolled in day activity programs ; last CPR = 64%
Other:
17/25 or 68% of the residents chose healthy living opportunities in programs; last CPR, 15/25 or 60% chose healthy living opportunities
0 Contraband (Trigger) items found in the programs over this time period; last CPR = 0
Staff Certifications:
100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED
90% of the staff are MAP certified; last CPR = 80%
Current CPR: Franklin 100%; Medway 80%; Milford 100%; Northborough 88%; and Wrentham 80%
Last CPR: Franklin 83%; Medway 70%; Milford 90%; Northborough 86%; and Wrentham 70%

18. RESULTS OF SQA MONITORING AUDITS
Oyeyemi Payne’s Cluster:
Positives
Average Scores
Confidential Files = 98.23%
Financial Records = 99.8% 
Program Forms = 95.75%
Walk-Throughs = passing
**Strengths of the Cluster
Financials
Walk-Throughs
Areas In Need of Improvement
Consents missing signatures
Skill Plans missing signatures

19. CPR ACTION PLAN
ISSUE: Increase the clinical hours per client/per month
COMMENTS: Review the reporting and documentation of clinical hours – ensure the clinical hours are correctly reported on MMR. Last CPR, the average clinical hours/per client per month = 1.7
IMPROVEMENTS MADE: No, decrease occurred in clinical hours.
The current average of clinical hours per month = 1.5
ISSUE: Increase the community inclusion hours
COMMENTS: Last CPR, the community inclusion hours per client/over six months was 6.6
IMPROVEMENTS MADE: The current average of community inclusion hours per client/over six months = 7.6
ISSUE: Increase the mainstream activities per client/per month
COMMENTS: Last CPR, the mainstream activities hours per client/over six months was 16.3
IMPROVEMENTS MADE: The current average of mainstream activities per client/over six months = 18.7
UPDATES TO BE PROVIDED:
Status of Facility Repairs in Milford