1. Comprehensive Program Review February 27, 2015
COMMUNITY STRATEGIES: Angelo Maroun Abington, Bellingham, Leominster-Elm, Leominster-Wachusetts, Marlborough, Winchendon-Alger and Winchendon-Teel
Comprehensive Program Review February 27, 2015

2. CLUSTER HIGHLIGHTS Caring Force participation/enrollment numbers
SQA Audit Scores
New cluster configuration as of 11/2014, team gelled and performs together

3. CHALLENGES
Behavioral issues: costly facilities requests/workers comp/injuries
Overtime
Employment procurement

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

5. STAFF TURNOVER RATES
Cluster average is 26.7% compared to the CSMA average of 27.5%
Last CPR, Cluster average was 28.4% compared to the CSMA average of 26.7%
Data obtained from HR Reports

6. STAFF RETENTION RATES
Cluster average is 73.5% compared to the CSMA average of 70.6%
Last CPR, Cluster average was 69% compared to the CSMA average of 73.4%
Data obtained from HR Reports

7. STAFF TRAINING HOURS
Total of 1,797.8 training hours; (25% increase from previous CPR). Average of 25.3 hours per staff
over six months.
Last CPR, a total of 1,438.3 training hours were completed; Average of 19.9 hours per staff /over six
months
Data obtained from MMRs and HR Reports

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

9. CLINICAL HOURS
Total Clinical Hours = (July 2014 – December 2014); Cluster Average of 1.9 clinical hours per client/month (This is a 58% increase from previous CPR)
Last CPR, Total Clinical Hours = (August 2013 – January 2014)); Cluster Average of 1.2 clinical hours per client/month
Data obtained from MMRs

10. Client Elopements July 2014- December 2014 August 2013 – January 2014
Abington
Bellingham
Leo - Elm 2
(both in /July)
Leo- Wachusetts
Marlborough
(both in September)
Winchendon - Alger
Winchendon - Teel
Cluster Totals 4
Total of 4 walk-aways/elopements reported for this reporting period.
Data obtained from MMRs

11. MEDICATION INCIDENTS & OCCURRENCES
A total of 13 medication incidents and 5 medication occurrences (This is a 20% increase from last CPR)
This is .08 medication incidents & occurrences per client per month
Last CPR, a total of 10 medication incidents and 5 medication occurrences
This is .07 medication incidents & occurrences per client per month
Data obtained from MMRs

12. De-Escalations : Restraints
August 2013 – January 2014
July 2014 – December 2014
De-escalations: Restraints
Ratio
Abington
173:1
175:0
Bellingham
172:4
4:1
25:0
Leo - Elm
364:73
5:1
447:65
7:1
Leo - Wachusetts
282:19
15:1
62:11
6:1
Marlborough
334:13
26:1
604:15
40:1
Win - Alger
570:17
34:1
277:34
8:1
Win - Teel
651:18
36:1
166:2
Cluster Totals
2,546:145
18:1
1,225:118
11:1
A total of 118 restraints; this is a 23% decrease from last CPR, with 145 restraints reported;
The ratios have been rounded off
Data obtained from MMRs

13. Community Inclusion Participated In and Offered Per Client/ Month
(July – December 2014)
A total of 1,051 community inclusion activities participated in across the cluster by all clients over six months. (This is a 6% increase from previous CPR)
Average of 5.3 community inclusion activities participated in by client/month (July 2014 – December 2014). This is a 8% increase from the previous CPR. The overall participation rate is 81%
Last CPR, a total of 988 community inclusion activities participated in; an average of 4.9 community inclusion activities participated in by client/month (August January 2014). The overall participation rate = 79%.
Data obtained from MMRs

14. MAINSTREAM ACTIVITIES
Mainstream Activities Participated In and Offered Per Client/ Month
(July – December 2014)
A total of 2,991 mainstream activities participated in across the cluster by all clients over six months. (This is a 7% increase from previous CPR)
Average of 14.8 mainstream activities participated in by client/month (July 2014 – December 2014). This is a 6% increase from the previous CPR. The overall participation rate is 89%
Last CPR, a total of 2,795 mainstream activities participated in; an average of 13.9 mainstream activities participated in by client/month (August January 2014). The overall participation rate = 86%.
Data obtained from MMRs

15. QUALITY ASSURANCE
Key MMR Results SQA Audit Results

16. KEY MMR RESULTS Employment/Education: (As of December 31, 2014)
15/34 (44%) of the residents are competitively employed; last CPR = 9/32 (28%)
12/34 (35%) of the clients are in an alternative day program; last CPR = 19/32 (59%)
4/34 (12%) of the clients are in a pre-vocational program; last CPR = 1/32 (3%)
3/34 (8%) of the residents are in a sheltered workshop; last CPR = 3/32 or (9%)
Other:
94% of the residents chose healthy living opportunities in programs; last CPR = 93%.
0 Contraband (Trigger) item found in the programs over this time period; last CPR = 0 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; last CPR = 76%
Current CPR: Abington 78%; Bellingham 82%; Leo-Elm 67%; Leo-Wachusetts 57%; Marlborough 75%; Win – Alger 85%; Win-Teel 100%
Last CPR: Abington 88%; Bellingham 73%; Leo-Elm 50%; Leo-Wachusetts 89%; Marlborough 64%; Win – Alger 80%; Win-Teel 100%

17. RESULTS OF SQA MONITORING AUDITS July 2014-December 2014
Positives
Average Scores
Confidential Files = 95.63%
Financial Records = 99.21% 
Program Forms = 92.41%
**Strengths of the Cluster
Financials
ISP Paperwork (Assessment and Provider Support Strategies)
Completion of Walk-Through Action Plans
Areas In Need of Improvement
Required Program Training Sign-offs
Obtaining co-guardian signatures on Skills Plans and Consents

18. CPR ACTION PLAN ISSUE: Increase Community Inclusion
COMMENTS: Last CPR, average of 4.9 community inclusion activities per client/month
IMPROVEMENTS MADE: Currently, average of 6.4 community inclusion activities per client/month
ISSUE: Decrease medication incidents & occurrences
COMMENTS: Last CPR, the total medication incidents & occurrences = 15
IMPROVEMENTS MADE: Currently, a total of 18 medication incidents & occurrences
Monitor:
Talk to Paul Swindlehurst about getting more donated tickets for increasing mainstream activities
Improve recruitment period (fill vacancies sooner) so as to eliminate overtime.