1. Comprehensive Program Review December 21, 2012
Community Strategies: Oyeyemi Payne’s Cluster Bellingham, Franklin, Marlborough, Medway, Milford, Northborough, and Wrentham
Comprehensive Program Review December 21, 2012

2. CLUSTER HIGHLIGHTS Client-Related:
Four individuals at the Franklin program are now competitively employed.
An individual with diabetes was taken off insulin since May.
One of our individuals was invited to DDS staff meeting in October to read his poetry.
Individuals from 3 of our programs are volunteering at the Knights of Columbus, local animal shelter and Meals on Wheels.
Individuals are participating in quality mainstream activities across the cluster.
Staff-Related:
Staff discovered a gas leak and acted appropriately to ensure the safety of everyone.
Successfully talked to one of our individuals in the Franklin program to stay when he decided to move out of the program with no support.
No LOM/Restraints in our Northborough program for over a year.
Two of our program managers won staff of the quarter award in July and October.

3. CLUSTER HIGHLIGHTS (continued)
Family/Community:
A parent of one of our individuals in the Wrentham program called to say how happy she was with the way we have treated her son.
Commendation from family citizen advisory board about staff retention, staff’s knowledge about individuals and strong emergency preparedness.
Bellingham program is now offering extra newspapers left from paper route to the neighbors.

4. AREAS IN NEED OF IMPROVEMENT
Areas of Improvements/Challenges:
Difficulty finding employment for many of our individuals that are employable.
De-escalating on-going episodes of violent behavior in our Marlborough program.
Too much overtime being used across the cluster due to FMLA or turnover.
Getting all staff to start implementing meaningful day activities with the assistance of the Meaningful Day Coordinators.
Increase in community inclusion activities across the cluster.

5. STAFFING
Staff Turnover Rates
Performance Evaluations
Staff Training

6. STAFF TURNOVER RATES March 2012 – August 2012 (9/12011 – 10/31/2012)
The current CS Cluster average is 15.6 % compared to the CSMA average of 21.4%
Last CPR, Cluster average was 16.7% versus CSMA overall of 25.5% (March 1, 2011 – February 29, 2012)
CS Cluster configuration has changed since the last CPR; Marlborough program started on 9/1/2012
Data obtained from HR Reports

7. OVERDUE PERFORMANCE EVALUATIONS
STAFFING
OVERDUE PERFORMANCE EVALUATIONS
May October 2012
Overdue Evaluations
2 > or more months FT PT
Bellingham NA
Franklin
Marlborough
Medway
Milford
Northborough 1
Wrentham 3
Cluster - Totals 4
May
June
July
Aug.
Sept.
Oct. FT PT
Bellingham
Franklin
Marlborough
Medway
Milford
Northborough 1
Wrentham 2 3
Cluster - Totals 4
Total of 17 FT and 0 PT overdue performance evaluations
Last CPR, a total of 38 ( 17FT and 21 PT) overdue performance evaluations from August January Please note: CS Cluster included Leominster Pleasant, Milford, Northborough, and Winchendon Alger.
Data obtained from HR Department & HR Personnel Summary

8. STAFF TRAINING HOURS May 2012 – October 2012
E Training Hours
MMR Training Hours
Total
Bellingham
42.25
183.75
226
Franklin
58. 5
296
354.5
Marlborough
48.4
524
532.5
Medway
22.65
182
226.5
Milford
30.9
217
309.25
Northborough
29.8
209
253.75
Wrentham 68
607
680
Cluster
34.8
2582.5
Total training hours were completed
Average of 34.8 hours per staff/over six months
Average per cluster per month = 430
Last CPR, total training hours = 832
Average per cluster per month = 139
CS Cluster configuration has changed since last CPR
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 May 2012 – October 2012
Cluster Average of 7.75 clinical hours per client/six-months or 1.3 hours/per client per month
Total Clinical Hours = 271.5
Last CPR, the cluster average of clinical hours per client/month was (August 2011 – January 2012); CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

11. Client Walk-Aways May 2012 – August 2012 August 2011 – January 2012
Bellingham
Franklin 1
Marlborough
N/A = New effective 9/1/12
Medway 3
Milford 2
Northborough
Wrentham
Cluster - Total 4
CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

12. MEDICATION INCIDENTS & OCCURRENCES May 2012- October 2012
Total of 8 medication incidents and occurrences
62.5% or 5 out of 8 medication incidents/occurrences were client refusal of medications
Last CPR, a total of 3 medications incidents and occurrences. CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

13. De-Escalations : Restraints
May 2012 – October 2012
August 2011 – January 2012
Bellingham
31:1
28.5:1
Franklin
35:1
40:1
Marlborough (new as of 9/1/12)
188:0
N/A
Medway
110:1
9:1
Milford
104:1
60.5:1
Northborough
605:0
467:0
Wrentham
88:1
71:1
Cluster Average
2,392 De-escalations:
28 Restraints
or 85:1
1,883 De-escalations:
40 Restraints
or 47:1
CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

14. COMMUNITY INCLUSION (Marlborough - new effective 9/1/12)
Community Inclusion Activities Participated In and Offered (March 2012 – August 2012)
Average of 4.9 community inclusion activities per client/six months
(Marlborough - new effective 9/1/12)
Last CPR, average of 2.9 community inclusion activities participated in per client/six months
CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

15. MAINSTREAM ACTIVITIES
Mainstream Activities Participated In and Offered (March 2012 – August 2012)
Average of Mainstream Activities Participated in Per Client/Six Month
(Marlborough - new effective 9/1/12)
Last CPR, average of 14.2 mainstream activities participated in per client/six months.
CS Cluster configuration has changed since last CPR.
Data obtained from MMRs

16. KEY MMR RESULTS Employment/Education: ( As of October 31, 2012)
8/35 or 23% of the residents are competitively employed
1/35 or 3% of the residents are in school
3/35 or 8% of the residents are in a sheltered workshop
23/35 or 66% of the clients are enrolled in day activity programs
Other:
28/35 or 80% of the residents chose healthy living opportunities in programs
0 Contraband (Trigger) items found in the programs over this time period
Staff Certifications:
100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED; Human Rights; Fire Safety
81% of the staff are MAP certified
Bellingham 75%; Franklin 100%; Marlborough 27%; Medway 100%; Milford 89%; Northborough 89%; and Wrentham 100%

17. CPR ACTION PLAN
See Handout