1. Comprehensive Program Review March 27, 2015
Community Strategies: Janet Kachadoorian’s Cluster Fitchburg, Wendell, Orange, Leominster-Crimson, Leominster-Union, Templeton and West Boylston
Comprehensive Program Review March 27, 2015

2. Fitchburg, Wendell, Orange, Leominster-Crimson, Leominster-Union, Templeton and West Boylston

3. CLUSTER HIGHLIGHTS (1)
Successful integration of Positive Behavioral Supports (PBS) as a pilot cluster
Organized a team to work on a project to raise enough money and gifts for 96 homeless people
Promoted 2 managers to Program Coordinators

4. CLUSTER HIGHLIGHTS (2)

5. CLUSTER HIGHLIGHTS (3)
One individual at Union Street has lost almost 30 pounds by with the implementation of the EO-509 dietary guidelines
We had our first cluster meeting with all the managers, assistants and meaningful day coordinators.  We enjoyed some team building exercises and we used the time to train lead staff across programs. Our next meeting on April 1, 2015 will focus on ways we can improve with medications

6. CHALLENGES for CONSULTATION
Losing new hires or entry level DSPs for a higher starting salary
Improved oversight for medication audits needed to improve services
Uniform file systems are needed for internal trainings/tracking/filing and maintaining when new staff are hired

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

8. STAFF TURNOVER RATES
The current CS Cluster average is 23.2% compared to the CSMA average of 27.9%
Orange: N/A = opened on 1/6/15
Last CPR, Cluster average was 29.2% compared to the CSMA average of 27.5%
Data obtained from HR Turnover & Retention Reports

9. STAFF RETENTION RATES
The current CS Cluster retention rate average is 69.8% compared to the CSMA average of 72.4%
Orange: N/A = opened on 1/6/15
Leo-Crimson = N/A ( reopened for less than one year, formerly Leo-Merriam)
Data obtained from HR Turnover & Retention Reports

10. STAFF TRAINING HOURS August 2014 – January 2015
Current CPR:
Total of 2, training hours were completed (This is a 5% decrease from last CPR)
Average of 29.8 hours per staff/over six months per cluster
Aug Jan. 2015
E Training Hours
MMR Training Hours
Total
Fitchburg
84.25
310
394.25
Leominster Crimson
86.75
166
252.75
Leominster Union 62
217
279
Templeton
64.75
129.5
194.25
Wendell
6.25
194
200.25
West Boylston
85.5
454
539.5
Orange
54.75
121
175.75
Cluster
444.25
1591.5
2,035.75
Last CPR:
Total of 2,153.8 training hours were completed
Average of 34.2 hours per staff/over six months per cluster
Data obtained from MMRs and HR Reports

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

12. CLINICAL HOURS August 2014 – January 2015
A total of clinical hours (46% decrease from previous CPR); the Cluster Average = 6.56 clinical hours per client/six-months or 1.09 hours per client per month.
Last CPR, a total of clinical hours; the Cluster Average = 15 clinical hours per client/six-months or 2.5 hours per client per month.
Data obtained from MMR

13. CLIENT ELOPEMENTS August 2014 – January 2015 September 2013 –
February 2014
Fitchburg
Leominster Crimson 1
Leominster Union
Templeton
Wendell
West Boylston
Orange
N/A
Cluster - Totals
Data obtained from MMR

14. MEDICATION INCIDENTS & OCCURRENCES August 2014 – January 2015
Total of 6 medication incidents and occurrences. This is a 33% decrease from last CPR.
50% or (3 out of 6) medication incidents/occurrences were client medication refusals.
Last CPR, a total of 9 medication incidents and occurrences.
44% or (4 out of 9) medication incidents/occurrences were client medication refusals.
Data obtained from MMR

15. DE-ESCALATIONS : RESTRAINTS
August 2014 –
January 2015
September 2013 –
February 2014
Fitchburg
1.4:1
2:1
Leominster Crimson
36:1
51:1
Leominster Union
23:0
5:0
Templeton
112:1
443:0
Wendell
12:1
West Boylston
68:1
7:1
Orange
4:0
N/A
Cluster Average
383 De-escalations: Restraints or 22:1
741 De-escalations: Restraints or 15:1
This is a 48% decrease in de-escalation and 67% decrease in restraints compared to previous CPR
Data obtained from MMR

16. COMMUNITY INCLUSION
Community Inclusion Activities Participated In and Offered (August 2014 – January 2015)
Data obtained from MMR

17. COMMUNITY INCLUSION
Community Inclusion Activities Participated In and Offered (August 2014 – January 2015)
A total of 965 community inclusion activities participated in; this is a 45% increase from the last CPR.
Average of 32 community inclusion activities per client/six months; overall participation rate = 80%
Last CPR:
Average of 20.2 community inclusion activities participated in per client/six month
A total of 665 community inclusion activities offered; a total of 499 community inclusion activities participated in; overall participation rate = 75%
Data obtained from MMR

18. MAINSTREAM ACTIVITIES
Community Inclusion Activities Participated In and Offered (August 2014 – January 2015)
Data obtained from MMR

19. MAINSTREAM ACTIVITIES
Community Inclusion Activities Participated In and Offered (August 2014 – January 2015)
A total of 2,541 mainstream activities participated in during this period; this is a 5.6% increase from the last CPR.
[Orange data is for one month only]
Average of 84 mainstream activities participated in per client/six months; overall participation rate = 91%
Last CPR:
Average of 81 mainstream activities participated in per client/six months
A total of 2,406 mainstream activities offered; a total of 1,993 mainstream activities participated in; overall participation rate = 83%
Data obtained from MMR

20. QUALITY ASSURANCE
Key MMR Results
SQA Audits Results

21. KEY MMR RESULTS Employment/Education: (As of January 31, 2015)
7 out of 30 or 23% individuals are employed or in a pre- vocational training program; last CPR = 3 out of 26 (12%)
5 out of 30 clients or 17% are attending a sheltered workshop; last CPR = 6 out of 26 (23%)
18 out of 30 clients or 60% are in meaningful day programs; last CPR =15 out of 26 (58%)
0 clients are in school; last CPR = 2 out of 26 (7%)
Other:
30 out of 30 (100%) clients chose to participate in the healthy living options within their program; last CPR = 100%
“0” contraband reported; last CPR = 0 contraband reported

22. KEY MMR RESULTS Staff Certifications:
100% certified in PAC/CPI: (last CPR = 90%)
Last CPR: Fitchburg = 100%; Leominster Crimson = 100%;
Leominster Union = 50%; Wendell = 90%; West Boylston = 100%;
Templeton = 100%; Orange = N/A
100% certified in First Aid/CPR : (last CPR = 98.3%)
Last CPR: Fitchburg = 100%; Leominster Merriam = 100%;
Leominster Union = 100%; Wendell = 90%; West Boylston = 100%;
Templeton = 100% ; Orange = N/A
89% of staff are MAP Certified (data does not include Orange);
Overall with Orange = 83%; last CPR = (85.2% of staff were MAP certified)
Current CPR: Fitchburg = 83%; Leominster Crimson = 80%; Leominster Union = 90%;
Wendell = 91%; West Boylston = 90%; Templeton = 100%; Orange = 38%
Last CPR: Fitchburg 80%; Leominster Crimson = 100%; Leominster Union = 70%;
Wendell = 80%; West Boylston = 90%; Templeton = 91%; Orange = N/A

23. RESULTS OF SQA MONITORING AUDITS August 2014 – January 2015
Positives
Average Scores
Confidential Files = 95.74%
Financial Records = 98.97% 
Program Forms = 90.5%
**Strengths of the Cluster
ISP Paperwork (Assessment and Provider Support Strategies)
Legal Paperwork
Monthly Financial Audits
Areas In Need of Improvement
Updating of Search and Disaster Plans
Updating of Consents

24. CPR ACTION PLAN (Past 6 months)
ISSUE: Increase Community Inclusion
COMMENTS: Last CPR, average of 20.2 community inclusion activities per client/over six months
IMPROVEMENTS: Currently, average of 32 community inclusion activities per client/over six months  The overall participation rate in community inclusion activities increased by 5 percentage points. From 75% last CPR, to the current rate of 80%.

25. CPR ACTION PLAN (Next 6 months)
Proposed Objective
Proposed Metric
1. Review and update the Search and Disaster Plans
July 2015
2. Updating of Consent forms as needed
May 2015
3. Consult with Human Resources to review starting salaries of competing organizations. Determine the budget impact on adjusting starting salaries

26. CPR ACTION PLAN (Next 6 months)
Proposed Objective
Proposed Metric
4. Discuss processes that would ensure medication audits are conducted more frequently and thoroughly, possibly by QA or assigning one staff to visit all programs to audit.
June 2015
5. Create an inventory of all program books and documents.  Then streamline the process so all cluster programs are uniform, including updated forms, color of binders, order of documents within binders, etc.
June 2015 implement in Janet’s cluster
6. Share practice of uniform program books and documents with all clusters.
Sept 2015 implement in all clusters