2. Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, Sargent House Data

3. Data obtained from HR Department & HR Personnel Summary STAFF TURNOVER RATE (10/1/10 – 9/30/11) OVERDUE PERFORMACE EVALUATIONS APRIL6 FT0 PT MAY7 FT0 PT JUNE3 FT0 PT JULY2 FT0 PT AUG.3 FT0 PT SEPT.4 FT0 PT -Sargent is currently fully staffed- 14 Budgeted Positions, 0 vacancies. Average of 4.2 Overdue Performance Evaluations April-September

4. Data obtained from Sargent House Utilization Rate By Month April-September Average Utilization Rate April-September 2011: 91% Sargent Is Currently At Capacity

5. Data obtained from MMRs An average of 12 mainstream community activities were participated in per client April-September At the time of the last CPR, there was an average of 13 mainstream community activities per client over a 6 month period. Average activities per client each month.

6. There was an average of 5 clinical hours* per client each month. * clinical hours include in-house clinical individual service hours and in-house clinical group service hours. Data obtained from MMRs April May June July August September There were 167 clinical hours total 4/11-9/11. At the time of last CPR, there was an average of 13 clinical hours per client each month.

7. Data obtained from MMRs There was a total of 3 medication incidents or occurrences 4/11-9/11 Per Client Each Month At the time of the last CPR, there was a total of 15 medication incidents or occurrences over a 6 month period.

8. De-escalation: Restraints APRIL38.5:1 MAY71:1 JUNE40:1 JULY 98:1 AUGUST82:0 SEPTEMBER84:0 82:1 For 6 Months Data obtained from the MMRs Last CPR (November-April) November:57:0 December:71:1 January34.5:1 February:74:0 March:82:1 April:38.5:1 71.6:6 For 6 Months -There was 1 elopement in May. - At the time of the last CPR, there were 0 elopements over a 6 month period. There was a total of 6 restraints over a 6 month period. At time of last CPR, there was a total of 6 restraints over a 6 month period.

9. Data obtained from Sargent Training Reports April May June July August Sept. Training Hours Completed Per Staff Member Per Month Total Training Hours April-Sept: 190 Total Training Hours Per Month APRIL0 MAY20.5 JUNE42 JULY 0 AUGUST3.5 SEPTEMBER124

10. Positives: - Staff are always helpful during visits. All necessary files, logs and information are always readily available. -There has been recent improvement regarding the cleanliness of the main floor (common room, computer room, etc.) and the kitchen/pantry area. -During a past visit, there was useful nutritional information posted for clients in the kitchen. -Minus a few exceptions, most client bedrooms have been organized at time of visit. -Staff Compliance with the dress code has improved in recent months. Needs Improvement: -Ongoing Issues: Not enough detail or description provided in most logs - This includes Unit Condition Reports, Shift Summaries & Client Daily Data Sheets. At times, logs/reports include contradictory data. Furthermore, the handwriting is often illegible. Staff at Sargent are in need of a Report Writing refresher training. -Cleanliness of client bathrooms is often an issue. - Incidents documented in the Communication Log do not always have corresponding Incident Reports. This was especially a problem in April and May 2011. On the same note, there were some instances in which not all staff member involved in the incident submitted their own report, or multiple staff members completed one report together. Data obtained from SQA Monitoring Visits

11. Results taken from survey conducted in November 2011 Data obtained from Youth Satisfaction Surveys The Best Thing About This Program So Far Is: -“The Support.” - “I am doing better than when I first came here.” - “ I like the privileges and all the staff and almost all the clients!” Some Things I Would Change About This Program Are: -“The rules.” -“The way people treat each other.” -“Clients threatening, stealing, instigating each other and to do what their (sic) told when they know better and for me to actually learn how to cook.” Other - “I like the staff.”

12. Data obtained from Youth Satisfaction Surveys Results taken from survey conducted November 2011