1. Community Strategies: Patrick White’s Cluster Athol, Brookfield, Westborough, Westminster, Winchendon Alger and Winchendon Teel Comprehensive Program Review October 17, 2014

2. Healthy Living: Continues to be a best practice in our cluster. Another individual has now been taken off all diabetic medications due to weight loss and cluster total weight loss during review period has been over 125 pounds. Meaningful Day has continued to increase across the cluster. MDC’s have been able to see increases in abilities of reading, writing, and arithmetic as well as continuous searches of new and different volunteering positions such as Hope Center, Princeton Wild Life Sanctuary, Athol Food Pantry, Knights of Columbus, and Forward Strides which has since created an opportunity for the agency to volunteer and take therapeutic horseback riding. Two of our individuals have been asked to do a video clip talking about their successes and challenges that they have overcome through the supports of staff.

3. Retention of staff in our behavioral homes Community Inclusion, Support from Community, and employment for our individuals

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

5. STAFF TURNOVER RATES (8/1/2013 – 7/31/2014) Data obtained from HR Reports  Cluster average is 28.7% compared to CSMA average of 26.7%  Last CPR, Cluster average was 26.3% compared to the CSMA average of 26.8%

6. STAFF RETENTION RATES (8/1/2013 – 7/31/2014) Data obtained from HR Reports  Cluster average is 69.9% compared to CSMA average of 71.8%  Last CPR, Cluster average was 73.6% compared to the CSMA average of 73.6%

7. Data obtained from HR Department & HR Personnel Summary Overdue Performance Evaluations 7/31/201411/30/2013 FTPTFTPT Athol0000 Brookfield0001 Westborough0013 Westminster0032 Winchendon Alger1000 Winchendon Teel0000 Cluster Totals1046 Total of 1 FT overdue performance evaluation; (75% decrease from last CPR) and 0 PT overdue performance evaluation (100% decrease from last CPR)

8.  A total of 1,953.3 staff training hours; 4.8% increase from last CPR  Cluster Average of 30.6 hours per staff/over six months  Last CPR, a total of 1,863 training hours were completed  Cluster average of 27.7 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.  Total Individual Clinical Hours = 193.3; (16% decrease from last CPR)  Average of 8.64 clinical hours per client/over six months  Last CPR, total Individual Clinical Hours = 231.75; average of clinical hours = 11.4 per client/over six months Data obtained from MMRs

11. CLIENT ELOPEMENTS/ WALK-AWAYS February 2014 – July 2014 June 2013 – November 2013 Athol10 Brookfield00 Westborough02 Westminster01 Winchendon Alger00 Winchendon Teel00 CS Cluster Total13 Data obtained from MMRs  Total of 1 Elopement (67% decrease from previous CPR).

12.  A total of 134 medication occurrences and incidents (19% decrease from last CPR). All 134 medication occurrences & incidents were client refusal of medications.  Last CPR, a total of 3 medication occurrences and 164 medication incidents; (89% or 148 out of 167 medication incidents/occurrences were client refusal of medications) Data obtained from MMRs

13. De-Escalations : Restraints February 2014 – July 2014 June 2013 – November 2013 Athol5:1 Brookfield8:1 Westborough11:1 12:1 Westminster367:160:1 Winchendon Alger23:1 Winchendon Teel32:1 25:1 Cluster1,579 De-escalations: 91 Restraints or 17:1 2,067 De-escalations: 126 Restraints or 16:1 Data obtained from MMRs

14. Community Inclusion Activities Participated In and Offered (February 2014 – July 2014) Data obtained from MMRs  A total of 1,490 community inclusion activities participated over six months; average of 8.6 community inclusion activities per client/over six months  Last CPR, a total of 1,482 community inclusion activities participated in; average of 8.9 per client/over six months

15. Mainstream Activities Participated In and Offered (February 2014 – July 2014) Data obtained from MMRs  A total of 2,355 mainstream activities participated over six months; (14% increase from last CPR)  Average of 13 mainstream activities per client/over six months  Last CPR, a total of 2,059 mainstream activities participated in; average of 11.6 per client/over six months

16.  KEY MMR RESULTS  SQA AUDITS  ACTION PLAN

17. Employment/Education: (As of July 31, 2014)  1/30 or 3% of the residents are competitively employed; last CPR = 3% employed  9/30 or 30% of the residents are in a sheltered workshop/pre-vocational training; last CPR = 43%  20/30 or 67% of the clients are enrolled in day activity programs; last CPR = 54% Other:  28/30 or 93% of the residents chose healthy living opportunities in programs; last CPR = 88%  O Contraband items; Last CPR = 5 out of 6 residences had 0 Contraband items found in the programs over this time period (Westminster had 3 contraband items) Staff Certifications:  100% of staff are PAC certified  100% of staff are current in FA/CPR/AED certifications:  85% of the staff are MAP certified; last CPR = 81% o Athol 90%; Brookfield 100%; Westborough 64%; Westminster 75%; Winchendon Alger 83%; and Winchendon Teel 100% o Last CPR: Athol 100%; Brookfield 82%; Westborough 64%; Westminster 67%; Winchendon Alger 92%; and Winchendon Teel 80%

18. Pat White’s Cluster: Positives Average Scores – Confidential Files = 93.2% – Financial Records = 99.2% – Program Forms = 94.8% – Walk-Throughs = passing **Strengths of the Cluster – Financials – Walk-Throughs Areas In Need of Improvement – Consents and LOM’s missing signatures – Missing Roger’s Monitor paperwork – ISP paperwork missing

19. ISSUE:Increase the clinical hours per client/per month COMMENTS:Last CPR, the average clinical hours/per client per month = 1.8 IMPROVEMENTS MADE:The current average of clinical hours per month = 1.4 ISSUE:Increase the community inclusion hours COMMENTS:The CRJ/CS goal is to have 4 community inclusion activities per client per month. Last CPR, the community inclusion hours per client/over six months was 8.9 IMPROVEMENTS MADE:The current average of community inclusion hours per client/over six months = 8.6 ISSUE:Increase the mainstream activities per client/per month COMMENTS:Last CPR, the mainstream activities hours per client/over six months was 11.6 IMPROVEMENTS MADE:The current average of mainstream activities per client/over six months = 13