2. COMMUNITY STRATEGIES: Mandy Adao’s Cluster Carver, Kingston, Leicester, Middleboro and Paxton Comprehensive Program Review February 27, 2015 1

3.  Stephen Kelly received Star Award  Opening Leicester (9/5/14)  Leominster-Merriam opening in January 2015  Increased Meaningful Day Participation Best Practice:  100% of all residents are participating in Healthy Living 2

4.  Being fully staffed in all programs  Finding Jobs for our individuals  Finding quality staff for the pay rate we offer 3

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

6. STAFF RETENTION RATES  The current CS Cluster average is 75.5% compared to the CSMA average of 70.6%  Last CPR, Cluster average was 73.2% compared to the CSMA average of 72.4% 5 Data obtained from HR Staff Retention & Turnover Report

7. STAFF TURNOVER RATES  The current CS Cluster average is 23.9% compared to the CSMA average of 27.5%  Last CPR, Cluster average was 28.6% compared to the CSMA average of 26.5% 6 Data obtained from HR Staff Retention & Turnover Report

8. Last CPR: (November 2013 – April 2014)  Total of 891.5 training hours were completed  Average of 27.9 training hours per staff/over six months Data obtained from MMRs and HR Reports  Total of 581.25 training hours were completed (This is a 34% decrease from last CPR)  Average of 15.4 training hours per staff/over six months 7

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

10.  A total of 154.1 clinical hours (this is a 27% decrease from the previous CPR); the Cluster average = 1.3 hours per client per month or 3.9 per client/per quarter.  Last CPR, a total of 213.75 clinical hours; the Cluster average was 1.9 hours per client per month. 9 Data obtained from MMRs

11. CLIENT ELOPEMENTS November 2013 – April 2014 July 2014 – December 2014 Carver00 Kingston00 LeicesterN/A0 Middleboro00 Paxton00 Cluster - Totals00 10 Data obtained from MMRs

12.  A total of 6 medication incidents and 9 medication occurrences  This is 0.10 medication incidents & occurrences per client per month  Last CPR, a total of 3 medication incidents and 0 medication occurrences  This is.02 medication incidents & occurrences per client per month 11 Data obtained from MMRs

13. DE-ESCALATIONS : RESTRAINTS November 2013 – April 2014 July 2014 – December 2014 De-escalations: restraints RatiosDe-escalations: restraints Ratios Carver228:376:1381:495:1 Kingston213:1 323:0 LeicesterN/A0:0 Middleboro213:0 249:0 Paxton175:515:1133:817:1 Cluster Totals639:9 71:11,086:12 91:1 12 Data obtained from MMRs

14. Community Inclusion Participated In and Offered Per Client/ Month (July 2014 – December 2014)  A total of 690 community inclusion activities participated in across the cluster by all clients over six months. (This is a 32% increase from last CPR)  Average of 5.9 community inclusion activities participated in by client/per month or 34.5 per client/six months (July 2014 – December 2014). The overall participation rate is 70% (C.I. offered = 984/C.I. participated in =690)  Last CPR, a total of 519 community inclusion activities participated in; an average of 4.9 community inclusion activities participated in by client/month; The overall participation rate = 87% (C.I. offered = 591/C.I. participated in =519) 13 Data obtained from MMRs

15. Mainstream Activities Participated In and Offered Per Client/ Month (July 2014 – December 2014)  A total of 1,766 mainstream activities participated in across the cluster by all clients over six months. (This is a 37% increase from previous CPR)  Average of 14.4 mainstream activities participated in by client/month or 86.4 per client over six months. (July 2014 – December 2014). This is a 20% increase from the previous CPR. The overall participation rate is 84% (mainstream offered = 2,108/mainstream participated in =1,766)  Last CPR, a total of 1,283 mainstream activities participated in; an average of 11.9 mainstream activities participated in by client/month. The overall participation rate = 96%. (mainstream offered = 1,331/mainstream participated in =1,283) 14 Data obtained from MMRs

16. Key MMR Results SQA Audit Results 15 QUALITY ASSURANCE

17. Employment/Education: (As of December 31, 2014)  1 out of 23 in pre-vocational program; last CPR = 0  2 out of 23 (13%) clients competitively employed; last CPR = 1 out of 18 (6%)employed  3 out of 23 (13%) clients are in school; last CPR, 2 out of 18 or (11%) = in school  8 out of 23 (35%) clients are attending a sheltered workshop; last CPR, 11 out of 23 (48%)  9 out of 28 (32%) clients are in day programs; last CPR, 4 out of 18 (22%) in day programs Other:  100% of the clients chose to participate in the healthy living options within their program; last CPR = 100%  “1” contraband reported; last CPR = 0 contraband reported Staff Certifications:  100% certified in PAC/CPI and First Aid/CPR:  70.4% of staff are MAP Certified; last CPR, (67% of staff were MAP certified)  Current CPR: Carver 78%; Kingston = 83%; Leicester = 63%; Middleboro = 40% ; Paxton = 88%  Last CPR: Carver 73%; Kingston = 80%; Leicester = N/A; Middleboro = 57% ; Paxton = 56% 16

18. Positives Average Scores – Confidential Files = 96.14% – Financial Records = 98.44% – Program Forms = 92.2% **Strengths of the Cluster – ISP Paperwork (Assessment and Provider Support Strategies) – Fire Drills – Required Training Sign-offs Areas In Need of Improvement – Walk-Throughs – Outdated Skills Plans and Required Signatures

19. ISSUE: Increase the number of clients employed COMMENTS: Last CPR, of the 18 clients: 1 competitively employed; 0 in pre-vocational; 11 in sheltered workshops (12 out of 18 or 67%) 2 in school and 4 in day programs IMPROVEMENTS MADE: Currently, of the 23 clients 2 competitively employed; 1 in pre-vocational; 8 in sheltered workshops (11 out of 23 or 48%) 3 in school and 9 in day programs Work with Development Office (Paul Swindlehurst and Anna Poplasky) to write a story about the collaboration with Habitat for Humanity – Re-Store – Habitat for Humanity – CS working with Habitat - -clients are working at the store; and ‘bringing home scraps of wood to create shelves and other functional items to give back to Habitat. – Bill Coughlin to notified Paul and Anna about the need to document this story 18