Community Strategies Mandy Adao s Cluster Carver Kingston Middleboro

Community Strategies: Mandy Adao’s Cluster Carver, Kingston, Middleboro and Paxton Comprehensive Program Review June 27, 2014 1

CLUSTER HIGHLIGHTS Highlights: v Seven Promotions: 1 Program Coordinator, 2 Managers, 2 Assistant Managers, and 2 Meaningful Day Coordinators v CM from Carver has been awarded her 3 rd recognition from the House of Representatives. v We have been able to accomplish more community inclusion activities for each client. Best Practice: v 100% of all residents are participating in Healthy Living with weight loss being shown. The residents have lost a total of 76 lbs which is a great start. 2

CHALLENGES v Hiring open positions (because of all the internal promotions) v Using less overtime 3

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

STAFF TURNOVER RATES Ø The current CS Cluster average is 28. 6% compared to the CSMA average of 26. 5% Ø Last CPR, Cluster average was 25. 6% compared to the CSMA average of 25. 7% Data obtained from HR Staff Retention & Turnover Report 5

STAFF RETENTION RATES Ø 6/30/13 Retention Data for CSMA and Overall-CRJ = N/A (data not available) Data obtained from HR Staff Retention & Turnover Report 6

STAFF OVERDUE PERFORMANCE EVALUATIONS November 2013 – April 2014 Overdue Evaluations As April 30, 2014 January 2013 – June 2013 Overdue Evaluations As June 30, 2013 FT PT Carver 1 0 0 1 2 0 0 0 Carver 2 0 0 0 2 0 0 0 Kingston Middleboro Paxton Cluster - Totals Ø Total of 2 FT and 0 PT overdue performance evaluations Ø Last CPR, a total of 2 FT and 0 PT overdue performance evaluations Data obtained from HR Report 7

STAFF TRAINING HOURS November 2013 – April 2014 E Training Hours MMR Training Hours Total Carver 70. 75 376 446. 75 Kingston 24. 75 231. 5 256. 25 Middleboro 29. 25 56 85. 25 Paxton 110 56 166 Cluster 234. 75 719. 5 954. 25 Ø Total of 954. 25 training hours were Data obtained from MMRs and HR Reports completed (22. 8% increase from previous CPR) Ø Average of 29. 9 training hours per staff/over six months Last CPR: (June 2013) Ø Total of 777 training hours were completed Ø Average of 21. 4 training hours per staff/over six months 8

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

CLINICAL HOURS November 2013 – April 2014 Ø A total of 213. 3 clinical hours; the Cluster average = 12 clinical hours per client/over sixmonths or 2 hours per client per month. Ø Last CPR, a total of 204. 5 clinical hours; the Cluster average was 11. 4 clinical hours per client/over six-months or 1. 9 hours per client per month. Data obtained from MMRs 10

CLIENT ELOPEMENTS November 2013 – April 2014 January 2013 – June 2013 Carver 0 0 Kingston 0 0 Middleboro 0 0 Paxton 0 1 Cluster - Totals 0 1 Data obtained from MMRs 11

MEDICATION INCIDENTS & OCCURRENCES November 2013 – April 2014 Ø Total of 3 medication incidents and occurrences. Ø For both time periods, all medication incidents and occurrences were client refusals. Ø Last CPR, a total of 3 medication incidents and occurrences. Data obtained from MMRs 12

DE-ESCALATIONS : RESTRAINTS November 2013 – April 2014 January 2013 – June 2013 Carver 76: 1 42: 1 Kingston 169: 0 139: 0 Middleboro 213: 0 412: 0 Paxton 15: 1 9: 0 Cluster Average 87: 1 135: 1 Totals 785 De-escalations: 814 De-escalations: 9 Restraints 6 Restraints ØThis is a 36% decrease in de-escalation and a 50% increase in restraints compared to previous CPR. Data obtained from MMRs 13

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (November 2013 – April 2014) Ø Average of 34. 4 community inclusion activities per client/over six months. Ø This is a 39. 8% increase from the last CPR Last CPR: Ø Average of 24. 6 community inclusion activities participated in per client/over six months Ø A total of 449 community inclusion activities offered; a total of 443 community inclusion activities participated in Data obtained from MMRs 14

MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered (November 2013 – April 2014) Ø Average of 90. 6 mainstream activities per client/over six months. Ø This is a 19% decrease from the last CPR Last CPR: Ø Average of 112 mainstream activities participated in per client/over six months Ø A total of 2, 103 mainstream activities offered; a total of 2, 018 mainstream activities participated in Data obtained from MMRs 15

QUALITY ASSURANCE • KEY MMR RESULTS • SQA AUDITS 16

KEY MMR RESULTS Employment/Education: (As of April 30, 2014) Ø 1 out of 18 (6%) clients competitively employed Ø 2 out of 18 (11%) clients are in school Ø 6 out of 18 (33%) clients are attending a sheltered workshop Ø 9 out of 18 (50%) clients are in day programs Other: Ø 18 out of 18 (100%) clients chose to participate in the healthy living options within their program; last CPR = 80% Ø “ 0” contraband reported; last CPR = 0 contraband reported Staff Certifications: Ø 100% certified in PAC/CPI and First Aid/CPR: Ø 74. 4% of staff are MAP Certified; this is a 3% decrease from the last CPR, (77% of staff were MAP certified) Ø Current CPR: Carver 73%; Kingston = 80%; Middleboro = 57% ; Paxton = 88% Ø Last CPR: Carver 86%; Kingston = 83%; Middleboro = 83% ; Paxton = 56% 17

RESULTS OF SQA MONITORING AUDITS November 2013 – April 2014 Positives • Average Scores – Confidential Files = 95% – Financial Records = 99% – Program Forms = 95% • Walk-throughs – All passed • **Strengths of the Cluster – ISP Paperwork (Assessment and Provider Support Strategies) – Fire Drills – Mandatory Medical Appointments Areas In Need of Improvement – Required Roger’s Monitor documentation – Required trainings for Skills Development Management Plans

CPR ACTION PLAN NOT APPLICABLE This is the first CPR for Mandy’s Cluster 19