COMMUNITY STRATEGIES:Angelo Maroun

Abington, Bellingham, Leominster-Betanray, Leominster-Elm, Leominster-Wachusett, and Marlborough

Comprehensive Program ReviewMarch 28, 2014 1

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New cluster configuration: new people, managers, clients

Utilization: still one bed open in Bellingham

Employment procurement

New performance appraisal system

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STAFFING

Staff Turnover RatesStaff Retention Rates

Performance EvaluationsStaff Training

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STAFF TURNOVER RATES

Cluster average is 30.2% compared to the CSMA average of 26.5% Last CPR, Cluster average was 34% compared to the CSMA average of 24%

Data obtained from HR Reports

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STAFF RETENTION RATES

6/30/13 Retention Data for CSMA; CSNH; and Overall-CRJ = N/A (data not available)

Data obtained from HR Reports

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OVERDUE PERFORMANCE EVALUATIONS

August 2013 – January 2014 Overdue EvaluationsAs of January 31, 2014

Overdue EvaluationsAs of March 31, 2013

ANNUAL REVIEWS ANNUAL REVIEWS

FT PT FT PT

Abington 0 1 2 0

Bellingham 0 0 2 0

Leo-Betanray 0 0 0 0

Leo - Elm 1 0 4 0

Leo - Wachusetts 1 0 0 0

Marlborough 0 1 0 0

Cluster - Totals 2 2 8 0 This CPR, a total 4 annual reviews: 2FT and 2 PT are due; last CPR = 8 FT and 0 PT This is a decrease of 50% from previous CPR.

Data obtained from HR Department & HR Personnel Summary 7

Total of 1180.6 training hours; (23% increase from previous CPR). Average of 20.4 hours per staff over six months. Last CPR, a total of 959 training hours were completed; Average of 16.4 hours per staff /over six months

Data obtained from MMRs and HR Reports 8

CLIENT RELATED

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

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Total Clinical Hours = 259.75 (October 2012 – March 2013); Cluster Average of 1.6 clinical hours per client/month Last CPR, Total Clinical Hours = 271 (March 2012 – August 2012); Cluster Average of 1.6 clinical hours per client/month

10Data obtained from MMRs

Client Elopements

August 2013 – January 2014 October 2012 – March 2013

Abington 0 0

Bellingham 0 0

Leo - Betanray 1 0

Leo – Elm (Pleasant) 1 0

Leo- Wachusetts 1 1

Marlborough 0 4

Cluster - Total 3 5

Data obtained from MMRs

Total of 3 walk-aways/elopements reported for this reporting period. This is a 40% decrease from last CPR.

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Data obtained from MMRs

August 2013-January 2014 October 2012 – March 2013

Average Per Client/Month

Medication Incidents

Medication Occurrences

Total Average Per Client/Month

Medication Incidents

Medication Occurrences

Total

Abington .08 0 2 2 0 0 0 0

Bellingham 0 0 0 0 0 0 0 0

Leo-Betanray .06 1 1 2 0 0 0 0

Leo-Elm .06 1 1 2 .34 3 6 9

Leo-Wachusetts .06 1 1 2 .06 1 1 2

Marlborough 0 0 0 0 0 0 0 0

Cluster .049 3 5 8 .06 4 7 11

This is a 27% decrease in medication incidents/occurrences from previous CPR. A total of 3 client medication refusals reported during this timeframe.

A total of 2 client medication refusals reported during this timeframe

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De-Escalations : Restraints August 2013 – January 2014 October 2012 – March 2013

De-escalations: Restraints

Ratio De-escalations: Restraints

Ratio

Abington 173:1 173:1 216:1 216:1

Bellingham 172:4 4:1 549:13 42:1

Leo - Betanray 104:3 35:1 39:0 39:0

Leo – Elm (Pleasant) 364:73 5:1 537:68 8:1

Leo -Wachusetts 282:19 15:1 604:15 40:1

Marlborough 334:13 26:1 490:46 11:1

Cluster Totals 1,429:113 13:1 2,435:143 17:1 Last CPR, the overall Cluster totals = 17:1

Data obtained from MMRs13

Average Mainstream Activities Participated In and Offered Per Client/ Month (August 2013 – January 2014)

Average of 14.2 mainstream activities participated in by client/month (August 2013 – January 2014). This is a 13% decrease from the previous CPR. The overall participation rate is 87%; This is a 3% decrease from previous CPR.

Data obtained from MMRs 14

Average Community Inclusion Activities Participated In and Offered Per Client/ Month (August 2013 – January 2014)

Average of 6.4 inclusion activities participated in by client/month (August 2013 – January 2014). This is a 45% increase from the previous CPR. The overall participation rate is 83%; This is a 10.6% increase from previous CPR.

Data obtained from MMRs 15

QUALITY ASSURANCE

Key MMR Results

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Employment/Education: (As of January 31, 2014) 11/27 (41%) of the residents are competitively employed; last CPR = 10/28 (36%) 2/27 (7%) of the residents are in a sheltered workshop; last CPR = 1/28 or (3%) 14/27 (52%) of the clients are in an alternative day program; last CPR = 16/28 (58%)

Other: 90% of the residents chose healthy living opportunities in programs; last CPR = 67%.

0 Contraband (Trigger) item found in the programs over this time period; last CPR =

0 Contraband (Trigger) item found

Staff Certifications: 100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED 78.3% of the staff are MAP certified; last CPR = 72%

o Current CPR: Abington 88%; Bellingham 80%; Betanray = 100%; Elm (formerly Pleasant) 50%; Wachusetts 88%; Marlborough 64%

o Last CPR: Abington 75%; Bellingham 64%; Betanray = 78%; Elm (formerly Pleasant) 73%; Wachusetts 78%; Marlborough 64%

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ISSUE: Need to improve number of clients participating in healthy livingCOMMENTS: Last CPR, clients participating in healthy living programming = 67%IMPROVEMENTS MADE: Currently, 90% participating in healthy living programming (34% increase from last CPR)

ISSUE: Increase Community Inclusion COMMENTS: Last CPR, average of 4.4 community inclusion activities per client/monthIMPROVEMENTS MADE: Currently, average of 6.4 community inclusion activities per client/month (45% increase from last CPR)

ISSUE: Decrease medication incidents & occurrencesCOMMENTS: Last CPR, the total medication incidents & occurrences = 11 IMPROVEMENTS MADE: Currently, a total of 8 medication incidents & occurrences

ISSUE: Improve on the Overdue Performance Evaluation Completion COMMENTS: Last CPR, 8 FT performance evaluations were overdueIMPROVEMENTS MADE: Currently, 4 evaluations are overdue: 2 FT and 2 PT

KEEP EYE ON:• Improve Meaningful Day activities – finding things all clients like to do and find how to market products made by the clients. • Improve recruitment period (fill vacancies sooner) so as to eliminate overtime.

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