COMMUNITY STRATEGIES:Mandy Adao’s Cluster

Carver, Kingston, Leicester, Middleboro and Paxton

Comprehensive Program ReviewFebruary 27, 2015

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Stephen Kelly received Star AwardOpening Leicester (9/5/14)Leominster-Merriam opening in January 2015Increased Meaningful Day Participation

Best Practice:100% of all residents are participating in Healthy

Living

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Being fully staffed in all programs

Finding Jobs for our individuals

Finding quality staff for the pay rate we offer

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STAFFING

Staff Turnover Rates

Staff Retention Rates

Staff Training Hours

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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%

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Data obtained from HR Staff Retention & Turnover Report

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%

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Data obtained from HR Staff Retention & Turnover Report

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

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CLIENT RELATED

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

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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.

9Data obtained from MMRs

CLIENT ELOPEMENTS

November 2013 – April 2014

July 2014 – December 2014

Carver 0 0

Kingston 0 0

Leicester N/A 0

Middleboro 0 0

Paxton 0 0

Cluster - Totals 0 0

10Data obtained from MMRs

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

11Data obtained from MMRs

DE-ESCALATIONS : RESTRAINTS

November 2013 – April 2014

July 2014 – December 2014

De-escalations: restraints

Ratios De-escalations: restraints

Ratios

Carver 228:3 76:1 381:4 95:1

Kingston 213:1 213:1 323:0 323:0

Leicester N/A 0:0 0:0

Middleboro 213:0 213:0 249:0 249:0

Paxton 175:5 15:1 133:8 17:1

Cluster Totals 639:9 71:1 1,086:12 91:1

12Data obtained from MMRs

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)

13Data obtained from MMRs

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)

14Data obtained from MMRs

Key MMR ResultsSQA Audit Results

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QUALITY ASSURANCE

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%

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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

• 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

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