Community Strategies:Patrick White’s Cluster

Athol, Brookfield, Westborough, Westminster, Winchendon Alger and Winchendon Teel

Comprehensive Program ReviewOctober 17, 2014

CLUSTER HIGHLIGHTS • 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.

CHALLENGES

• Retention of staff in our behavioral homes

• Community Inclusion, Support from Community, and employment for our individuals

STAFFING

Staff Turnover RatesStaff Retention Rates

Overdue Performance EvaluationsStaff Training Hours

STAFF TURNOVER RATES (8/1/2013 – 7/31/2014)

Data obtained from HR Reports

Athol Brookfield Westborough Westminster Win. Alger Win. Teel Cluster Average CSMA CSNH CSCT Overall CRJ - Average

52.6

15.8

26.1 27.8

2015.4

26.3 26.8

30.6 31.828.8

41.2

33.330

15.4

45

7.1

28.7 26.7

40 38.9

29.2

11/30/20132 7/31/2014

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%

STAFF RETENTION RATES(8/1/2013 – 7/31/2014)

Data obtained from HR Reports

Athol Brookfield Westborough Westminster Win. Alger Win. Teel Cluster Average CSMA CSCT CSNH CRJ- Overall

53.3

100

73.3

62.5

81.377.8 74.7 73.6

35.7

63 6963.6

70 71.4 71.4

52.9

90

69.9 71.8

26.7

62.2

69.2

11/30/2013 7/31/2014

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%

STAFFING

Data obtained from HR Department & HR Personnel Summary

Overdue Performance Evaluations

7/31/2014 11/30/2013

FT PT FT PT

Athol 0 0 0 0

Brookfield 0 0 0 1

Westborough 0 0 1 3

Westminster 0 0 3 2

Winchendon Alger 1 0 0 0

Winchendon Teel 0 0 0 0

Cluster Totals 1 0 4 6

Total of 1 FT overdue performance evaluation; (75% decrease from last CPR) and 0 PT overdue performance evaluation (100% decrease from last CPR)

STAFF TRAINING HOURSFebruary 2014 – July 2014

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

Athol Brookfield Westborough Westminster Win. Alger Win. Teel

36.4 23.1 19.2 30.6 33.9 43.1

62.8

30.36.3

38.0 39.3

21.8

330

178

239 237

435

336

392.8

208.3245.3

275.0

474.3

357.8

Avg. Per Staff/Six Month E Learning MMR Hours Total

Data obtained from MMRs and HR Reports

CLIENT RELATED

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

CLINICAL HOURSFebruary 2014 – July 2014

Athol Brookfield Westborough Westminster Win. Alger Win. Teel

27.5

18.7

55.8

42.5

25.423.5

22

15 17 159

29.7

20.7

70.75

59

39.9

32.5

5.9 4.2

14.1 13.58.2 6.5

In-House Clinical: Individual In-House Clinical: GroupsTotal Average per Client/Over Six Months

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

CLIENT ELOPEMENTS/WALK-AWAYS

February 2014 – July 2014

June 2013 – November 2013

Athol 1 0

Brookfield 0 0

Westborough 0 2

Westminster 0 1

Winchendon Alger 0 0

Winchendon Teel 0 0

CS Cluster Total 1 3

Data obtained from MMRs

Total of 1 Elopement (67% decrease from previous CPR).

MEDICATION INCIDENTS & OCCURRENCESFebruary 2014 – July 2014

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)

Athol Brookfield Westborough Westminster Win. Alger Win. Teel Cluster

0 1 0 0 1 1 31

130

0 0 0 0

131

Medication Occurrences Medication Incidents

Data obtained from MMRs

De-Escalations : RestraintsFebruary 2014

– July 2014June 2013 –

November 2013

Athol 5:1 5:1

Brookfield 8:1 8:1

Westborough 11:1 12:1

Westminster 367:1 60:1

Winchendon Alger 23:1 23:1

Winchendon Teel 32:1 25:1

Cluster 1,579 De-escalations: 91 Restraints

or 17:1

2,067 De-escalations: 126 Restraints

or 16:1

Data obtained from MMRs

COMMUNITY INCLUSION

Athol Brookfield Westborough Westminster Win. Alger Win. Teel Cluster

242

40

883

255

92150

1662

21634

830

225

72 113

1490

7.2 1.2 27.7 8.7 2.5 3.8 8.6

Total Offered Over Six MonthsTotal Participated In Over Six Months Average Participated In Per Client/ Over Six Month

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

MAINSTREAM ACTIVITIES

Athol Brookfield Westborough Westminster Win. Alger Win. Teel Cluster

105

414

611

318732

469

2649

93337

605

282630

408

2355

3.1 11.2 20.2 9.4 21 13.6 13

Total Offered Over Six Months Total Participated In Over Six Months Average Participated In Per Client/Over Six Months

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

QUALITY ASSURANCE

KEY MMR RESULTS

SQA AUDITS

ACTION PLAN

KEY MMR RESULTS

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%

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

RESULTS OF SQA MONITORING AUDITS

CPR ACTION PLANISSUE: 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 11.6IMPROVEMENTS MADE: The current average of mainstream activities per client/over six

months = 13