Comprehensive Program Review December 21, 2012

Community Strategies:Oyeyemi Payne’s ClusterBellingham, Franklin, Marlborough, Medway, Milford, Northborough, and Wrentham Comprehensive Program Review December 21, 2012

CLUSTER HIGHLIGHTS Client-Related: • Four individuals at the Franklin program are now competitively employed. • An individual with diabetes was taken off insulin since May. • One of our individuals was invited to DDS staff meeting in October to read his poetry. • Individuals from 3 of our programs are volunteering at the Knights of Columbus, local animal shelter and Meals on Wheels. • Individuals are participating in quality mainstream activities across the cluster. Staff-Related: • Staff discovered a gas leak and acted appropriately to ensure the safety of everyone. • Successfully talked to one of our individuals in the Franklin program to stay when he decided to move out of the program with no support. • No LOM/Restraints in our Northborough program for over a year. • Two of our program managers won staff of the quarter award in July and October.

CLUSTER HIGHLIGHTS (continued) Family/Community: • A parent of one of our individuals in the Wrentham program called to say how happy she was with the way we have treated her son. • Commendation from family citizen advisory board about staff retention, staff’s knowledge about individuals and strong emergency preparedness. • Bellingham program is now offering extra newspapers left from paper route to the neighbors.

AREAS IN NEED OF IMPROVEMENT Areas of Improvements/Challenges: • Difficulty finding employment for many of our individuals that are employable. • De-escalating on-going episodes of violent behavior in our Marlborough program. • Too much overtime being used across the cluster due to FMLA or turnover. • Getting all staff to start implementing meaningful day activities with the assistance of the Meaningful Day Coordinators. • Increase in community inclusion activities across the cluster.

STAFFING Staff Turnover Rates Performance Evaluations Staff Training

STAFF TURNOVER RATESMarch 2012 – August 2012 (9/12011 – 10/31/2012) • The current CS Cluster average is 15.6 % compared to the CSMA average of 21.4% • Last CPR, Cluster average was 16.7% versus CSMA overall of 25.5% (March 1, 2011 – February 29, 2012) • CS Cluster configuration has changed since the last CPR; Marlborough program started on 9/1/2012 Data obtained from HR Reports

STAFFING • OVERDUE PERFORMANCE EVALUATIONS • May 2012 - October 2012 • Total of 17 FT and 0 PT overdue performance evaluations • Last CPR, a total of 38 ( 17FT and 21 PT) overdue performance evaluations from August 2011- January 2012. Please note: CS Cluster included Leominster Pleasant, Milford, Northborough, and Winchendon Alger. • Data obtained from HR Department & HR Personnel Summary

STAFF TRAINING HOURSMay 2012 – October 2012 • Total 2582.5 training hours were completed • Average of 34.8 hours per staff/over six months • Average per cluster per month = 430 • Last CPR, total training hours = 832 • Average per cluster per month = 139 • CS Cluster configuration has changed since last CPR Data obtained from MMRs and HR Reports

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

CLINICAL HOURSMay 2012 – October 2012 • Cluster Average of 7.75 clinical hours per client/six-months or 1.3 hours/per client per month • Total Clinical Hours = 271.5 • Last CPR, the cluster average of clinical hours per client/month was 1.4 (August 2011 – January 2012); CS Cluster configuration has changed since last CPR. • Data obtained from MMRs

MEDICATION INCIDENTS & OCCURRENCESMay 2012- October 2012 • Total of 8 medication incidents and occurrences • 62.5% or 5 out of 8 medication incidents/occurrences were client refusal of medications • Last CPR, a total of 3 medications incidents and occurrences. CS Cluster configuration has changed since last CPR. Data obtained from MMRs

COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (March 2012 – August 2012) • Average of 4.9 community inclusion activities per client/six months • (Marlborough - new effective 9/1/12) • Last CPR, average of 2.9 community inclusion activities participated in per client/six months • CS Cluster configuration has changed since last CPR. • Data obtained from MMRs

MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered (March 2012 – August 2012) • Average of 12.9 Mainstream Activities Participated in Per Client/Six Month • (Marlborough - new effective 9/1/12) • Last CPR, average of 14.2 mainstream activities participated in per client/six months. • CS Cluster configuration has changed since last CPR. • Data obtained from MMRs

KEY MMR RESULTS Employment/Education: ( As of October 31, 2012) • 8/35 or 23% of the residents are competitively employed • 1/35 or 3% of the residents are in school • 3/35 or 8% of the residents are in a sheltered workshop • 23/35 or 66% of the clients are enrolled in day activity programs Other: • 28/35 or 80% of the residents chose healthy living opportunities in programs • 0 Contraband (Trigger) items found in the programs over this time period Staff Certifications: • 100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED; Human Rights; Fire Safety • 81% of the staff are MAP certified • Bellingham 75%; Franklin 100%; Marlborough 27%; Medway 100%; Milford 89%; Northborough 89%; and Wrentham 100%

CPR ACTION PLAN • See Handout

Comprehensive Program Review December 21, 2012