COMMUNITY STRATEGIES OYEYEMI PAYNE LEOMINSTER PLEASANT MILFORD NORTHBORO

COMMUNITY STRATEGIES: OYEYEMI PAYNE LEOMINSTER PLEASANT – MILFORD – NORTHBORO – WINCHENDON ALGER ST. MARCH 16, 2012 COMPREHENSIVE PROGRAM REVIEW

PROGRAM HIGHLIGHTS & AREAS IN NEED OF IMPROVEMENT � � � 2 individuals in Northboro started volunteering at a church in Woonsocket, RI with Milford guys, 2 individuals in Northboro joined a bowling league and individuals at Winchendon Alger volunteer weekly at Monadnock Human Society and Church. An individual in Milford was taken off probation and lifetime parole. Individual in Milford recently obtained employment at Waverly Redemption Center and an individual in Leominster Pleasant has been employed at Mc. Donalds for two years and continues to get good reviews. Residents in Leominster Pleasant visited the Boston aquarium in January. Winchendon Alger won program of the quarter in January! Winchendon Alger was one of the programs identified to have the best meaningful day activities in CS. Verbal commendation from service coordinator regarding ISP assessments and timely submission. Awards & Training: Godwin Adansi recently won a CRJ Star Award! Additionally, staff attended the Emerging Leaders Program and are (Formal) Fire Safety Certified. Need to involve individuals in their communities and provide more volunteer opportunities for the individuals served. Completely eliminate overtime by hiring more staff. Increase development of the nutritional and healthy living education and practices, including more exercising programs. Data obtained from CSMA

Staff Turnover Rate Overdue Performance Evaluations August 2011 -January 2012 March 1, 2011 – February 29, 2012 35. 00% 30. 00% 25. 00% 20. 00% 33. 3% CSMA: 25. 5% CRJ: 26% Leominster Pl: 11 FT 13 PT Milford: 2 FT 0 PT Northboro: 1 FT 4 PT Wnchdn Alger: 3 FT 4 PT 15. 4% 10% 15. 00% 10. 00% 8. 3% 5. 00% 0. 00% Leominster Milford Northboro Wnchdn Pl. Alger Average of 16. 7% Turnover for past year. Last CPR: Average of 18. 7% turnover for year. Total of 38 (17 FT & 21 PT) Overdue Performance Evaluations over 6 months. Last CPR: Programs had total of 12 Overdue Performance Evaluations over 6 months. Data obtained from HR’s Personnel Summary

MEDICATION ADMINISTRATION Medication Incidents and Occurrences: Average per Client (6 months) August 2011 – January 2012 0. 4 0. 35 0. 3 0. 25 0. 2 0. 15 0. 1 0. 05 0 0 0 Leominster Pl. Milford Northboro 0 Wnchndn Alger Total of 3 medication incidents or occurrences over 6 months. Last CPR: Total of 33 medication incidents or occurrences over 6 months. Data obtained from MMRs

CLINICAL HOURS Average Per Client 1. 5 2 1. 8 August 2011 – January 2012 1. 5 1. 9 1. 6 1. 4 1. 2 0. 700000001 1 0. 8 0. 6 0. 4 0. 2 0 Leominster Pl. Milford Northboro Wnchndn Alger Average of 1. 4 clinical hours per client (6 months) Total of 165 Clinical Hours over 6 months Data obtained from MMRs Last CPR: Average of 12. 3 clinical hours per client each month.

COMMUNITY INCLUSION & MAINSTREAM COMMUNITY ACTIVITIES AUGUST 2011 – JANUARY 2012 Community Inclusion Activities Average Per Client (6 months) 24. 8 25 Mainstream Community Activities 17. 6 20 15 10 5 3. 7 3. 4 5. 1 9. 6 4. 2 0. 600000001 0 LEOMINSTER PL. MILFORD NORTHBORO WNCHNDN ALGER Average of 2. 9 community inclusion activities per client (6 months) Average of 14. 2 mainstream community activities per client (6 months) Last CPR: Average of 4. 4 community inclusion activities per client (6 months) Average of 38. 2 mainstream community activities per client (6 months) Data obtained from MMRs

DE-ESCALATIONS: RESTRAINTS ELOPEMENTS August 2011 – January 2012 LEOMINSTER PLEASANT 3. 4: 1 LEOMINSTER PLEASANT 0 MILFORD 70. 5: 1 MILFORD 2 NORTHBORO 467: 0 NORTHBORO 0 WINCHENDON ALGER 27. 9: 1 WINCHENDON ALGER 0 13. 2: 1 For 6 months Last CPR: 10. 4: 1 Data obtained from MMRs Total Elopements: 2 Last CPR: Total of 18

RESULTS OF MONITORING AUDITS CLUSTER POSITIVES Mandatory Medical Appointments: 100% of annual physicals completed. 90% of dental exams completed. 90% of vision exams completed. Mandatory ISP Documents: 91% of Assessments completed. 94% of Provider Support Strategies completed. 84% of Progress Summaries completed. All four programs scored over the 90% ranking in their previous financial audits! Data obtained from SQA Quality Assurance Coordinator for CS CLUSTER AREAS TO IMPROVE UPON Mandatory Signatures 50% of behavioral plans were signed. 67% of Psychotropic Treatment Plans (PTP) were signed 71% of consent forms were signed. 45% of Limitation of Movement (LOM) forms were signed. 50% of clients received budgeting sessions. 44% of DDS dated documentation has been completed.

KEY MMR RESULTS � Ratio of de-escalations: restraints has improved since last CPR (13. 2: 1 vs. 10. 4: 1). � There were no incidents involving contraband August-January (all programs). � � � � Leominster Pleasant, Milford and Northboro all had no medication incidents or occurrences (August-January). Also, the total number of medication incidents/occurrences for the cluster has decreased by 91% (since last CPR)! There were no elopements in Northboro, Winchendon Alger or Leominster Pleasant. Furthermore, Leominster Pleasant went from having 18 elopements last CPR to having 0 August-January! Winchendon Alger had a total of 57 clinical hours over 6 months (the highest number in the cluster). Leominster Pleasant offered a total of 744 mainstream activities (the highest of cluster) and Milford offered a total of 30 mainstream activities (the lowest of cluster). August-January: 20% of Leominster Pleasant clients, 37% of Milford clients, 22% of Northboro clients and 0% of Winchendon Alger clients were competitively employed. Northboro offered a total of 127 community inclusion activities August-Jan (the highest number in cluster) and Winchendon Alger offered a total of 22 community inclusion activities (the lowest of the cluster). There has been an 89% decrease in the average number of clinical hours each client receives per month (12. 3 1. 4). Data obtained from MMRs

STAFF TRAINING HOURS Cluster Monthly Totals 180 Total Hours: 832 160 140 August 2011 -January 2012 123 167 133 September October 151 125 120 100 80 60 40 20 0 August Data obtained from CSMA November December January Monthly Average Per Program: 139