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Community Strategies: Mandy Adao’s Cluster Carver, Kingston, Middleboro and Paxton. Comprehensive Program Review June 27, 2014. CLUSTER HIGHLIGHTS. Highlights: Seven Promotions: 1 Program Coordinator, 2 Managers, 2 Assistant Managers, and 2 Meaningful Day Coordinators
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Community Strategies:Mandy Adao’s ClusterCarver, Kingston, Middleboro and Paxton Comprehensive Program Review June 27, 2014
CLUSTER HIGHLIGHTS Highlights: • Seven Promotions: 1 Program Coordinator, 2 Managers, 2 Assistant Managers, and 2 Meaningful Day Coordinators • CM from Carver has been awarded her 3rd recognition from the House of Representatives. • We have been able to accomplish more community inclusion activities for each client. Best Practice: • 100% of all residents are participating in Healthy Living with weight loss being shown. The residents have lost a total of 76 lbs which is a great start.
CHALLENGES • Hiring open positions (because of all the internal promotions) • Using less overtime
STAFFING Staff Turnover Rates Staff Retention Rates Overdue Performance Evaluations Staff Training Hours
STAFF TURNOVER RATES • The current CS Cluster average is 28.6% compared to the CSMA average of 26.5% • Last CPR, Cluster average was 25.6% compared to the CSMA average of 25.7% Data obtained from HR Staff Retention & Turnover Report
STAFF RETENTION RATES • 6/30/13 Retention Data for CSMA and Overall-CRJ = N/A (data not available) Data obtained from HR Staff Retention & Turnover Report
STAFF OVERDUE PERFORMANCE EVALUATIONS • Total of 2 FT and 0 PT overdue performance evaluations • Last CPR, a total of 2 FT and 0 PT overdue performance evaluations Data obtained from HR Report
STAFF TRAINING HOURSNovember 2013 – April 2014 • Total of 954.25 training hours were completed (22.8% increase from previous CPR) • Average of 29.9 training hours per staff/over six months • Last CPR: (June 2013) • Total of 777 training hours were completed • Average of 21.4 training hours per staff/over six months Data obtained from MMRs and HR Reports
CLIENT RELATED • Clinical Hours • Elopements • Medication • De-escalation and Restraints • Mainstream/Community Inclusion Activities
CLINICAL HOURSNovember 2013 – April 2014 • A total of 213.3 clinical hours; the Cluster average = 12 clinical hours per client/over six-months or 2 hours per client per month. • Last CPR, a total of 204.5 clinical hours; the Cluster average was 11.4 clinical hours per client/over six-months or 1.9 hours per client per month. Data obtained from MMRs
MEDICATION INCIDENTS & OCCURRENCESNovember 2013 – April 2014 • Total of 3 medication incidents and occurrences. • For both time periods, all medication incidents and occurrences were client refusals. • Last CPR, a total of 3 medication incidents and occurrences. Data obtained from MMRs
COMMUNITY INCLUSION Community Inclusion Activities Participated In and Offered (November 2013 – April 2014) • Average of 34.4 community inclusion activities per client/over six months. • This is a 39.8% increase from the last CPR • Last CPR: • Average of 24.6 community inclusion activities participated in per client/over six months • A total of 449 community inclusion activities offered; a total of 443 community inclusion activities participated in Data obtained from MMRs
MAINSTREAM ACTIVITIES Mainstream Activities Participated In and Offered (November 2013 – April 2014) • Average of 90.6 mainstream activities per client/over six months. • This is a 19% decrease from the last CPR • Last CPR: • Average of 112 mainstream activities participated in per client/over six months • A total of 2,103 mainstream activities offered; a total of 2,018 mainstream activities participated in Data obtained from MMRs
QUALITY ASSURANCE • KEY MMR RESULTS • SQA AUDITS
KEY MMR RESULTS Employment/Education: (As of April 30, 2014) • 1 out of 18 (6%) clients competitively employed • 2 out of 18 (11%) clients are in school • 6 out of 18 (33%) clients are attending a sheltered workshop • 9 out of 18 (50%) clients are in day programs Other: • 18 out of 18 (100%) clients chose to participate in the healthy living options within their program; last CPR = 80% • “0” contraband reported; last CPR = 0 contraband reported Staff Certifications: • 100% certified in PAC/CPI and First Aid/CPR: • 74.4% of staff are MAP Certified; this is a 3% decrease from the last CPR, (77% of staff were MAP certified) • Current CPR: Carver 73%; Kingston = 80%; Middleboro = 57% ; Paxton = 88% • Last CPR: Carver 86%; Kingston = 83%; Middleboro = 83% ; Paxton = 56%
RESULTS OF SQA MONITORING AUDITS November 2013 – April 2014 Positives • Average Scores • Confidential Files = 95% • Financial Records = 99% • Program Forms = 95% • Walk-throughs – All passed • **Strengths of the Cluster • ISP Paperwork (Assessment and Provider Support Strategies) • Fire Drills • Mandatory Medical Appointments Areas In Need of Improvement • Required Roger’s Monitor documentation • Required trainings for Skills Development Management Plans
CPR ACTION PLAN NOT APPLICABLE This is the first CPR for Mandy’s Cluster