Community Strategies: Patrick White’s Cluster Athol, Brookfield, Westborough, Westminster,...
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Transcript of Community Strategies: Patrick White’s Cluster Athol, Brookfield, Westborough, Westminster,...
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