1. Comprehensive Program Review August 17, 2012 Athol, Brookfield, Paxton, Westboro, Windsor

2.  Unified team (staff) within programs that are distant from each other ◦ Flexible in schedule to meet program needs and individual needs during staff shortages and incidents  Windsor staff found bikes for individuals to help increase activity and promote healthy living, with no cost to program  All CT women involved in vocational programming and all Brookfield women involved in day programming

3.  Volunteer Opportunities for individuals : o Sherry House (clothing drive) ◦ Walk for Hunger (walked) o Habitat for Humanity (clean/stock) ◦ KOC (cleaning) o Local animal shelter (walked dogs)◦ Self-advocacy fund raiser o Local nursing home (serving food and companion) o Wrote letters to Soldiers and Malia (terminally ill child)  Community Involvement for individuals - INCREASED ◦ Brookfield Bowling League – ALL 5 women ◦ Horseback Riding lessons and horse show ◦ Paxton family cookout ◦ Local gyms; churches memberships ◦ Art and Music classes; guitar lessons ; dance classes and recitals ◦ art shows; museums; knitting classes (at local community center) ◦ Small mechanics class (rebuilding go-carts); and enrolled in fall college automotive courses

4.  Far distance away from Shirley and Boston and other CS programs ◦ Staff coverage is difficult due to this ◦ Lack of interaction with others  CT staff are not required to complete a full Medication training as compared to MA staff ◦ Increase in medication occurrences and incidents  Client medication refusals  Staff turn over  Funds needed for meaningful day supplies  Integration of new intakes with peers and program ◦ Time consuming for staff and program ◦ Limits staff involvement with other individuals, can lead to increased behaviors ◦ Difficulties trying to find common interests

5. OVERDUE PERFORMANCE EVALUATIONS Data obtained from HR Department & HR Personnel Summary Average: 3.3 Overdue FT Performance Evaluations January – June 2012 ** Westboro – data from May & June only. As of June 30, 2012, only 1 PT evaluation was overdue for the cluster. Last CPR, average: 2.2 for overdue performance evaluations – included only Brookfield, Westboro, and Windsor. Brookfield, Westboro, and Windsor average is 2.7 compared to the 2.2 last CPR.

6. STAFF TURNOVER RATE (7/1/2011 – 6/30/2012) Data obtained from HR Department & HR Personnel Summary

7.  Average: 1.12 medication incidents and occurrences per client/month  Total of 142 medication incidents and occurrences (January – June 2012  Last CPR, average of 2.4 medication incidents/occurrences per client/month. Last CPR included Brookfield, Westboro and Windsor, only  Data obtained from MMRs

8.  Average of 2.42 clinical hours per client/month  Total Clinical Hours = 305 (January – June 2012)  Last CPR, average clinical hours per client per month was 1.5 Last CPR included Brookfield, Westboro and Windsor, only Data obtained from MMRs Clinical hours include in-house individual service hours and in-house clinical group service hours.

9. Average of 6.5 community inclusion activities were participated in per client/month, compared to 2.77 at the last CPR. (Last CPR included Brookfield, Westboro and Windsor, only). Total of 891 community inclusion activities were participated in by all clients. Average of 8.67 community inclusion activities were offered per client/month. Total of 1093 community inclusion activities were offered Jan – June 2012. Average Community Inclusion Activities Participated In and Offered Per Client/ Month (January - June 2012) Data obtained from MMRs

10. Average of 15.75 mainstream community activities participated in per client/month, compared to 3.46 at the last CPR (April –Sept. 2011). (Last CPR included Brookfield, Westboro and Windsor, only). Total of 1985 mainstream activities were participated in by all clients. Average of 19.53 mainstream activities were offered per client/month; Total of 2462 mainstream activities were offered in Jan – June 2012. Average Mainstream Activities Participated In and Offered Per Client/Month (January - June 2012) Data obtained from MMRs

11. De-Escalations : Restraints January – June 2012 Athol5.62:1 Brookfield10:1 Paxton22:1 Westboro124:1 Windsor6.76:1 Average - Cluster33.7:1 Total De- Escalations/Restraints for This Period 1079/101 Elopements January – June 2012 Athol8 Brookfield0 Paxton0 Westboro3 Windsor2 Cluster Total13 Previous CPR (April – Sept.2011), Average Cluster Ratio = 16.6:1 Brookfield 13.3:1 Westboro 13:1 Windsor 23.6:1 4 Elopements reported

12. Data obtained from MMRs Average 19.3 training hours per staff Total 955 training hours were completed January – June 2012 Last CPR, total training hours = 1,068. (Last CPR included Brookfield, Westboro and Windsor, only).

13. CONFIDENTIAL FILES AVERAGE = 74% Positives  ISP Documents were completed 100% in 4 out of the 5 programs  Satisfaction Surveys completed 100% (2011) Areas to Improve  LOM/Restraint forms and the Behavioral data do not match in 4 out of the 5 programs  Mandatory medical appointments ◦ Annual Physical examination 80% ◦ Dental exam 80% ◦ Vision Exams 80%  Acquiring mandatory signatures on the proper forms

14. FINANCIAL RECORDS AVERAGE = 87% Positives  All Resident Funds records matched the amount of cash on hand (100%)  All bank books were balanced (100%) Areas to Improve  Budgeting Sessions 20% being completed correctly  Accuracy of the Funds Management Teaching plans PROGRAM FORMS AVERAGE = 80% Positives  Fire drills completed (100%) and documented properly (91%)  Up to date Safety plans with proper signatures (100%) Up to date trainings (80%) Areas to Improve  Up to date Carbon Monoxide training (40%)  House meetings with proper documentation (40%)

15.  Total of 22 clients in Randi’s Cluster  Employment/Education: (as of June 30, 2012) ◦ 3 clients are employed ◦ 4 enrolled in full-time education ◦ 10 enrolled in sheltered workshops ◦ 5 enrolled in pre-vocational or job training  Other: ◦ Client incidents involving contraband was “0” this reporting period. Last CPR, no contraband (“trigger items”) found in the programs.