Comprehensive Program ReviewSeptember 21, 2012

SOMERVILLE TRANSITION SHELTER

Laura McSparron became the new Clinical Director at STS in June 2012. Kayla Streussnig joined STS as the new clinician. Kayla had previously worked at STS as the clinical Intern. This afforded a smoother transition within the clinical program at STS.

STS served 80 students between Feb and July teaching a full course of Science, mathematics, history, English language arts, and life skills to students whose grade levels ranged from 6th to 12th grade.

◦ Sports casting – students worked on various aspects of reading, research and writing related to sports and athletes. They created a set and costumes and made a five minute TV show called “DYS sports Etc.”

◦ Students were excited to see a concert with a Jazz Trio as part of their Life skills class. The trio played some music and talked about careers in music and in the ‘regular’ jobs.

According to youth satisfaction surveys, the majority residents feel as though the teachers care about their understanding of the subject matter.

PROGRAM HIGHLIGHTS

Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, RPMs, Youth Satisfaction Surveys

Utilization rates are quite low; average of 40.45% utilization per month (Feb. – July 2012), lower when compared to last CPR, (May-Oct. 2011), when the average was 61%.

As noted in SQA monitoring and DYS monitoring reports, there were a number of facilities issues to be addressed: furniture tagged with graffiti and/or needing to be replaced. STS has addressed the tagged furniture – all furniture re-sanded and repainted;

new furniture has been ordered to replace broken furniture. No tagging evident in last walk through conducted August 22, 2012.

The new furniture arrived on September 7, 2012.

STS making improvements in the UCRs , Advocacy and Supervision notes. Continue to maintain and enhance completion rates of reports.

Weekly Fire Inspection Reports and Monthly Reports have low completion rates.

Other: Internal Investigation on 7/15 based on PREA note: program filed 51A – results were not substantiated. (Last CPR – 3 internal investigations conducted)

AREAS IN NEED OF IMPROVEMENT

Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, RPMs, Youth Satisfaction Surveys

Feb-ruary

March April May June July

0%

10%

20%

30%

40%

50%

60%

37.00% 40.20%37.20%

56.60%

35.00% 36.70%

Utilization Rate by Month: February – July 2012

UTILIZATION

Total Capacity = 16 residents Average Utilization Rate (February – July 2012): 40.45%; Average Utilization Rate at last CPR, (May-October 2011): 61%At the end of August 31, 2012, STS had a total of 6 clients.

STAFF TURNOVER RATE

STAFFINGOVERDUE PERFORMANCE

EVALUATIONS

FEB 8 FT 1 PT

MAR 2 FT 0 PT

APRIL 4 FT 0 PT

MAY 3 FT 0 PT

JUNE 4 FT 0 PT

JULY 3 FT 0 PT

Average: 4 Overdue Performance Evaluations; Last CPR, average was 6 (May-October 2011)

STSSJS

CRJ (Corp./CJI) Overall

Yearly Average

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

17.10%

35.70%

15.40%

25.60%

(8/1/2011 – 7/31/2012)

Data obtained from HR Department & HR Personnel Summary

PROGRAM TRAINING HOURS

Data obtained from MMRs, OMs and HR Training Report

Total Training Hours via MMR from Feb.– July 2012 = 302 hours Total Essential Learning Training (on-line) hours = 4.75 hours Average Total Training Hours Per Staff Per Month = 1.75 hours

Feb-ruary March

AprilMay

JuneJuly

0

50

100

150

200

5.60.53

00.34 3.79

0.24

0 00

0 2.252.5

168

160 10

104

4

Average Per Staff/Month E Training Hours/Month Total Training via MMR

Total of 5medication incidents or occurrences from February – July 2012

The medication incidents/occurrences consisted of 3 refusals; 1missed dose; and 1client cheeking meds.

Last CPR, there was a total of 13 medication incidents or occurrences from May – October 2011

MEDICATION INCIDENTS & OCCURRENCES

Data obtained from MMRs and Residential Program Monthly Reports

February

March

April

May

June

July

0

0.5

1

1.5

2

2.5

3

3.5

4

00

0

0

4

1

Medication Incidents and Occurrences

Last CPR (May - October 2011) MAY 10:0 JUNE 22:0 JULY 16:3 AUGUST 7:0 SEPTEMBER 3:0 OCTOBER 11:0

Average was 23:1 For 6 Months

DE-ESCALATIONS & RESTRAINTS

DE-ESCALATIONS: RESTRAINTS(Feb – July 2012)

FEBRUARY 1:0 MARCH 5.5:1 APRIL 11:0 MAY 20:1 JUNE 2:1 JULY 2:1

Average = 8:1 For 6 Months

00.20.40.60.8

11.21.41.61.8

2

0

2

0

1 1

2

Restraints

Total of 6 restraints from Feb – July 2012. Last CPR, total of 3 restraints from May – Oct. 2011

Data obtained from MMRs and OMs

February March April May June July0

10

20

30

40

50

60

1316

2924

60

30

4 3 3 3 30 0.4

0.380000000000001 0.3

0.330000000000001

0.330000000000001

Offered Participated In Average Per Client/Month

Data obtained from OM and MMRs

RECREATIONAL ACTIVITIES

A total of 145 recreational activities were offered from Feb – July 2012 An average of .3 recreational activities per client/month (Feb. – July 2012) Last CPR, total of 8 recreational activities from May –Oct. 2011. Average of .2 recreational activities per client/month.

February March April May June July0

20

40

60

80

100

120

16 18

81

104

57

44

4 40

4 4 4

12 14

81

100

53

40

1.6 1.8

10.1 10.46.3 4.9

Total Hours Life Skills Cognitive Behavioral Average Per Client/Month

CLINICAL HOURS Average of 5.65

clinical hours per client/month

Average of .35 life skills hours per client/month

Average of 5.35 cognitive behavioral hours per client/month.

Total Clinical Hours = 320 (February – July 2012)

Last CPR, (May – Oct. 2011), average of 5.5 clinical hours per client/month; average of 0.4 life skills and 4.2 cognitive behavioral hours per client/month.

Data obtained from MMRs and OMs

UCRs: Average of 99% complete Feb. – July 2012.

Last CPR: Average of 62% complete (May – Nov. 2011)

SEARCHES AND INSPECTIONS

100% of Unit Room Searches were conducted Feb – July.

Last CPR: Average of 100% of Unit Room Searches were conducted ( May-Nov. 2011) 100% of Kitchen

Inspections were completed (Feb – July 2011)

Last CPR, average of 99% of kitchen inspections were completed

An average of 20% of Weekly Fire Safety Inspections were completed Feb.–June 2012 (July data not reviewed) Last CPR: Average of 25%

of weekly Fire Safety Inspections were completed (May- Oct. 2011)

Data obtained from Outcome Measures and SQA Managers Log Reviews

ADVOCACY & CASE FILE REVIEWS

Feb March April May June July80%

82%

84%

86%

88%

90%

92%

94%

96%

86%

95%

92%

95% 95%

93%

Clients receiving appropriate levels of advocacy each month

An average of 93% clients received appropriate levels of advocacy .

Last CPR, an average of 94% clients received appropriate levels of advocacy ( May-Nov. 2011)

Client Progress Reports

An average of 63% of Progress Reports were completed.

Last CPR, an average of 49% of the Progress reports were completed (May – Nov. 2011)

Data obtained from Outcome Measures and SQA Managers Log Reviews

Cognitive-behavioral and individual clinical support hours have remained steady at 40 hours per month Feb – July 2012; consistent with last CPR

Youth Satisfaction Survey results showed residents at STS felt safe at STS: 100% indicated that they “always” felt safe.

The past 6 months showed a significant decrease in the number of medication incidents/occurrences. There were 5 medication incidents in the last six months, compared to last STS CPR which had 13.

100% of all STS reports were submitted on time in the past 6 months (Outcome Measures, Residential Program Monthly, MMR)

Client incidents involving contraband was “0” this reporting period.

KEY MMR RESULTS

Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, RPMs, Youth Satisfaction Surveys

RESULTS OF MONITORING VISITS (SQA & DYS)

Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, RPMs, STS Data, Youth Satisfaction Survey Results

POSITIVES

The most recent SQA walkthrough found great improvement - graffiti and peeling paint in the resident’s bedrooms – had been fixed. The resident bathrooms, common rooms and laundry room were all clean.

There were no incidents involving contraband Feb – July 2012; Last CPR no incidents of contrabands.

Room searches were completed daily February – July

Unit Condition Reports have significantly improved, with a 99% completion rate.

STS is actively working toward improving the areas in which they are non-compliant.

AREAS IN NEED OF IMPROVEMENT:

Staff Supervision notes are improving; however, they are all not up to date at the time of monitoring visits. During reviews of the logs, some supervisors are better than others in completing the notes. The last SQA monitoring visit – the average staff supervision rate was 77%.

DYS conducted a monitoring visit in March. Unfortunately, some issues included graffiti and broken furniture in the resident’s bedrooms and non-compliance with staff supervision, UCRs, and Advocacy.

As previously noted, the issues with graffiti and broken furniture has been addressed. STS is working on improving the UCR, Advocacy and staff supervision.

Continue to work on consistency between reports. STS has made significant progress. At the last CPR, data found in the Outcome Measures, Monthly Management Reports, and Residential Program Monthly had inconsistencies.

RESULTS OF MONITORING VISITS (SQA & DYS)

Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, RPMs, STS Data, Youth Satisfaction Survey Results

June 2012YOUTH SATISFACTION SURVEYS

5 5

4 4 4 4 4 4

5

1 1

2

1 1

2

1 1 11 1 1 1 1 1

About Staff

Never Sometimes Most Times Always No Answer/Not Applicable

January 2012

YOUTH SATISFACTION SURVEYS

I like the food in the program

I feel safe in the program.

Everything is working properly (showers, toilets, etc.) in the unit.

I am given cloth-ing, shoes,

sheets, towels and toiletries

when I needed them.

I receive medical care when I need

it while in the program.

I am able to take my medication when I am sup-posed to while I was in the pro-

gram.

I have had personal prop-

erty stolen.

I have been physically as-

saulted or threatened with

violence.

1 1 1 1 1 1

2

3

4 4

1 1 1 1 1 11 1

4 4 4 4

2 2

1

Program Experience

Never Sometimes Most Times Always No Answer/Not Applicable

See Handout

CPR ACTION PLAN