COMPREHENSIVE PROGRAM REVIEWNOVEMBER 18 T H , 2011

SARGENT HOUSE

Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, Sargent House Data

PROGRAM HIGHLIGHTS & KEY MMR RESULTS

- New Director Len Andrews started in August & Clinician, Jacqueline Diaz, began work in July. At the time of this CPR, all residents have been meeting with her routinely.

- For the first time, a Sargent resident will soon be transferring to a CS program!

- The percentage of competitively employed clients rose from 17% in April to 67% in August.

- Sargent is at Capacity with 6 residents and is also fully staffed (0 vacancies).

- Staff is able to de-escalate most situations before utilizing restraint (82:1 ratio of de-escalation: restraint over 6 month period).

- Decrease in medication incidents/occurrences since last CPR. (Nov 2010-April 2011: 15 over 6 months.

April 2011-Sept 2011: 3 over 6 months).AREAS IN NEED OF IMPROVEMENT- 5 out of 6 residents claim they have had personal property stolen while in the program.

- Sargent is unable to enlist the services of a nutritionist to review menus (more funding needed?)

- Only 33% of clients indicated that they “always” or “most times” feel safe in the program. 67% of clients stated that they “never” or only “sometimes” feel safe.

- Staff often fills out or completes logs and reports incorrectly and illegibly. Sargent Staff need to attend a Report Writing Refresher Training.

STAFFING

Data obtained from HR Department & HR Personnel Summary

STAFF TURNOVER RATE(10/1/10 – 9/30/11)

OVERDUE PERFORMACE EVALUATIONS

APRIL 6 FT 0 PT

MAY 7 FT 0 PT

JUNE 3 FT 0 PT

JULY 2 FT 0 PT

AUG. 3 FT 0 PT

SEPT. 4 FT 0 PT

-Sargent is currently fully staffed-

14 Budgeted Positions, 0 vacancies.

Sargent

SJS CRJ22%

23%

24%

25%

26%

27%

28%

25.0%

25.8%

24.1%

Average of 4.2 Overdue Performance Evaluations April-

September

UTILIZATION

Data obtained from Sargent House

April May June July August September0%

20%

40%

60%

80%

100%

120%

100%90%

75% 79%

100% 100%

Utilization Rate By Month April-September

Average Utilization Rate April-September 2011: 91%

Sargent Is Currently At Capacity

MAINSTREAM COMMUNITY ACTIVITIES

Data obtained from MMRs

An average of 12 mainstream community activities were participated in per client

April-September

At the time of the last CPR, there was an average of 13 mainstream community activities per client over a 6 month period.

Average activities per client each month.

April

May

June

July

August

Septe

mbe

r0

2

4

6

8

10

12

14

16

18

0.5

13

1716

1314

CLINICAL HOURS

There was an average of 5 clinical hours* per client each month. * clinical hours include in-house clinical individual service hours and in-house clinical group service hours.

Data obtained from MMRs

April May June July August September

There were 167 clinical hours total 4/11-9/11.

At the time of last CPR, there was an average of 13 clinical hours per client each month. 0

2

4

6

8

10

12

2

0 0

4

11 11Per Client Each Month

MEDICATION INCIDENTS & OCCURENCES

Data obtained from MMRs

There was a total of 3 medication incidents

or occurrences4/11-9/11

Per Client Each Month

At the time of the last CPR, there was a total of 15 medication incidents or occurrences over a 6 month period.

April May June July August September0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.2

0 0 0 0

0.3Chart Title

DE-ESCALATIONS & RESTRAINTS

De-escalation: Restraints APRIL 38.5:1 MAY 71:1 JUNE 40:1 JULY 98:1 AUGUST 82:0 SEPTEMBER 84:0

82:1 For 6 Months

Data obtained from the MMRs

Last CPR (November-April)November: 57:0December: 71:1January 34.5:1February: 74:0March: 82:1April: 38.5:1

71.6:6 For 6 Months

-There was 1 elopement in May.

- At the time of the last CPR, there were 0 elopements over a 6 month period.

April May June July August September0

1

2

3

2

1

2

1

0 0

There was a total of 6 restraints over a 6 month period.

At time of last CPR, there was a total of 6 restraints over a 6 month period.

PROGRAM TRAINING HOURS

Data obtained from Sargent Training Reports

April May June July August Sept.

Training Hours Completed Per Staff Member Per Month

Total Training Hours April-Sept: 190

Total Training Hours

Per Month

APRIL 0MAY 20.5JUNE 42JULY 0AUGUST 3.5SEPTEMBER 124

0

1

2

3

4

5

6

7

8

9

10

0

1.7

3

0 0.3

8.9

RESULTS OF MONITORING VISITS (SQA)

Positives:- Staff are always helpful during visits. All necessary files, logs and information are always readily available.- There has been recent improvement regarding the cleanliness of the main floor (common room, computer

room, etc.) and the kitchen/pantry area.- During a past visit, there was useful nutritional information posted for clients in the kitchen.

- Minus a few exceptions, most client bedrooms have been organized at time of visit.- Staff Compliance with the dress code has improved in recent months.

Needs Improvement:- Ongoing Issues: Not enough detail or description provided in most logs - This includes Unit Condition

Reports, Shift Summaries & Client Daily Data Sheets. At times, logs/reports include contradictory data. Furthermore, the handwriting is often illegible. Staff at Sargent are in need of a Report Writing refresher

training.- Cleanliness of client bathrooms is often an issue.

- Incidents documented in the Communication Log do not always have corresponding Incident Reports. This was especially a problem in April and May 2011. On the same note, there were some instances in which not all staff member involved in the incident submitted their own report, or multiple staff members completed one

report together.

Data obtained from SQA Monitoring Visits

YOUTH SATISFACTION SURVEYS

Results taken from survey conducted in November 2011Data obtained from Youth Satisfaction Surveys

Some-what

Prepared83%

Very Prepared

17%

How prepared are you to move to your next placement or to go

home?

The Best Thing About This Program So Far Is:

- “The Support.” - “I am doing better than when I first

came here.” - “ I like the privileges and all the

staff and almost all the clients!”

Some Things I Would Change About This

Program Are:- “The rules.”

- “The way people treat each other.” - “Clients threatening, stealing,

instigating each other and to do what their (sic) told when they know

better and for me to actually learn how to cook.”

Other- “I like the staff.”

YOUTH SATISFACTION SURVEYS

Data obtained from Youth Satisfaction Surveys

Results taken from survey conducted November 2011

0

1

2

3

4

5

6 Clinical Services Never

Sometimes

Most Times

Always

No Answer/Not Appli-cable

I am treated with re-

spect by staff.

Staff are friendly

and easy to talk to.

Staff lis-tens to

everyone in the

program.

Staff are very clear

about what the program rules are and what

is ex-pected of

me.

Staff are able to

calm me down

when my emotions get a little

out of control.

Staff are good role models.

Staff use respectful language (i.e., they

never swear or

yell).

Staff use restraints appropri-

ately (i.e., only when

neces-sary).

The way staff

treats me encour-ages me

to im-prove my behavior.

0123456 About the Staff Never

Sometimes

Most Times

Always

No Answer/Not Appli-cable