BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR

Transcription

1 S T A T E O F F L O R I D A D E P A R T M E N T O F J U V E N I L E J U S T I C E BUREAU OF QUALITY IMPROVEMENT PROGRAM REPORT FOR Outward Bound-Scottsmoor Outward Bound, Inc. (Contract Provider) 3500 Sunset Avenue Scottsmoor, Florida Review Date(s): February 5-7, 2014 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES W A N S L E Y W A L T E R S, S E C R E T A R Y J E N N I F E R R E C H I C H I, B U R E A U C H I E F

2 Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; or limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or systemic exceptions with corrective action already applied and demonstrated. Systemic exceptions to the requirements of the indicator; exceptions to the requirements of the indicator that result in the interruption of service delivery; and/or typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team The Bureau of Quality Improvement wishes to thank the following review team members for their participation in this review, and for promoting continuous improvement and accountability in juvenile justice programs and services in Florida: Donna Connors, Lead Reviewer, DJJ Bureau of Quality Improvement Latrice Covington, Contract Manager, DJJ Office of Prevention and Victim Services Kevin George, Executive Director, Paxen Learning Corporation Kristen Richardson, Review Specialist, DJJ Bureau of Quality Improvement

3 Program Name: Outward Bound, Scottsmoor QI Program Code: 1283 Provider Name: Outward Bound, Inc. Contract Number: X1452 Location: Brevard County / Circuit 18 Number of Beds: 11 Review Date(s): February 5-7, 2014 Lead Reviewer Code: 97 Methodology This review was conducted in accordance with FDJJ-1720 (Quality Improvement Policy and Procedures), and focused on the areas of (1) Management Accountability, (2) Assessment Services, (3) Intervention Services, and (4) Services, which are included in the Outward Bound Standards (March 2013). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff # Maintenance Personnel # Program Supervisors 9 # Other (listed by title): 2 course directors, lead instructor, Documents Reviewed assistant instructor, 2 interns, director of at-risk programming, logistics coordinator, intake coordinator Accreditation Reports Affidavit of Good Moral Character CCC Reports Confinement Reports Continuity of Operation Plan Contract Monitoring Reports Contract Scope of Services Egress Plans Escape Notification/Logs Exposure Control Plan Fire Drill Log Fire Inspection Report Fire Prevention Plan Grievance Process/Records Key Control Log Logbooks Medical and Mental Health Alerts PAR Reports Precautionary Observation Logs Program Schedules Sick Call Logs Supplemental Contracts Table of Organization Telephone Logs Surveys Vehicle Inspection Reports Visitation Logs Youth Handbook 3 # Health Records # MH/SA Records 13 # Personnel Records 3 # Training Records/CORE 3 # Youth Records (Closed) 3 # Youth Records (Open) # Other: 3 # Youth 3 # Direct Care Staff # Other: Observations During Review Admissions Confinement Facility and Grounds First Aid Kit(s) Group Meals Medical Clinic Medication Administration Posting of Abuse Hotline Program Activities Recreation Searches Security Video Tapes Sick Call Social Skill Modeling by Staff Staff Interactions with Youth Comments Staff Supervision of Youth Tool Inventory and Storage Toxic Item Inventory and Storage Transition/Exit Conferences Treatment Team Meetings Use of Mechanical Restraints Youth Movement and Counts Items not marked were either not applicable or not available for review. Office of Program Accountability Page 3 of 25 (Revised August 2013)

4 Standard 1: Management Accountability Outward Bound Rating Profile Indicator Ratings Standard 1 - Management Accountability 1.01 * Initial Background Screening 1.02 Five-Year Rescreening 1.03 Pre-Service Training 1.04 In-Service Training 1.05 Episodic/Emergency Services Limited 1.06 Medication Management - Medication Storage Limited 1.07 Cleanliness and Sanitation 1.08 Administration 1.09 Incident Reporting (CCC)* * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Episodic/Emergency Services 1.06 Medication Management - Medication Storage Office of Program Accountability Page 4 of 25 (Revised August 2013)

5 Standard 2: Assessment Services Outward Bound Rating Profile Indicator Ratings 2.01 Standard 2 - Assessment Services Referral and Intake Process 2.02 Intake Conference and Orientation 2.03 Medication Management Verification of Medications 2.04 * Mental Health/Substance Abuse Screening 2.05 Outward Bound School/F.I.N.S Program Needs Assessment or (PACT) Full Assessment 2.06 Individualized Performance Plan 2.07 * Abuse Reporting (DCF) * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 5 of 25 (Revised August 2013)

6 Standard 3: Intervention Services Outward Bound Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Individualized Performance Plan (IPP) Process 3.02 Individual Performance Plan reviews and revisions 3.03 Individual Performance Plan Summary 3.04 Non-violent Crisis Intervention and Reporting 3.05 Behavior Management 3.06 Separations/Isolations 3.07 Transition Plan/Contract 3.08 Follow-up * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). Office of Program Accountability Page 6 of 25 (Revised August 2013)

7 Standard 4: Services Outward Bound Rating Profile Indicator Ratings Standard 4 - Services 4.01 Disaster Preparedness 4.02 Fire Prevention and Evacuation Procedures Limited 4.03 Water Activities 4.04 Boating Activities 4.05 Food Services 4.06 Transportation 4.07 Life Management Skills 4.08 Supervisory Reviews Limited * The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below Department standards. A program must therefore achieve at least a Compliance rating in each of these indicators. Failure to do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation). The following limited and/or failed indicators require immediate corrective action Fire Prevention and Evacuation Procedures 4.08 Supervisory Reviews Office of Program Accountability Page 7 of 25 (Revised August 2013)

8 Strengths and Innovative Approaches The program takes three fully stocked first aid kits on each expedition. There are four separate bags, each a different color. The items in the bags are also color-coded based on the type of treatment: the red bag contains emergency items, the yellow bag contains over-the-counter medications, the blue bag contains routine items and the orange bag contains trauma items. In addition, the program maintains two epipen bags, which contain an emergency dosage. Each December, the program conducts instructor-led in-service training, which all staff are required to attend. The training topics include: back to basics, how to complete incident reports, updates to the program s driving training, feedback and a year-end debriefing. Prior to the beginning of an expedition, the program holds a meeting with the course instructors to provide information on each youth about to start the expedition; the meeting is called Kid Brief. The program s intake specialist reviews the files for all youth registered for the expedition with the course instructors and the course director. The course instructors are encouraged to begin developing individual goals for each youth, which are finalized during each youth s orientation on the first day of the expedition. Office of Program Accountability Page 8 of 25 (Revised August 2013)

9 Standard 1: Management Accountability Overview The Department of Juvenile Justice contracts with Outward Bound, Inc. to provide a twenty-day wilderness expedition program for youth. The base camp office is located in Scottsmoor, Florida. During the course expedition, youth participate in a variety of activities, including canoeing, hiking, and camping; youth learn leadership skills, teamwork, how to set up and tear down the campsites, and how to prepare meals. The program primarily accepts youth from Flagler, Seminole, Orange, Brevard, and Volusia counties. The program staff consists of lead instructors, assistant instructors, and interns, as well as a program director, logistics coordinator, intake coordinator and secretary. There are separate course expeditions for male and female youth; eight to eleven youth participate on each course expedition. There were six course expeditions conducted between August 2013 and January 2014; fifty-two youth participated in the six expeditions. There are three sites for course expeditions for juveniles, two in Florida and one in Alabama. The course expedition staff rotate among the three sites on a regular basis. The base camp is located in a converted house; there are several offices in the main building, for the program director and other administrative staff, a large conference room, and a kitchen for use by the program staff. There is a former stable and barn that is used as the staging area for the course expeditions and to house the equipment Initial Background Screening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient em-ployees, volunteers, mentors, and interns with access to youth. The background screening process is completed prior to hiring an employee or utilizing the services of a volunteer, mentor, or intern. An Annual Affidavit of Compliance with Level 2 Screening Standards is com-pleted annually. The program has written policies and procedures requiring background screening. The program conducts various screenings on all staff prior to hire, in addition to the screening from the Department of Juvenile Justice Background Screening Unit (BSU). All staff are screened through a multi-state sex offender database, and have local law enforcement checks conducted. There were thirteen new staff hired in the last year; the personnel records of all applicable staff were reviewed. Each record contained documentation that a clearance had been received by the BSU, as well as a local background check and the multi-state sex offender database. The Annual Affidavit of Compliance with Level 2 Screening Standards was completed and sent to the Department's BSU on January 10, 2014, meeting the annual requirement Five-Year Rescreening Compliance Background screening is conducted for all Department employees, contracted provider and grant recipient em-ployees, volunteers, mentors, and interns with access to youth. Employees and volunteers are rescreened every five years from the initial date of employment. There were no staff applicable for a five-year rescreen. The program s administrative assistant places the names of all program staff on a spreadsheet; the database also includes the date the original screening was conducted through the Department of Juvenile Justice Background Screening Unit (BSU) and the date each five year rescreen is due. The database is reviewed Office of Program Accountability Page 9 of 25 (Revised August 2013)

10 regularly to allow for any required documents to be sent at least ten business days prior to the staff member s five-year anniversary date Pre-Service Training Compliance Contracted non-residential Outward Bound staff are trained in accordance with Outward Bound Program Core Orientation policy within 15 working days of their start date. Contracted non-residential staff that have not completed essential skills training and untrained interns do not have any direct, unsupervised contact with youth. The program has written policies and procedures regarding the provision of pre-service training. In addition to complying with the Department of Juvenile Justice training requirements, program staff are trained in wilderness first aid, and are required to be certified in water safety and be able to pass a swim test. Per the program s contract, one instructor on each expedition is required to be trained on the use of an EpiPen. The training files of two new staff were reviewed for the receipt of pre-service training; the files documented between 204 and 315 hours of preservice training. Both training files documented receipt of the required certifications in cardiopulmonary resuscitation (CPR), wilderness first aid and non-violent physical crisis intervention (NPCI). The files documented receipt of training on the EpiPen, in professionalism and ethics, and suicide prevention In-Service Training Compliance Contracted non-residential Outward Bound staff must complete twenty-four hours of annual inservice training, beginning the calendar year after the staff has completed pre-service training. Supervisory staff shall complete eight hours of training in the areas listed below, as part of the twenty-four hours of annual in-service training. The training file of one staff was reviewed for the receipt of in-service training requirements; the applicable staff was a supervisor. The training file documented 150 hours of in-service training in The applicable staff had current certification in cardiopulmonary resuscitation (CPR), wilderness first aid and non-violent physical crisis intervention (NPCI), and training in professionalism and ethics, and suicide prevention. The training file documented eight hours of specific supervisory training; all required topics were covered. The program maintains an annual training plan as required Episodic/Emergency Services Limited Compliance The program shall have a comprehensive process for the provision of Episodic Care, First Aid, and Emergency Care. The program shall be capable of facilitating an appropriate response to an emergency situation. The program has written policies and procedures regarding the provision of episodic and emergency services to applicable youth. The program has an agreement with a medical doctor who voluntarily provides on-call medical services to the youth; during course expeditions, the instructors are permitted to contact the doctor to discuss medical issues. The doctor will provide instructions, and prescriptions when necessary for applicable youth. The files of three youth requiring episodic or emergency medical services were reviewed. The documentation included the date and time the episodic care was provided, the nature of the complaint, the findings of the person rendering care, and the treatment provided. Two of the Office of Program Accountability Page 10 of 25 (Revised August 2013)

11 three youth were entered on the episodic log as required. The parents/guardians of all three applicable youth were notified via telephone. An alert log is developed for each youth on an expedition, prior to the start of the course; the list includes any medications the youth is taking, and an allergies. The program does not revise the alert list while the youth are on the course expedition, regardless of whether there is a change in the youth s health status. One youth was prescribed antibiotic ear drops by the doctor providing on-call services; upon receipt of the ear drops, the youth reported that the pain had abated, and he did not want to have the ear drops administered. Several days later, the applicable youth complained again of ear pain and the drops were administered. One youth complained of leg pain from a car accident two months prior to the course expedition. The youth was taken to a walk-in clinic, and prescribed pain medication. A doctor s report form was completed; the form documented that the youth was to have no physical activity until seen by an orthopedic surgeon. All documentation resulting from the doctor s visit stated that the youth was cleared to return to the course expedition; there was no alert placing the youth on restricted activity. All three applicable youth were placed on the episodic care log; the applicable youth was not placed on the log for receiving emergency care by the doctor. There are first aid kits with many types of over-the-counter (OTC) medications that are taken on the course expeditions. Prior to the start of a course expedition, the course instructors review the contents to ensure all required items are in the kits. There is one bag with suicide prevention items, such as wire cutters and trauma scissors. The training files of three staff confirm the receipt of training in emergency procedures and response plan. There was no documentation of the program conducting emergency drills or of cardiopulmonary resuscitation (CPR) being demonstrated at least quarterly. During the Quality Improvement review, interviews were conducted with three staff; all reported being permitted to call when a youth is identified with a medical emergency. The staff also reported being informed of youth s medical alerts via the information from the intake interview Medication Management Medication Storage Limited Compliance All medications (prescriptions, over-the-counter, topical, etc.) shall be stored in separate, secure (locked) are-as that are inaccessible to youth and ensures proper inventory control. The program has written policies and procedures regarding the storage of medications. The program has first aid kits containing various types of over-the-counter (OTC) medications that are taken on course expeditions. The items are separated into four canvas bags, and all four canvas bags are placed in one large water-proof bag. One bag contains gauze pads, band aids, adhesive tape and bandages, one bag contains liquid soap, zinc oxide, and ointments, one bag contains calamine lotion, eye drops, ear wash and anti-fungal cream and the fourth bag contains incident forms, pencils, surgical gloves, a first aid book, a thermometer and biohazard disposal bags. In addition, there are two smaller kits in which limited quantities of commonly used OTCs such as ibuprofen, decongestant, poison ivy cleaner, and antacids are placed. If youth require prescription medications, medications are placed in boxes made of heavy plastic, with two locks. During the Quality Improvement review, five OTCs were spot checked against the inventory; one item was correct on the inventory, with the remaining four items being incorrect. In addition, when reviewing the contents of the smaller first aid kits, there were approximately forty ibuprofen tablets and twenty Benadryl tablets that had not been accounted for on any inventory. The program completes inventories of the OTC closet roughly every two weeks; the program s policy required a weekly inventory. Office of Program Accountability Page 11 of 25 (Revised August 2013)

12 1.07 Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment in a wilderness setting that includes maintenance and sanitation of the campsites. The program has written policies and procedures regarding cleanliness and sanitation requirements. The program s base camp is located in a building that was formerly a house. There are offices for the administrative staff, a conference room, and a kitchen. There is a stable that is used as a staging area for the expeditions. The buildings were well maintained; there was no graffiti noted. The program s policy requires that the campsites are inspected for safety and sanitation; several course logs were reviewed. It was noted that the course logs for course expeditions conducted prior to October 2013 did not document this practice; the course logs for expeditions conducted after October 2013 did document that the campsites had been inspected. The staff carry a repair kit on the course expeditions to complete minor repairs of equipment. There was documentation to support that staff reported to the base camp that certain equipment was damaged; the damaged equipment was quickly replaced Administration Compliance The Outward Bound program provides a safe and appropriate treatment environment that includes administrative and operational oversight. The program has written policies and procedures regarding administrative and oversight requirements. The program director maintains statistical data for each course expedition, such as admissions, releases, absconds, abuse reports, medical/mental health emergencies, incidents, personnel actions, and the average length of stay. This information is placed on a report that is provided to the Department of Juvenile Justice on a monthly basis. The program maintains a course log for each course expedition, which is updated daily. During the Quality Improvement review, several course logs were reviewed. The daily entries consistently included the date, course day, phase of the expedition, campsite, number of youth accounted for in the morning and in the evening, boat partners and tent partners and a description of any significant incidents. It was noted that the entries did not include the name of the person making the entries; during the QI review, the program revised the course log to include a line for the person making the daily entry Incident Reporting (CCC) Compliance Whenever a reportable incident occurs, the program notifies the Department s Central Communications Center (CCC) within two hours of the incident, or within two hours of becoming aware of the incident. A review of Central Communications Center (CCC) reports for the past six months revealed the program had two incidents for this reporting period. One report was for a medical incident while the other was classified as miscellaneous. Both reports were called in to the CCC within the required time frame. A review of the program s internal incident reports did not determine any additional calls needed to be made to the CCC. Office of Program Accountability Page 12 of 25 (Revised August 2013)

13 Standard 2: Assessment Services Overview The program accepts male and female students, ages thirteen to seventeen, who are in good health and not in need of any specialized overlay services. The program accepts referrals for students from school counselors, social service agencies, case managers, parents, and youth themselves. All student applications are pre-screened based on program-specific admission criteria, to include, open or pending charges, history of violent behavior, medical and/or mental health concerns, and if the youth voluntarily wants to complete the program. Upon acceptance to the program, a face-to-face interview is conducted with each youth s parent/guardian, and additional admission information is obtained. On the first day of each new course expedition, an orientation is conducted with the youth and their parents/guardians to discuss program policies and expectations for the youth, parent/guardian, as well as program staff Referral and Intake Process Compliance Upon receipt of a student s referral packet, the pro-gram shall perform an initial screening to determine whether or not the student is eligible for program services. The program has written policies and procedures for the provision of a referral and intake process. The program accepts referrals from the Department of Juvenile Justice, school counselors, social service agencies, case managers, parents/guardians, as well as youth themselves. A formal application must be completed and submitted to the program to determine eligibility; eligibility requirements include: male or female students, between the ages of thirteen and seventeen. The youth must be in good physical and mental health condition, and not in need of any specialized overlay services. Following the submission of an application, each youth is pre-screened based on program-specific criteria as outlined by the program s contract. The admission criteria includes the following: each student s open or pending charges, history of violent behavior, medical and/or mental health concerns, and whether the youth voluntarily wishes to successfully complete the program. Upon verification of student eligibility, the program must confirm with the referring party that their application was received, and the youth s parent/guardian is contacted to schedule a face-to-face interview. As part of the interview process the parent/guardian is informed of their responsibilities, both the youth and parent/guardian receive an overview of program expectations, and a clothing list is provided. Three closed youth files were reviewed; each contained a completed application, and there was documentation to support the referring party was notified of the receipt. Each file reflected that the parent/guardian, as well as the youth, participated in a face-to-face interview with program staff, prior to acceptance, and all contacts with the families were clearly documented in case notes Intake Conference and Orientation Compliance The Outward Bound program shall perform a face-to-face interview with both the student and parent(s)/guardian(s) and, at a minimum, review the following: Video, if applicable Parent commitments and responsibilities Office of Program Accountability Page 13 of 25 (Revised August 2013)

14 Successful completion criteria as defined in policy Overview of program expectations and wilderness expedition realities Clothing list Consent to release information Student rights Upon verification of student eligibility the program staff must ensure that a face-to-face interview is conducted with each youth and their parent/guardian. During this interview, each youth must complete an Outward Bound needs assessment. Should a youth be in need of further assessment, the program completes a counseling questionnaire, to be completed by a mental health counselor. Prior to each youth s first day of an expedition, the program must have received a completed individual student record to include, a completed application, physician medical record, acknowledgement of personal responsibility, approved correspondence list, photo, parent/guardian approval form, immunization record, release of records form, school information, significant information regarding the student and their family, needs assessment, and any medical/mental health information. Prior to a new expedition beginning, the program holds a meeting with the instructors to provide insight and information on all youth about to start the program. During the Quality Improvement review, this process, known as Kid Brief, was observed. The intake specialist was prepared to review all ten youth records with the four course instructors, as well as the course director. A brief overview of each youth was given and the staff were encouraged to start thinking about individual goals for each of the youth, to be finalized during each youth s orientation on their first day of the expedition. Three closed youth files were reviewed; all three contained documentation to support each youth received an orientation to the program on the first day of the course. The program s policy states that both the staff and student are required to initial and date each individual check box on the orientation form; one of the reviewed files supported this practice. The remaining two files contained an orientation form, however both the staff and student initialed and dated the first box, and drew an arrow to the last box, which is not permitted per the program s policy. All three files contained all of the required forms, to include, successful completion criteria, overview of program expectations, consent to release information, student rights, needs assessment, and a mental health and substance abuse screening form Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. The program has written policies and procedures as it relates to the verification of medications. Each youth is screened for medical issues utilizing the Department s Facility Entry Physical Health Screening (FEPHS) form. As part of the screening process, each youth and their parent/guardian is interviewed regarding the youth s current medical conditions and any medication the youth may be prescribed. The parents/guardians are informed by program staff that only prescribed medications from a licensed pharmacy, with a current patient-specific label will be accepted in the program. During the Quality Improvement review, student orientation was observed. There were a few youth who were currently prescribed medication. The staff member was observed verifying the medication as required, and initiating a medication distribution log. Following the verification Office of Program Accountability Page 14 of 25 (Revised August 2013)

15 process, the medications were stored in bags that were placed inside a locked dry box. Three closed youth files were reviewed; each included documentation of a medical screening being conducted, however, none of the youth were prescribed medications. Three additional closed files were reviewed for compliance with medication verification. Each file appropriately contained a medical screening form, which indicated each youth was currently taking prescribed medication. Each medication was verified, upon admission, and each file contained medication distribution logs. Upon review of the medication distribution logs, it was noted that one youth missed one dose of a prescribed medication. The applicable youth did not appear to have an adverse reaction as a result of the missed dose. Staff training files were reviewed, which validated staff have been trained in assisting youth in the delivery, supervision, and oversight of youth who perform self-administration of medications Mental Health/Substance Abuse Screening Compliance Youth are screened for mental health/substance abuse issues at the time of admission to determine if the youth has any conditions that require further assessment and/or immediate attention. Screening may be performed by non-licensed staff during the admission process. The screening includes a review of available information and completion of the Residential Intake Mental Health & Substance Abuse Screening Form or MAYSI-2. The program ensures further assessment of the youth, or immediate intervention, as indicated by the mental health/substance abuse screening. (For the entire indicator statement, please reference the Quality Improvement FY Outward Bound indicators.) The program has written policies and procedures as it relates to mental health and substance abuse screening. Prior to admission, each youth is screened for mental health and substance abuse concerns utilizing a program-specific residential intake mental health and substance abuse screening form. Should the form indicate the youth is in need of further assessment, the program is required to have a mental health professional complete a program-specific counseling questionnaire form, for clearance into the program. Three closed youth files were reviewed; all three files contained documentation to support each youth submitted to a mental health and substance abuse screening, prior to admission to the program. Each file contained a residential intake mental health and substance abuse screening form however none were completed in their entirety. The last section of each form was consistently left blank, which is the disposition section of the form. One of the files indicated the youth did not need further assessment, while the remaining two youth did. One file contained a completed counseling questionnaire form, which indicated the youth was clear to complete the program. The remaining file did not contain the counseling questionnaire form. Three staff were interviewed; the staff reported the process to follow in the event a youth expresses suicidal thoughts while on a course expedition Outward Bound School/F.I.N.S Program Needs Assessment or Prevention Positive Achievement Change Tool (P-PACT) Full Compliance Assessment The Outward Bound School/F.I.N.S Program Needs Assessment or the PACT Full Assessment is completed by program staff for all youth, regardless of risk to reoffend, during the face-to-face Intake Interview. Office of Program Accountability Page 15 of 25 (Revised August 2013)

16 The program has written policies and procedures as it relates to a needs assessment. The program utilizes the Outward Bound Needs Assessment tool, which is completed as part of the intake interview. The assessment contains information about the youth and family, and is a summary of information to assist in reviewing and identifying needs, strengths, and limitations of the youth and his/her family. All of the information gathered as part of the needs assessment is used to assist when initiating goals for the individualized performance plan. On the first day of the expedition, during orientation, the program staff, youth, and parent/guardian create three initial goals for education performance, transition/family issues, and social skills. This process was verified during the Quality Improvement review. The program staff informed the Quality Improvement team that the performance plans are a living document, and can be changed or modified during the course of the expedition. Three closed youth files were reviewed; each contained a completed needs assessment, which was administered prior to the expedition beginning. The assessment was signed and dated by the youth, program director, course director, all instructors, as well as the education coordinator Individualized Performance Plan (IPP) Compliance Staff complete an Individualized Performance Plan for each youth within 7 calendar days from the youth s admission. The Plan includes written Performance Plan goals, and action steps documented on corresponding Outreach Performance Goal forms. The program has written policies and procedures for the provision of individualized performance plans. The program s practice is to create each youth s individualized performance plan on the first day of the expedition. The plan is created based on the youth s needs assessment, as well as input from both the youth and his/her parent/guardian. Each plan is to include performance goals and action steps that target the following areas; social skills, education, transition goals, and mental health/substance abuse goals. Three closed youth files were reviewed; each contained a valid needs assessment, which was the basis for the individualized performance plan. There was communication with each youth and their parent/guardian during the intake interviews, as well as during the orientation meeting; there was no clear documentation in the case notes to reflect the youth and their parent/guardian was involved in the development of the individualized performance plan. Each of the three plans included information on the family s strengths and challenges, measureable goals, time frames for completion, and defined responsibilities for the youth, parent/guardian, and staff at the program. There was no documentation in any of the reviewed files to support the parents/guardians received a copy of the individualized performance plan Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined by Florida Statute, or that a child is in need of supervision and care and has no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, reports such knowledge or suspicion to the Florida Abuse Hotline. The program strives to provide an environment for youth in which they feel safe and secure, and are free from threats, abuse or harassment. The program has a code of conduct, which staff must abide by. Each staff member receives a copy of the policy, which is also signed, to acknowledge their understanding. Observations found that the Florida Abuse Hotline telephone Office of Program Accountability Page 16 of 25 (Revised August 2013)

17 number was posted in the base camp office. During staff interviews, all staff acknowledged an understanding of the process of abuse reporting. Staff training files support that each staff is trained on abuse reporting requirements, as well as the state of Florida requirement of being a mandated reporter. There have been no abuse reports filed by youth during the past year, and therefore no Central Communications Center (CCC) reports as a result of reported abuse. Three closed youth records were reviewed; each contained documentation to support that each youth received an orientation to the program, which includes providing information regarding the Florida Abuse Hotline, and procedures on how to contact them. Three staff were interviewed during the Quality Improvement review; none reported ever hearing another staff member use profanity or threats toward a youth. The staff were also able to describe the process for reporting child abuse. Three youth were also reviewed; none of the youth reported ever hearing staff use profanity or threats. The youth also reported feeling safe, and that staff are respectful. Standard 3: Intervention Services Overview Each youth receives a needs assessment prior to participating on a course expedition. The information obtained on the needs assessment is utilized to create an individualized performance plan that contains goals and action steps. A progress review is conducted on each approximately midway through the course expedition, to review the goals and discuss the youth s overall program behavior and progress. The staff complete an individualized performance plan summary on each youth at the end of the course expedition and follow-up to inform the youth, parent/guardian, referring agency, school, and other pertinent parties of the youth s performance, overall adjustment, and progress made during the course expedition. The youth are provided guidelines for expected behaviors while on the expedition, as well as consequences for inappropriate behaviors. Program staff assist the youth and family in the development of a transition plan/contract to focus on issues at home and at school. The program has an expedition schedule that includes structured outdoor recreational, leisure, and educational activities Individualized Performance Plan (IPP) Process Compliance Outward Bound staff shall document through the performance planning process individualized goals and objectives for each student that stress, at a minimum, social skills, education, transition, and family needs. The IPP shall include two or more, as indicated by assessment and screening, behavioral goals, family concerns, education and vocational goals, family living skills and family relations. The program has a written policy and procedures regarding Individualized Performance Plans (IPP) for prevention programs. The program completes an Individualized Performance Plan (IPP) for each youth prior to the start of the course expedition. The IPP is created using information from the needs assessment that is completed during intake portion of the course expedition. During the course start observation, staff create an IPP with the youth and their parent/guardian; each IPP has a minimum of three goals that are specific to each youth. The IPP is signed by each youth, parent/guardian, and the applicable program staff. The goals focus on social skills, education, performance, and transition/family issues. Three closed youth files were reviewed; there was an IPP in each file that contained a minimum of three goals, and Office of Program Accountability Page 17 of 25 (Revised August 2013)

18 actions steps for each goal. The IPP documented the completion of each action step for each goal. The files did not contain chronological notes for each youth during the course expedition. There were chronological notes of contacts made with the youth s parents/guardian to provide an update on the youth s progress during course expedition. Three youth were interviewed during the Quality Improvement review; the youth were able to discuss a goal for the course expedition course they had just completed Individualized Performance Plan reviews and revisions Compliance The Individualized Performance Plan shall be reviewed and revised as necessary at least once per week during the wilderness expedition. The review shall include re-negotiation of the performance to insure that the services provided to the youth while in the program compliment and support the youth s re-integration into the home and community. The program has a written policy and procedures regarding Individualized Performance Plans (IPP) for prevention programs. A review of three closed files documented that an individualized performance plan had been completed for each youth. Each IPP included several action steps for each of the three goals, and when an action step was completed. One file included the renegotiation of an action step. All action steps were completed by the end of the course expedition in all three reviewed files Individualized Performance Plan Summary Compliance An Individualized Performance Plan Summary will be completed on each youth at the end of the wilderness expeditionary program and follow-up to inform the youth, parent/guardian, referring agency, school, and other pertinent parties the youth performance and status on his or her Individualized Performance Plan and overall adjustment and progress during the wilderness expedition. The program has written policies and procedures regarding the completion of an individualized performance plan summary. Three closed files were reviewed; each file contained an individualized performance plan (IPP) summary that had been completed at the end of the course expedition and follow-up. Each IPP summary included the youth s academic status, overall program behavior, significant positive and negative events, and the youth s performance during the follow-up period. All files contained documentation of the IPP summary being sent to the appropriate parties. The IPP summaries did not contain any signatures or dates to document to whom the IPP summary was sent, when the summary was completed or who was on the treatment team to complete the IPP summary Non-violent Physical Crisis Intervention and Reporting Compliance Outward Bound staff will use only Non-violent Physical Crisis Intervention Techniques (NPCI) by the Crises Prevention Institute (CPI) to manage a potentially violent youth. Any staff member using physical intervention must be certified in the use of NCPI. Any physical intervention technique will be documented in an incident report within 48 hours of the incident and turned in to a base staff member at the next face-to-face meeting. The program has written policies and procedures requiring the completion of non-violent physical crisis intervention (NPCI) training. The training files of three staff were reviewed; each training file validated that staff are trained in NPCI techniques. Prior to the start of each course expedition, the program director reviews the NPCI techniques with staff. The program director Office of Program Accountability Page 18 of 25 (Revised August 2013)

19 and a member of the program s corporate team complete a recertification training class on NPCI techniques each December. There were no reports of the use of NPCI techniques for the past year. In the event there is an incident involving the use of a NPCI technique, staff are required to provide the program director with a complete incident report and any written statements. The program will conduct a debriefing between the instructor and the course director, the instructor and the youth; this is known as the coping debrief, which is part of the NPCI process Behavior Management System Compliance The Outward Bound program utilizes a behavior management system that provides privileges and consequences to encourage youth to fulfill programmatic expectations. Consequences are fair and directly correlate with the behavior problem or demonstrated level of responsibility. Disciplinary procedures are carried out promptly. Youth are not allowed to have control over or discipline other youth. All significant behavior problems, isolations and movement between Training, Main, and Final phases are documented in the course log. The program has a behavior management system (BMS) that provides privileges and consequences to encourage youth to complete expectations; the BMS includes reality therapy and choice therapy techniques. The program has the Department of Juvenile Justice mission and vision posted. There is a youth and family handbook that provides a program description, educational goals, and objectives. The youth are presented with a list of non-negotiable rules, to which the youth are expected to follow. The program s BMS includes three phases: training, main, and final; there are more choices and privileges with each phase. There are checklists of items that must be completed in order to complete the phase and move to the next phase. All youth on the course expedition are on the same phase. The youth are permitted to explain their inappropriate behavior, and the youth are expected to hold each other accountable for their behavior. During each course expedition, the staff maintain a group journal that includes the nonnegotiable rules and what is required to move from training, main, and final. There is a course log that is updated daily; the course log includes information on the movement of the youth between each of the three phases. The course logs were not signed by the person completing the entry; the course logs were updated while the Quality Improvement team was on site to include the applicable staff signature. Three closed youth files were reviewed; each contained documentation of signed and dated non-negotiable rules. Three staff and three youth were interviewed; all staff and youth were aware of the behavior management system. All reported that youth are not allowed to control or discipline other youth. The youth responding to the reported that consequences for inappropriate behavior were fair and happened immediately Separations/Isolations Compliance While participating on a wilderness course before an isolation is imposed, staff attempt a number of alternatives including behavioral contracting, peer mentoring/counseling, constructive and natural consequences, and increased one-on-one time with staff. The Course Di-rector shall be notified at the next available call-in time when an isolation is imposed. Youth may be separated away from the group, in a staff s canoe, on-site or across the river, but within sight and sound of the group. The program has written policies and procedures regarding placing youth on separation. When youth are in need of time to reflect on their behavior, they are removed from the remainder of the youth, which is known as separation. When the youth feels ready to rejoin the group, it is Office of Program Accountability Page 19 of 25 (Revised August 2013)

20 expected that the youth will take ownership of the behavior and make a plan for improving their attitude. A review of the course reports, course logs, and three closed youth files documented that separation is used after other alternatives have been attempted to no avail. If a youth is placed on separation for longer than eight hours, it is referred to as isolation. The youth placed on isolation sleep in a separate tent, placed at the door of the instructor s tent. There was no documentation to support any youth were placed on isolation during this review period. Three closed youth files were reviewed; the files documented several behavior contracts prior to the youth being placed on separation and after the placement on separation. One file documented a variety of instructional styles and clearly communicated consequences. The course logs and reports documented that the instructors were always within sight and sound of youth placed on separation, with one exception; there was one instance of a youth not being within sight and sound of staff during separation. There was no consistent documentation of the duration of each separation Transition Plan/Contract Compliance Outward Bound staff shall assist in the development, with the youth and family/guardian, of a Transition Plan/Contract to focus on issues at home and in school utilizing tools learned during the wilderness expedition and parent guardian meeting. The program has written policies and procedures regarding the completion of a transition plan. The program completes a transition plan with each youth that focuses on what the youth will work on upon their return home. Three closed files were reviewed; each file contained a written transition plan that focused on the youth s home and school. Each transition plan was created with the youth and the youth s parent/guardian; each transition plan was signed by all family members and the program staff. Each transition plan contained at least one action step for each goal, the positive and negative consequences for each action step, and a target date for completion. Each file contained documentation of a discussion of the transition plan goals and action steps to be completed at home and school. The program conducted home and school visits for each youth; the home and school visits documented when action steps had been completed, and the addition of new or updated action steps Follow-up Compliance Outward Bound staff shall conduct follow-up visits with the youth at school and in the family to monitor the completion of the youth s Transition Plan/Contract goals and objectives. The program has written policies and procedures requiring follow-up visits on the youth after an expedition course has concluded. Three closed files were reviewed; each contained documentation of at least four home visits and one school visit. There was documentation to support discussions of each youth s transition plan and action steps. The documentation included the completion of action steps and the creation of new or revised action steps; all new or revised action steps are also documented on the transition plan. The documentation of the home visits supports that the program staff consistently spent at least one hour with the youth and parents/guardian or other family members. Each file contained documentation of one school visit, which focused on the youth s education status; the school visits documented the inclusion of necessary school staff. Two of the three files documented that the school visits were at least one half hour in duration. Office of Program Accountability Page 20 of 25 (Revised August 2013)