BUREAU OF MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR

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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 MONITORING AND QUALITY IMPROVEMENT PROGRAM REPORT FOR Outward Bound Scottsmoor North Carolina Outward Bound Schools (NCOBS) (Contract Provider) 3500 Sunset Boulevard Mims, Florida Review Date(s): October 23-25, 2017 PROMOTING CONTINUOUS IMPROVEMENT AND ACCOUNTABILITY IN JUVENILE JUSTICE PROGRAMS AND SERVICES

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 Monitoring and 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: Paul Czigan, Office of Program Accountability, Lead Reviewer (Standard 1) Barbara Koppelmann, Senior Juvenile Probation Officer, Circuit 6 (Standard 3) Vernon Pryer, Regional Monitor, Office of Program Accountability (Standard 4) Laurie Stern, Transition s Director, Eckerd Kids Project Bridge Circuit 9 (Standard 3) Bonita Williams, Regional Monitor, Office of Program Accountability (Standard 2)

3 Program Name: Outward Bound Scottsmoor QI Program Code: 1283 Provider Name: North Carolina Outward Bound School (NCOBS) Contract Number: Location: Brevard County / Circuit 18 Number of Beds: 165 per year Review Date(s): October 23-25, 2017 Lead Reviewer Code: 77 Methodology This review was conducted in accordance with FDJJ-2000 (Contract Management and Program Monitoring and 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 (September 2014). Persons Interviewed Program Director DJJ Monitor DHA or designee DMHCA or designee # Case Managers # Clinical Staff # Food Service Personnel # Healthcare Staff Documents Reviewed 1 # Maintenance Personnel 2 # Program Supervisors 0 # Other (listed by title): 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 # Health Records # MH/SA Records 10 # Personnel Records 10 # Training Records/CORE 3 # Youth Records (Closed) 5 # Youth Records (Open) # Other: 5 # Youth # 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 24 (Revised October 2017)

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 Initial Training 1.04 Annual Training 1.05 Episodic/Emergency Services 1.06 Medication Management - Medication Storage 1.07 Medication Management - Delivery of Medications 1.08 Cleanliness and Sanitation 1.09 Administration 1.10 *Incident Reporting (CCC) 1.11 *Abuse-Free Environment * 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 4 of 24 (Revised October 2017)

5 Standard 2: Assessment Services Outward Bound Rating Profile Indicator Ratings Standard 2 - Assessment Services 2.01 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 (PAT) * 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 24 (Revised October 2017)

6 Standard 3: Intervention Services Outward Bound Rating Profile Indicator Ratings Standard 3 - Intervention Services 3.01 Individualized Performance Plan (IPP) Process 3.02 Individualized Performance Plan Reviews and Revisions 3.03 Individualized Performance Plan Summary 3.04 *Non-violent Physical Crisis Intervention and Reporting 3.05 Behavior Management System 3.06 Transition Plan/Contract 3.07 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 24 (Revised October 2017)

7 Standard 4: Services Outward Bound Rating Profile Indicator Ratings Standard 4 - Services 4.01 Disaster Preparedness 4.02 Fire Prevention and Evacuation Procedures 4.03 Water Activities 4.04 Boating Activities 4.05 Food Services 4.06 Transportation 4.07 Life Management Skills 4.08 Supervisory Reviews * 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 7 of 24 (Revised October 2017)

8 Standard 1: Management Accountability Overview Through a contract with the Department of Juvenile Justice, North Carolina Outward Bound School, Inc. provides a short-term wilderness expedition program for youth. The base camp for the program is located in Scottsmoor, Florida, in Brevard County. For most of the review period, the program served youth from Orange, Brevard, Seminole, Osceola, Duval, St. Johns, Volusia, Lake, Polk, and Flagler counties. On August 16, 2017, a contract amendment eliminated specific counties listed in both the Scottsmoor and the Key Largo contracts and added language which indicates the provider is responsible for identifying its service area. The youth are taken on a twenty-day wilderness expedition (herein after referred to as expedition), which consists of canoeing, hiking, and camping. The expeditions generally have eight to eleven youth. The admission requirements include youth exhibiting inappropriate behavior, such as truancy, expulsion from school, or a history of running away from home. Prior to being admitted into the program, youth must be cleared by a physician. Prior to any water activity the youth are evaluated for swim competency and provided with an appropriate level of personal flotation device (PFD) according to the results. If a youth is unable to swim, he or she must always use a PFD and not be in the same canoe as another non-swimmer. While on the expedition, the youth are assigned chores to complete each day, such as assisting in setting up and tearing down of camp, participating in meal preparation and clean up, navigating, and setting up latrines and garbage sites. The youth work on life management skills, leadership skills, communication, and coping mechanisms while on the river expedition. Upon their return, all youth participate in a community service project. The program conducts followup services on each youth, including home visits and school visits, upon their return from the expedition. A review of contract requirements for family programs manager position includes two positions with the staff qualifications of master s degree in social work, counseling, or a related field is preferred, but may be waived if the employee exceeds the required experience with this or similar programs. The family programs manager position in south Florida is filled by a staff with a master s degree who is also a registered marriage and family therapist intern. However, the family programs manager position filled in the base camp location does not have a bachelor s degree, but has numerous years of field experience. The contract language of staff qualifications of a master s degree implies the staff would at least have a bachelor s degree; further the exception allowed in the contract of having extensive experience was to waive the preferred master s degree not also to waive having a bachelor s degree. Interviews with staff indicated the merger of the Key Largo and Scottsmoor programs was essentially complete. All programming is managed and all expeditions have launched from the Scottsmoor base camp since the August 16, 2017, amendment. Staff confirmed the program has no Department of Juvenile Justice property, including vehicles. The program has an expanded need for space, as evidenced by the portables on the grounds, which do not have power yet. The program still services youth and families from south Florida using an office in Hollywood, FL to perform assessments, gather screenings, meet with families, gather the expedition youth for transport to Scottsmoor, and perform the follow-up case management services. Office of Program Accountability Page 8 of 24 (Revised October 2017)

9 1.01 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 completed annually. The program has a policy and procedures in place to provide background screening for all new staff. Fifteen staff were applicable for background screenings. Nine staff received an eligible background screening prior to hire. Six staff background screenings were completed after hire; however, all six were in training and not allowed access to youth until after their respective background screening was completed. An Annual Affidavit of Compliance with Level 2 Screening Standards was completed January 5, 2017 and sent to the Department 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. The program has a policy and procedures in place to provide for the rescreening of staff at intervals of five years from the initial hire date. A review of program rosters revealed no staff were applicable for five-year rescreening. The policy indicates the human resources (HR) coordinator keeps a list of screening dates on all staff and visually checks the list monthly to ensure all background screenings are up to date. The HR staff is responsible for facilitating the screening process. When the HR staff finds the five-year mark is near, the respective staff is informed they need to be rescreened. There was no written procedure of this process found Initial Training Compliance Contracted non-residential Outward Bound staff are trained in accordance with Outward Bound Program Core Orientation policy. Contracted non-residential staff who have not completed essential skills training and untrained interns do not have any direct, unsupervised contact with youth. A review of five new staff training records revealed all received the required training within ninety days of hire. Training included nonviolent physical crisis intervention, cardio pulmonary resuscitation (CPR), first aid, suicide prevention, emergency disaster preparedness and emergency response plan, Prison Rape Elimination Act (PREA), child abuse and incident reporting, grievance procedures, Continuity of Operations Plan (COOP), trauma informed care, equal employment opportunity, and sexual harassment. In addition, all staff had emergency water safety, swim test, civil rights, and medication management. Two staff records contained documentation staff had certification in Wilderness First Responder. Office of Program Accountability Page 9 of 24 (Revised October 2017)

10 1.04 Annual Training Compliance Contracted non-residential Outward Bound staff must complete forty hours of annual in-service 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. A review of five records revealed each staff received in excess of the required forty hours of inservice training in the review year. The five staff averaged receiving eighty-six (from fifty-three to 122) hours of in-service training. All required elements were either certified or the certification was continued over the previous year. In addition to the required courses and certifications, staff logged in training in emergency water safety, wilderness first responder, and river skills training Episodic/Emergency Services 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 a comprehensive process for the provision of episodic care, first aid, and emergency care. The program has a policy and procedures in place detailing how staff facilitate response to an urgent or emergency situation. The emergency response plan includes processes for reporting, incident management and investigation, impact, findings, questions, and communications. Procedures include off-site emergency care to include parent/guardian notification and transportation. The corporate policy included provisions for adverse medical events analysis including root cause analysis. Two cases were reviewed for provision of episodic or emergency care. In both cases the staff provided care on-site, notified supervisory staff, parent/guardian, and in one situation, off-site medical care. The program provides first aid kits for each expedition which are replenished at each time the team receives resupply. A review of the first aid kits revealed each included the required items, none of which were expired. All five interviewed staff indicated they could call 9-1-1; one of the staff added they call with issues of life and limb, while another staff specified they are able to call in the field. All staff training records indicated each received training in cardio pulmonary resuscitation and first aid care Medication Management Medication Storage Compliance All medications (prescriptions, over-the-counter, topical, etc.) shall be stored in separate, secure (locked) and are inaccessible to youth and ensures proper inventory control. The program has a policy and procedures regarding the storage of medications. The program stores medications in four locked medical kit bags. The medical kit bags are secured with a zip tie or lock. Each type of medication is stored separately and color coded for easy identification. The trauma items are kept in an orange kit, routine over the counter medications (OTC) in a yellow kit, the emergency items are in a red kit, and the routine medical items are in a blue kit. The controlled medications are to be stored in combination locked pelican bags. The storage bags are clean and free from extreme moisture. The epi-pens and the suicide kit are secured in the manager s office until needed for the expedition. The suicide kit contained all necessary items as required. Office of Program Accountability Page 10 of 24 (Revised October 2017)

11 The program did not have any syringes or sharps on site. A review of all medications maintained by the program revealed none were expired and all were accounted for. The inventory count documentation for the past six months for all medications was reviewed; the inventory counts were consistent for each medication Medication Management Delivery of Medications Compliance The program shall have a process in place to assist youth with self-administration of oral medications. The program has a policy and procedures regarding the delivery of medications. All five youth had signed consent forms for over the counter medications and/or prescription medications. All staff who have contact with youth were trained in medication administration. Three of the five youth were applicable for prescription medications and a medication distribution log was maintained in their records. The medication administration record (MAR) included all required elements. A review of three MAR s concluded the staff and youth initial when medication is administered. The supervisor or expedition director reviews the MAR s weekly for accuracy and documentation Cleanliness and Sanitation Compliance The program provides a safe and appropriate treatment environment in a wilderness setting including maintenance and sanitation of the campsites. The program has a policy and procedures regarding the cleanliness and sanitation of the site. During the review, a tour of the base camp was conducted which included staff cabins, showers, staff kitchen, equipment wash area, maintenance area, staff office and pantry/food storage. During the tour, staff were observed making repairs to tents. A review of course logs included issuance of flashlights and lanterns and a staff inspection of each campsite for safety and sanitation hazards Administration Compliance The Outward Bound program provides a safe and appropriate treatment environment including administrative and operational oversight. The program completed the monthly reports since the last annual compliance review. A comparison with Juvenile Justice Information System (JJIS) revealed the population was consistent with the monthly report. The monthly reports include admissions, releases, transfers/removals, youth served, Prevention Assessment Tool (PAT), life management skill s hours, solo experiences, non-clinical counseling/mentoring, parent workshops, case management weeks, program planning, partners, and barriers and challenges. Each expedition was documented on a course log, and maintained by the instructors leading the expedition. The expedition directors documented a review on each visit to the deployed group. A review of the logs revealed documentation of activities events, and incidents. There were no errors found written over. Incidents included youth and staff involved within the summary narrative. Incidents were more detailed in the incident report. The program filed monthly reports with the Department providing all the elements stipulated in the contract. Office of Program Accountability Page 11 of 24 (Revised October 2017)

12 1.10 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. Two applicable reports to the Central Communications Center (CCC) were reviewed. Both were reported within the two-hour time-frame. There was documentation in the course log on one applicable report. The other report was concerning the hurricane evacuation, and no expeditions were out with a course log, on which to document the event. All five reviewed staff records documented pre-service training in the incident reporting process. All expeditions launch with mobile communications equipment capable of reaching management in case of an incident on the trail. A review of course logs did not reveal any additional incidents which should have reported to the CCC Abuse-Free Environment Compliance Any person who knows, or has reasonable cause to suspect, 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 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 has a policy and procedures in place to ensure an abuse free environment. The program had no documented abuse complaints or grievances processed during the review period. There were postings observed in the base camp offices, of the phone number for the Central Communications Center and the Florida Abuse Hotline. Youth rights, to include abuse reporting, are included in the orientation materials processed with each youth. The staff interviews revealed no occasions in which youth were threatened or abused. Interviews also revealed staff knew how and when to call the Florida Abuse Hotline. A review of five staff records revealed each had signed a code of conduct upon hire. All five-interviewed youth indicated staff were consistently respectful, and each youth expressed they felt safe in the program. One of four interviewed youth indicated staff has used curse words occasionally when upset; however, he clarified staff did not curse at them or threaten them. The same youth described staff as very patient and caring. An interview with the program director indicated each staff signs a code of conduct which includes expectation of staff and consequences of failure to comply. A review of five staff personnel records revealed each record included documentation of receipt of the code of conduct. Office of Program Accountability Page 12 of 24 (Revised October 2017)

13 Standard 2: Assessment Services Overview The program accepts male and female youth, between the ages of twelve to seventeen. The youth must be in good physical health and not in need of any specialized overlay services. Youth referrals may come from the parent/guardian, school, community agencies, or prevention/diversion programs. Once a referral is received, the program reviews the application and if appropriate, the youth and parent/legal guardian move on to an interview and screening process with the program s intake coordinator. A face-to-face interview is conducted with each youth and their parent/legal guardian prior to admission to the program. On the first day of each new expedition, the youth and parent/guardian participate in an orientation process. The orientation to the program outlines program expectations, as well as policies and procedures for the youth, parent/legal guardian, and program staff. Youth and parent/legal guardian interviews of those from central Florida are conducted in the intake coordinator s office in the base camp building in Scottsmoor. Youth and parent/guardian interviews of those from south Florida since August 16, 2017, are conducted in the intake coordinator s office in Hollywood, Florida 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 a written policy and procedures regarding the referral and intake process. Five of the five youth records reviewed included documentation of review of applications. All five youth records had documentation the program scheduled an appointment to conduct a face to face interview with the parent/guardian to complete the medical screening process. Upon completion of the referral and intake process, the program informed the parent/legal guardian regarding youth acceptance into the program. The program documented any contacts, attempts or s with the family in the chronological notes, which located within each youth record 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 Successful completion criteria as defined in policy Overview of program expectations and wilderness expedition realities Clothing list Consent to release information Student rights The program has a written policy and procedures regarding the intake conference and orientation process. Five of the five youth records included a checklist acknowledging youth were advised of program expectations. The checklist included the required elements. In addition, the youth records included complete needs assessments, successful completion criteria, correspondence procedures, behavior management system, the referral application, the Office of Program Accountability Page 13 of 24 (Revised October 2017)

14 completed participant record and physician medical record, signed consents and release of records, immunization records, photo release, the individual determination report for the national school lunch program (NSLP) funding, acknowledgement of personal responsibility, and a counseling questionnaire Medication Management Verification of Medications Compliance The program shall determine a youth s medication regimen upon admission to the program. The program has a written policy and procedures regarding the verification of medications. One of the five youth records were applicable for this indicator. Two additional youth records were requested and reviewed for this indicator. Two of the three applicable youth were on Vyvanse and the other youth was on Loratadine. In each of the three applicable records, there was documentation the youth and parent/legal guardian were interviewed regarding current medication during the medical screening process. The program accepted only medications from a licensed pharmacy in each applicable record. The medications had the current patient specific label on the original medication container in each case. All three youth records included a medication distribution log (MDL) which had been initiated after medication verification. The program did not accept any medication which could not be verified according to the programs policy. Non-licensed staff only provided oral and topical medication with exception of emergency treatment and/or use of patient specific Epi-Pen auto injector. Each time a medication is administered the program staff document it on the MDL 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 requiring 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 a validated suicide risk screening instrument. The program ensures referral for 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 Monitoring and Quality Improvement FY Outward Bound indicators.) The program has a written policy and procedures regarding mental health and substance abuse screening for youth. One of the five youth records reviewed were applicable for this indicator. Two additional youth records were requested and reviewed. Two of the three applicable youth were on Vyvanse and one of the three was on loratadine. Each youth were on the medications because of being diagnosed with attention deficit hyperactivity disorder (ADHD). The program documented the review of the referral packet for any mental health issues in each youth record. One of the three applicable records documented suicide risk factors and were reported to the appropriate staff. Staff completed a validated suicide risk screening instrument for each youth. None of the youth screening instruments indicated the need for completion of an assessment of suicide risk. However, one of the youth was receiving counseling before admittance into the program, and the parent/legal guardian provided written documentation from the youth s licensed mental health therapist confirming the youth was not currently presenting any suicidal ideations. Office of Program Accountability Page 14 of 24 (Revised October 2017)

15 2.05 Outward Bound School/F.I.N.S Program Needs Compliance Assessment or Prevention Assessment Tool (PAT) The Outward Bound School/F.I.N.S Program Needs Assessment or the PAT is completed by program staff for all youth, regardless of risk to reoffend, during the face-to-face Intake Interview. The program has a written policy and procedures regarding conducting the Prevention Assessment Tool (PAT) and Families in Need of Services (FINS) program needs assessments. Five of the five youth records reviewed included both the PAT and needs assessment. The PAT was administered during the intake interview as part of the needs assessment process. Each youth s PAT was entered into the Juvenile Justice Information System (JJIS) within seventy-two hours of the expedition start. The needs assessments for each of the five youth were completed during the intake process. The needs assessments included information about the youth s, identified strengths and weaknesses, needs and family. The staff documented the youth needs on the needs assessment in each youth record. Office of Program Accountability Page 15 of 24 (Revised October 2017)

16 Standard 3: Intervention Services Overview The program conducts a needs assessment on each youth prior to their participation on a river expedition. The information from the assessment is utilized to create an Individualized Performance Plan (IPP). The IPP is developed within seven days of the youth s admission to the program. The youth are provided with the program s guidelines and expectations, as well as the consequences for inappropriate behaviors. The program staff assist the youth and parent/guardian with the development of goals and action steps with measurable outcomes. Each IPP is reviewed at least weekly with the youth. The youth s overall program behavior and progress is discussed during the weekly review. At the end of the river expedition, the instructors complete an IPP summary and follow-up to inform the youth, parent/guardian, referring agency, school, and other parties of the youth s performance, overall adjustment, and progress made during the river expedition. The expedition instructors assist the youth and the youth s parent/guardian in developing a transition plan/contract. The follow-up plan focuses on the youth s issues at home and at school Individualized Performance Plan (IPP) Compliance Outward Bound staff shall complete an Individualized Performance plan for each youth within seven calendar days from the youth s admission. The Plan includes written Performance Plan goals, and action steps documented on corresponding Performance Goal forms. Staff shall document through the performance planning process individualized goals and objectives for each student stressing, 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 the completion of individualized performance plans. Five open youth records were reviewed, and all performance plans were developed with the youth and parent/legal guardian on the date of the youth s admission. The five reviewed individual service plans included strengths and challenges for the youth and family as discussed on the youth s needs assessment. Each goal identified and included a target date, which was measurable. The individual service plan also includes a section in the beginning in which it discussed expectations during and after the program. Each goal for the youth and family has three individualized steps in order to meet the goal. The chronological notes in all five records included a note in which it referenced the performance plan was completed. In all five records, the performance plan was signed by the youth, parent/legal guardian, and program staff to include the director. Office of Program Accountability Page 16 of 24 (Revised October 2017)

17 3.02 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 ensure 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 the completion of individualized performance plans. Five open records were reviewed and chronological notes documented weekly reviews of the performance plans. Each of the five reviewed records documented the performance plans were completed on September 22, 2017 and reviewed on September 27, October 4, and October 11 th. None of the records documented the plan required renegotiation. The program provided an additional record for review. The extra record documented a renegotiation was completed with all required elements 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 a written policy and procedures regarding the completion of individualized performance plan summaries. Three closed youth records were reviewed. The performance summary was located in all reviewed records. Each summary included a detailed section to reference the youth s individual performance during their tenure in Outward Bound and the completion of goals. The youth s behavior was discussed in all three records including any significant incidents which may have been positive or negative. The youth s performance during the follow-up phase was discussed in all three reviewed records. The performance summaries were consistently signed by the director. Each of the summaries were signed, dated, and sent to the appropriate parties 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 a written policy and procedures regarding nonviolent physical crisis intervention and reporting. Records were reviewed for the past six months and there were no occasions documenting utilization of non-violent physical crisis intervention. The program was able to showcase a log in which incident reports would be filed and maintained. The program director was interviewed to explain the policy in place. The interview confirmed the director was very familiar with the policy and requirements of intervention and reporting. The interview revealed if staff have to use their hands for intervention, they have to call the supervisor and family within twelve hours, use the log to monitor incidents, fill out the incident report within twenty-four hours in the field, and the director inputs the information in the data base within a week. Office of Program Accountability Page 17 of 24 (Revised October 2017)

18 3.05 Behavior Management System Compliance The Outward Bound program utilizes a behavior management system providing 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. Five open youth records were reviewed and each included a behavior contract in each. Consequences were fair and documented in the local policy and procedures, as well as in the student handbook. Both the local policy and procedures and the student handbook included a list of non-negotiables for behavior. The behavior contracts included positive and negative consequences, as well as defined the problem and the goal. Youth signed off as reviewing the behavior management system including consequences and discipline actions during their orientation and initialed this on the student orientation checklist. The mission statement was displayed in the main office by the front door and on a bulletin board in the meeting area. The student handbook included the vision, mission, and guiding principles of Outward Bound. The handbook further included a program description, daily schedule, expectations, responsibilities, and graduation criteria. Daily activity schedules were listed in the daily flow schedule. The daily schedule was reviewed in all five youth records in the youth s activity book. The activity book further included the youth s movement between training, main and final phase, indicated by the instructor circling the youth s phase on a daily basis. Youth were interviewed and discussed their knowledge of the behavior management system. The program director was interviewed and summarized the behavior management system written policy. Staff were interviewed and summarized the behavior management system written policy. Youth understand the consequences and system in place 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 a written policy for the completion of transition plans/contracts. Three closed records were reviewed. Of the three records, all included a written transition plan/contract in which family and school issues were referenced. The transition plan was reviewed with the family, youth, and staff member during follow-up meetings. Each youth in the three reviewed records had at least four follow-up visits, and one youth had five follow-up visits. All three reviewed records, documented all the visits included the youth, parent, and staff member from Outward Bound. Each youth also had a school visit documented by the Outward Bound staff member. All follow-up activities were documented on the chronological sheets included in all three records. Office of Program Accountability Page 18 of 24 (Revised October 2017)

19 3.07 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 a written policy and procedures pertaining to follow-ups. Three closed records were reviewed. Chronological sheets in all three closed records were reviewed and contained in the youth s records. The chronological sheets reflect telephone calls, labeled as TC on the sheets. Each youth record documented a total of twelve telephone contacts. School visits were completed and included required school personnel. All three closed records documented home visits; two of the records included the youth and one parent/guardian and youth; the third record included the youth and both parents/legal guardians. Office of Program Accountability Page 19 of 24 (Revised October 2017)

20 Standard 4: Services Overview The program has a corporate plan and a local plan, specific to Scottsmoor, to provide for disaster preparedness and water and boating safety. The program has protocols to provide for food safety and vehicle maintenance. The river expedition plans include the provision of life skills and immediate oversight of the expedition director. The base camp includes a food preparation area in which meals are planned and packed for each expedition, according to the number of days and the menu requirements. The camp also includes parking spaces for the transport vans, pick-up trucks, and sedans. Maintenance on vehicles is completed by program staff on the grounds using portable ramps. The program maintains all camping and boating gear in cubicles designed to contain all requirements, other than the actual water craft and the food. This includes tents, personal flotation devices, water containers, and safety equipment. The program also maintains water craft and trailers for transport. The annual compliance review team observed staff from the most recent expedition performing cleaning and maintenance on the water craft and gear following completion of the off-campus portion of the program The program provides a safe environment for a variety of outdoor activities. The program has written safety policy and procedures for water activities, boating activities, fire prevention, and disaster preparedness. Youth can participate in these types of activities while on a course expedition. Program staff are trained on the proper use of vehicles and trailers and are responsible for ensuring each youths safety. All youth and staff are required to wear seat belts while a vehicle is in operation. During the course expedition, youth are provided with nutritional meals and snacks and fluids to maintain hydration. While youth are on a course expedition, each youth works on life management skills, leadership skills, and communication and coping mechanisms. The expedition director is required to make on-site visits to ensure youth are making progress on their Individualized Performance Plan goals and action steps. September 6, 2017, the program received a waiver from the Department of Agriculture for provision of fresh milk requirements, allowing them to use nonfat dry milk as part of the National School Lunch Program (NSLP). An additional waiver dated July 10, 2017, from the Department of Agriculture grants the program permission to use the grades 9-12 production record to include grades 6-8, as all meals served will be meeting the grades 9-12 meal pattern Disaster Preparedness Compliance Outward Bound shall have detailed safety policies and procedures. The program will produce an annual safety report. The program has a written Disaster Preparedness Plan outlining safety practices inclusive of procedures regarding major disturbances, hostage situations, shooting, chemical spills, bomb threats, and wilderness emergencies. Also included are procedures for fire, severe weather, hurricane warnings, tornado warnings, flooding and any communicable disease outbreak inclusive of transport plans. The severe weather section covers lightning, hurricane, tropical storms/depressions, tornado, and flood. Office of Program Accountability Page 20 of 24 (Revised October 2017)

21 The wilderness emergency section refers to the North Carolina Outward Bound Scottsmoor response plan, the basic specific emergency action plan (EAP), and the wilderness expeditions specific evacuation notes. The disaster preparedness plan was reviewed in October 2017 and is required to be reviewed annually Fire Prevention and Evacuation Procedures Compliance The program provides a safe and appropriate treatment environment including fire prevention and evacuation procedures. The program has a written policy and procedures in place addressing safety procedures. Fire drill procedures and fire protection equipment locations and safety checks are part of the prevention plan. The plan requires monthly fire drills, bi-monthly evacuation drills, and quarterly fire safety and equipment checks. The plan, required to be reviewed annually, was reviewed by the Brevard County Fire Marshal on March 29, A review of the program documentation regarding fire drills for past six months found fire drills are being conducted as outlined in the plan located in the disaster preparedness Continuity of Operations Plan (COOP). A review of fire extinguishers on campus revealed each one was tagged as inspected in October 2017 and the gauge on each device was in the green zone. A review of staff training records confirmed all staff were trained in the proper operation and use of fire protection equipment. The program contracted with an Bobbs Fire Equipment, Inc to perform annual maintenance on all fire equipment. The maintenance was completed on July 18, 2017, and a receipt was maintained in the inspections binder. A review of fire extinguishers on campus revealed each one was tagged as inspected in October 2017 and the gauge on each device was in the green zone. Fire extinguishers were located throughout the facility in accordance with the fire exit plan approved by the Brevard County Fire Marshal Water Activities Compliance The Outward Bound program provides a safe and appropriate treatment environment including procedures for water activities. All students will complete a Water Comfort Assessment prior to participating in any water related activity. Non-swimmers will wear an approved Personal Floatation Device (PFD) at all times when on or near the water. The program has a written policy and procedures regarding water safety plans. The program s water safety plan contains emergency procedures outlining specific directions regarding prompt notification of a youth s parent or guardian in cases of serious illness, injury, or death. The plan further requires at least one Emergency Water Safety trained staff to be present when youth are participating in water activities. Additionally, the plan requires all youth to be swim tested prior to participating in any water-related activities. Youth identified as non-swimmers are required to wear an approved Personal Floatation Device (PFD). Review of five youth records documented four of five youth completed the swim test the same day of admission, the fifth youth completed his swim test within forty-eight hours of admission to the program. Each record documented the name of the person conducting the test, whether the youth passed the test, and the location of an approved testing site. The instructor performing all tests was certified to conduct swim tests. Office of Program Accountability Page 21 of 24 (Revised October 2017)

22 Five youth were interviewed; all reported being swim tested prior to any water activities. A review of the course log did not identify any additional water-related activities, except for canoeing. The gear check-out log for each expedition documented there were enough PFDs for each youth and staff. A review of staff training records confirmed staff were trained in and certified for emergency water safety (EWS) Boating Activities Compliance Outward Bound programs will provide ample canoe training to the students throughout the wilderness expedition and the instructional team will make periodic assessments to determine when additional training is needed, e.g. tidal changes, high water levels, open water, fast moving water, high winds, and actual student abilities. The program maintains a written policy and procedures regarding boating activities. The program also has a water safety plan in place. A review of staff training records found evidence of staff receiving training and certification in Canoe Training 1, 11, and 111. The course log indicated a canoe class was conducted on the second day of each river expedition. The course log included notes on various days indicating follow-up assessments of the travel plan for each day conducted. The result of these assessments included alterations of the route and additional training due to weather conditions or tidal movement. Five youth were interviewed; all reported having received canoe and boating training prior to participating in any boating activities 4.05 Food Services Compliance During the Outward Bound wilderness excursions, staff shall provide nutritional, well-balanced meals and snacks for each youth. The menus shall follow the meal patterns of the National School Breakfast and Lunch (NSBL) prepa-ration requirements and all Florida Department of Education guidelines. The program has a written policy and procedures regarding the provision of food services for program youth. The program has a menu approved by a registered dietitian/nutritionist dated September The menu follows the requirements of the National School Lunch Program (NSLP), which is inclusive of five regular days, pre and post-solo meal days, and vegetarian variations. The menu documents the calorie count per meal, and collectively for each day. The daily menu also includes two snacks. The policy also requires staff and youth to eat the same food. The dietitian holds clear and active credentials with the Bureau of Medical Quality Assurance, Department of Health, which expires May 31, The youth are assigned chores for each meal, to include preparing for, and cleaning up after, meals. A review of the past six month s menus and special diets did not find any evidence of staff or youth requiring special diets. Interviews of staff and youth verified the staff and youth eat the same food while on the river expedition Transportation Compliance The Outward Bound program provides a safe and appropriate treatment environment including transportation. The program has a written policy and procedures regarding transportation. The program utilizes various sized vehicles to provide daily transportation for youth and staff. All vehicles were found to be secured, in sound mechanical condition, had current proof of insurance, and registration. Office of Program Accountability Page 22 of 24 (Revised October 2017)