Charms Collaborative CAP 2012
COORDINATED PROGRAM REVIEW
Collaborative: CHARMS
Corrective Action Plan Forms
Program Area: Special Education
Prepared by: Alan Dewey
All corrective action must be fully implemented and all noncompliance corrected as soon as possible and no later than one year from the issuance of the Coordinated Program Review Final Report to the school or district.
Mandatory One-Year Compliance Date: April 22, 2013
COORDINATED PROGRAM REVIEW
CORRECTIVE ACTION PLAN
(To be completed by the collaborative)Criterion & Topic: SE 43 Behavioral Intervention / Rating: Partially Implemented
Department CPR Finding: Classroom observation and follow-up interviews indicated that there were students whose behavior impeded their learning or the learning of others to the extent that they were removed from the learning environment. There was no evidence that there was a behavior plan separate from an IEP goal or the overall program behavioral goals or requirements.
Narrative Description of Corrective Action: Behavioral intervention plans developed as a result of a functional behavioral assessment (FBA) or teacher observation / assessment will be included in all student files as required.
Title/Role of Person(s) Responsible for Implementation: Program Coordinator / Expected Date of Completion for Each Corrective Action Activity: September 2012
Evidence of Completion of the Corrective Action: Behavioral intervention plans will be placed in all student files as required.
Description of Internal Monitoring Procedures: Program coordinator will regularly check student files to ensure that required behavioral intervention plans have been filed in the student files.
CORRECTIVE ACTION PLAN APPROVAL SECTION
(To be completed by the Department of Elementary and Secondary Education)
Criterion: SE 43 / Status of Corrective Action:
Approved Partially Approved X Disapproved
Basis for Partial Approval or Disapproval: The collaborative response focused on ensuring that behavior plans were placed in student files rather than responding to the finding regarding the development of behavior plans for students whose behavior impeded their learning or the learning of others to the extent that they were removed from the learning environment. There was no corrective action plan regarding the process for determining and developing a behavior plan separate from an IEP goal or the overall program behavioral goals or requirements.
Department Order of Corrective Action: The Collaborative must conduct a review of its protocols to determine whetherit has developed procedures for determining whether a student needs a functional behavioral assessment and/or a behavior plan separate from an IEP goal or the overall program behavioral goals or requirements. Once the Collaborative has determined whether there are procedures in place, a training should be conducted for staff. The Collaborative must also conduct an administrative review of records to determine whether the procedures have been followed regarding conducting a functional behavior assessment and developing behavior intervention plans for students.
Required Elements of Progress Report(s): By November16, 2012 provide the Department with a copy of the proceduresin place or developed for determining whether a studentneeds a functional behavioral assessment and/or a behavior plan separate from an IEP goal or the overall program behavioral goals or requirements. Provide the Department with a copy of the training agenda, date(s) the training was conducted and a sign-in sheet with the name and role/titleof the attendees.
By February 28, 2013 provide the Department with the results of the internal administrative review conducted by the Collaborative. The progress report should contain the number of records reviewed, as well as the number of records found to be in compliance and/or noncompliance. If the collaborative finds that there are records out of compliance provide the Department with an analysis of the root cause and the steps the Collaborative proposes to take to correct the non-compliance
Progress Report Due Date(s): November 16,2012 and February 28, 2013.
MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
COORDINATED PROGRAM REVIEW
Collaborative: CHARMS
Corrective Action Plan Forms
Program Area: Approved Public Day Standards
Prepared by: Alan Dewey
All corrective action must be fully implemented and all noncompliance corrected as soon as possible and no later than one year from the issuance of the Coordinated Program Review Final Report to the collaborative.
Mandatory One-Year Compliance Date: April 22, 2013
COORDINATED PROGRAM REVIEW
CORRECTIVE ACTION PLAN
(To be completed by the collaborative)Criterion & Topic: APD 5.2 Policies and Procedures for Coordination/Collaboration with Public School
District / Rating: Partially Implemented
Department CPR Finding: Review of student records indicated that the collaborative sends a letter to the school district that indicates that they are enclosing two hard copies of the IEP with a request to return IEP8 for the collaborative’s files after it has been signed by the district and the parent(s)/guardian. There is no formal written agreement between the collaborative and the LEA that relieves the school district of its responsibilities under 603 CMR 28.10.
Narrative Description of Corrective Action:
We will change the current letter which is sent to the sending school districts by using the following sentence: “Enclosed is one draft copy of the IEP for your student ( ). Please review the draft IEP and send us a signed final copy of the IEP for our files.” Attached is a copy of the revised letter.
Title/Role of Person(s) Responsible for Implementation: Program Coordinator / Expected Date of Completion for Each Corrective Action Activity: May 21, 2012
Evidence of Completion of the Corrective Action: Attached revised letter to sending school district.
Description of Internal Monitoring Procedures: Random monitoring of draft IEPs sent to the sending school districts.
CORRECTIVE ACTION PLAN APPROVAL SECTION
(To be completed by the Department of Elementary and Secondary Education)
Criterion: APD 5.2 / Status of Corrective Action:
X Approved Partially Approved Disapproved
Basis for Approval or Disapproval: The collaborative response indicated they have revised their practice of sending a letter to the school district that indicatedtwo hard copies of the IEP were being provided with a request to return the IEP for their files after it has been signed by the district and the parent(s)/guardian. A copy of the revised letter was provided
Department Order of Corrective Action: Not Applicable
Required Elements of Progress Report(s): By November 16, 2012 provide the Department with a copy of the revised procedures related to the development of IEPs by the sending school district. Include the name/role of the person responsible and evidence that the procedures have been provided to the appropriate staff members.
By February 28, 2013 provide the Department with the results of the internal administrative review conducted by the Collaborative. The progress report should contain the number of records reviewed, as well as the number of records found to be in compliance and/or noncompliance. If the collaborative finds that there are records out of compliance provide the Department with an analysis of the root cause and the steps the Collaborative proposes to take to correct the non-compliance.
Progress Report Due Date(s): November 16, 2013 and February 28, 2013
COORDINATED PROGRAM REVIEW
CORRECTIVE ACTION PLAN
(To be completed by the collaborative)Criterion & Topic: APD 5.2(a) Contracts / Rating: Partially Implemented
Department CPR Finding: The collaborative has a written contract with the sending school district that includes all the required elements; however the practice of sending the IEP to the school district for signatures as cited under criterion 5.2 is not included as part of the contract.
Narrative Description of Corrective Action:
Charms has amended its practice under APD 5.2 and does not send the final IEP to the sending school districts. Consequently, no change to the contracts are required.
Title/Role of Person(s) Responsible for Implementation: Executive Director / Expected Date of Completion for Each Corrective Action Activity: May 21, 2012
Evidence of Completion of the Corrective Action: See attached revised letter in APD 5.2
Description of Internal Monitoring Procedures: Random monitoring of draft IEPs to the sending school districts.
CORRECTIVE ACTION PLAN APPROVAL SECTION
(To be completed by the Department of Elementary and Secondary Education)
Criterion: 5.2(a) / Status of Corrective Action:
X Approved Partially Approved Disapproved
Basis for Approval or Disapproval: The collaborative response indicated they have revised their practice of sending a letter to the school district that indicatedtwo hard copies of the IEP were being provided with a request to return the IEP for their files after it has been signed by the district and the parent(s)/guardian. Due to the change in practice the contract does not need to be amended to include the practice of the Collaborative developing a final IEP.
Department Order of Corrective Action: See APD 5.2
Required Elements of Progress Report(s): See APD 5.2.
COORDINATED PROGRAM REVIEW
CORRECTIVE ACTION PLAN
(To be completed by the collaborative)Criterion & Topic: APD 12.2 In-Service Training Plan and Calendar / Rating: Partially Implemented
Department CPR Finding: It could not be determined from the documentation submitted and staff interviews that the two hours of training on average every month on the required topics has been provided.
Narrative Description of Corrective Action:
Agendas and sign in sheets will be required for all monthly training.
Title/Role of Person(s) Responsible for Implementation: Program Coordinator / Expected Date of Completion for Each Corrective Action Activity: September 2012
Evidence of Completion of the Corrective Action: A file will be maintained in the Charms Collaborative office of all agendas and attendance sheets.
Description of Internal Monitoring Procedures: Random checks on the status of monthly training agendas and sign in sheets.
CORRECTIVE ACTION PLAN APPROVAL SECTION
(To be completed by the Department of Elementary and Secondary Education)
Criterion: APD 12.2 In-Service Training Plan and Calendar / Status of Corrective Action:
X Approved Partially Approved Disapproved
Basis for Approval or Disapproval: The Collaborative responseindicated that Agendas and Sign-in sheets for all monthly training would be required to be kept on file and that random checks on the status of training would be conducted.
Department Order of Corrective Action: Not Applicable
Required Elements of Progress Report(s): By November 16, 2012 provide the Department with the agendas, topics, dates and sign-in sheets with the name and role/title of attendees.
By February 28, 2013 provide the Department with the agendas, topics, dates and sign-in sheets with the name and role/title of attendees.
Progress Report Due Date(s): November 16, 2012 and February 28, 2013
COORDINATED PROGRAM REVIEW
CORRECTIVE ACTION PLAN
(To be completed by the collaborative)Criterion & Topic: APD 12.2(d) Required Training-
Medication Training / Rating: Partially Implemented
Department CPR Finding: It could not be determined from documentation or staff interviews that training about the nature of a medication, potential side effects and any special precautions or requirements was provided by a physician or registered nurse to all staff providing care or instruction to students for whom any staffadministers medication.
Narrative Description of Corrective Action: Agendas and sign in sheets will be required for all training on medications, side effects and special precautions or requirements by the Charms nurse.
Title/Role of Person(s) Responsible for Implementation: Program Coordinator / Expected Date of Completion for Each Corrective Action Activity: September 2012
Evidence of Completion of the Corrective Action: Program Coordinator will work with the nurse to ensure that medication training agendas and sign in sheets are completed for each training and evidence of such placed in the training file at the Charms Collaborative main office.
Description of Internal Monitoring Procedures:
CORRECTIVE ACTION PLAN APPROVAL SECTION
(To be completed by the Department of Elementary and Secondary Education)
Criterion: APD 12.2(d) Required Training-Medication Training / Status of Corrective Action:
Approved X Partially Approved Disapproved
Basis for Approval or Disapproval: The collaborative response did not indicate a description of an internal monitoring procedure to ensure that the required training had been conducted.
Department Order of Corrective Action: The internal monitoring conducted by the collaborative must include a random review of personnel files to ensure that the required training was conducted.
Required Elements of Progress Report(s): By November 16, 2012 provide the Department with the results of the internal administrative review of personnel files. Include a copy of the agendas, dates the training was conducted, and the sign-in sheets with the name and role/title of attendees. In addition provide the Department with a description of the internal monitoring system developed to ensure that the training will be conducted.
Progress Report Due Date(s): November 16, 2012
COORDINATED PROGRAM REVIEW
CORRECTIVE ACTION PLAN
(To be completed by the collaborative)Criterion & Topic: APD 15.5 Parent Consent and Required Notification / Rating: Partially Implemented
Department CPR Finding: Review of student records indicated that the consent for administering medication, where applicable, and permission to video or photograph was not in the student record.
Narrative Description of Corrective Action: All student records in the Charms Collaborative main office will contain copies of medication administration forms and video/photograph permission forms as required.
Title/Role of Person(s) Responsible for Implementation: Program Coordinator / Expected Date of Completion for Each Corrective Action Activity: September 2012
Evidence of Completion of the Corrective Action: Medication and video/photograph forms in the student files at the Charms main office.
Description of Internal Monitoring Procedures: Random checks on the student files to ensure that these forms are in the files.
CORRECTIVE ACTION PLAN APPROVAL SECTION
(To be completed by the Department of Elementary and Secondary Education)
Criterion: APD 15.5 Parent Consent and Required Notification / Status of Corrective Action:
X Approved Partially Approved Disapproved
Basis for Approval or Disapproval: The collaborative response indicated that all student files will include the consent for administering medication, where applicable, and permission to video or photograph. The Collaborative also indicated that an internal administrative review of student records will be conducted.
Department Order of Corrective Action: Not Applicable
Required Elements of Progress Report(s): By November 16,2012 provide the Department with the results of the internal administrative review conducted by the Collaborative. The progress report should contain the number of records reviewed, as well as the number of records found to be in compliance and/or noncompliance. If the collaborative finds that there are records out of compliance provide the Department with an analysis of the root cause and the steps the Collaborative proposes to take to correct the non-compliance.
Progress Report Due Date(s): November 16, 2012
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