MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
Program Quality Assurance Services
PROGRAM REVIEW

CORRECTIVE ACTION PLAN

Special Education Agency: Children's Study Home

Program Review Onsite Year: 2012-2013

Programs under review for the agency:

A - Latency Residential Program

B - Mill Pond Day Program

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 Program Review Final Report dated 02/28/2013.

Mandatory One-Year Compliance Date: 02/28/2014

Summary of Required Corrective Action Plans in this Report

Criterion / Criterion Title / Applies To / PR Rating /
PS 8.8 / IEP - Progress Reports / A,B / Partially Implemented
PS 9.1(a) / Student Separation Resulting from Behavior Management / A,B / Partially Implemented
PS 11.4 / Teachers (Special Education Teachers and Regular Education Teachers) / A,B / Partially Implemented
PS 12.1 / New Staff Orientation and Training / A,B / Partially Implemented
PS 12.2 / In-Service Training Plan and Calendar / A,B / Partially Implemented
PS 16.7 / Preventive Health Care / B / Partially Implemented
PS 19 / Anti-Hazing / A,B / Partially Implemented
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 8.8 IEP - Progress Reports / PR Rating:
Partially Implemented
Applies To:
All
Department Program Review Findings:
A review of student records and interviews indicate that evidence of when and to whom progress reports are sent is not consistently documented.
Description of Corrective Action:
A Progress Report Tracking Log has been placed in each student's office file. The log lists the recipients of the progress report, their relation to the student, and the date the report was sent. The secretary will automatically complete the log when she places a copy of the progress report in the student's file.
Title/Role(s) of Responsible Persons:
Executive Director, Director of Education, school secretary / Expected Date of Completion:
02/10/2013
Evidence of Completion of the Corrective Action:
The Progress Report Tracking Log along with the Progress Report itself in each student's file, will be the evidence of proper notification of student progress.
Description of Internal Monitoring Procedures:
The secretary, responsible for copying and mailing Progress Reports, will complete the log for each quarterly report. The Director of Education will check logs quarterly after reports have been mailed.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 8.8 IEP - Progress Reports / Corrective Action Plan Status: Approved
Status Date: 05/31/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
Children's Study Home must submit the third quarter progress report tracking log for the four students whose records the Department reviewed when the ESE team was onsite.
Progress Report Due Date(s):
06/20/2013

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MA Department of Elementary & Secondary Education , Program Quality Assurance Services

Children's Study Home Corrective Action Plan

PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 9.1(a) Student Separation Resulting from Behavior Management / PR Rating:
Partially Implemented
Applies To:
All
Department Program Review Findings:
A review of documentation, student records and interviews indicate that the time out log does not include the length of time and who monitored the student during the time out; and staff are not consistently implementing the same procedures for all students in the rooms utilized for separation resulting from behavior management.
Description of Corrective Action:
A new Time-out form, which includes both the name of the staff person monitoring the time out and the start and finish time of the separation, has been implemented. Additionally, a new Time-out log has been developed to track the frequency,timing, and types of behavior requiring separation.
All staff were involved in standardizing policy for the use of break-out rooms. All staff met and were trained on the policy on Feb. 26, 2013 and March 6, 2013 in order to implement the new policy immediately.
Title/Role(s) of Responsible Persons:
Executive Director, Director of Education, Principal, Staff monitoring time outs / Expected Date of Completion:
03/07/2013
Evidence of Completion of the Corrective Action:
Completed Time-out forms and logs will show the required information that was missing on previous forms.
A copy of the break-out room policy and attendance sheets from the trainings will be evidence of the new policy and the training of staff in its use.
Description of Internal Monitoring Procedures:
The Time-out log and forms will be reviewed by the Director of Education and Principal monthly to monitor implementation and to analyse the data.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 9.1(a) Student Separation Resulting from Behavior Management / Corrective Action Plan Status: Approved
Status Date: 05/31/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
Children's Study Home must submit a copy of the revised time out log for the month of May, 2013. The program must submit a copy of the break-out room policy and the attendance sheets from the training conducted on 2/26/13 and 3/6/13 specific to the new policy and the use of the break-out room.
Progress Report Due Date(s):
06/20/2013

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MA Department of Elementary & Secondary Education , Program Quality Assurance Services

Children's Study Home Corrective Action Plan

PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 11.4 Teachers (Special Education Teachers and Regular Education Teachers) / PR Rating:
Partially Implemented
Applies To:
All
Department Program Review Findings:
A review of documentation and interviews indicate that not all teaching staff are appropriately licensed in the grade level and subject area(s) in which they are teaching.
Description of Corrective Action:
The teacher (JM), whose license had lapsed, has resigned as of March 8, 2013. A new teacher, who is eligible for a Special Ed. Moderate Needs waiver (5-8), has been hired and will be available as of April 5, 2013.
Title/Role(s) of Responsible Persons:
Executive Director, Director of Education, Principal / Expected Date of Completion:
04/15/2013
Evidence of Completion of the Corrective Action:
Evidence of the waiver request will be available on ELAR. A copy of the teacher's schedule will indicate the classes he has taken over in order to relieve staff teaching out of their certification.
Description of Internal Monitoring Procedures:
The Director of Education and Principal will develop the schedule and monitor its implementation.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 11.4 Teachers (Special Education Teachers and Regular Education Teachers) / Corrective Action Plan Status: Approved
Status Date: 05/31/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
Children's Study Home must submit a current teacher roster that includes all required elements on the Teacher Roster Template that can be found in the WBMS Document Library. A copy of a current license and/or approved waiver must be submitted for each teacher listed on the roster.
Progress Report Due Date(s):
06/20/2013
09/12/2013

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MA Department of Elementary & Secondary Education , Program Quality Assurance Services

Children's Study Home Corrective Action Plan

PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 12.1 New Staff Orientation and Training / PR Rating:
Partially Implemented
Applies To:
All
Department Program Review Findings:
A review of staff records and interviews indicate that while staff report receiving required trainings, evidence of program's philosophy, organization, practices, goals, runaway policy, and civil rights training during new staff orientation are not documented.
Description of Corrective Action:
A review of all staff training records has been made and all staff have been brought up to date. The Director of Admissions (including Human Resources) is keeping and updating a spreadsheet of required trainings as receipts of completed trainings are received.
A checklist for new staff, listing all DESE trainings required under Criteria 12.1 a-e, has been developed and will be completed by the Director of Education at the time of hire. The completed checklist will be filed in the staff member's personnel file.
Title/Role(s) of Responsible Persons:
Executive Director, Director of Education, Director of Administration / Expected Date of Completion:
03/15/2013
Evidence of Completion of the Corrective Action:
The spreadsheet of required trainings will reflect completion. Personnel files will have evidence of training completions. The checklist for new employees will demonstrate completion of 12.1 trainings.
Description of Internal Monitoring Procedures:
The Director of Administration updates the spreadsheet after monthly trainings and shares it with the Director of Education who will make arrangements for any staff who missed that month's training.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 12.1 New Staff Orientation and Training / Corrective Action Plan Status: Partially Approved
Status Date: 05/31/2013
Basis for Partial Approval or Disapproval:
Children's Study Home states a new checklist for new staff to include the mandated training has been developed and will be completed by the Director of Education at the time of hire.
Department Order of Corrective Action:
Children's Study Home must submit a narrative to describe how the program will ensure new staff receive all required training prior to their assignment of direct care duties with students.
Required Elements of Progress Report(s):
In the 06/20/2013 progress report Children's Study Home must submit a completed New Staff Orientation checklist for any new hire for both programs that includes all mandated trainings listed under criterion 12.2 a-e, as well as evidence the staff participated in training of the program's philosophy, practices and goals. Children's Study Home must also submit a narrative describing how both programs will ensure that new staff receive all required training prior to their assignment of direct care duties with students. In the 09/12/2013 progress report Children's Study Home must submit a completed New Staff Orientation checklist for any new hire between 06/20/2013 and 09/12/2013 for both programs that includes all mandated trainings listed under criterion 12.2 a-e, as well as evidence the staff participated in training of the program's philosophy, practices and goals. Children's Study Home must also submit a narrative describing how both programs ensured the new staff received all required trainings prior to their assignment of direct care duties with students.
Progress Report Due Date(s):
06/20/2013
09/12/2013

7

MA Department of Elementary & Secondary Education , Program Quality Assurance Services

Children's Study Home Corrective Action Plan

PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 12.2 In-Service Training Plan and Calendar / PR Rating:
Partially Implemented
Applies To:
A - Latency Residential Program
Department Program Review Findings:
A review of staff records and interviews indicate that residential staff do not receive all required trainings annually or on average at least two hours per month.
Description of Corrective Action:
A new staff training calendar for the 2013-2014 school year has been developed with the cooperation of the Residential Director. The calendar includes more than 2 hours of training per month, covers all DESE required trainings and will be attended by both the school and residential staff in the Res/Ed program.
Title/Role(s) of Responsible Persons:
Executive Director, Director of Ed., Director of Residences, Director of Admin. / Expected Date of Completion:
03/15/2013
Evidence of Completion of the Corrective Action:
The new training calendar shows the required trainings, scheduled date, hours of training, and the name of the presenter. Training record receipts will show staff participation and will be filed in personnel files and recorded on the training spreadsheet.
Description of Internal Monitoring Procedures:
The Director of Administration updates the spreadsheet after monthly trainings and shares it with the Director of Education who will make arrangements for any staff who missed that month's training.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 12.2 In-Service Training Plan and Calendar / Corrective Action Plan Status: Approved
Status Date: 05/31/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
In the 06/20/2013 progress report Children's Study Home must submit the in-service training plan and calendar for the Latency Residential Program that includes all required trainings and specifically documents how staff are offered an average of at least 2 hours of training each month. In the 09/12/2013 progress report Children's Study Home must submit evidence of training record receipts showing staff participation that has been filed in staff files and recorded on the program's training spreadsheet for the Latency Residential Program.
Progress Report Due Date(s):
06/20/2013
09/12/2013

8

MA Department of Elementary & Secondary Education , Program Quality Assurance Services

Children's Study Home Corrective Action Plan

PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 12.2 In-Service Training Plan and Calendar / PR Rating:
Partially Implemented
Applies To:
B - Mill Pond Day Program
Department Program Review Findings:
A review of staff records and interviews indicate that all staff do not receive on average at least two hours per month of in-service training.
Description of Corrective Action:
A review of the present training calendar shows that over 2 hours of trainings per month have been scheduled and improved documentation procedures will reflect that in the personnel files. The Director of Admissions (including Human Resources) is keeping and updating a spreadsheet of required trainings as receipts of completed trainings are received.
The Director of Administration updates the spreadsheet after monthly trainings and shares it with the Director of Education who will make arrangements for any staff who missed that month's training.
Title/Role(s) of Responsible Persons:
Executive Director, Director of Ed., Director of Administration (includes HR) / Expected Date of Completion:
03/15/2013
Evidence of Completion of the Corrective Action:
The present training calendar reflects 39.5 hours of training hours and the spreadsheet of trainings and staff personnel records reflect the completed trainings.
Description of Internal Monitoring Procedures:
The Director of Administration updates the spreadsheet after monthly trainings and shares it with the Director of Education who will make arrangements for any staff who missed that month's training.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 12.2 In-Service Training Plan and Calendar / Corrective Action Plan Status: Approved
Status Date: 05/31/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
For the 09/12/2013 progress report, Children's Study Home must specifically document for the Mill Pond Day Program how staff are offered an average of at least 2 hours of training each month by submitting evidence of training record receipts showing staff participation that have been filed in staff files and recorded on the program's training spreadsheet.
Progress Report Due Date(s):
09/12/2013

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