Program Quality Assurance Services
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
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 3/30/2012.
Mandatory One-Year Compliance Date: 4/2/2013
Summary of Required Corrective Action Plans
Farr Academy, Inc CPR/Program Review Onsite Year: 2011-2012
Programs under review for the agencyA - Farr Academy Day Program
B - Farr Academy Summer Program
Criterion # / Criterion Title / CPR Rating / Applies To / CAP Status
12.1 / New Staff Orientation and Training / Partially Implemented / A,B / Approved
12.2 / In-Service Training Plan and Calendar / Partially Implemented / A,B / Approved
16.7 / Preventive Health Care / Partially Implemented / A / Approved
16.7 / Preventive Health Care / Partially Implemented / B / Approved
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Corrective Action Plan Detail
Farr Academy, Inc
CPR/Program Review Onsite Year: 2011-2012
PS Criterion #12.1 - New Staff Orientation and Training
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 04/02/2013Program Review Finding / While interviews revealed that new staff orientation occurs, documentation and staff record reviews revealed that orientation for new staff members is not documented as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / New Staff Orientation and Training documentation is now included in the new staff records as a separate document from the annual Inservice Training document and will continue to be maintained as such.
* Evidence of Completion of Corrective Action / Evidence of New Staff Orientation and Training and attendance sheets are maintained in the staff files and will be uploaded to DESE.
* Description of Internal Monitoring Process / Upon the completion of any New Staff Orientation the Program Director will review new staff files to ensure that documentation of participation of the new staff is contained therein.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Farr Academy has indicated their understanding of this requirement and discussed with the liaison ways to come into compliance and ongoing monitoring of this criterion by stating that the required training document is now included in the New Staff records.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/17/2012
11/17/2012
Required Elements of Progress Report(s) / Farr Academy must submit a New Staff Orientation checklist that includes all of the following required elements: 1.Program's Philosophy; 2.Organization; 3.Program; 4.Practices; 5.Goals: 6. ESE required topics (12.2 a-e); and Provisions for orientation of intern, volunteers or others who work at the program, if applicable. Farr Academy must upload copies of all completed orientation checklists for all new staff hired for the 2012-2013 school year that includes the name of the staff member, date of hire and completion date for all required training topics.
PQA Review Complete
PS Criterion #12.2 - In-Service Training Plan and Calendar
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 04/02/2013Program Review Finding / While interviews revealed that in-service training occurs, documentation and staff record reviews revealed that staff in-service training is not documented as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / The Annual Inservice Training Plan and Calendar for individual staff members will now reflect wording that states the staff attended the trainings listed on the documentation contained in their file as well as signed attendance for each training attended.
* Evidence of Completion of Corrective Action / Evidence of Annual Inservice Training Plan and Calendar and signed attendance forms are maintained in the staff files and will be uploaded to DESE.
* Description of Internal Monitoring Process / The Program Director and Associate Director will annually review staff files to ensure documentation of attendance and participation in Staff Inservice Training is contained therein.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Farr Academy has indicated their understanding of this requirement and discussed with this liaison ways to come into compliance and ongoing monitoring of this criterion by revising their Annual In-Service Training Plan to include signed attendance for each training which will be kept in individual staff files.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/17/2012
11/17/2012
Required Elements of Progress Report(s) / Farr Academy must submit evidence of its procedure to ensure documentation that all new and returning staff members have participated in all required in-service training topics which must be provided annually and also submit evidence of at least two hours of training per month and that this documentation is kept for each staff member in their personnel files. Farr Academy must submit the In-Service Training documentation for the records of at least five staff in various positions for the 2012-2013 school year.
PQA Review Complete
PS Criterion #16.7 - Preventive Health Care
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 04/02/2013Program Review Finding / Documentation, student record review, and interviews revealed that not all students in the Day Program had evidence of physical and dental examinations and vision, hearing and postural screenings as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Physical Exams and Postural Screenings - Physical examinations with evidence of postural screenings are requested upon acceptance into the program. If a written report from the physician of the results of the examination and any recommendations and/or modifications of the students' activity are not submitted a second written request will be issued to the parent/guardian as well as telephone contact. A tracking log of telephone contact will be maintained. Copies of letters requesting this information currently contained in the Student Records will be contained in the Student Medical Files. Dental Exams - Dental examinations are currently requested upon acceptance into the program. If a written report from the dentist of the results of the examination and any recommendations and/or modifications of the students' activity are not submitted a second written request will be issued to the parent/guardian as well as telephone contact. A tracking log of telephone contact will be maintained. Copies of letters requesting this information currently contained in the Student Records will be contained in the Student Medical Files. Vision and Hearing Screenings - Vision and Hearing Screenings are conducted annually by a technician from the Cambridge Public Health Department. Following the screenings any positive findings are sent to each students' parent/guardian along with any recommendations. Written notification of these screenings has been moved from the Student Record files to the Student Medical Files.
* Evidence of Completion of Corrective Action / Documentation will be contained in the Student Medical Files.
* Description of Internal Monitoring Process / The Parent Clinical Coordinator will review, track and maintain a log of the requests for and receipt of the evidence of Physical and Dental examinations.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Farr Academy has indicated their understanding of this requirement and discussed with this liaison ways to come into compliance and ongoing monitoring of this criterion and have proceeded to require proof of exams and screenings and documentation of efforts to receive them from parents/guardians based on annual or Department of Public Health requirements.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/17/2012
11/17/2012
Required Elements of Progress Report(s) / Farr Academy must submit a chart containing the dates of the following for all currently enrolled students: 1. Last physical exam 2. Last dental exam 3. Last vision screening 4. Last hearing screening 5. Last postural screening
PQA Review Complete
PS Criterion #16.7 - Preventive Health Care
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 04/02/2013Program Review Finding / Documentation, student record review, and interviews revealed that not all students in the Summer Program had evidence of physical and dental examinations and vision and hearing screenings as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Physical Exams - Physical examinations are requested upon acceptance into the program. If a written report from the physician of the results of the examination and any recommendations and/or modifications of the students' activity are not submitted a second written request will be issued to the parent/guardian as well as telephone contact. A tracking log of telephone contact will be maintained. Copies of letters requesting this information currently contained in the Student Records will be contained in the Student Medical Files. Dental Exams - Dental examinations are currently requested upon acceptance into the program. If a written report from the dentist of the results of the examination and any recommendations and/or modifications of the students' activity are not submitted a second written request will be issued to the parent/guardian as well as telephone contact. A tracking log of telephone contact will be maintained. Copies of letters requesting this information currently contained in the Student Records will be contained in the Student Medical Files. Vision and Hearing Screenings - Vision and Hearing Screenings are conducted annually by a technician from the Cambridge Public Health Department. Following the screenings any positive findings are sent to each students' parent/guardian along with any recommendations. Written notification of these screenings has been moved from the Student Record files to the Student Medical Files.
* Evidence of Completion of Corrective Action / Documentation will be contained in the Student Medical Files.
* Description of Internal Monitoring Process / The Parent Clinical Coordinator will review, track and maintain a log of the requests for and receipt of the evidence of Physical and Dental examinations.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Farr Academy has indicated their understanding of this requirement and discussed with this liaison ways to come into compliance and ongoing monitoring of this criterion and have proceeded to require proof of exams and screenings and documentation of efforts to receive them from parents/guardians based on annual or Department of Public Health requirements.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/17/2012
11/17/2012
Required Elements of Progress Report(s) / Farr Academy must submit a chart containing the dates of the following for all currently enrolled students: 1. Last physical exam 2. Last dental exam 3. Last vision screening 4. Last hearing screening 5. Last postural screening
PQA Review Complete
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MA Department of Elementary & Secondary Education,Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan