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 June 6, 2012.
Mandatory One-Year Compliance Date: 06/07/2013
Summary of Required Corrective Action Plans
Little People’s School, Inc.CPR/Program Review Onsite Year: 2011-2012
Programs under review for the agencyA - Learning Prep School Day Program
Criterion # / Criterion Title / CPR Rating / Applies To / CAP Status
8.8 / IEP - Progress Reports / Partially Implemented / A / In Process
9.1(a) / Student Separation Resulting from Behavior Management / Partially Implemented / A / In Process
10.1 / Staffing for Instructional Groupings / Partially Implemented / A / In Process
10.2 / Age Range / Partially Implemented / A / In Process
11.3 / Educational Administrator Qualifications / Partially Implemented / A / In Process
11.4 / Teachers (Special Education Teachers and Regular Education Teachers) / Partially Implemented / A / In Process
11.5 / Related Services Staff / Partially Implemented / A / In Process
11.6 / Master Staff Roster / Partially Implemented / A / In Process
11.9 / Organizational Structure / Partially Implemented / A / In Process
15.1 / Parental Involvement and Parents' Advisory Group / Partially Implemented / A / In Process
16.7 / Preventive Health Care / Partially Implemented / A / In Process
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Corrective Action Plan Detail
Little People’s School, Inc.
CPR/Program Review Onsite Year: 2011-2012
PS Criterion #8.8 - IEP - Progress Reports
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/07/2013Program Review Finding / Student records and interviews indicate that while progress reports provide a comprehensive course description, they do not specifically reflect progress made towards the benchmarks and goals for each student as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / LPS will ensure that progress reports will provide a comprehensive course description that specifically reflects progress made towards the benchmarks and goals for each student as required. LPS will conduct trainings on the appropriate reporting of student progress which will include how to specifically reflect progress towards the benchmarks and goals for each student. These trainings will be mandatory for all staff responsible for preparing progress reports. The first term progress reports will be reviewed by the supervisor to ensure the progress reports reflect progress made towards the benchmarks and goals for each student. Supervisors will provide additional training if necessary.
* Evidence of Completion of Corrective Action / LPS will submit the the sign in sheets for the Progress Report Training. LPS will submit to DESE a sampling of Progress Reports prepared by staff for the first term, that demonstrates compliance with progress reports that reflect student progress made towards the benchmarks and goals.
* Description of Internal Monitoring Process / Progress Reports will be reviewed by supervisors before submission to ensure documentation compliance. Additional training will be provided to staff when necessary.
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 / As requested LPS has submitted a plan to ensure that progress reports specifically address individual progress made toward the IEP goals and benchmarks for each student. Furthermore, LPS has submitted a statement assuring the Department that it has committed to providing the necessary training to all staff members in order to ensure school wide compliance.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/19/2012
10/19/2012
11/30/2012
Required Elements of Progress Report(s) / LPS must submit to the evidence that all staff who are responsible for writing progress reports have received training on the appropriate reporting of student progress. This documentation must include the name and job title of the person who conducted the training, the date of the training, the time of the training, the agenda of the training and the names and positions of all staff who participated in the training. For any staff who did not participate, LPS must list the names and positions of those staff members and describe how and when they will receive the training. Additionally, LPS must submit progress reports for 5 students from each level (Elementary, Middle and High School) that were issued to sending school districts, parents and other appropriate parties from the first quarter of the 2012/2013 school year.
PQA Review Complete
PS Criterion #9.1(a) - Student Separation Resulting from Behavior Management
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/07/2013Program Review Finding / A review of documentation and interviews indicated that the policies and procedures for Behavior Management did not contain all of the required elements, specifically: guidelines for staff utilizing time-out space; identification of the person responsible for implementing such procedures; a means of documenting the use of time-out for an individual student, including length of time, reason for the intervention, who approved the procedure, and who monitored the time out; and a statement assuring the time-out room will not be locked and that any room or space used for the practice of separation must be physically safe and appropriate to the population served by the facility.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / The revision of the policies and procedures for Behavior Management has taken place during a series of actions for revision by the Dean of Students. Before the revision was implemented there was a training for all staff with required elements including guidelines for staff utilizing time-out space; identification of the person responsible for implementing such procedures; a means of documenting the use of time-out for an individual student, including length of time, reason for the intervention, who approved the procedure, and who monitored the time out; and a statement assuring the time-out room will not be locked and that any room or space used for the practice of separation must be physically safe and appropriate to the population served by the facility.
* Evidence of Completion of Corrective Action / There will be additional training at the orientation for all staff on August 27th to ensure all staff understand the revised policy and procedures. The revised Policies and Procedures for Behavior Management will be submitted to the DESE with the Behavior Management Training agenda and sign in sheet. Upon approval of the revised Behavior Management Policy, LPS will send the revised policy to all parents and LEAs of currently enrolled students. The new policy will be inserted in the Policy and Procedure Manual. The new policy will also be added to the admissions packet so all new students' parents and LEAs will be aware of the Behavior Management Policy prior to admission to LPS.
* Description of Internal Monitoring Process / For internal monitoring the Executive Director will review the time out logs to ensure that the logs identify the names of the staff who approved/monitored the time out procedures. Tje Executive Director will provide feedback to the appropriate staff, when necessary. With this method LPS will be able to direct further training/monitoring to ensure on-going compliance.
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 / LPS has submitted a statement that the behavior management policy has been updated to include all necessary elements that are outlined in criterion 9.1(a).
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/19/2012
10/19/2012
11/30/2012
Required Elements of Progress Report(s) / LPS must submit a copy of the updated behavior management policy that includes all required elements. LPS must also submit evidence of staff training on the revised behavior management policy that includes the name and job title of the person who conducted the training, the date of the training, the time of the training, the agenda of the training and the names and positions of all staff who participated in the training. For any staff who did not participate, LPS must list the names and positions of those staff members and describe how and when they will receive the training on the revised behavior management policies. LPS must also submit copies of all time out logs for each level (Elementary, Middle and High School) that includes all required elements listed in this criterion.
PQA Review Complete
PS Criterion #10.1 - Staffing for Instructional Groupings
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/07/2013Program Review Finding / Observations, documentation and interviews indicate that at the high school level some classes have up to 8 students with 1 Licensed Educator, exceeding the program's approved ratio of 6:1.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / LPS will ensure that all classes will comply with the program's approved ratio of 6:1. All classrooms will have a maximum of 6 students to 1 Licensed Educator.
* Evidence of Completion of Corrective Action / LPS will submit the block schedules to DESE that will indicate the number of students per classroom demonstrating compliance of a maximum of 6 students to 1 Licensed Educator, per the DESE approved ratio of 6:1..
* Description of Internal Monitoring Process / The Executive Director will review and approve all block schedules prior to implementation to ensure the classroom assignments do not exceed the program's approved ratio of 6 students to 1 Licensed Educator.
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 / LPS submitted a statement noting that "all classes will comply with the program's approved ratio of 6:1. All classrooms will have a maximum of 6 students to 1 licensed educator." Based on the current pending 2012 Reconstruction it is expected that LPS is implementing new ratios of 8:1 instead of 6:1.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/19/2012
10/19/2012
11/30/2012
Required Elements of Progress Report(s) / LPS must submit copies of block schedules that indicate the number of students and licensed educators in all classrooms. LPS must also submit a listing of all students by grade level and classroom. Additionally, the Department will conduct an onsite visit to verify that a staff to student ratio of 8:1 is being maintained.
PQA Review Complete
PS Criterion #10.2 - Age Range
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/07/2013Program Review Finding / A review of documentation indicates that there were instructional groupings of students who were beyond the 48 month age span requirement and the program had not requested a waiver by the Department in this regard.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / LPS will ensure that all instructional groupings of students shall not differ by more than forty-eight months.
* Evidence of Completion of Corrective Action / LPS will ensure that all classroom assignments comply with the forty-eight month age span requirement. The block schedules will identify the birthdates of each student. LPS will submit the block schedules to DESE demonstrating classroom assignments comply with the 48 month age span requirement.
* Description of Internal Monitoring Process / The Executive Director will review and approve all block schedules prior to implementation, to ensure the classroom assignments comply with the forty-eight month age span requirement.
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 / LPS submitted a statement noting that "LPS will ensure that all instructional groupings of students shall not differ by more than forty-eight months."
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/19/2012
10/19/2012
11/30/2012
Required Elements of Progress Report(s) / LPS must submit block schedules for all classrooms indicating the initials of students with corresponding birth dates.
PQA Review Complete
PS Criterion #11.3 - Educational Administrator Qualifications
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/07/2013Program Review Finding / Documentation and staff interviews indicate that some of the job responsibilities of the Educational Administrator are being delegated to and implemented by staff who are not appropriately qualified to serve in this position.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / LPS has three Educational Administrators for 262 students, titled Educational Team Facilitator. One Educational Team Facilitator will be designated as Director of Educational Team Facilitators to ensure consistency in supervision of the provision of special education services. The Director of Educational Team Facilitators will be a member of the Administrative Management Team. The Director of Educational Team Facilitators and the other two Educational Team Facilitators will supervise the provision of special education services in the program and ensure that the services specified in each student's IEP are delivered.
* Evidence of Completion of Corrective Action / The three Educational Administrators are appropriately qualified to serve in this position. Given the number of students and number of services specified in each student's IEP, the Educational Administrators may delegate the responsibility of review of the progress notes to Department Heads. Any delegation of the job responsibilities of the Educational Administrator will only be to staff that are appropriately qualified to serve in this position. The Department Heads or any other staff assigned responsibilities of the Educational Administrator will possess licensure as a special educational administrator or possess all of the following: License as a special educator, a minimum of a master's degree in special education or a related field; and a minimum of one year of administrative experience. The Department Head job description will include the above qualifications. LPS will submit the Department Head job Descriptions, the names of the staff and the appropriate documentation to DESE demonstrating the staff assuming responsibilites of the Educational Administrator are qualified to serve in the position.
* Description of Internal Monitoring Process / The Executive Director will ensure that the delegation of the job responsibilities of the Educational Administrator will be to staff appropriately qualified to serve in this position by approving the staff prior to the delegation of the responsibilities. The Executive Director will require documentation indicating the staff have licensure as a special educational administrator or possess all of the following: License as a special educator, a minimum of a master's degree in special education or a related field; and a minimum of one year of administrative experience.
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 / LPS has submitted a plan to ensure that the job responsibilities of the Educational Administrator are only being implemented by staff members who are appropriately qualified to serve in this position.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
09/19/2012
10/19/2012
11/30/2012
Required Elements of Progress Report(s) / LPS must submit the names and qualifications of the designated Educational Administrator, as well as the names and job descriptions of all staff members who perform some or all job functions on behalf of the Educational Administrator. This information must be submitted by 9/19/2012. By 11/30/2012, LPS must submit copies of sign-in sheets for all IEP meetings that occur during the first quarter of the 2012/2013 school year, highlighting the person from LPS who served in the role of Educational Administrator.