MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
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 7/13/2012.

Mandatory One-Year Compliance Date: 7/12/2013

Summary of Required Corrective Action Plans

Stetson School, IncCPR/Program Review Onsite Year: 2011-2012

Programs under review for the agency
A - Stetson Residential Program
Criterion # / Criterion Title / CPR Rating / Applies To / CAP Status
5.2(a) / Contracts / Partially Implemented / A / Approved
8.8 / IEP - Progress Reports / Partially Implemented / A / Approved
9.1(a) / Student Separation Resulting from Behavior Management / Partially Implemented / A / Approved
11.1 / Personnel Policies and Procedures Manual / Partially Implemented / A / Approved
12.2 / In-Service Training Plan and Calendar / Partially Implemented / A / Approved
16.7 / Preventive Health Care / Partially Implemented / A / Approved
PROGRAM REVIEW
CORRECTIVE ACTION PLAN

Corrective Action Plan Detail

Stetson School, IncCPR/Program Review Onsite Year: 2011-2012

PS Criterion #5.2(a) - Contracts

Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 07/12/2013
Program Review Finding / Student record review indicates that written contracts for some enrolled students do not include all required language nor are they signed by the sending district.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / If Stetson does not receive a signed contract from a sending district upon the child's admission, a letter will be sent to the district requesting the signed contract. If the contract does not have the required five elements, Stetson will send an amendment that includes the required elements and request that the amendment be signed.
* Evidence of Completion of Corrective Action / A tracking matrix, letters to school systems, and copies of the signed contracts will be used as evidence of completion of the corrective action.
* Description of Internal Monitoring Process / Stetson will create a matrix to track contracts received, signatures, and contains the five required elements.
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 / Stetson states that a letter will be sent to the district requesting the signed contract. Stetson will also send an amendment if the contract does not have the required five elements and request it be signed.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
02/08/2013
05/06/2013
Required Elements of Progress Report(s) / Stetson must submit the matrix developed to track contracts received for all currently enrolled Massachusetts students. If the contract is not signed by the district and/or it does not include the five required elements, Stetson must submit a copy of the letter sent to the district requesting the signed contract and a copy of the amendment to be signed that includes the required language.
PQA Review Complete

PS Criterion #8.8 - IEP - Progress Reports

Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 07/12/2013
Program Review Finding / Documentation and student record review indicate that the person who is to receive the progress reports is not evident for all students.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Stetson will create an online database to track who IEP progress reports are sent to, the date sent, and who sent them. All staff responsible for sending IEP progress reports will be trained in the use of the new system. The secretary-education will ensure all progress reports are sent and tracked properly at the end of each marking quarter.
* Evidence of Completion of Corrective Action / Reports from the online database will be used as evidence of completion.
* Description of Internal Monitoring Process / Attendance sheets from the database training will be used to ensure that all staff needed to be trained in the system are trained. Reports from the online database will be used to check and ensure that progress reports are being sent at the end of each marking quarter.
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 / Stetson will utilize a created online database to track who is to receive IEP progress reports, the date sent and who sent them. Stetson will train staff who are responsible for sending the IEP progress reports on this new system.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
02/08/2013
05/06/2013
Required Elements of Progress Report(s) / Stetson must submit an updated report from the online database that includes to whom progress reports are sent, the date sent, and who sent the progress reports for all currently enrolled Massachusetts students sent for the first quarter. Stetson must also submit attendance sheets from the training conducted for the staff on the new system including the date of the training, the name and title of the trainer, the date and time of the training and the names and titles of all staff who are trained.
PQA Review Complete

PS Criterion #9.1(a) - Student Separation Resulting from Behavior Management

Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 07/12/2013
Program Review Finding / Documentation, student record review, and interviews indicate that while Stetson maintains a time out log as required, the reasons for intervention and who monitored the student during the time out are not included as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Stetson School's Separation From General Community procedure will be updated to include that staff must document the use of the time out room for individual students utilizing a Time Out Room Log. A Time Out Room Log will be created and will include the date of the time out, the length of time the student was in the time out room, the reasons for the time out, name of staff who approved the time out, and the name of the staff who monitored the student during the time out. Staff will be trained in the new procedure and use of the new log.
* Evidence of Completion of Corrective Action / Stetson will provide the updated procedure, attendance sheets for the staff training, and copies of the filled in logs as evidence of completion of the corrective action.
* Description of Internal Monitoring Process / Our Staff Development and Performance Quality Improvement (PQI) Coordinator will ensure all staff who need to be trained in this procedure are trained. Completed logs will be kept in binders in the school for the school time out rooms and on the residence for the residential time out rooms. The Education Director and Residential Director will be responsible for checking periodically to ensure logs are being used consistently and properly.
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 / Stetson will update their Separation from General Community Procedure to include all required elements. Stetson will train staff in the new procedure and use of the time out log.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
02/08/2013
05/06/2013
Required Elements of Progress Report(s) / Stetson must submit a copy of the updated Separation from General Community Procedure and a copy of time out logs for the months of October 2012 through January 2013. The updated form must include the date of the time out, the length of time the student was in the time out room, the reasons for the time out, the name of staff who approved the time out and the name of the staff who monitored the student during the time out. Stetson must also submit attendance sheets for all staff required to be trained on the new Separation from General Community Procedure and use of the time out log including the date of the training, the name and title of the trainer, the date and time of the training and the names and titles of all staff who were trained.
PQA Review Complete

PS Criterion #11.1 - Personnel Policies and Procedures Manual

Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 07/12/2013
Program Review Finding / Staff record review indicates that not all staff received written performance evaluations.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / The Personnel Records procedure will be updated to include an auditing procedure . As part of the procedure and audit, Human Resources will check all personnel files once a year to ensure all staff have received written performance evaluations in accordance with our policies and procedures regarding staff evaluation. If an evaluation has not been completed, H.R. will follow up with the appropriate department head to ensure that the evaluation is completed.
* Evidence of Completion of Corrective Action / Copies of the updated procedure and one completed audit will be provided as evidence of completion of the corrective action.
* Description of Internal Monitoring Process / The annual audit will serve as our internal monitoring process.
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 / Stetson will update the personnel records procedure to include an auditing procedure to ensure that all staff receive written performance evaluations.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
02/08/2013
05/06/2013
Required Elements of Progress Report(s) / Stetson must submit a copy of the updated personnel procedure. Stetson must submit a timeline that includes the the following: the date of the most recent written performance evaluation that was reviewed and signed by both the employee and supervisor for each employee; the date each staff is scheduled to be reviewed; and when Human Resources will follow-up if necessary. For the May 6, 2013 progress report: Stetson must submit evidence of the one completed audit and provide a detailed narrative on any follow up required by Human Resources.
PQA Review Complete

PS Criterion #12.2 - In-Service Training Plan and Calendar

Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 07/12/2013
Program Review Finding / Documentation, staff record review and interviews indicate that Program Directors and Unit Directors who conduct trainings and are involved in policy making do not receive the other required trainings annually.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Program directors and administrators will sign all attendance sheets even when conducting the training. Our Staff Development and Performance Quality Improvement (PQI) Coordinator will use our training database to audit and ensure that all program administrators are receiving all required trainings annually. Our Staff Development and Performance Quality Improvement (PQI) Coordinator will use the weekly Program Administrators Meeting to make up any trainings missed by program administrators.
* Evidence of Completion of Corrective Action / Reports from our training database will be created to show the trainings each program administrator received during 2012 and the date they received those trainings. Attendance sheets from those trainings can also be provided.
* Description of Internal Monitoring Process / Our Staff Development and Performance Quality Improvement (PQI) Coordinator will use our training database to do periodic audits to ensure all program administrators are receiving required trainings.
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 / Stetson has assigned the Staff Development and Performance Quality Improvement (PQI) Coordinator to audit and ensure that all program administrators receive all required trainings annually.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
02/08/2013
05/06/2013
Required Elements of Progress Report(s) / Stetson must submit the names of all program administrators and copies of each person's training sheets for all required trainings conducted prior to the submission of this progress report 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 / 07/12/2013
Program Review Finding / Student record review indicates that not all students have a record of hearing screenings at the grade levels required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Hearing Screenings are completed as part of the student's annual physical at Barre Health Center. We will create a form for the doctor to fill out during the annual physical to indicate all tests completed including hearing, vision, and posture.
* Evidence of Completion of Corrective Action / A copy of the matrix used for the internal monitoring process will be provided as evidence of completion of the corrective action.
* Description of Internal Monitoring Process / A matrix will be completed to track all screenings required in Criteria 16.7.
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 / Stetson will develop a matrix to track all required hearing, vision and postural screenings. Stetson will create a form for the doctor to fill out at the annual physical at Barre Health Center to indicate all tests are conducted at the time of the annual physical visit.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
02/08/2013
05/06/2013
Required Elements of Progress Report(s) / Stetson must submit a copy of the form developed for the Barre Health Center which includes the information for hearing, vision and postural screenings. Stetson must submit a copy of the matrix for all currently enrolled Massachusetts students. The program must also submit evidence of hearing screenings that have since been conducted for the 8 records the Department reviewed onsite at the time of the program review.
PQA Review Complete

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

StetsonSchool, Inc. PR Corrective Action Plan