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MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

COORDINATED PROGRAM REVIEW

Bi-County Collaborative

Corrective Action Plan Forms

Program Area: Special Education

Prepared by: Susan L. Cuoco, Ed.D/Arlene Grubert, Ph.D.

CAP Form will expand to as many lines as necessary. Before completing and emailing to pqacap@doe.mass.edu, please see separate

Instructions for Completing Corrective Action Plans.

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: August 26, 2014

COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: SE 6 Determination of Transition

Services

Rating: Partially Implemented

Department CPR Finding: Review of student records and staff interviews indicated that students 14 years of age and older are not consistently invited to IEP Team meetings to discuss transition services.

Student record review also demonstrated that Transition Planning Forms are not completed or updated annually for all students of transition age.

Narrative Description of Corrective Action: Beginning the 2013-2014 school year, the Collaborative added a Transition Coordinator position to oversee, supervise and coach teachers and support staff of all middle/high school alternative programs on the transition planning process. This position is in addition to a Transition Coordinator who is similarly responsible to oversee, supervise, and coach teachers and support staff of the middle/high school developmental and severe disabilities programs.

The Transition Coordinators will work with the Executive Director, Program Directors and Special

Educators to revise procedures to ensure that transition planning procedures are implemented, including inviting students ages 14 and older to Annual IEP meetings, engaging student participation in the completion of the Transition Planning Form (TPF), and annually updating the TPF for all students

14 years and older. Collaborative staff will be trained in policies and procedures to ensure transition planning takes place at scheduled Annual Review IEP meetings. An IEP checklist will be developed for use by Program Directors and staff to ensure that all required components are met for each eligible student.

It is the responsibility of school districts sending students to Collaborative programs to issue invitations to IEP meetings. The Collaborative will work with sending school districts to coordinate inviting students to IEP meetings and including them on meeting invitations and attendance sheets.

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Title/Role of Person(s) Responsible for

Implementation: Executive Director, Program

Directors, Transition Coordinators, Special

Educators

Expected Date of Completion for Each

Corrective Action Activity: April 30, 2014

Evidence of Completion of the Corrective Action: Meeting agendas, Attendance sign-in sheets,

Training Materials

Description of Internal Monitoring Procedures: The Executive Director and Program Directors will conduct an internal random sampling of student records to ensure compliance with policies and protocols and procedures relating to transition.

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: SE 6 Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s):

Please submit the following for progress report 1:

For those student records identified by the Department, submit a copy of the IEP, Transition

Planning Form and the Special Education Team Meeting Attendance Sheet (N3A) to indicate that the IEP Teams have reconvened with the student in attendance to discuss transition services and to update the Transition Planning Form;

A copy of the revised procedures for ensuring that students 14 years of age and older are invited to the IEP meetings, along with procedures for ensuring that Transition Planning Forms are completed annually (upon receipt of the draft procedures the Department may require revisions);

A copy of the newly developed IEP checklist to ensure that all required components are met for each eligible student; and

Evidence of staff training on the revised procedures (agendas, training materials, and signed attendance sheets).

Please submit the following for progress report 2:

Conduct an internal review of student records of students 14 and older, in which a Team meeting was scheduled for after the training, and submit the results of the internal record review and report: o The number of student records reviewed; o The number of records that are compliant; o For all records not in compliance, determine and report the root cause(s) of the noncompliance; and o The collaborative’s plan to remedy any non-compliance.

* Please note that when conducting internal monitoring the collaborative must maintain the following documentation and make it available to the Department upon request: a) List of student names and grade levels for the record review; b) Date of the review; c) Name of person(s) who conducted the review, their roles(s), and their signature(s).

Progress Report Due Date(s): January 10, 2014 & April 11, 2014

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COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: SE 13 Progress Reports and

Content

Rating: Partially Implemented

Department CPR Finding: Review of student records and staff interviews indicated that some parents do not receive reports on the student's progress towards reaching the goals set in the IEP at least as often as parents are informed of the progress of non-disabled students. Specifically, student records from the Keller-Sullivan Alternative Middle School Program did not always include progress reports.

Additionally, progress reports from Franklin High School’s Secondary Therapeutic Program were prepared in a narrative format that does not always include information on the student’s progress towards the annual IEP goals.

Narrative Description of Corrective Action: The BICO Collaborative will conduct staff training on how to write progress reports to specifically address student progress based on goals, objectives and/or benchmarks in a given area. Training will reinforce that progress reports must be prepared on the IEP form provided in SEMSTRACKER and include progress toward Annual IEP goals. Program Director will review progress reports during this school year at Franklin High School’s Secondary Therapeutic

Program and the Keller-Sullivan Alternative Middle School Program to ensure information regarding progress toward IEP goals is included.

A checklist system to monitor distribution of Progress Reports on a quarterly basis to parents, school districts, and for filing in student records will be developed by collaborative staff.

Title/Role of Person(s) Responsible for

Implementation: Program Directors, Special

Education Teachers

Expected Date of Completion for Each

Corrective Action Activity: April 30, 2014

Evidence of Completion of the Corrective Action: The Department will receive a copy of Staff

Meeting Agenda and training specific to procedures for completing progress reports, sign-in sheets documenting staff attendance, and checklist developed to monitor this process.

Description of Internal Monitoring Procedures: A random sample of progress reports and checklists used for monitoring the process will be reviewed by Program Directors and Executive Director from the two programs cited.

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: SE 13 Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s):

Please submit the following for progress report 1:

IEP checklist (upon receipt of the draft procedures the Department may require revisions).

Evidence of staff training, specifically staff from Franklin High School’s Secondary

Therapeutic Program and the Keller-Sullivan Alternative Middle School Program (agendas, training materials, and signed attendance sheets).

Please submit the following for progress report 2:

Conduct an internal review of student records for progress reports written subsequent to the training and submit the results of the internal record review. Indicate:

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o The number of student records reviewed from the Keller-Sullivan Alternative Middle

School Program and Franklin High School’s Secondary Therapeutic Program; o The number of records that are compliant; o For all records not in compliance, determine and report the root cause(s) of the noncompliance; and o The collaborative’s plan to remedy any non-compliance.

* Please note that when conducting internal monitoring the collaborative must maintain the following documentation and make it available to the Department upon request: a) List of student names and grade levels for the record review; b) Date of the review; c) Name of person(s) who conducted the review, their roles(s), and their signature(s).

Progress Report Due Date(s): January 10, 2014 & April 11, 2014

COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: SE 22 IEP Implementation and

Availability

Rating: Partially Implemented

Department CPR Finding: Review of student records and interviews indicated that there are cases where students are enrolled in the collaborative program without an accepted IEP or placement.

Narrative Description of Corrective Action: Student referral and intake checklist will ensure that signatures on IEPs and Placement forms are in place in accordance with regulations. Student intake tracking form/checklist will be updated to include date of signed IEP and Placement. The Collaborative will work with sending districts to ensure IEPs and Placements are signed prior to enrolling students.

The Collaborative will document efforts to ensure signed IEPs and Placements.

Title/Role of Person(s) Responsible for

Implementation: Director of Clinical Services,

Program Directors

Expected Date of Completion for Each

Corrective Action Activity: April 30, 2014

Evidence of Completion of the Corrective Action: Student referral and intake checklist tracking signed IEP signatures and Placement; official notification to sending school districts, and staff meeting agendas, attendance, and materials used to address the issue of signed IEPs and Placement forms.

Description of Internal Monitoring Procedures: Program Directors and Office Staff will continue to randomly select student records to ensure that IEPs and Placement forms across programs and grades are signed.

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: SE 22 Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s):

Please submit the following for progress report 1:

For those students whose records were identified by the Department, the collaborative must submit a copy of the signed IEP and signed placement page;

Copy of the student intake tracking form/checklist; and

Evidence of staff training (agendas, training materials, and signed attendance sheets)

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Please submit the following for progress report 2:

Conduct an internal review of student record and submit the results of the internal record review. Indicate: o The number of student records reviewed; o The number of records that are compliant; o For all records not in compliance, determine and report the root cause(s) of the noncompliance; and o The collaborative’s plan to remedy any non-compliance.

* Please note that when conducting internal monitoring the collaborative must maintain the following documentation and make it available to the Department upon request: a) List of student names and grade levels for the record review; b) Date of the review; c) Name of person(s) who conducted the review, their roles(s), and their signature(s).

Progress Report Due Date(s): January 10, 2014 & April 11, 2014

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MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

COORDINATED PROGRAM REVIEW

Bi-County Collaborative

Corrective Action Plan Forms

Program Area: Civil Rights

Prepared by: Susan L. Cuoco, Ed.D./Arlene Grubert, Ph.D.

CAP Form will expand to as many lines as necessary. Before completing and emailing to pqacap@doe.mass.edu, please see separate

Instructions for Completing Corrective Action Plans.

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: August 26, 2014

COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: CR 10A Student handbooks and codes of conduct

Rating: Partially Implemented

Department CPR Finding: Review of documentation indicated that the student code of conduct does not contain procedures assuring due process in disciplinary proceedings or appropriate procedures for the discipline of students with special needs.

The nondiscrimination policy has not been updated to include the protected category of gender identity.

Narrative Description of Corrective Action: The student code of conduct in the Student Handbook will be revised to include procedures assuring due process in disciplinary proceedings and the appropriate procedures for the discipline of students with special needs. Such policies and procedures exist in the Collaborative’s Employee and Student Health Manual. These will be reviewed and all policies and procedures aligned in all pertinent documents. The revised Student Handbook will be posted on the BICO website. Parents will be notified in writing of the changes in Student Handbook, its location in the handbook on the BICO website and that they may request to receive a hard copy in the mail. The revised Student Handbook will replace the current handbook in new student registration packets.

Nondiscrimination policy will be updated to include the protected category of gender identity; such revision will also be placed in Student Handbook version.

All staff members will be notified via email of these revisions and update to the Collaborative’s policies and Student Handbook as well as that all parents/guardians have been informed.

Title/Role of Person(s) Responsible for

Implementation: Executive Director and Program

Directors

Expected Date of Completion for Each

Corrective Action Activity: April 30, 2014

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Evidence of Completion of the Corrective Action: Revised Student Code of Conduct and

Nondiscrimination policy in Student Handbook; correspondence to staff and parents/guardians; website posting; updated registration packet to include revised Student Handbook.

Description of Internal Monitoring Procedures: Executive Director will review tracking list to ensure that all parents have received notification; ensure that revised Student Handbook is in new student registration packet.

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: CR 10A Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s):

Please submit the following for progress report 1:

C

opy of the revised student handbook which should include:

1.

Procedures assuring due process in disciplinary proceedings and the appropriate procedures for the discipline of students with special needs

2.

Nondiscrimination policy including the protected category of gender identity

Evidence of notification to staff and parents of these changes/updates

Progress Report Due Date(s): January 10, 2014

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MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

COORDINATED PROGRAM REVIEW

Bi-County Collaborative

Corrective Action Plan Forms

Program Area: Approved Public Day Program Standards

Prepared by: Susan L. Cuoco, Ed.D./Arlene Grubert, Ph.D.

CAP Form will expand to as many lines as necessary. Before completing and emailing to pqacap@doe.mass.edu, please see separate

Instructions for Completing Corrective Action Plans.

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: August 26, 2014

COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: APD 5.2(a) Contracts Rating: Partially Implemented

Department CPR Finding: Review of student records and interviews indicated that the collaborative does not have contracts with all school districts for each student enrolled in the day program.

Narrative Description of Corrective Action: The BICO Collaborative will work with sending school districts to ensure that all districts have contracts for students enrolled in the Collaborative’s public day schools. BICO will notify sending school districts in writing of the requirement for each student enrolled in The Finberg School or Kelly Boulevard public day school that a signed contract by BICO and the Collaborative is needed. The BICO Collaborative will create a tracking form for all students enrolled in these public day school programs. Student referral and intake process and forms will be revised to include this requirement. Upon enrollment, new student names will be added to the list noting the sending district and the sending district will be reminded in writing of the need for a student contract. During the intake process, the Out-of-District Placement Coordinator or Administrator of

Special Education processing the referral will be reminded by the Director of Clinical Services of the need for a student contract. This topic will be placed on an Agenda of the members of the Operating

Committee (Member District Administrators of Special Education) , Out-of-District Placement

Coordinators and BICO Leadership Staff meeting.

Title/Role of Person(s) Responsible for

Implementation: Executive Director, Director of

Clinical Services, School District Personnel

Expected Date of Completion for Each

Corrective Action Activity: April 30, 2014

Evidence of Completion of the Corrective Action: Meeting agendas; written communication to sending school districts; tracking form; revised student referral and intake form, training materials.

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Description of Internal Monitoring Procedures: Executive Director, Director of Clinical Services,

Program Directors and Office Staff will monitor student contract list to ensure contracts are submitted by sending school districts. In the event that a student contract has not been received, the Executive

Director will notify the sending district.

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: APD 5.2(a) Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s):

Please submit the following for progress report 1:

Written notification to sending school districts of the requirement for each student enrolled in The Finberg School and Kelly Boulevard Public Day School stating that a signed contract is needed.

Please submit the following for progress report 2:

Conduct an internal review of student records; submit the results of the internal record review and report: o The number of student records reviewed; o The number of records that are compliant; o For all records not in compliance, determine and report the root cause(s) of the noncompliance; and o The collaborative’s plan to remedy any non-compliance.

* Please note that when conducting internal monitoring the collaborative must maintain the following documentation and make it available to the Department upon request: a) List of student names and grade levels for the record review; b) Date of the review; c) Name of person(s) who conducted the review, their roles(s), and their signature(s).

Progress Report Due Date(s): January 10, 2014 & April 11, 2014

COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: APD 8.5 Current IEP & Student

Roster

Rating: Partially Implemented

Department CPR Finding: Review of student records and interviews indicated that the public day program does not always have an updated and signed IEP for every student enrolled in the program.

Narrative Description of Corrective Action: See SE 22

Title/Role of Person(s) Responsible for

Implementation: Director of Clinical Services,

Program Directors

Expected Date of Completion for Each

Corrective Action Activity: April 30, 2014

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Evidence of Completion of the Corrective Action: The collaborative updated and obtained a signed

IEP for the students enrolled in the public day program whose records reviewed by the Department indicated outdated information and unsigned IEPs. The collaborative will utilize a student referral and intake checklist tracking signed IEP signatures and Placement; official notification to sending school districts, and staff meeting agendas, attendance, and materials used to address the issue of updated and signed IEPs and Placement forms.

Description of Internal Monitoring Procedures: : Program Directors and Office Staff will continue to randomly select student records to ensure that IEPs and Placement forms across programs and grades are signed.

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: APD 8.5 Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s): See SE 22.

Progress Report Due Date(s): January 10, 2014 & April 11, 2014

COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: APD 13.4 Physical

Facility/Architectural Barriers

Rating: Partially Implemented

Department CPR Finding: Observations, documentation and interviews indicated that the Finberg

School, which houses the public day program, is a multi-level building that is not accessible to students with limited physical mobility. The Finberg School only allows access into the building from any outside point by stairs and areas within the building require stair access also. Programs within the building are designed for students with full mobility.

Students and staff with limited mobility, along with those enrolled who later require accessibility, are transferred to other locations within the collaborative on a permanent or temporary basis. The program does not have a timetable as to how it will make the building and programs accessible.

Narrative Description of Corrective Action: The BICO Collaborative Executive Director met with a representative from the Attleboro School Department on October 3, 2013 to discuss needed renovations to make the Finberg School accessible to all individuals including those with physical disabilities. A previously designed accessibility plan will be reviewed by the Collaborative and Attleboro Public

Schools to determine the present viability of such plans and any needed changes/additions to the plan.

The Attleboro School Department has indicated they wish to maintain a long-term relationship with the

BICO Collaborative and will work towards an extended lease and plan for the needed renovations. The results of these negotiations will be brought to the Collaborative Board of Directors and the Attleboro

School Committee for authorization.

A timetable for renovations will be developed in partnership with Attleboro Public Schools.

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Title/Role of Person(s) Responsible for

Implementation: BICO Executive Director and

Attleboro School Department

Expected Date of Completion for Each

Corrective Action Activity:

Evidence of Completion of the Corrective Action: TBD

Ongoing

Description of Internal Monitoring Procedures: TBD

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: APD 13.4 Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s):

Please submit the following for progress report 1:

An accessibility plan indicating how the collaborative will make the building programs accessible, with specific timelines for ensuring compliance.

Progress Report Due Date(s): January 10, 2014

COORDINATED PROGRAM REVIEW

CORRECTIVE ACTION PLAN

(To be completed by collaborative)

Criterion & Topic: APD 15.5 Parent Consent and

Required Notification

Rating: Partially Implemented

Department CPR Finding: Student record review indicated that not all records contain updated annual parental consent for: a) Emergency medical treatment; b) Restraints; and c) Medication

Administration (when applicable).

Narrative Description of Corrective Action: The procedures for monitoring receipt of updated annual parent consent for a) Emergency medical treatment; b) Restraints; and c) Medication

Administration (when applicable) will be revised. A checklist /tracking form for student registration including receipt of these forms will be used and kept for each student entering BICO programs. Upon receipt of registration packets, tracking forms will be completed. If there are missing components, individual follow-up will be conducted and arrangements will be made with parents/guardians to obtain these forms/signatures. After several documented attempts by Collaborative staff to obtain completed and signed consent forms, in the event of “no response” from the parent/guardian, the BICO program will send a certified letter to the parent/guardian with a copy to the sending school district notifying them of these requirements. In the event that there is continued noncompliance with this request, an

IEP team meeting and/or home visit will be arranged by the sending school district and /or BICO staff to review the presenting obstacles to obtaining completed forms. The forms will be brought to the IEP team meeting and/or home visit in an effort to secure parent/guardian signature.

Procedures will be reviewed/revised by the BICO Leadership staff, the BICO Operating Committee

(Member District Administrators of Special Education) and then disseminated to all BICO programs, sending school districts and out-of-district placement coordinators.

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Title/Role of Person(s) Responsible for

Implementation: Executive Director and Program

Directors

Expected Date of Completion for Each

Corrective Action Activity: April 30, 2014

Evidence of Completion of the Corrective Action: Tracking form; meeting agendas and procedural changes; parent/guardian letter; documentation of new procedures in appropriate handbook and policy manuals.

Description of Internal Monitoring Procedures: Executive Director and Program Directors will conduct a random review of student registration packets and current student records from all programs.

CORRECTIVE ACTION PLAN APPROVAL SECTION

(To be completed by the Department of Elementary and Secondary Education)

Criterion: APD 15.5 Status of Corrective Action:

Approved Partially Approved Disapproved

Basis for Partial Approval or Disapproval:

Department Order of Corrective Action:

Required Elements of Progress Report(s):

Please submit the following for progress report 1:

Procedures reviewed and/or revised by BICO leadership staff;

Copy of the student intake tracking form/checklist;

Sending district and/or parent/guardian reminder letter; and

Evidence of staff training (agendas, training materials, and signed attendance sheets)

Please submit the following for progress report 2:

Conduct an internal review of student records, post-training, and submit the results of the internal record review. Indicate: o The number of student records reviewed; o The number of records that are compliant; o For all records not in compliance, determine and report the root cause(s) of the noncompliance; and o The collaborative’s plan to remedy any non-compliance.

* Please note that when conducting internal monitoring the collaborative must maintain the following documentation and make it available to the Department upon request: a) List of student names and grade level for the record review; b) Date of the review; c) Name of person(s) who conducted the review, their roles(s), and their signature(s).

Progress Report Due Date(s): January 10, 2014 & April 11, 2014

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