MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY
EDUCATION
Program Quality Assurance Services
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Special Education Agency: Eagleton, Inc.
Program Review Onsite Year: 2012-2013
Programs under review for the agency:
Intensive Residential 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 06/19/2013.
Mandatory One-Year Compliance Date: 06/19/2014
Summary of Required Corrective Action Plans in this Report
Criterion
PS 1.2
Criterion Title
Program & Student Description, Program Capacity
PS 4.4
Advance Notice of Proposed Program/Facility Change
PS 5.1
Student Admissions
PS 9.1(a)
Student Separation Resulting from Behavior Management
PS 10.1
Staffing for Instructional Groupings
PS 10.2
Age Range
PR Rating
Partially
Implemented
Partially
Implemented
Partially
Implemented
Not
Implemented
Partially
Implemented
Partially
Implemented
Criterion
PS 11.1
Criterion Title
Personnel Policies and Procedures Manual
PS 11.4
PS 11.6
Teachers (Special Education Teachers and Regular Education
Teachers)
Master Staff Roster
PS 11.9
Organizational Structure
PS 12.1
New Staff Orientation and Training
PS 12.2
In-Service Training Plan and Calendar
PS 13.2
Kitchen, Dining, Bathing/Toilet and Living Areas:
PS 20
Bullying Prevention and Intervention
PR Rating
Partially
Implemented
Partially
Implemented
Partially
Implemented
Partially
Implemented
Partially
Implemented
Partially
Implemented
Partially
Implemented
Partially
Implemented
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 1.2 Program & Student Description, Program Capacity
Partially Implemented
Department Program Review Findings:
While documentation addressed the program's description for this criteria, observations
and interviews indicated that the educational services, philosophy, goals and objectives,
and pre-vocational services were not understood by some staff. In addition, through
observations and interviews, the Department was unable to determine how residential
services and educational services are fully coordinated. Observations and interviews
further indicated staff working with students diagnosed with Autism who have educational
and behavioral characteristics requiring additional supports do not have the necessary
training to effectively and adequately provide the services to that specific population.
Description of Corrective Action:
Eagleton will ensure that all staff receive training and will understand the Program and
Student Description including the educational services, philosophy, goals and objectives
and pre-vocational services. Eagleton will revise the narrative that describes the program
and services so that all staff will be able to understand and articulate the Program and
Student Description. The narrative will be in bullet format replicating the DESE legal
standard for Criterion 1.2. Each new employee will receive a copy of the Program and
Student Description at the time of hire and during orientation training. At the end of
orientation, employees will receive a multiple choice test to determine their level of
understanding of the Program and Student Description. Employees who do not score
100% on the test will receive additional training and re-take the test until 100% is
achieved.
For existing employees, Eagleton will conduct a training introducing the newly drafted
narrative, with emphasis on the educational services, philosophy, goals and objectives
and pre-vocational services. Each employee will receive a copy of the Program and
Student Description. At the end of the training, employees will take a multiple choice test
to determine the employee’s level of understanding of the Program and Student
Description. Employees who do not score 100% on the test will receive additional training
and re-take the test until 100% is achieved.
Eagleton will ensure that residential services and educational services are fully
coordinated and that staff will be able to articulate how these services are coordinated
(team meetings that include residential and school staff. Communication notebooks that
go from school to residence; clinical Team meetings with residential and school staff)
Eagleton will ensure that all staff will receive all necessary training to effectively and
adequately provide services to students diagnosed with Autism. Eagleton has hired
Shannon Kay, Ph.D., BCBA-D of Autism Intervention Specialists to provide consultation
for the students diagnosed with Autism. Consultation from Shannon Kay will begin on
July 1, 2013. Shannon Kay will provide 5 hours of consultation weekly that will include
staff training, functional assessment of problem behaviors, behavior plan development
and assistance with curriculum development. Additionally, Eagleton will provide any
additional supports to staff as recommended by Shannon Kay.
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
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Title/Role(s) of Responsible Persons:
Bruce Bona, Executive Director
Expected Date of
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
Revised narrative that describes the program and student services
Agenda of the training/orientation training for Program and Student Services, name and
job title of the person conducting the training, the audience to whom the training was
provided, the dates and time of the training and a list of all attendees of the training.
Copy of the Multiple Choice Test given to new employees during orientation and to
existing employees during the training held between July and September of 2013
Policy regarding Team Meetings
Policy regarding clinical meetings
Schedule of Team Meetings/Clinical Meetings
Sample agenda for Team/Clinical Meetings
Policy regarding Communication Notebooks including the Daily Cross-Disciplinary
Communication Sheet
Contract with Shannon Kay Ph.D., BCBA-D
List of Trainings provided by Shannon Kay
Agenda of the training, the audience to whom the training was provided, the dates and
time of the training and a list of all attendees of the training for those trainings already
provided by Shannon Kay.
List of any additional supports given to staff
Description of Internal Monitoring Procedures:
1) Department directors will directly supervise ongoing training. The Human Resources
Director will maintain documentation of participation in all required trainings.
2) The Education Director and Quality of Life Coordinator will monitor and review on a
quarterly basis the individual service delivery checklists from academic and residential
settings.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Approved
PS 1.2 Program & Student Description,
Status Date: 07/26/2013
Program Capacity
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit the revised written narrative for
the program and student description that addresses all elements to include educational
services, philosophy, goals and objectives, pre-vocational services and how residential
services and educational services are fully coordinated. Eagleton must also submit the
agenda and attendance sheets for trainings conducted, including any training with staff
specific to students diagnosed with Autism who have educational and behavioral
characteristics requiring additional supports. Eagleton must also submit the policy
regarding communication notebooks and a copy of the daily cross-disciplinary
communication sheet. In the 01/06/2014 progress report, Eagleton must submit the
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
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quarterly review conducted by the Education Director and the Quality of Life Coordinator.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 4.4 Advance Notice of Proposed Program/Facility Change
Partially Implemented
Department Program Review Findings:
A review of student records and interviews indicated Eagleton did not notify the
Department through a Form 1 regarding a vacancy in a Speech and Language Pathologist
position that was not filled by another appropriately credentialed Speech and Language
Pathologist that had a direct impact on the service delivery to students. In addition, the
program did not send a notification letter to funding public school district(s) of students
affected by the vacancy.
Description of Corrective Action:
Eagleton will notify the Department of Elementary and Secondary Education through a
Form 1, of all vacancies in approved staff positions not filled by another appropriately
licensed or waivered staff person that have a direct impact on the service delivery to
students; vacancies that result in students not receiving services as indicated on their
IEPs. Eagleton will clearly describe its alternative methods for providing these services to
students while attempting to fill any vacant positions. When the school is able to
temporarily fill a vacant position with a substitute teacher, it will notify ESE if substitute
teachers are being used and Eagleton will continue to document its efforts to fill the
position with an appropriately licensed staff person. Eagleton will notify the sending public
school districts of staff vacancies only for those students affected by the vacancy and not
receiving services as indicated on their IEPs. At this time there are no vacancies.
Title/Role(s) of Responsible Persons:
Expected Date of
Vickie Shufton, Education Director
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
In the event that vacancies arise, Copies of all Form 1 submittals maintained by the
Education Director, and such Forms 1 will be submitted to the Department per
regulations. Copies of letters notifying school districts will be placed in files of students
affected by the vacancy. A master staff roster addressing any changes made to staffing
of the school due to such a vacancy will be submitted to ESE.
Description of Internal Monitoring Procedures:
Quarterly quality review of the processes and documents mentioned above conducted by
the Education Director.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Approved
PS 4.4 Advance Notice of Proposed
Status Date: 07/26/2013
Program/Facility Change
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must report the results of its internal
monitoring to the Department, including whether records of notification to school districts
were found in any effected students' files if such a vacancy occurred. In the 01/06/2014
progress report, Eagleton must submit the outcome of its quarterly review conducted by
the Education Director.
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Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 5.1 Student Admissions
Partially Implemented
Department Program Review Findings:
While documentation indicates that the program has procedures to prepare staff and
students in the living unit for a new student’s arrival, interviews indicate a lack of
implementation of such procedures for those students with Autism who require toileting
and personal care assistance, behavior plans, and charting of particular behaviors.
Description of Corrective Action:
Eagleton will ensure that all procedures to prepare staff for new student’s arrival will be
implemented for those students who require toileting and personal care assistance,
behavior plans and charting of particular behaviors. Prior to a student moving in,
Eagleton will develop an individual checklist specific to the student’s needs, based on the
student’s IEP. The individual checklist will include the Goal, Activity and Method of
Instruction. Eagleton will implement Daily Service Delivery Log, which will document the
progress of the goals, as identified on the individual checklist. Shannon Kay, Ph.D.,
BCBA-D, will provide targeted training to residential staff regarding toileting, personal
care assistance, behavior plans and charting of particular behaviors.
Title/Role(s) of Responsible Persons:
Expected Date of
Vickie Shufton, Education Director
Completion:
Carla Duby, Residential Director
09/30/2013
Evidence of Completion of the Corrective Action:
A copy of the individual checklist
A copy of the Daily Service Delivery Log
List of Trainings provided by Shannon Kay
Agenda of the training, the audience to whom the training was provided, the dates and
time of the training and a list of all attendees of the training for those trainings already
provided by Shannon Kay.
Description of Internal Monitoring Procedures:
Training rosters will be monitored and maintained by the Human Resources Director;
daily residential checklists will be monitored by the Quality of Life Coordinator and
reviewed at quarterly at Individual Service Plan meetings and annually at Individualized
Educational Program meetings.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 5.1 Student Admissions
Corrective Action Plan Status: Partially
Approved
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states procedures to prepare staff for new student's arrival will be
implemented and training specific to residential staff will be conducted by a BCBA, the
program did not address the internal monitoring process that will be used to determine
whether this identified area of noncompliance has been corrected and how the program
will ensure continued compliance by the Education and Residential Directors.
Department Order of Corrective Action:
Eagleton must submit a description of the internal monitoring process by the Education
and Residential Directors that will be used to determine whether this identified area of
noncompliance has been corrected and how the program will ensure continued
compliance.
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Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit a copy of written admissions
criteria from the policies and procedures manual; a copy of the individual checklist specific
to the student’s needs and the daily service delivery log that documents the progress of
the student’s goals. Eagleton must also submit the agenda and attendance sheet to
include all required elements conducted by Shannon Kay and delivered to all residential
staff regarding toileting, personal care assistance, behavior plans and charting of
particular behaviors. Eagleton must also submit a description of the internal monitoring
process by the Education and Residential Directors that will be used to determine whether
this identified area of noncompliance has been corrected and how the program will ensure
continued compliance. In the 01/06/2014 progress report, Eagleton must submit the
results of it's internal monitoring. Eagleton must also submit completed copies of
individual checklists and daily service delivery logs for students requiring such plans.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 9.1(a) Student Separation Resulting from Behavior
Not Implemented
Management
Department Program Review Findings:
While documentation and interviews of administrative staff indicated the program's
behavior management policy and procedures do not result in a student being separated in
a room apart from the group or program activities, observations and interviews of direct
care staff indicated students are separated and documentation of separation is not
maintained.
Description of Corrective Action:
Eagleton will ensure documentation is maintained for any students separated from their
designated program activities for the purpose of behavioral management. The
documentation will include length of time, reasons for the separation, who approved the
separation, and who monitored the student during the separation. Eagleton will revise
the policy and procedures regarding behavior management specific to student separation
that will comply with criterion 9.1(a). Eagleton will provide training to all staff regarding
the revised policy.
Title/Role(s) of Responsible Persons:
Expected Date of
James Yeaman, Program Director
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
A copy of the revised Student Separation Resulting from Behavior Management policy
A copy of the log used to document when students are separated from their designated
program activities for the purpose of behavioral management
Agenda of the training, the audience to whom the training was provided, the dates and
time of the training and a list of all attendees of the training
Description of Internal Monitoring Procedures:
Training rosters will be monitored and maintained by the Human Resources Director; daily
residential checklists will be monitored by the Quality of Life Coordinator and reviewed at
quarterly at Individual Service Plan meetings and annually at Individualized Educational
Program meetings.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Partially
PS 9.1(a) Student Separation Resulting
Approved
from Behavior Management
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states that documentation regarding student separation as a result of
behavior management will be documented and the policy will be revised, the description
of the internal monitoring process does not address the ongoing monitoring procedures by
the Program Director that will be used to determine whether this area of identified
noncompliance has been corrected and how the program will ensure continued
compliance.
Department Order of Corrective Action:
Eagleton must submit a description of the internal monitoring process by the Program
Director that will be used to determine whether this area of identified noncompliance has
been corrected and how the program will ensure continued compliance.
Required Elements of Progress Report(s):
MA Department of Elementary & Secondary Education , Program Quality Assurance Services
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In the 10/01/2013 progress report, Eagleton must submit the revised copy of the written
policies and procedures regarding behavior management specific to student separation;
the agenda and attendance sheets of training conducted regarding the revised policy and
a copy of the log used to document students separation resulting from behavior
management. Eagleton must also submit a description of the internal monitoring process
by the Program Director that will be used to determine whether this area of identified
noncompliance has been corrected and how the program will ensure continued
compliance. In the 01/06/2014 progress report, Eagleton must submit documentation
maintained to record student separation for students from 10/01/2013 and 01/06/2014.
Eagleton must also submit the results of it's internal monitoring.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 10.1 Staffing for Instructional Groupings
Partially Implemented
Department Program Review Findings:
While documentation indicated instructional groupings do not exceed the approved ESE
ratios, observations and interviews indicated several classrooms exceeded the approved
Student: Licensed Educator ratio of 8:1 and the Student: Licensed Educator: Aide ratio of
8:1:1.
Description of Corrective Action:
Eagleton will ensure that instructional groupings do not exceed the approved ESE Student
: Licensed Educator ratio of 8:1 and the Student : Licensed Educator : Aide ratio of 8:1:1.
Title/Role(s) of Responsible Persons:
Expected Date of
Vickie Shufton, Education Director
Completion:
09/15/2013
Evidence of Completion of the Corrective Action:
Block schedules that clearly display the numbers and initials of students and the number
and initials of certified educators and aides in all classrooms for all periods throughout the
school day.
Description of Internal Monitoring Procedures:
Internal Monitoring will be conducted as needed, when student and staffing room
assignments change.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Approved
PS 10.1 Staffing for Instructional
Status Date: 07/26/2013
Groupings
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
For both the 10/01/2013 and the 01/06/2014 progress reports, Eagleton must submit
block schedules that clearly display the numbers and initials of students, and the numbers
and initials of certified educators and aides in all classrooms for all periods throughout the
school day. Eagleton must identify on the schedules if staff are licensed educators or
aides.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 10.2 Age Range
Partially Implemented
Department Program Review Findings:
Documentation and interviews indicated that several classrooms have instructional
groupings that exceed a forty-eight month age span and the program does not have a
Department-issued waiver.
Description of Corrective Action:
Eagleton will ensure that the ages of the youngest and oldest child in any instructional
grouping shall not differ by more than forty-eight months. Prior to exceeding the fortyeight month age span, Eagleton will submit an Alternative Compliance Waiver to DESE for
approval.
Title/Role(s) of Responsible Persons:
Expected Date of
Vickie Shufton, Director of Education
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
Block Schedules for every classroom and every period indicating the initials of students
with corresponding dates of birth
Description of Internal Monitoring Procedures:
The Education Director will carefully screen age ranges when grouping students in
classrooms; information on age ranges within classrooms will be reviewed at regular
intervals.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 10.2 Age Range
Corrective Action Plan Status: Approved
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
For both the 10/01/2013 and the 01/06/2014 progress reports, Eagleton must submit
block schedules that clearly display the numbers and initials of students, and the numbers
and initials of certified educators and aides in all classrooms for all periods throughout the
school day.
Progress Report Due Date(s):
10/01/2013
01/06/2014
MA Department of Elementary & Secondary Education , Program Quality Assurance Services
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 11.1 Personnel Policies and Procedures Manual
Partially Implemented
Department Program Review Findings:
A review of staff records indicated that staff performance evaluations are not consistently
scheduled annually or maintained with the signatures of the employee and supervisor per
the program's policy.
Description of Corrective Action:
Eagleton will ensure adherence of the policy and procedure regarding staff performance
evaluations. All staff will receive performance evaluations and sign off by both employee
and supervisor.
Title/Role(s) of Responsible Persons:
Expected Date of
Kathleen Young, Human Resources Director
Completion:
09/01/2013
Evidence of Completion of the Corrective Action:
A spread sheet reflecting every employee of Eagleton School, the name of their
supervisor, the scheduled date of the employee’s evaluation, check off that evaluation
was conducted, and check off that both employee and supervisor signed the evaluation.
Description of Internal Monitoring Procedures:
The Human Resources Director will maintain a log of all current employees and notify
department directors in writing of missing or late evaluations.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Approved
PS 11.1 Personnel Policies and
Status Date: 07/26/2013
Procedures Manual
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
For both the 10/01/2013 and the 01/06/2014 progress reports, Eagleton must submit the
staff performance evaluation spreadsheet to include the name of the supervisor of the
employee, the scheduled date of the employee evaluation, and evidence that the
evaluation was conducted and signed by both the employee and supervisor. In the event
an evaluation is not conducted at the scheduled annual date, Eagleton must also submit
it's plan for when it will be completed.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 11.4 Teachers (Special Education Teachers and Regular
Partially Implemented
Education Teachers)
Department Program Review Findings:
A review of documentation and interviews indicated that one teacher was not licensed or
on a Department-approved waiver at the time of the Program Review. During the onsite
visit, documentation was submitted that showed the school was recently granted a
waiver. However, observations and interviews also revealed that one other individual who
is not licensed or on an approved waiver is acting as the teacher in a classroom, and this
person is designing and implementing special education services for all students despite
not having a license in special education.
Description of Corrective Action:
Eagleton will ensure that all teaching staff have teaching licenses appropriate to meet the
needs of the population being served pursuant to the requirements of 603 CMR 7.00 or
have a current certification waiver. To the extent that teaching staff is providing special
education services, Eagleton will ensure that the services shall be provided, designed, or
supervised by a special educator.
Title/Role(s) of Responsible Persons:
Expected Date of
Kathleen Young, Human Resources Director
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
Current teaching staff roster
ELAR activity sheet
Description of Internal Monitoring Procedures:
The Human Resources Director will review the licensure status of all individuals teaching
at Eagleton School on a quarterly basis to ensure that they are properly licensed or
waivered. A Form 1 will be submitted in the event that teachers lose their license or
waiver and a qualified replacement cannot be identified within 90 days.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Partially
PS 11.4 Teachers (Special Education
Approved
Teachers and Regular Education
Status Date: 07/26/2013
Teachers)
Basis for Partial Approval or Disapproval:
While Eagleton states the Human Resource Director will ensure all teachers will be
appropriately licensed or on approved waivers, the program did not identify who would
ensure that special education services will be provided, designed, or supervised by a
special educator and that the licenses are appropriate to meet the needs of the population
being served.
Department Order of Corrective Action:
Eagleton must submit the name of the individual who will ensure that the teaching
licenses are appropriate to meet the needs of the population being served and will ensure
that special education services will be provided, designed, or supervised by a special
educator.
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit a current teaching staff roster
that includes all required information and a copy of a current license and/or approved
MA Department of Elementary & Secondary Education , Program Quality Assurance Services
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waiver for each teacher listed on the roster. Eagleton must also submit the name of the
individual who will ensure that the teaching licenses are appropriate to meet the needs of
the population being served and will ensure that special education services will be
provided, designed, or supervised by a special educator. In the 01/06/2014 progress
report, Eagleton must submit the results of the Human Resource Director's quarterly
review of current teacher licenses to include how the program remains in compliance if a
teacher is not appropriately licensed, on an approved waiver or has been in the role of a
substitute exceeding 90 days.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 11.6 Master Staff Roster
Partially Implemented
Department Program Review Findings:
A review of documentation and interviews indicated the following: some Uniform
Financial Report numbers (UFR's) do not correspond to UFR titles; position titles do not
reflect how the program is operating; positions indicated on the Master Staff Roster differ
from the last approved program budget; and all staff currently identified as employees of
the program are not all indicated on the Master Staff Roster.
Description of Corrective Action:
Eagleton will ensure that the Master Staff UFR numbers correspond to UFR titles, that
position titles reflect how the program is operating, that positions reflect the last
approved program budget and all staff currently identified as employees of the program
are listed on the Master Staff Roster.
Title/Role(s) of Responsible Persons:
Expected Date of
Lori Ann Kueblbeck, Finance Director
Completion:
Kathleen Young, Human Resources Director
09/30/2013
Evidence of Completion of the Corrective Action:
Master Staff Roster
Description of Internal Monitoring Procedures:
The Human Resources Director and Finance Director will monitor the information
quarterly.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 11.6 Master Staff Roster
Corrective Action Plan Status: Approved
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
In both the 10/01/2013 and the 01/06/2014 progress reports, Eagleton must submit the
current master staff roster that includes for each staff person: corresponding UFR#s;
UFR titles; full time equivalents (FTEs); position title; first and last name; vacancies; and
justification for any discrepancies from the last approved budget. In addition, in the
01/06/2014 progress report, the program must submit the results of the Human Resource
Director and Finance Director's quarterly review.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 11.9 Organizational Structure
Partially Implemented
Department Program Review Findings:
A review of documentation and interviews indicated the organizational structure does not
provide for the effective and efficient operation of the school, supervision of school staff,
and supervision of students. In addition, the organizational chart does not include the
program position titles for all staff and observation and interviews indicated that lines of
supervision between the educational and behavioral components of the program are not
clear or understood by education staff.
Description of Corrective Action:
Eagleton will develop an organizational structure that provides for the effective and
efficient operation of the school, supervision of school staff, a clear delineation of
supervision between the educational and behavioral components of the program and
supervision of students. The organizational chart will include all program position titles
for all staff. Eagleton will provide training to all staff presenting the new organizational
structure, lines of supervision and new job descriptions. For any changes in supervision
of staff, or responsibilities, Eagleton will revise job descriptions. Eagleton will ensure that
all staff are clear and understand the organizational structure of the program.
Title/Role(s) of Responsible Persons:
Expected Date of
Bruce Bona, Executive Director
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
Organizational Chart
Job Descriptions, if necessary
Agenda of the training, the audience to whom the training was provided, the dates and
time of the training and a list of all attendees of the training.
Description of Internal Monitoring Procedures:
The Human Resources Director will ensure that all new employees are provided with
accurate charts and descriptions of duties. The information will be reviewed at orientation
training to ensure that new employees understand the organizational structure of
Eagleton School.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 11.9 Organizational Structure
Corrective Action Plan Status: Approved
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
In the 10/01/2013 and the 01/06/2014 progress reports, Eagleton must submit an
organizational chart for the program that provides for the effective and efficient operation
of the school, supervision of school staff, and supervision of students. The chart should
illustrate and describe the lines of supervision between the educational and behavioral
components of the program for staff and students. Eagleton must also submit the agenda
for the training on the revised organizational structure, the name and job title of the
person conducting the training, the date and time of the training and the attendance
sheet which includes the name and job title of the staff participants. Eagleton must also
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submit any revised job descriptions as a result of the new organizational structure.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 12.1 New Staff Orientation and Training
Partially Implemented
Department Program Review Findings:
While a review of documentation and interviews of administrative staff indicated new staff
orientation is implemented, staff record review and interviews of direct care staff
indicated that staff do not receive training and new staff are assigned direct care duties
with students prior to the staff participating in all mandated training listed under criterion
12.2 a-e. Interviews also indicated that staff do not receive training that is consistent
with the needs of some of the population the program is currently serving; specifically
students with Autism and students with emotional impairments. In addition, interviews
indicated that some staff do not understand the program's philosophy, organization,
practices and goals.
Description of Corrective Action:
Eagleton will ensure that new staff will participate in an orientation-training program
which includes the following and that new staff are assigned direct care duties only after
participating in all mandated trainings listed below:
Program’s philosophy
Organization
Program
Practices
Goals
Reporting abuse and neglect of students to the Department of Children and Families
and/or the Disabled Persons Protection Commission;
Disciplinary and Behavior Management Procedures used by the program, such as positive
reinforcement, point/level systems, token economies, time-out procedures and
suspensions and terminations; as well as Restraint Procedures including de-escalation
methods used by the program;
Runaway policy;
Emergency procedures including Evacuation Drills and Emergency Drills; and
Civil rights responsibilities (discrimination and harassment).
To ensure new staff and current staff receive training that is consistent with the needs of
the students with Autism and students with emotional impairments, Eagleton has hired
Shannon Kay, Ph.D., BCBA-D of Autism Intervention Specialists to provide consultation
for the students diagnosed with Autism. Consultation from Shannon Kay will begin on
July 1, 2013. Shannon Kay will provide 5 hours of consultation weekly that will include
staff training, functional assessment of problem behaviors, behavior plan development
and assistance with curriculum development. Additionally, Eagleton will provide any
additional supports to staff as recommended by Shannon Kay.
Title/Role(s) of Responsible Persons:
Expected Date of
Kathleen Young, Human Resources Director
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
The agenda for the trainings listed above
The audience to whom the training was provided, the dates and time of the training and a
list of all attendees of the training
Contract with Shannon Kay Ph.D., BCBA-D
List of Trainings provided by Shannon Kay
Agenda of the training, the audience to whom the training was provided, the dates and
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time of the training and a list of all attendees of the training for those trainings already
provided by Shannon Kay.
List of any additional supports given to staff
Description of Internal Monitoring Procedures:
The Human Resources Director will review training logs and rosters to ensure that all staff
have received the training described above.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Partially
PS 12.1 New Staff Orientation and
Approved
Training
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states documentation of all new staff orientation training will be
documented and include mandated training and will now include specific training
consistent with the needs of students with Autism, the program did not indicate how the
program would include specific training consistent with the needs of students with
emotional impairments. In addition, while the program indicates it will ensure that new
staff orientation training specific to program philosophy, organization, practices and goals
will be conducted, the program does not address the Department's finding that some staff
do not understand the program's philosophy, organization, practices and goals.
Department Order of Corrective Action:
Eagleton must submit how the program will address specific training consistent with the
needs of students with emotional impairments. Eagleton must also submit how the
program will address new staff orientation training specific to the program's philosophy,
organization, practices and goals. Eagleton must also submit a narrative to describe how
the program will ensure that new staff receive all mandated training prior to their
assignment of direct care duties with students.
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit a copy of the written
orientation and training program for staff; copies of the agendas for specific training
consistent with the needs of students with Autism and students with emotional
impairments; and program philosophy, organization, practices and goals for all staff.
Eagleton must also submit a narrative describing how the program will ensure that new
staff receive all mandated training prior to their assignment of direct care duties with
students. In the 01/06/2014 progress report, Eagleton must submit agendas and
attendance sheets for any new staff that were hired prior to this submission date.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 12.2 In-Service Training Plan and Calendar
Partially Implemented
Department Program Review Findings:
A review of documentation indicated the length of time allotted for each topic is not
included and the audience to whom the trainings are offered is inconsistent. In addition,
while a review of staff records indicated some in-service training occurs, evidence of a
minimum of 24 training hours for a twelve month program was lacking. Interviews
revealed that all staff are not being trained on the mandated in-service topics.
Description of Corrective Action:
Eagleton will ensure that all staff, including new employees, interns and volunteers must
participate in annual in-service training on average at least two hours per month for a
total of 24 hours of training. Additionally, all required in-service training topics will be
provided annually to all staff. The length of time allotted for each topic will be included
and the audience to whom the trainings are offered will be included on the training
calendar.
Title/Role(s) of Responsible Persons:
Expected Date of
Kathleen Young, Human Resources Director
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
Revised training calendar that complies with the criterion 12.2
A list of all staff that attended the mandated in-service topics, ensuring that all staff are
trained on the mandated in-service topics
A tracking spreadsheet of all trainings to ensure that at least two hours of training per
month or 24 hours of training for the 12 month period is provided to all employees.
Description of Internal Monitoring Procedures:
The Human Resources Director will maintain and review the delivery, content, and
documentation of all required training.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Partially
PS 12.2 In-Service Training Plan and
Approved
Calendar
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states the Human Resource Director will maintain and review the delivery,
content and documentation of all required training, the program did not identify how the
program proceeds when a staff misses mandated training and/or does not participate in
annual in-service training on average at least two hours per month.
Department Order of Corrective Action:
The program must submit the procedure the program has developed to address a staff
who misses a mandated training and/or does not participate in annual in-service training
on average at least two hours per month.
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit the in-service training plan
calendar that includes all mandated trainings and specifically documents how staff are
offered an average of at least 2 hours of training each month. Eagleton must also submit
the attendance sheets showing that staff participation has been filed and recorded on the
tracking spreadsheet. The program must also submit the procedure the program has
developed to address a staff who misses a mandated training and/or does not participate
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in annual in-service training on average at least two hours per month. In the 01/06/2014
progress report, Eagleton must submit the tracking spreadsheet to include evidence of
mandated trainings and any additional training. Eagleton must also submit evidence of
having rescheduled training dates for any staff that have missed a training.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 13.2 Kitchen, Dining, Bathing/Toilet and Living Areas:
Department Program Review Findings:
Observations and interviews indicated the following:
PR Rating:
Partially Implemented
Kitchen, Dining, Bathing/Toilet and Living Areas:
Several bathrooms including a bathroom in a vocational classroom and some bedrooms in
the residences were not maintained in a clean manner and had strong unsanitary odors.
In addition, space designated for administrative use was not well maintained, including
overflowing trash barrels and bathroom facilities in need of repair.
Classroom Space:
Each room or area that is utilized for the instruction of students was not adequate with
respect to the number of staff and students, size and age of students and students
specific educational needs, physical capabilities, educational/vocational activities and the
program's identification of the behaviors students may exhibit as part of their disability.
Throughout the program and in one particular classroom, the textbooks, equipment,
technology, materials and supplies needed to provide the special education and related
services specified on the IEPs of enrolled students were essentially non-existent and no
resources were available for teachers.
Description of Corrective Action:
All bathrooms with the exception of Dorm 458 and one closed prevocational classroom
have been repaired and maintained in a sanitary state (refer to professional cleaning
contract, attached). The pre-vocational bathroom will be complete by July 8th and the
dorm bathroom will be completed by July 22nd. Trash barrels are emptied on a daily
basis. Two classrooms have been enlarged to provide for the physical, educational and
programmatic needs of students and staff. A third classroom will be enlarged by August
30, 2013. All teaching staff have been provided with appropriate textbooks, technology,
equipment, and supplies to meet the needs of their students. We have completed work
orders documenting these improvements.
Title/Role(s) of Responsible Persons:
Expected Date of
Bruce Bona, Executive Director
Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
Completed work orders for enlarged classrooms and facilities repairs. Inspection
checklists completed and maintained by Quality of Life coordinator. Janitorial Service
contract.
Description of Internal Monitoring Procedures:
Facilities will be inspected and monitored for cleanliness on a daily basis by Quality of Life
Coordinator to ensure that the environment is clean, safe, and maintained for the benefit
of students; classrooms will be inspected weekly to ensure that all teachers have
appropriate classroom resources and supplies.
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CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Partially
PS 13.2 Kitchen, Dining, Bathing/Toilet
Approved
and Living Areas:
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states it will submit work orders specific to the improvements to
classrooms and facilities, the Department is unable to determine the efforts made to
provide all teaching staff with appropriate textbooks, technology, equipment, and supplies
to provide the special education and related services specified on the IEPs of enrolled
students.
Department Order of Corrective Action:
Eagleton must submit the process the program has taken to provide all teaching staff with
not only supplies but appropriate textbooks, technology and equipment necessary to
provide the special education and related services specified on the IEPs of enrolled
students.
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit the inspection checklists for
the months of July, August and September completed and maintained by the Quality of
Life Coordinator for the administrative, residential and educational facility repairs and a
description of how the program has ensured the classroom spaces are adequate with
respect to the number of students, size and age of students, and students' specific
educational needs, physical capabilities, and educational and vocational activities.
Eagleton must also describe the process the program has taken to provide all teaching
staff with not only supplies but appropriate textbooks, technology and equipment
necessary to provide the special education and related services specified on the IEPs of
enrolled students. In the 01/06/2014 progress report, Eagleton must submit inspection
checklists for facilities to include administrative, residential and educational spaces for the
months of October, November and December completed and maintained by the Quality of
Life Coordinator and the classroom inspections specific to ensuring teaching staff have the
appropriate textbooks, technology, equipment and supplies to provide the special
education and related services specified on the IEPs of enrolled students.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PR Rating:
PS 20 Bullying Prevention and Intervention
Partially Implemented
Department Program Review Findings:
A review of documentation indicated a description of the professional development plan
developed by the program for all staff and evidence of its implementation to include
dates, format(s) used and agenda(s) was not provided. In addition, interviews indicated
staff do not understand the program's policy and/or the process to follow if they witness
bullying or if it is reported to them.
Description of Corrective Action:
New employees will receive training specific to bullying prevention and intervention prior
to assuming their duties. The anti-bullying policy will be provided to them in writing, and
will be described and discussed. Following training, staff will demonstrate their
understanding of the school’s anti-bullying policy by passing a written assessment. This
training will be repeated annually.
Title/Role(s) of Responsible Persons:
Expected Date of
Vickie Shufton, Education Director
Completion:
Kathleen Young, Human Resources Director
09/30/2013
Evidence of Completion of the Corrective Action:
Signed documentation of training maintained in each employee’s personnel file; written
assessments maintained in each employee’s personnel file; signed training rosters
maintained by the Human Resources Director; Training agendas with all required
elements listed.
Description of Internal Monitoring Procedures:
The Education Director, Clinical Director, and Program Director will directly supervise
ongoing training. The Human Resources Director will maintain and review on a monthly
basis the delivery, content, and documentation of all required training.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
Corrective Action Plan Status: Partially
PS 20 Bullying Prevention and
Approved
Intervention
Status Date: 07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states the process for training specific to the bullying intervention and
intervention plan will be amended with new employees, the program does not address
training specific to the bullying intervention plan with existing employees and did not
indicate a corrective action plan specific to a professional development plan developed by
the program for all staff. It is also unclear to the Department the process the program
would follow in the event a staff member does not pass the written assessment thus
demonstrating the lack of the staff's understanding of the anti-bullying policy.
Department Order of Corrective Action:
Eagleton must submit a professional development plan developed by the program for all
staff and evidence of its implementation to include dates, format(s) used and agenda(s).
The program must also submit attendance sheets to include all required elements
indicating training specific to the bullying prevention and intervention plan have been
conducted with existing Eagleton staff. The program must also submit the procedure it
will follow if a staff member does not pass the written assessment.
Required Elements of Progress Report(s):
In the 10/01/2013, Eagleton must submit a professional development plan developed by
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the program for all staff and evidence of its implementation to include dates, format(s)
used and agenda(s). The program must also submit attendance sheets to include all
required elements indicating that training specific to the bullying prevention and
intervention plan have been conducted with existing Eagleton staff. The program must
also submit the procedure it will follow if a staff member does not pass the written
assessment. In the 01/06/2014 progress report, Eagleton must submit the results of the
review conducted by the Human Resource Director of the bullying prevention and
intervention training for the months of November and December. In addition, for any
staff member that did not pass the written assessment Eagleton must submit the steps
taken to ensure that the particular staff member(s) demonstrate their understanding of
Eagleton's anti-bullying policy.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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